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Cardiovascular Biophysics Laboratory, Washington University School of Medicine, St. Louis, Missouri
Submitted 29 September 2006 ; accepted in final form 8 January 2007
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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Pavg/Vavg) is an important diastolic function index. An E-wave-based determination of Pavg/Vavg (Little WC, Ohno M, Kitzman DW, Thomas JD, Cheng CP. Circulation 92: 1933–1939, 1995) predicted that deceleration time (DT) determines stiffness as follows: Pavg/Vavg = N(
/DT)2 (where N is constant), which implies that if the DTs of two LVs are indistinguishable, their stiffness is indistinguishable as well. We observed that LVs with indistinguishable DTs may have markedly different Pavg/Vavg values determined by simultaneous echocardiography-catheterization. To elucidate the mechanism by which LVs with indistinguishable DTs manifest distinguishable chamber stiffness, we use a validated, kinematic E-wave model (Kovács SJ, Barzilai B, Perez JE. Am J Physiol Heart Circ Physiol 252: H178–H187, 1987) with stiffness (k) and relaxation/viscoelasticity (c) parameters. Because the predicted linear relation between k and Pavg/Vavg has been validated, we reexpress the DT-stiffness (Pavg/Vavg) relation of Little et al. as follows: DTk 
. Using the kinematic model, we derive the general DT-chamber stiffness/viscoelasticity relation as follows: DTk,c = 
(where c and k are determined directly from the E-wave), which reduces to DTk when c << k. Validation involved analysis of 400 E-waves by determination of five-beat averaged k and c from 80 subjects undergoing simultaneous echocardiography-catheterization. Clinical E-wave DTs were compared with model-predicted DTk and DTk,c. Clinical DT was better predicted by stiffness and relaxation/viscoelasticity (r2 = 0.84, DT vs. DTk,c) jointly rather than by stiffness alone (r2 = 0.60, DT vs. DTk). Thus LVs can have indistinguishable DTs but significantly different Pavg/Vavg if chamber relaxation/viscoelasticity differs. We conclude that DT is a function of both chamber stiffness and chamber relaxation viscoelasticity. Quantitative diastolic function assessment warrants consideration of simultaneous stiffness and relaxation/viscoelastic effects.
echocardiography; mathematical modeling; diastole
Pavg/Vavg) = (Ped – Pmin)/(Ved – Vmin) (where Ped and Ved represent end-diastolic pressure and volume and Pmin and Vmin represent minimum pressure and volume) is a reasonable approximation for the average operating LV stiffness. Determination of Pavg/Vavg via high-fidelity, micromanometric pressure recording defines the invasive "gold standard." Because Pavg/Vavg is a "relative," rather than an "absolute," index, the requirement to use invasive methodology for its determination is not absolute. Accordingly, noninvasive methods for estimation of LV stiffness have been proposed (9, 10, 21, 25, 26, 28, 35). Little et al. (26), as well as other groups (10, 28), experimentally validated a strong correlation between the E-wave deceleration time (DT) and the invasively determined LV hemodynamic operating stiffness (Pavg/Vavg). Specifically, Little et al. used a kinematic approach to derive chamber stiffness, KLV, related to DT as
 | (1) |
is the density of blood, L is the effective mitral plug flow length, and AMV is the constant effective mitral valve area (MVA). Equation 1, which was validated in eight dogs, shows a strong linear relation between DT-predicted KLV and measured Pavg/Vavg. Further validation of Eq. 1 for humans undergoing open-heart surgery and humans undergoing catheterization was achieved by Garcia et al. (10) and Marino et al. (28), respectively.
Importantly, the relation between DT and stiffness specified by Eq. 1 implies that two LVs with E-waves having indistinguishable DTs should have indistinguishable LV stiffness (Pavg/Vavg), if it is assumed that chamber volumes are similar and that the constant lumped coefficient in Eq. 1 is the same for both. Therefore, subjects with similar MVA, blood density, and chamber volumes and indistinguishable DTs by Doppler echocardiography, but significantly different Pavg/Vavg by catheterization, would suggest that although Eq. 1 is an excellent correlate of chamber stiffness, it is incomplete.
Our work was motivated by a specific example (Fig. 1) from two subjects with similar EDVs undergoing elective diagnostic catheterization in whom simultaneous micromanometric LV pressure (Millar) and transmitral flow (E waves) were recorded. For both subjects, catheterization-determined stiffness (Pavg/Vavg) and an E-wave-derived kinematic LV stiffness analog (k) (21, 25) were calculated for several consecutive beats (see METHODS). Although the DTs in Fig. 1 are indistinguishable, all the invasive and noninvasive stiffness indexes were significantly different between the two subjects (see Table 1).
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Pavg/Vavg)" dilemma, we investigated the functional relation between DT and Pavg/Vavg. We address the dilemma conceptually and provide experimental data in support of our model-predicted hypothesis that DT is determined jointly by chamber stiffness and chamber relaxation/viscoelasticity. |
METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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Inclusion criteria.
Eighty subjects were selected from an existing Cardiovascular Biophysics Laboratory database of simultaneous Doppler echocardiographic transmitral flow recordings and micromanometric catheter-derived LV pressures obtained during diagnostic cardiac catheterization (2, 25). All subjects underwent elective cardiac catheterization at the request of their referring physician. Before data acquisition and cardiac catheterization, all subjects provided signed, informed consent to participate in the study, which was approved by the Washington University Medical Center Human Studies Committee (Institutional Review Board). Selection criteria from the database required that subjects have normal sinus rhythm, normal valvular function, and clearly identifiable E and A waves. Subjects with significant merging of E and A waves were excluded. In 19 of the 80 subjects, ejection fraction was <55%; in 35 of the 80 subjects, LV end-diastolic pressure was 
19 mmHg. Demographic information for the group is summarized in Table 2.
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Doppler analysis methods. DT was measured manually as defined by standard criteria (1) as the base of the triangle approximating the deceleration portion of the E wave (Fig. 1).
For each beat, the PDF formalism was also used to fit the E-wave contour (11, 18). The PDF formalism is a lumped-parameter, predictive, rather than accommodative, model (24) that characterizes transmitral flow according to damped simple harmonic oscillatory (SHO) motion in terms of elastic, inertial, and damping/viscoelastic forces (see APPENDIX A for review of the PDF formalism).
As in earlier work (25), diastolic volume differences (V) were calculated by multiplication of MVA by the velocity-time integral (VTI) over the relevant portion of the diastolic period. For estimation of the effective (constant) MVA, the ventriculography-determined (calibrated) stroke volume was divided by the average total VTI (E-wave VTI + A-wave VTI).
Calculation of LV hemodynamic operating stiffness.
Two subjects with similar EDV from the group (Fig. 1) and clear diastasis intervals between E and A waves were chosen for a preliminary analysis. For each subject, DT and Pavg/Vavg were measured in 7–10 consecutive beats. In addition, E waves were fit by the PDF formalism for each beat. Beats from each subject with indistinguishable DT were grouped together. To test whether LV stiffness values were indistinguishable in subjects with indistinguishable DT, hemodynamically determined operating stiffness values, as well as PDF model-derived LV stiffness (k), were compared between beats with indistinguishable DT. In addition to comparison of mean values between subjects for stiffness parameters and DT, all measured values (DT, hemodynamic stiffness, and PDF stiffness) for each beat from subject 1 (9 beats) were compared with measured values from subject 2 (7 beats) by ANOVA using Microsoft Excel (Microsoft, Redmond, WA) see Table 1.
The method for determining LV hemodynamic operating stiffness is described elsewhere (25). Briefly, average chamber stiffness and early rapid filling stiffness were calculated from ratios of LV pressure changes to volume changes over appropriate time intervals. In accordance with the method of Little et al. (26), average chamber stiffness was defined as Pavg/Vavg = (Ped – Pmin)/(Ved – Vmin). Early rapid filling stiffness, the effective E-wave LV stiffness, was defined as the ratio of the change in pressure to the change in volume from minimum LV pressure to diastasis LV pressure: PE/VE = (Pdiastasis – Pmin)/(Vdiastasis – Vmin).
General expression for DT.
Using a kinematic approach, in 1995 Little et al. (26) modeled E-wave deceleration, starting at the E-wave peak (Epeak), via Newton's law (F = ma). The inertial force was opposed solely by elastic ventricular forces, which were proportional to ventricular stiffness. This kinematic undamped model of filling for fitting the DT portion of the Doppler E wave is based on the following equation: d2v/dt2 = KLV2 (
) (where is E-wave velocity), which is mathematically equivalent to an undamped SHO having the following equation of motion (per unit mass):
 | (2) |
is the second time derivative of displacement [or acceleration (cm/s2)].
To account for the role of the LV as a mechanical suction pump in early diastole and to predict E-wave contours, the PDF formalism utilizes a damped SHO. The equation of motion (per unit mass) is
 | (3) |
is the velocity (cm/s), and x, k, and are defined as for Eq. 2. Apart from the choice of initial conditions for the two models, c is the primary difference between the PDF formalism and the model of Little et al. (26). Thus, in deriving a PDF formalism-based equivalent to the period of oscillation-DT relation (Eq. 1), we expect the PDF formalism-derived formula to be a function of stiffness (k) and relaxation/viscosity (c), as shown in APPENDIX A (Eq. A1).
To find the PDF model-predicted stiffness-DT relation, we derive a closed-form expression for DT in terms of PDF parameters. We calculate DT from Eq. A1 by taking the difference between the time at which the velocity crosses the origin [E-wave duration (Edur)] and the time of peak velocity [acceleration time (AT)]. We simplify the result via a Taylor series expansion (see APPENDIX B) in the limit 2k > c2. The simplified expression becomes
 | (4) |
 | (5) |
Comparative analysis between DTk and DTk,c.
Lisauskas et al. (25) showed for a large sample size (n = 131) that the E-wave-derived kinematic stiffness k is strongly linearly correlated with catheterization-determined Pavg/Vavg. Kovács et al. (21) showed that k is equal to a constant multiple of the Little et al. (26) DT-determined stiffness for low c-valued E waves. Thus, instead of calculating Pavg/Vavg (as we did for the preliminary work presented in Fig. 1) for all 80 subjects in the comparative analysis, we used PDF-derived k as a surrogate for invasively determined stiffness. To ensure the validity of using k, instead of Pavg/Vavg, as a surrogate, we once again determined the correlation between k and Pavg/Vavg in a subgroup of our patients (n = 20) using the methods of Lisauskas et al. Consistent with results of Lisauskas et al., a strong linear correlation (r = 0.76) between k and Pavg/Vavg was observed for the subgroup of subjects (data not shown).
By incorporation of the established linear relation between k and Pavg/Vavg (21, 25), the prediction between DT and kinematic stiffness of Little et al. (26) in Eq. 1 becomes
 | (6) |
For computation of DTk,c and DTk, stiffness (k) and relaxation/viscosity (c) were substituted into Eqs. 4 and 6. Clinically measured DT was compared with the model-predicted DTk,c and DTk by least-mean-square regression. The difference between measured and predicted DT values was analyzed by paired t-test (Microsoft Excel, Microsoft).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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Pavg/Vavg and PE/VE), as well as PDF-determined stiffness (k), was calculated for seven beats in subject 2 and 10 beats in subject 1, (see Table 1). Although DT values were indistinguishable between the two subjects (P = 0.89), invasively derived and kinematically derived stiffness values were significantly different (P < 0.001, ANOVA).
The predicted relation between DT, k, and c (Eq. 4) was compared with the established (inverted) relation of Little et al (26) in Eq. 6. In Fig. 2, the raw data of measured DT are plotted against model-predicted DTk,c using Eq. 4 and the model of Little et al. (Eq. 6). Least-mean-square regression yields DT = 1.15DTk,c + 0.01 (r2 = 0.84) vs. Eq. 1 (DT = 1.48DTk + 0.03, r2 = 0.60). (DT – DTk), the average difference between the measured DT and DT predicted by the model of Little et al. (26), was 0.082 (SD 0.022) s, whereas (DT – DTk,c), the average difference between measured DT and DT predicted by the model of Kovács et al. (18), was 0.036 (SD 0.031) s. Paired t-test analysis of the difference between measured and predicted DT (DT – DTk,c vs. DT – DTk) at a significance level of 
= 0.05 yields t = 32 and p 10–47 for a two-tailed test.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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The model of Little et al. (26) was used to derive Eq. 6, which relates DT to ventricular chamber stiffness. Although the approach of Little et al. provides an excellent approximation to the deceleration portions of many E-wave contours, for deceleration portions of E waves exhibiting an inflection point or the "delayed-relaxation" pattern, a cosine function has limited applicability. In addition, a cosine (quarter wavelength, "concave-down") model cannot fit an E-wave deceleration contour with an inflection point (concave-down changing to "concave-up"). Thus the cosine model works best for ventricles where relaxation/viscoelastic effects are negligible relative to stiffness.
To determine why two subjects with indistinguishable DTs and chamber volume can have different catheterization-determined values of chamber stiffness, we used the PDF formalism to derive the general expression between DT, ventricular stiffness, and relaxation/viscoelasticity (Eq. 4). The relaxation/viscoelastic effects during filling declare themselves in the damped oscillatory features of the velocity contour, transforming a pure sine wave (low damping)-shaped E wave to an E wave well fit by a sine wave modulated by a damped exponential, as frequently encountered clinically in the delayed-relaxation pattern.
The viscoelastic parameter c resolves the dilemma of two subjects with indistinguishable DTs, MVAs, and EDVs having distinguishable values for invasively determined chamber stiffness (Fig. 1). Importantly, although two E waves, approximated as triangles, can have indistinguishable numeric values for DT, the actual shape and amplitude of the deceleration portion of these E waves can be different. The specific contour of the E wave, in conjunction with DT, is important, because it reflects underlying physical properties of the ventricle (5). The PDF model fits amplitude, shape, and duration of the deceleration portion and provides the information needed to uniquely determine stiffness (k) and relaxation/viscosity (c) parameters. Since Eq. 4 does not require a one-to-one correspondence between k and DT, it is possible for two LVs to have indistinguishable DT but distinguishable k, as long as c is different. The plot of stiffness parameter k vs. relaxation parameter c in Fig. 3, shows how k and c must change in order for DT to remain constant.
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Diastolic function and chamber material properties. The simplest model for the material properties of the chamber assumes that the tissue is a linear elastic material. This approach lumps complex cellular and extracellular interactions into a single stiffness parameter that relates stress to strain (pressure differences to volume differences). Although some models treat tissue as purely elastic, many studies have shown that tissue is viscoelastic (8, 14, 17, 22, 36, 42, 47). The connection between a simple elastic model and a viscoelastic model for the LV is subtle but was elucidated in the pioneering work of Templeton and Nardizzi (42). They dynamically filled canine ventricles with a sinusoidally varying volume and measured the resulting chamber pressure changes as well as the operating chamber stiffness. They found that the peak of the chamber pressure perturbation was offset (in time) from the peak of the driving volume perturbation, indicating viscous effects. Importantly, any offset introduced by the coupling of regional pressure gradients to regional ventricular dimension (6, 23, 31) cannot account for the observed offset, since volume changes were measured precisely from calibrated driving piston motion, and not from ventricular dimensions. To account for viscous effects, Templeton and Nardizzi used a three-component (stiffness, damping, and inertia) linear model for the pressure contour. Inversion of the model allowed determination of the elastic stiffness and the "viscous stiffness" for each ventricle from the pressure-volume data. Templeton and Nardizzi showed that ventricular stiffness could be divided into elastic components, measured by instantaneous dP/dV measurements, and viscous components, measured by phase differences between hemodynamic pressures and volumes. Thus ventricular stiffness is best approximated by elastic dP/dV stiffness only if viscous effects are negligible.
Several studies, however, have shown viscous effects to be significant in animal models and in humans, particularly in those with pathology. For example, Rankin et al. (36) found that a viscoelastic, rather than a purely elastic, model of the ventricle was required to fit observed stress-strain data obtained in open-chest dogs. In an extension of these results to humans, Hess et al. (14) showed that, for patients with myocardial hypertrophy, a model that included viscous and elastic parameters provided a better fit to ventricular stress-strain relations than a simple elastic model. Hess et al. concluded that "it is important for the assessment of diastolic myocardial stiffness to evaluate the viscous influences during filling, because the simple elastic constants reflect a composite of elastic and viscous forces and may be misleading, especially in patients with myocardial hypertrophy."
In the present study, we sought to integrate the experimental insights that show that ventricular tissue has significant viscous components with the well-established stiffness equation of Little et al. (26), which assumed viscous effects to be negligible. Through mathematical modeling of the physiology, we provide mechanistic insight into how the heart works when it fills by showing that DT can be decomposed into "elastic stiffness" and viscous stiffness or, in our terms, stiffness and relaxation/viscoelasticity components
 | (7) |
P/V and c represent stiffness and viscosity/relaxation components, respectively. Consideration of DT as a purely elastic parameter neglects the second viscous term in Eq. 7 and may lead to the prediction that subjects with indistinguishable DT must have indistinguishable catheterization-determined chamber stiffness. Additionally, the damping term in Eqs. 4 and 7 provides a more accurate estimate of the clinically measured DT than a model with no damping (Eq. 6).
Classical physiology-to-clinical cardiology connection.
In current practice, the elastic stiffness component (due to collagen, titin, and a myriad of other factors) of Templeton and Nardizzi (42) is routinely measured (P/V) and the viscous stiffness component is referred to as viscosity/relaxation effects (15). General consensus has developed that diastolic dysfunction is associated with pathophysiology related to stiffness and relaxation (15, 34, 45, 46).
Significance of relaxation/viscoelasticity.
Relaxation is intuitively appealing as a parameter that determines diastolic function, and it is a term that has clinical and physiological interpretations. From a physiological perspective, it includes viscoelastic effects and involves processes related to the reuptake of Ca2+ after cross-bridge cycling and force generation, intracellular components including microtubules, and actin-titin interactions (15, 17, 22). Clinically, impaired relaxation can be characterized by two dominant phenomena: 1) prolonged time constant (
), determined by catheterization, or prolonged isovolumic relaxation time, determined by echocardiography, often indicates impaired Ca2+ handling and poor relaxation of the ventricle during isovolumic relaxation, and 2) an E wave with prolonged DT is referred to as having the delayed-relaxation pattern. Although these measurements differ mechanistically, the delayed-relaxation pattern and a prolonged jointly indicate that the ventricle is operating in a regime of impaired relaxation/increased viscoelasticity necessarily associated with diastolic dysfunction (15, 34, 45, 46).
Through mathematical modeling and experimental validation, we have advocated the use of a lumped damping parameter c to account for all viscous effects during filling, including prolonged effects and viscous effects of the tissue and blood. In two studies, one animal and one human, c was significantly higher in E waves acquired from diabetic than from nondiabetic control hearts (7, 38). Higher c values implied that the diabetic hearts had dynamic force relations during diastole that differ from diastolic force relations in normal controls, and these different relations reliably generated distinguishable transmitral velocity profiles between the two groups. Furthermore, a recent study using simultaneous echocardiographic-catheterization data predicted and validated a significant linear correlation between the E-wave-derived c and 1/, the invasively derived time constant of isovolumic relaxation (5).
Relaxation/viscosity effects on diastolic filling.
The main difference between the two models presented in Fig. 2 resides in the relative significance of relaxation/viscosity effects on filling. When relaxation/viscosity effects are small, Eqs. 4 and 6 predict the same value for DT, and the two models are virtually equivalent (8). In clinical situations where E waves have a "restrictive pattern," i.e., tall and narrow waves with short DT, the waves necessarily have high PDF k values, but that does not imply that c = 0. Nevertheless, in such cases, the value of c/2k in Eq. 4 is much smaller than the value of , and DT predicted by Eq. 4 is very close to DT predicted by the method of Little et al. (26) in Eq. 6. In other words, for patients with restrictive E waves, use of DT to estimate stiffness by the equation of Little et al. will not introduce a significant error. However, for patients with a delayed-relaxation (long-DT) E wave, c is significant, and c/2k cannot be ignored. In this case, use of the equation of Little et al. to estimate stiffness from DT alone will significantly underestimate LV stiffness, as can be seen by setting c = 0 in Eq. 5.
An interesting kinematic consequence of the presence of relaxation/viscoelastic effects relates to the atrioventricular pressure gradient. If damping were absent, the elastic recoil of the ventricle would be completely converted to fluid motion, and the atrioventricular pressure gradient would vanish when blood acceleration is zero, i.e., at Epeak. However, if viscosity is present, zero atrioventricular pressure gradient implies that the damping forces opposing flow equal the inertial force. The PDF model predicts that the atrioventricular pressure gradient vanishes not at Epeak but, rather, at a time interval DT–AT after Epeak (APPENDIX C); e.g., it is phase shifted. In the c = 0 limit, DT – AT = 0, and the zero atrioventricular pressure gradient occurs, as expected, at Epeak. This analysis is similar to the work of Templeton and Nardizzi (42), because it predicts that viscous effects will introduce a phase shift between the pressure gradient and the resulting flow. Previous work utilizing frequency-based (Fourier) analysis of in vivo pressure-volume data has also characterized such a phase difference during the E wave.
Limitations of the study. It is well known that many ventricular diastolic properties are nonlinear, and nonlinear models of filling have advantages over linear models, such as the PDF model employed in the present study, e.g., an ability to more completely characterize complex physiology. However, the more complex models, having many model parameters, cannot be inverted to generate a unique set of parameters determined by using the clinical data as input (33). Furthermore, previous work from our group has demonstrated that the PDF model-generated fit to the clinical E-wave contour was numerically indistinguishable from fits provided by well-established, complex, nonlinear models (33). A key advantage of using the simplest model that can be validated by experiment resides in its ability to directly (and uniquely) characterize in vivo clinically recorded E-wave contours in terms of three easily understood, lumped kinematic parameters. The associated limitation is the inability to determine the selective effects of individual parameters (of the nonlinear models) on the E-wave contour.
Another potential limitation may be that k, c, and DT are derived from the E wave. Therefore, one may suspect that k and c are algebraically related, and, therefore, one of the variables in Eq. 6 can be eliminated, resulting in a one-to-one correspondence between k and DT. Although physiology constrains the range of observed values for c and k, we note that k and c are mathematically independent. Apart from the restriction that the wave shape is underdamped (4k > c2) and that the parameters are nonnegative, there is no explicitly known functional relation between the two parameters.
Although a highly linear relation between k and Pavg/Vavg has been demonstrated in a large sample (n = 131) by Lisauskas et al. (25) and independently repeated for a smaller sample (n = 20) in the present study, one may surmise, in Fig. 2, that a more appropriate comparison would be to use Eq. 7, utilizing Pavg/Vavg from catheterization data for all 80 patients, instead of Eq. 4, and k as a surrogate for Pavg/Vavg. However, our use of k, instead of Pavg/Vavg, would be inappropriate only if it resulted in a tautology, in the sense of not being able to differentiate between the ability of alternate expressions (with and without viscoelasticity) to fit the same data (Fig. 2). If viscoelasticity were not an important determinant of DT and the E-wave contour is purely the result of elastic and inertial forces, then Fig. 2 would yield indistinguishable plots for DT vs. DTk and DT vs. DTk,c. The two equations are equivalent when resistive forces are absent, and previous work (21) has shown that if viscous effects are negligible, then k is (within a multiplicative constant) equal to KLV, as proposed by the model of Little et al. (26). In contrast, if viscoelastic/resistive forces play a discernible role in determining the E-wave contour, then we anticipate a better fit to the data with DTk,c than with DTk, as shown in Fig. 2. Thus using the stiffness parameter k, rather than Pavg/Vavg, for comparative analysis is reasonable and appropriate.
A further limitation involves the calculation of PE/VE (Table 1). PE/VE is calculated over a shorter duration (by about a factor of 2) than Pavg/Vavg and, as such, is more sensitive to exact temporal alignment of the pressure and echo waveform than Pavg/Vavg. This sensitivity manifests in Table 1 as a larger standard deviation in PE/VE values, which contributes to the higher P value. Pavg/Vavg, however, is more robust and is the measure also used by Little et al. (26). Importantly, the more significant (P = 0.0015) difference between the two subjects in Fig. 1 is in Pavg/Vavg values. This difference in Pavg/Vavg is intended to serve as motivation for the conceptual basis of the present study and as a basis for the experimental validation for the 80 subjects shown in Fig. 2.
Another minor limitation is the use of E-wave VTIs, instead of conductance catheter data, for V determination. Indeed, MVA has been shown to vary during diastole (3), and conductance catheter volumes may avoid the error introduced by multiplying the VTI by a constant effective MVA. However, use of constant effective MVA is inherent in the derivation of the expression by Little et al. (26) in Eq. 1. Specifically, when V is expressed as VTI·MVA, MVA cancels from Eq. 1, leaving only P and VTI:
 | (8) |
Finally, left atrial properties, particularly left atrial stiffness, may play a role in determining DT. Although some studies suggest that DT is affected jointly by left ventricular and atrial stiffness, during the E wave the atrium is a conduit and is passive. Recently, Marino et al. (27) measured atrial stiffness during diastole in relation to ventricular stiffness and concluded that its role was minor and did not significantly affect DT.
In conclusion, different LVs with the same duration of E-wave DT and similar chamber volume can have different catheterization-determined values for chamber stiffness (Pavg/Vavg). Model-based analysis of E waves provides unique values for chamber stiffness (k 
Pavg/Vavg) and chamber viscoelasticity (c). For E waves that are very nearly symmetrically shaped (AT 
DT) about the E wave peak, DT and chamber stiffness are related as follows: 
. Once asymmetry is present and AT 
DT, the E-wave deceleration portion manifests an inflection point and lengthens. The general expression for DT applicable to all E waves depends on chamber stiffness but also requires inclusion of chamber relaxation/viscoelastic effects as follows: 
.
We conclude that quantitative diastolic function assessment warrants consideration of viscoelastic effects in addition to those of stiffness, because E-wave DT is determined by both. The DT vs. stiffness-viscoelasticity relation described above is a general finding applicable to all ventricles and is most significant for ventricles with relaxation abnormalities.
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APPENDIX A |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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PDF formalism.
During filling, the elastic driving force generates inertial force, which causes acceleration, and resistive (damping) force, which opposes acceleration. The three (mathematically) independent model parameters k (spring constant), c (relaxation/viscosity/damping constant), and x0 (initial spring displacement) fully characterize the velocity of the SHO (i.e., E-wave velocity contour). These parameters were determined, for each beat, by solution of the "inverse" problem of filling, with the clinical E-wave contour used as the beat-by-beat input and the model parameters as the best-fit-determined output (11). Most clinical E-wave velocity contours are fit by solutions in the "underdamped" regimen of motion of the SHO, defined by 4k > c2:
 | (A1) |
= c/2 and 
= 
. Setting c = 0 yields undamped sinusoidal behavior, originating at the start of the E wave, which is algebraically equivalent to the solution of the model of Little et al. (26), yielding a cosine function that originates at Epeak. The PDF model-predicted velocity (Eq. A1) and its "overdamped" equivalent provide an excellent fit to all clinically recorded Doppler E-wave contours (11, 18, 19). Accordingly, Eq. A1 allows integration of the velocity to yield the E-wave VTIs.
In addition to generating accurate fits to all E-wave contours, the PDF model parameters have physiological analogs that have been experimentally validated in vivo. On the basis of a large sample (n = 131), Lisauskas et al. (25) showed that average LV hemodynamic operating stiffness (Pavg/Vavg), extracted from invasive measurements of pressure and volume differences, showed a strong linear correlation with the PDF model-derived elastic stiffness (k) extracted purely from the E-wave contour. Additionally, the peak-force kx0, which drives the oscillator, is the analog of the peak atrioventricular pressure gradient generating transmitral flow (2); the slope of the kx0-cEpeak relation obtained at variable loads has recently been shown in normal control subjects and patients with diastolic dysfunction to be a load-independent index of diastolic function (39); 1/2kx
is the energy (ergs) available before valve opening (18), and x0 is linearly related to the volumetric load, i.e., the VTI of the E wave (18). Furthermore, the PDF formalism has been tested and validated in subjects with a wide range of cardiac pathologies and loads, including hypertension (20), heart failure (29, 37), diabetes (7, 38), and caloric restriction (30).
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APPENDIX B |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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(t) in terms of model parameters (per unit mass) is
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| (B1) |
= (c/2) and = . Edur is from the origin where (0) = 0 to the time at which the v(t) contour again crosses the abscissa. The sine has its first zero at t = , or t = /. Thus
 | (B2) |
 | (B3) |
 | (B4) |
/ > 1:
 | (B5) |
/ > 1 is equivalent to 2k > c2, which is slightly more restrictive than the underdamped condition (4k > c2) but is easily satisfied by most observed underdamped waves. Keeping the first two terms in Eq. B5, Eq. B4 becomes
 | (B6) |
 | (B7) |
 | (B8) |
= (c/2) and = . Further simplification of Eq. B6 is achieved by Taylor expansion of –1
 | (B9) |
 | (B10) |
 | (B11) |
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APPENDIX C |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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P = kx(t). Thus the atrioventricular pressure gradient vanishes when the displacement x(t) = 0. Accordingly, for underdamped (c2/4k < 1) kinematics, the displacement as a function of time is
 | (C1) |
 | (C2) |
 | (C3) |
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GRANTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX AAPPENDIX BAPPENDIX CGRANTSREFERENCES |
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70 years of age with congestive heart failure. Am J Cardiol 84: 82–86, 1999.[CrossRef][Web of Science][Medline]This article has been cited by other articles:
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 S. F. Nagueh, C. P. Appleton, T. C. Gillebert, P. N. Marino, J. K. Oh, O. A. Smiseth, A. D. Waggoner, F. A. Flachskampf, P. A. Pellikka, and A. Evangelisa Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography Eur J Echocardiogr, March 1, 2009; 10(2): 165 - 193. [Full Text] [PDF]
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