DIAGNOSTIC METHODS
VENTRICULAR PERFORMANCE
Noninvasive evaluation of left ventricular
performance based on peak aortic blood acceleration
measured with a continuous-wave Doppler
velocity meter
HANI N. SABBAH, B.S., FAREED KHAJA, M.D., JAMES F. BRYMER, M.D.,
THOMAS M. MCFARLAND, M.D., DAVID E. ALBERT, M.D., JONATHAN E. SNYDER, PH.D.,
SIDNEY GOLDSTEIN, M.D., AND PAUL D. STEIN, M.D.
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
ABSTRACT Peak aortic blood acceleration is recognized to be a sensitive index of global left
ventricular performance. In the present study peak acceleration was assessed noninvasively in patients
with a continuous-wave Doppler velocity meter. Peak aortic blood velocity and peak blood acceleration
were measured by placing the ultrasonic transducer at the suprastemal notch. Measurements were
obtained in 36 patients undergoing diagnostic cardiac catheterization. Peak velocity and acceleration
were measured at rest just before left ventriculography. In patients with ejection fractions greater than
60%, peak acceleration was 19 5 m/sec/sec. In patients with ejection fractions of 41% to 60%, peak
acceleration was lower, at 12 2 m/sec/sec (p < .001). In patients with ejection fractions of 40% or
less, peak acceleration (8 2 mlsec/sec) was markedly lower than in patients with ejection fractions
greater than 60% (p <. 001). Peak acceleration showed a good linear correlation with ejection fraction
(r = .90), and a better power fit (r = .93). These results indicate that peak acceleration, measured
noninvasively with a continuous-wave Doppler velocity meter, is a useful indicator of global left
ventricular performance.
Circulation 74, No. 2, 323-329, 1986.
±
IN 1964 Rushmer suggested that the left ventricle acts
as an impulse generator and that the "initial ventricular
impulse" is a descriptive term for the dynamic properties of ventricular ejection.1 Ventricular impulse was
defined as the product of force and time, where the net
force (mass x acceleration) acts over time from the
beginning of ejection to the attainment of peak flow.
Because the peak acceleration of blood out of the ventricle occurs in early systole, it is thought to represent a
manifestation of the initial ventricular impulse.' Studies by Noble et al.2 suggested that peak acceleration
was closely related to the maximum force exerted by
the ventricle in early systole, and they believed that
peak acceleration was also related, in some way, to the
maximum initial velocity of shortening of left ventricular muscle. Studies by Stein and Sabbah3 showed that
blood acceleration was intrinsic to the rate of change in
power developed by the left ventricle and related closeFrom Henry Ford Heart and Vascular Institute, Detroit.
Address for correspondence: Paul D. Stein, M.D., Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202.
Received Dec. 2, 1985; revision accepted May 8, 1986.
Vol. 74, No. 2, August 1986
ly to it. Peak blood acceleration was also shown to be a
function of both the rate and acceleration of shortening
of the radius of the left ventricle.4
Studies in anesthetized dogs showed that peak acceleration of aortic blood flow was sensitive to alterations
in the inotropic state but was less affected by an augmentation of preload and afterload.3 Peak acceleration
of aortic blood flow was also found to be sensitive to
alterations in the contractile state induced by temporary regional myocardial ischemia in conscious dogs.2
Studies by Stein and Sabbah5 using catheter-tip velocity sensors during cardiac catheterization in patients
showed that peak acceleration was capable of differentiating patients with normal from those with abnormal
left ventricular performance. In 12 patients undergoing
diagnostic cardiac catheterization, Bennett et al. ,6
using catheter-tip velocity transducers, demonstrated
a close relationship between peak acceleration and
left ventricular ejection fraction calculated angiographically.6
The above investigations establish peak blood acceleration as a good index of global left ventricular per323
SABBAH et al.
formance. The routine use of this index of ventricular
function in patients, however, has been limited by the
need to invasively measure phasic aortic blood velocity. Recent advances in Doppler ultrasound technology
have overcome this hurdle and now allow a noninvasive measurement of aortic blood velocity from which
peak acceleration can be derived. The purpose of the
present study was to noninvasively evaluate peak aortic blood acceleration with use of a continuous-wave
Doppler velocity meter in patients undergoing diagnostic cardiac catheterization, and to relate this parameter to left ventricular performance as assessed by ejection fraction.
cycle is pinpointed. It is capable of detecting peak modal velocity in the range of 0.2 to 2.5 m/sec and peak acceleration in the
range of 2 to 99 m/sec/sec. The ability of this device to accurately measure peak aortic blood velocity and acceleration has been
previously demonstrated in dogs.7 A comparison of peak velocity and peak acceleration measured with the continuous-wave
Doppler velocity meter and an electromagnetic flow transducer
placed at the root of the aorta resulted in correlations of .95 and
.96, respectively.7 When the Doppler unit was used in patients
to measure velocity in the ascending aorta, we attempted to
align the ultrasound beam with the direction of flow. We assumed that the intercept angle of the Doppler velocity meter was
180 degrees to the direction of flow. This is consistent with
previous methodology.>l°
The continuous-wave Doppler system used in this study is
capable of producing an analog signal of the velocity waveform
in the ascending aorta. The analog signal of acceleration, however, if needed, must be obtained by external differentiation of
the velocity waveform. The system provides an internally derived digital output, on a beat-to-beat basis, of peak acceleration, peak modal velocity, and the systolic velocity integral. A
typical example of the velocity and acceleration waveforms and
of the digital output from a normal subject is shown in figure 1.
The accuracy and repeatability of the digital values fall within
+ 5% of the values derived from the analog waveforms. Once a
sufficient number of beats is completed, the Doppler instrument
automatically computes an arithmetic average of peak acceleration, peak modal velocity, and systolic velocity integral. This
average value includes all of the beats except those that fall
outside preselected limits determined by an internally installed
algorithm. The algorithm excludes beats with a signal-to-noise
ratio of less than 10 dB. In addition, a stack average is calculated by averaging eight data points consisting of values from the
most recently obtained data set. The stack average is then compared with the current value of the parameter. All values for a
given beat are excluded if any value falls outside the following
empirically derived limits: peak acceleration + 40% of the
stacked average, peak velocity + 25% of the stack average, and
systolic velocity integral ± 40% of the stack average. This
algorithm, even though empirically derived, has been useful in
rejecting beats with a poor signal-to-noise ratio and in rejecting
extrasystolic beats and postextrasystolic beats. The values re-
Methods
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The Doppler system. Ascending aortic blood velocity was
evaluated transcutaneously from the suprasternal notch by a
conventional continuous-wave Doppler transmitter and receiver
operating at 3.0 MHz (ExerDop, Quinton Instrument Co., a
division of A.H. Robins, Inc., Seattle). The received Dopplershifted blood velocity signal is processed by quadrature demodulation so that only signals representing flow toward the
transducer are detected. This directional signal is bandpass filtered with 3 dB cutoff frequencies of 480 Hz and 11.5 kHz. The
band-limited directional signal is then fed into a fast-attack fastdecay instrumentation, automatic gain control circuit so that its
amplitude remains constant. This constant-amplitude Doppler
signal is fed into a velocity circuit that tracks the instantaneous
modal frequency and derives the modal peak velocity. The
system samples the velocity signal every 5 msec to determine
the instantaneous modal velocity (within + 10%). It then compares each instantaneous modal velocity with the previous value
and retains the larger one. The largest value for instantaneous
modal velocity is defined as peak modal velocity.
The system internally derives peak acceleration and the systolic velocity integral (which may also be termed stroke distance) at a high sample rate (200 Hz) to ensure that the maximum value of blood acceleration occurring during the cardiac
1 sec -|
I
1111111111
30
ACCELERATION
(ml sec/sec)
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UT
14. 1
14.2
1.
115
1.0
2E4
_5
25
9
1.1
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:.:
(misec)05
VELOCITY
14.7
1-.
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16
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FIGURE 1. Left, Velocity waveforms and acceleration waveforms measured with the continuous-wave Doppler velocity meter
in the ascending aorta of a normal adult. Right, Simultaneous beat-to-beat digital output from the Doppler system of peak
acceleration (Pk A), peak velocity (Pk V), and systolic velocity integral (SD). Note the beat-to-beat variation in peak velocity and
peak acceleration, which required the averaging of values over a large number of beats.
324
CIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
ported in this study are based on the arithmetic average provided
by the digital output of the Doppler instrument.
Studies in vitro. The accuracy of the velocity signal obtained
with the Doppler instrument was evaluated in vitro in a closedloop, pump-driven, steady-flow system. The test section consisted of an entrance region where the velocity profile was flat.
Flow was calibrated with use of a beaker and stop watch. Velocity was calculated as the product of volumetric flow and the
cross-sectional area of the test section that was constant. The
fluid in the system was seeded with 1.5 ,gm silicon microspheres to allow the measurement of velocity with the ultrasound Doppler method. A range of velocities between 0.3 and
3.0 m/sec was evaluated.
Studies in normal adults. To determine if values of peak
velocity measured with this continuous-wave Doppler meter
were comparable to values reported in the literature, we measured peak modal velocity in 16 normal volunteers. None of the
16 volunteers had any symptoms or history of cardiovascular
disease and none were taking any medication. Age, sex, heart
rate, and blood pressure of these subjects are shown in table 1.
All were studied while they were at rest in the supine position.
The reported values of peak velocity, peak acceleration, and
systolic velocity integral in each subject represent the average of
14 to 39 consecutive sinus beats.
Patient population. Doppler measurements were made in
patients undergoing diagnostic left heart catheterization. The
study was approved by the hospital human rights committee.
Informed consent was obtained from all patients in the study.
Patients with aortic valve disease or mitral insufficiency were
excluded from the study. Studies were attempted in 43 consecutive patients undergoing cardiac catheterization, and reliable
Doppler measurements were obtained in 36. Data reported in
this study, therefore, relate only to these 36 patients. In the
remaining seven, appropriate aortic velocity measurements
could not be obtained. In all cases this was believed to be due to
obesity. Reliable Doppler measurements, therefore, were obtained in 84% of patients. Among the 36 patients studied, 25
were men and 11 were women. The average age of the patients
was 57 ± 14 years (range 28 to 78 years). Twenty-eight patients
had coronary artery disease of varying severity, one patient had
cardiomyopathy, and seven patients were free of any demonstrable cardiac disease.
The data were examined by separating the patients into three
groups based on ejection fraction. The first group (n = 17)
TABLE 1
Age, sex distribution, and hemodynamic characteristics of normal
adult and patient groups reported in the study
Parameter
Age (yr)
Sex
Heart rate
(beats/min)
Systolic pressure
(mm Hg)
Diastolic pressure
(mm Hg)
LVEDP (mm Hg)
Normal
adults
Patients
EF
>60%
Patients
41%
s EF
.60%
Patients
EF
C40%
62±12
53±4
31+5
55+14
8M, 8F 13M, 4F 9M, 3F 3M, 4F
69± 8
65 ± 11
72± 9
91±+ 15
106± 12
141 ±20
128 ± 27
118 ±21
68±11
75-±+9
74±13
15±6
19±6
72±8
22±6
EF = ejection fraction; LVEDP = left ventricular end-diastolic
pressure.
Vol. 74, No. 2,
August 1986
consisted of patients with ejection fractions greater than 60%.
The second group (n = 12) consisted of patients with ejection
fractions between 41% and 60%. The third group (n = 7)
consisted of patients whose ejection fractions were 40% or less.
The ages, sex distributions, and hemodynamic characteristics of
the three groups of patients are shown in table 1. Among the 17
patients with ejection fractions greater than 60%, 12 had coronary artery disease, three had a previous history of a myocardial
infarction, and 13 were on calcium-channel blockers or /3blockers. Among the 12 patients with ejection fractions of 41%
to 60%, 10 had coronary artery disease, four had a previous
history of a myocardial infarction, three were on calcium-channel blockers, and none were on f-blockers. Among the seven
patients with ejection fractions of 40% or less, six had coronary
artery disease and one had cardiomyopathy. Two of these patients were on calcium-channel blockers and none were on 3blockers.
Doppler measurements in patients. Continuous-wave
Doppler measurements were obtained in supine patients at rest.
Measurements were made just before left ventriculographic examinations. The reported values of peak velocity, peak acceleration, and systolic velocity integral in each patient represent
the average of a minimum of 14 consecutive sinus beats. Multiple beats were averaged to account for the beat-to-beat variability in the values of peak velocity, peak acceleration, and stroke
velocity integral. A demonstration of this beat-to-beat variability is shown in figure 1.
Ventriculography. Left ventriculograms were obtained in
each patient immediately after completion of Doppler measurements. In all patients, ventriculograms were obtained in the
right anterior oblique projection during the injection of 30 to 45
ml of meglumine and sodium diatrizoates (Angiovist 370). Ventriculograms were recorded on 35 mm film at 50 frames/sec.
Correction for image magnification was made with a calibrated
grid placed at the level of the left ventricle. The ejection fraction
was calculated as the ratio of the difference between end-diastolic and end-systolic left ventricular volume to end-diastolic
volume. Left ventricular cavity volumes were calculated by the
area-length method of Dodge et al.11 Premature ventricular
beats and postextrasystolic beats were excluded.
Data reduction and analysis. Statistical differences among
groups were based on a one-way analysis of variance
(ANOVA). An overall level of .05 was considered indicative of
a significant difference. Pairwise comparisons with the rejection p value adjusted for multiple testing by Bonferroni's method (which is conservative) were used if the ANOVA F statistic
was significant. For pairwise comparisons, a p value of less than
.017 was considered indicative of a significant difference. For
each group, the data are reported as the mean + 1 SD. The
correlation between the ejection fraction and each of the three
output parameters of the Doppler velocity meter (peak velocity,
peak acceleration, and the systolic velocity integral) was determined. Both a linear regression and a power curve fit were used.
Results
Studies in vitro. Studies performed in vitro showed a
direct linear relationship between the measured velocity and the velocity detected by the Doppler instrument. This relationship is depicted in figure 2. The
correlation coefficient was .995, the slope of the linear
regression line was nearly unity (1.12), and the intercept was nearly zero (0.09).
Studies in normal adults. Peak aortic blood velocity
measured with continuous-wave Doppler ultrasound in
325
SABBAH et al.
seven patients in whom the ejection fraction was abnormally low (c40%), peak velocity (0.34 + 0.8
m/sec) was significantly lower than that in patients
with ejection fractions greater than 60% (p < .001).
Similarly, peak acceleration (8 ± 2 m/sec/sec) was
3. Or-
2x-0.09
r=0.995
y= 1.1
0
a)
CO,
/
2.51
E
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35
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0
0
_J
W
1.5
I:
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0
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U)
E
W
z
0
C0.
0
*
15
S5
hi1J
0
LJ
nd
W-
0
1
1
.------------------
--
0.5
1.0
1.5
2.0
-
- 1-
-
2.5
3.o
MEASURED VELOCITY (m/sec)
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
FIGURE 2. Relationship between experimentally measured velocity
and velocity measured with the continous-wave Doppler method in a
steady-flow system in vitro.
<
5
a-
NORMAL
ADULTS
:
0
*
1 O
E
_
.8~
0
.6
*
<
*
P<Q
a1<
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P
-J
hii
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1-1
326
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Q)
+ 5.1 cm. Individual values for peak velocity, peak
acceleration, and systolic velocity integrals in this
group of patients are shown in figure 3.
Patients with ejection fractions of 40% or less. Among the
PATIENTS
PATIENTS
PATIENTS
WITH
WITH
WITH
EF>60% EF= 41-60%. EF<40%
r
1.2
0
LLi
Among the 12 patients in whom the ejection fraction
was between 41% and 60%, peak velocity was lower
than in the group of patients with ejection fractions
greater than 60% (0.47 0.9 vs 0.68 0.20 rn/sec, p
< .001). Peak acceleration was also significantly low2 vs 19
er (12
5 m/sec/sec, p < .001). The
systolic velocity integral, however, was not different
than that in patients with ejection fractions greater than
60% (8.2 + 2.7 vs 10.7 5.1 cm). Individual values
for peak velocity, peak acceleration, and systolic velocity integrals in this group of patients are shown in
figure 3.
001
v
Studies in patients
Patients with ejection fractions of greater than 60%.
Among the 17 patients in whom the ejection fraction
was greater than 60%, peak aortic blood velocity was
0.68 + 0.20 m/sec. Peak acceleration was 19 + 5
m/sec/sec and the systolic velocity integral was 10.7
Patients with ejection fractions between 41% and 60%.
p<
001
P< 7T
10
1.4
normal adults was 0.91 ± 0.15 m/sec (range 0.77 to
1.22 m/sec). Peak acceleration was 20 + 4 i/sec/sec
and ranged between 14 and 26 rn/sec/sec. The systolic
velocity integral was 14.3 + 4.0 cm and ranged between 9.4 and 22.0 cm. Individual values for peak
velocity, peak acceleration, and the systolic velocity
integral in the group of normal adults are shown in
figure 3.
P<.
.4
2
O1
NORMA'
ADULTS
0-
25
PATIENTS
WITH
PATIENTS
PATIENTS
WITH
WITH
EF>60%; Er-=41 -60% EF<40%
r
*
20
[
0
0
0
hii
z
15
F
10
F
0
Ih
0
0
hii
0
-
__
-1-
.TT
5
F-)
i.
0
0
0
C,)
NORMAL
ADULTS
PATIENTS
WITH
EF>60%
PATIENTS
WITH
EF= 41-60Z
PATIENTS
WITH
EF<40%
FIGURE 3. Individual values for peak acceleration (top), peak velocity
(middle), and systolic velocity integral (bottom) in normal adults and in
three groups of patients categorized on the basis of ejection fraction
(EF). Probabilities are based on comparisons with patients with EF
>60%.
CIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
also markedly lower in these patients (p < .001) and
the systolic velocity integral (4.4 ± 1.6 cm) was diminished in comparison with that in patients with an
ejection fraction of greater than 60% (p < .01). Individual values for peak velocity, peak acceleration, and
systoliG velocity integrals in this group of patients are
shown in figure 3.
Correlations with ejectionfraction. Among the Doppler
parameters tested in the 36 patients, peak acceleration
showed the best linear correlation with ejection fraction, with a correlation coefficient of .90 (figure 4).
When the data were fitted to a power curve, the correlation coefficient improved slightly to .93 (figure 4).
Peak velocity showed a good linear correlation (r =
.77; figure 5), but the systolic velocity integral showed
only a fair correlation with ejection fraction (r = .59).
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
Discussion
The present study shows that peak acceleration of
blood in the ascending aorta, measured noninvasively
by a continuous-wave Doppler method, can be used to
differentiate between patients with normal and abnormal left ventricular performance as assessed by the
ejection fraction. The observations made in this study
were limited to a group of patients who underwent
diagnostic cardiac catheterization because of documented or suspected coronary artery disease or because of cardiomyopathy. Patients with aortic valve
disease or mitral regurgitation were excluded from the
35.
o
(L)
1
r
(0)
QI)
0
POWER CURVE FIT
y-0.33x 0.03
r-0.93
E 25.
Z
0
LINEAR REGRESSION
y-0.28x-1.72
r-O.90
30.
00
00
20.
0
00D0
15. I.p
uji.
0
cl010)
0
.
L
.
EL
1
L-
0.
__j
20.
40.
60.
80.
100.
EJECTION FRACTION (%)
FIGURE 4. Relationship between left ventricular ejection fraction
measured angiographically and peak acceleration of blood in the ascending aorta measured noninvasively with the continuous-wave Doppler method.
Vol. 74, No. 2, August 1986
1.
20r
o 1. 00
0
0
LINEAR REGRESSION
y=O.Ol x+0.03
r=0.77
(0
E
.
0
E30II-
00
o00
-
0
. 60
0
08
0
0
0
>
.
0
40'I-
0
0
LJ
cl
06)
. 20 I.~
0.
00_
0. 00
20. 00
40. 00
60. 00
80. 00
100. 00
EJECTION FRACTION (x)
FIGURE 5. Relationships between left ventricular ejection fraction
measured angiographically and peak velocity of blood in the ascending
aorta measured noninvasively with the continuous-wave Doppler method.
study. Patients with aortic valve disease were excluded
because the dynamics of flow in the ascending aorta
can be markedly influenced by a diseased aortic valve.
In patients with mitral regurgitation the dynamics of
flow across the aortic valve also may be influenced by
the degree of regurgitant mitral flow during systole.
In patients who underwent diagnostic cardiac catheterization, and therefore in whom a left ventricular
ejection fraction was calculated, a close correlation
was observed between peak acceleration and the ejection fraction. Both of these indexes of left ventricular
performance are empirically derived and each depends
on different physical constraints. Nevertheless, both
are ejection indexes of left ventricular performance.
Their close correlation implies that both are comparably sensitive to differences in global left ventricular
function. The mathematic relationships derived in this
study were considered only as a measure of the closeness of the correlation and not as a means of deriving
the ejection fraction from a measurement of peak acceleration. This interpretation also applies with respect
to the correlations between peak velocity, systolic velocity integral, and the ejection fraction.
The close correlation between the peak acceleration
and ejection fraction observed in the patients in the
present study is consistent with previous reports. Bennett et al.,6 using a catheter-tip electromagnetic velocity probe placed in the ascending aortas of 12 patients,
showed that peak acceleration was related to the ejection fraction with a correlation coefficient of .88. In
their study, peak acceleration ranged between 4 and 19
327
SABBAH et al.
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
m/sec/sec for a range of ejection fractions between
17% and 74%.6 This is also consistent with our measurements of peak acceleration in the range of 6 to 32
m/sec/sec for a range of ejection fractions between
22% and 78%. A good correlation between peak acceleration and ejection fraction was also observed in patients by Chandraratna et al. 12 using similar techniques
to those used in this study. In their study, patients with
ejection fractions of greater than 50% had a peak acceleration of greater than 11.6 m/sec/sec, whereas in patients with ejection fractions less than 50% peak acceleration was less than 11.6 m/sec/sec.'2 A correlation
coefficient of .83 was reported between peak acceleration and ejection fraction.'2
A number of investigators have measured peak acceleration using ultrasound Doppler via the suprasternal notch approach in normal subjects or patients.9 13 14
Innes et al. 14 measured peak acceleration using a
pulsed Doppler device applied to the suprasternal
notch in six normal subjects at rest and after each of
four levels of seated bicycle exercise. They found an
increase in peak acceleration with an increased level of
exercise. Mehta and Bennett'3 used a continuous-wave
Doppler method to evaluate peak acceleration in patients with acute myocardial infarction. They showed
that peak acceleration was significantly lower in patients with an acute myocardial infarction than in agematched normal subjects. '3 Other investigators have
also used continuous-wave Doppler techniques to
evaluate peak acceleration in normal subjects in whom
the inotropic state and loading conditions of the heart
were altered.9 Loading conditions had little effect on
peak acceleration, whereas an augmentation of the inotropic state produced a significant increase in peak
acceleration.9 Another study in which a pulsed, rangegated ultrasonic Doppler method was used in normal
subjects showed a decline of peak acceleration with
age.'5 Even though these studies did not correlate peak
acceleration with established indexes of ventricular
performance, their findings support the use of this
technique for the noninvasive evaluation of global left
ventricular performance.
The magnitude of peak velocity in the ascending
aorta, obtained noninvasively in our study with a continuous-wave Doppler method, is consistent with values obtained invasively in patients with the use of
electromagnetic catheter-tip velocity probes positioned in the ascending aorta. In patients with an ejection fraction of greater than 60%, peak velocity measured with a catheter-tip velocity probe ranged
between 0.67 and 0.83 rn/sec6 and in our Doppler
study it ranged between 0.42 and 1.16 m/sec. Similar328
ly, in patients with ejection fractions of less than 40%,
peak velocity measured with a catheter-tip velocity
probe ranged between 0.16 and 0.44 m/sec and in our
Doppler study it ranged between 0.24 and 0.50 rn/sec.
The values of peak aortic blood velocity measured in
our group of normal adult volunteers (0.91 + 0.15
m/sec) were comparable to values obtained by Gardin
et al.'6' 17 in a similar group of normal adults. In their
study of 20 normal adult subjects (age 21 to 46), the
average value for peak velocity was 0.92 + 0.11
m/sec (range 0.72 to 1.20 m/sec). Our values for peak
velocity and those of Gardin et al. 16, 1" were somewhat
lower than those reported by Hatle and Angelsenl8 in a
group of normal adults ranging in age between 18 and
72 years. The ultrasound Doppler system used in our
study is a continuous-wave system designed to measure modal peak velocity. The systems used by Gardin
et al. 16 17 and Hatle and Angelsenl8 were pulsed Doppler devices. Given the differences in available ultrasound Doppler instrumentation, it is reasonable to suppose that the range of normal values observed may
depend on the specific instrumentation that is used.
The values for peak aortic velocity reported in the
present study in patients with ejection fractions greater
than 60% were lower than values observed in normal
healthy adults, including those reported in this study
and in studies by Gardin et al.'6 17 The lower peak
velocity that we observed in patients with ejection fractions in the normal range may be due to two factors. (1)
The normal adults studied by us and by Gardin et al.
were younger than the patients with ejection fractions
in the normal range and peak velocity has been shown
to decrease with increasing age.'5 (2) A large proportion of our patients with ejection fractions in the normal range had coronary artery disease and were being
treated with either calcium-channel blockers or ,Bblockers.
Neither peak velocity nor the systolic velocity integral related as closely to the ejection fraction as did
peak acceleration. Changes in peak aortic velocity and
in the systolic velocity integral, however, have been
shown to provide an accurate assessment of changes in
stroke volume.'9 Both peak velocity and the systolic
velocity integral, therefore, may prove to be clinically
useful in estimating changes of stroke volume. A study
of the sensitivity and specificity of various indexes of
left ventricular performance by Lambert et al.20
showed that peak acceleration was far more sensitive
to alterations of the inotropic state than was stroke
volume and was also more sensitive than peak aortic
blood velocity.
In conclusion, peak acceleration of blood in the asCIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
cending aorta of patients, measured noninvasively
with a continuous-wave Doppler velocity meter, was
shown to be a good indicator of global left ventricular
performance. This represents a relatively simple, inexpensive, and noninvasive technique for the evaluation
of left ventricular performance in patients.
References
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
1. Rushmer RF: Initial ventricular impulse. A potential key to cardiac
evaluation. Circulation 29: 268, 1964
2. Noble MIM, Trenchard D, Guz A: Left ventricular ejection in
conscious dogs. 1. Measurement and significance of the maximum
acceleration of blood from the left ventricle. Circ Res 19: 139,
1966
3. Stein PD, Sabbah HN: Rate of change of ventricular power. An
indicator of ventricular performance during ejection. Am Heart J
91: 219, 1976
4. Stein PD, Sabbah HN: Comparison of the acceleration and velocity
of shortening of the ventricular radius. Their potential applicability
for noninvasive measurements of ventricular performance. Chest
70: 57, 1976
5. Stein PD, Sabbah HN: Ventricular performance measured during
ejection. Studies in patients of the rate of change of ventricular
power. Am Heart J 91: 599, 1976
6. Bennett ED, Else W, Miller GAH, Sutton GC, Miller HC, Noble
MIM: Maximum acceleration of blood from the left ventricle in
patients with ischemic heart disease. Clin Sci Mol Med 46: 49,
1974
7. Stein PD, Sabbah HN, Albert DE, Snyder JE: Blood velocity and
acceleration. Comparison of continuous wave Doppler with electromagnetic flowmetry. Fed Proc 44: 1565, 1985 (abst)
8. Huntsman LL, Stewart DK, Barnes SR, Franklin SB, Colocousis
JS, Hessel EA: Noninvasive Doppler determination of cardiac output in man. Clinical validation. Circulation 67: 593, 1983
9. Bennett ED, Barclay SA, Davis AL, Mannering D, Mehta N:
Ascending aortic blood velocity and acceleration using Doppler
Vol. 74, No. 2, August 1986
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
ultrasound in the assessment of left ventricular function. Cardiovasc Res 18: 632, 1984
Creekmore SP, Graham MM, Jahn GE, Targett RC, McIlroy MB:
Comparison of methods of recording and analysis of Doppler blood
velocity signals in normal subjects. Ultrasound Med Biol 8: 525,
1982
Dodge HT, Sandler H, Ballew DW, Hawley RR: Usefulness and
limitations of radiographic methods for determining left ventricular
volume. Am J Cardiol 18: 10, 1966
Chandraratna PAN, Silveira B, Aronow WS: Assessment of left
ventricular function by determination of maximum acceleration of
blood flow in the aorta using continuous Doppler ultrasound. Am J
Cardiol 45: 398, 1980
Mehta N, Bennett ED: Impaired LV function in acute myocardial
infarction (AMI), assessed noninvasively by Doppler ultrasound.
Clin Sci 67: 42p, 1984 (abst)
Innes JA, Murphy K, Guz A: Measurement of stroke volume, peak
velocity and acceleration of aortic blood flow at rest and on exercise
in man by range-gated ultrasound. Clin Sci 67: 31p, 1984 (abst)
Levy B, Targett RC, Bardou A, Mcllroy MB: Quantitative ascending aortic Doppler blood velocity in normal human subjects. Cardiovasc Res 19: 383, 1985
Gardin JM, Burn CS, Childs WJ, Henry WL: Evaluation of blood
flow velocity in the ascending aorta and main pulmonary artery of
normal subjects by Doppler echocardiography. Am Heart J 107:
310, 1984
Gardin JM, Iseri LT, Elkayam U, Tobis J, Childs W, Burn CS,
Henry WL: Evaluation of dilated cardiomyopathy by pulsed Doppler echocardiography. Am Heart J 106: 1057, 1983
Hatle L, Angelsen B: Doppler ultrasound in cardiology. Physical
principles and clinical applications, ed 2. Philadelphia, 1982, Lea
and Febiger, p 93
Elkayam U, Gardin JM, Berkley R, Hughes CA, Henry WL: The
use of Doppler flow velocity measurement to assess the hemodynamic response to vasodilators in patients with heart failure. Circulation 67: 377, 1983
Lambert CR, Nichols WW, Pepine CJ: Indices of ventricular contractile state: comparative sensitivity and specificity. Am Heart J
106: 136, 1983
329
Noninvasive evaluation of left ventricular performance based on peak aortic blood
acceleration measured with a continuous-wave Doppler velocity meter.
H N Sabbah, F Khaja, J F Brymer, T M McFarland, D E Albert, J E Snyder, S Goldstein and P
D Stein
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Circulation. 1986;74:323-329
doi: 10.1161/01.CIR.74.2.323
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