World Journal of Cardiovascular Surgery, 2011, 1, 11-17
doi:10.4236/wjcs.2011.12003 Published Online December 2011 (http://www.SciRP.org/journal/wjcs)
How to Identify Latent Systolic Dysfunction and Post
Operative Risk in Patients with Mitral Incompetence
and Normal Ejection Fraction?
Galal Eldin Nagib Elkilany1, Maryam De Groef2, Ibrahim Kabbash3
1Adult Cardiology Department, Medical School, Tanta University, Tanta, Egypt
2SOAS, London, UK
3Public Health and Statistics, Tanta, Egypt
Received October 25, 2011; revised November 27, 2011; accepted Decembe r 6, 2011
Abstract
Purpose: To study the significance of impaired positive peak rate of left ventricular (LV) pressure develop-
ment (MR + dp/dt) and global systolic strain (GLPSS) values in patients presented with significant mitral
incompetence (MR) in coronary artery disease (CAD) and early dilated cardiomyopathy (DCM) with normal
ejection fraction (EF). Methods: A description of LV contractile behavior requires measurement of the abil-
ity of the ventricle to develop force (pressure) and to shorten. Hence, performance of the ventricle as a pump
assessed in the present study by measuring the pressure developed by the ventricle (Left ventricular +dP/dt is
estimated from MR jet as the rate of pressure rise from 1 to 3 m/sec) and shortening assessed by GLPSS (this
Doppler technology allowed measurement of LV systolic strain for the entire length of LV myocardium).
GLPSS and MR + dp/dt were calculated in 30 consecutive patients (mean age was 55 ± 12 years) character-
ized by echocardiographic evidence of moderate or severe MR (in CAD and DCM patients) and normal EF
(mean LV Ejection Fraction of 50.9% ± 5.9%) and compared with those obtained in 35 consecutive controls
(age 54.7 ± 11.4 years) with normal echocardiographic study of the heart. Results: The mean values of MR
+dp/dt and GLPSS averaged from the 3 apical views, differed significantly in DCM and CAD patients
(characterized by significant MR with normal EF) compared with control group, (MR + dp/dt = 733 ± 170
mmhg/s and GLPSS –13% ± 1.3%) versus (1420 ± 210 mmhg/s and −19.5% ± 3.3%) for patients versus
control, respectively, p < 0.001. A depressed values of MR + dp/dt were highly correlated with GLPSS val-
ues in patients with CAD and DCM, r = 0.78. The combined use of 2D Strain (<−13%) and MR dp/dt (<900
mmhg/s) in the presence of MR (grade II or more) had 89% sensitivity and 92% specificity for detection of
patients at risk of post-operative major cardiac events after MR and coronary artery bypass surgery. Conclu-
sions: Latent LV systolic dysfunction could be defined noninvasively by depressed peak MR + dp/dt and
GLPSS in the echocardiography laboratories.
Keywords: Mitral Incompetence, Systolic Dysfunction, MR dp/dt, Global Strain
1. Introduction
The most commonly used index of LV contractile func-
tion is the EF which represents volume strain (change in
volume divided by initial volume). However, the EF is
influenced by acute or short-term as well as chronic al-
terations in preload, afterload and contractility. A full
assessment of the contractile behavior of the ventricle
requires the combined use of indices that reflect LV sys-
tolic performance, function, and contractility, as well as a
consideration of global and regional function [1].
Load-sensitive measures of systolic function, including
fractional area change, fractional shortening, ejection frac-
tion, and positive peak rate of LV pressure development.
Load-insensitive measures of systolic function, including
the preload recruitable stroke work relationship and the
end-systolic P-V relationship. Regional wall motion as-
sessed by circumferential shortening velocity suggested
enhanced circumferential fiber contractility in LVH, but
tissue Doppler imaging, used to assess longitudinal func-

G. E. N. ELKILANY 12
tion, was not different between controls and LVH groups.
LV hypertrophy (LVH) represents the commonest condi-
tion whereby load-sensitive measures of contractility can
be misinterpreted [2]. The contraction of excess sar-
comeres may mask subnormal function of cardiomyocytes
in the presence of LVH by maintaining normal wall
shortening and thickening values. Furthermore, radial and
circumferential fiber contractility is preserved in LVH, but
longitudinal fiber function may be impaired, possibly due
to the effects of subendocardial ischemia [3].
We hypothesized that load-sensitive methods of as-
sessing cardiac contractility, which rely on circumferen-
tial or radial fiber function, such as the ejection fraction
(EF), fractional shortening (FS), fractional area change
(FAC), and the myocardial velocity of LV circumferen-
tial shortening (Vcf), may overestimate cardiac contractil-
ity in the presence of mitral incompetence and that load-
insensitive contractility indexes derived from Global
Strain and MR dp/dt (rate of pressure development)
analysis would better reflect and predict cardiac contrac-
tility at the cardiac myocyte level.
2. Subjects
Of the 65 individuals evaluated, 30 patients had signifi-
cant MR allowing dp/dt measurement and were included
in this study (ischaemic 18 and non-ischaemic 12). Most
patients were in New York Heart Association Class II
(69%) and the remaining were class III NYHA. 35
served as control.
3. Methods
A description of LV contractile behavior requires
measurement of the ability of the ventricle to develop
force (pressure) and to shorten. Hence, performance of
the ventricle as a pump assessed in the present study
by measuring the pressure developed by the ventricle
(Left ventricular + dp/dt is estimated from MR jet as
the rate of pressure rise from 1 to 3 m/sec) and short-
ening assessed by GLPSS (this Doppler technology
allowed measurement of LV systolic strain for the en-
tire length of LV myocardium which is normalized and
do not require correction for LV size). GLPSS and MR
+ dp/dt were calculated in 30 consecutive patients
(mean age was 55 ± 12 years) characterized by echo-
cardiographic evidence of moderate or severe MR (in
CAD and DCM patients) and normal EF (mean LV
Ejection Fraction of 50.9% ± 5.9%) and compared
with those obtained in 35 consecutive controls (age
54.7 ± 11.4 years) with normal echocardiographic
study of the heart Figure 1.
Figure 1. Bulls eye technique (automated function imaging algorithm) generated from apical 2, 3 and 4 chamber views illus-
trated the impaired global longitudinal peak systolic strain (GLPSS) of −13% in patient with significant mitral incompetence
but normal ejection fraction (EF = 51%), note that : MR + dp/dt = 645 mmhg/s only.

G. E. N. ELKILANY 13
The automated function imaging (AFI) algorithm non-
invasively tracks and analyzes peak systolic strain based
on 2D strain: Digital loops were acquired from apical 2-,
3- and 4-chamber views and a line was traced along the
LV endocardium (Figure 1). Around this line, the soft-
ware selected natural acoustic markers moving with the
tissues automatic frame by frame tracking of these
markers during the heart cycle yielded a measure of con-
tractility along the selected region of interest.
GLPSS and MR + dp/dt were calculated in 30 con-
secutive patients (mean age was 55 ± 12 years) (Figures
2-3).
4. Statistics Used
The collected data were tabulated and statistically ana-
lyzed using SPSS software statistical package version 17.
Figure 2. Global Longitudinal Peak Systolic Strain in 4
chamber view is below normal values (−14%) inspite of
normal EF by 2 Dimensional echocardiography [Biplane
Technique].
Figure 3. Left ventricular dp/dt is estimated from mitral
regurgitation (MR) jet as the rate of pressure rise (RPR)
from 1 to 3 m/sec. Isometric Contraction was estimated as
pre-ejection time minus Q-first sound (S1).
For quantitative variables, mean and standard deviation
were calculated. Because of small sample size of each
studied categories, non parametric tests of significance
were used. Kruskal-Wallis test was used to compare be-
tween mean values of studied groups if they were more
than two and Mann-Whitney test to compare two groups.
Wilcoxon singed rank test was used to compare mean
values of EF% before and after the intervention. Cate-
gorical variables were represented as number and per-
centage and Monte Carlo test was used as test of signifi-
cance. The level of significance was adopted at p < 0.05.
5. Results
The mean values of MR + dp/dt and GLPSS averaged
from the 3 apical views, differed significantly in DCM
and CAD patients (characterized by significant MR with
normal EF) compared with control group, (MR + dp/dt =
733 ± 170 mmhg/s and GLPSS –13% ± 1.3%) versus
(1420 ± 210 mmhg/s and −19.5% ± 3.3%) for patients
versus control, respectively, p < 0.001.
The combined use of 2D Strain(<−13%) and MR dp/dt
(<900 mmhg/s) in the presence of MR (>grade II/IV) had
89% sensitivity and 92% specificity for detection of pa-
tients at risk of post-operative major cardiac events fol-
lowing mitral repair and/or coronary artery bypass sur-
gery (Figure 4).
6. dp/dt
After cardiac surgery, EF and + dp/dt were significantly
improved (p < 0.001) in the group of patients character-
ized by an average pre operative value of dp/dt > 900
mmhg/s overall, with no difference between the ischemic
and non-ischemic groups (Figure 5).
However, a depressed values of MR + dp/dt pre opera-
tively were highly correlated with post operative depres-
sion of EF in patients with CAD and DCM, r = 0.790, p
= 0.001, Figure 6.
7. Global Logitudinal Peak Systolic Strain
(GLPSS)
Global strain was calculated as the average of maximum
strain in all LV segments. in order to test if global strain
could express the ideal LV systolic function in compari-
son with 2 dimensional & real time 3 dimensional echo-
cardiography. GLPSS averaged from the 3 apical views
(Bulls-eye display), differed significantly in patients with
left ventricular systolic dysfunction (depressed values of
dp/dt in DCM and ischemic MR) compared with control
patients (GLPSS –13%) versus (−19.5%) for patients vs
control, respectively, (p < 0.0001) (Figure 7).

G. E. N. ELKILANY 14
Figure 4. Recipient-observer characteristic curve: showed
high incidence of major cardiac events (cardiac death in-
cluded) among patients with significant mitral incompe-
tence and depression of Global strain (GLPSS) as well as
low MR + dp/dt values. Note that: patients represented by
blue line who have pre operative low global systolic strain
and depressed dp/dt values Showed severe depression of
cardiac function (EF < 25%) and high incidence of major
cardiac events post operatively on 140 days follow up (in-
spite of normal EF pre operatively).
In intermediate term follow up (140 days), a depressed
values of GLPSS had 89% sensitivity and 92 specificity
for prediction of patients prone to develop severe LV
systolic dysfunction (EF of ≤30% - 35%) post opera-
tively and patients at risk for major cardiac events (car-
diac death, acute heart failure, pumonary edema, fre-
quent hospitalization for progressive heart failure symp-
toms, need for cardiac re synchronization therapy, re-
vascularization, and/or need for cardiac transplantation).
8. Discussion
Our study shows for the first time that echocardiographic
assessment of Global Strain and MR + dp/dt is a useful
predictor of Intermediate-term clinical outcome in ischemic
and non-ischemic mitral incompetence.
This is consistent partly with previous work from
Oguz E. et al., showing that LV dp/dt-rise was the single
variable significantly different between CRT (cardiac
resynchronization therapy) responders and non-respond-
ers (defined by the change in NYHA-class) [4].
Moreover, there is limited information regarding whether
an acute hemodynamic response to CRT (assessed as
percent change of the baseline dp/dt) is associated with a
favorable clinical course, and whether there are cardiac
substrate specific outcome in ischemic and non-ischemic
cardiomyopathy. However, recent work has indicated
that acute beneficial hemodynamic changes are sustained
at a 6-month follow-up [5].
Furthermore, Tournoux et al., concluded that acute in-
Figure 5. Correlation between EF% before intervention and dp/dt, r = 0.598, p = 0.001.

G. E. N. ELKILANY15
Figure 6. Correlation between EF% after intervention and dp/dt, r = 0.790, p = 0.001.
50.00 60.00 70.00 80.00
EF%
10.00
12.50
15.00
17.50
20.00
22.50
25.00
AFI
Figure 7. Correlation between EF% and AFI (GLPSS) among studied control.
crease in LV dp/dt (Δdp/dt) by Doppler echocardiogra-
phy is a relatively simple non-invasive test for the acute
haemodynamic response after CRT implantation.
In the Cox proportional hazard model, change in dp/dt
was the only significant predictor of event-free survival
after adjustment (HR 1/4 0.95 per unit dp/dt change, P
1/4 0.0176). Other clinical variables kept in the model
(serum creatinine, etiology of the cardiomyopathy, per-
cent change in EF acutely after CRT, and percent change
in ESV acutely after CRT), were not significant predic-
tors after adjustment [6].
The Previous works concluded that ventricular con-
tractility as measured by dp/dt max is a predictor of
outcome in patients with heart failure [7].
In the present study, MR + dp/dt and Global Strain
(utilizing automated function imaging algorithm) were

G. E. N. ELKILANY 16
calculated in 65 subjects (30 patients and 35 controls)
and EF measured by 2 and 3 dimensional echocardi-
ography [biplane and tri-plane geometry], providing a
more accurate measure of the extent of global and re-
gional dysfunction of the left ventricle even in the pres-
ence of apparently normal ejection fraction.
Acute and intermediate-term hemodynamic improve-
ment due to revascularization or/and mitral valve surgery
were correlated to basic pre operative normal values of
dp/dt and minimally reduced GLPSS values, with mini-
mal chance for time-dependent changes in factors such
as pre-load to confound the analysis.
In this study , measurements of Global peak systolic
strain had excellent correlation with LVEF (derived from
2 & 3 dimensional echocardiography) and of great help
in identifying patients at risk of major cardiac events
when rate of pressure development was also depressed.
This observation has important diagnostic and therapeu-
tic implications and lead to improvement in non invasive
risk stratification for individual patients with significant
mitral incompetence and borderline LVEF.
In accordance with our study, a recent study conducted
by Edvardsen, revealed that: Global strain correlated
well with total infarct size; a global strain value less than
−11.7% in absolute values had very good sensitivity and
specificity to predect infarct size including more than
18% of the total LV [8].
Indeed, in CAD patients LVEF showed a poor correla-
tion to infarct size by MRI. One possible reason is that
LVEF describes the global LV function, where as the
infarcted area and reduced function is regional. A de-
crease in LVEF is supposes that several LV segments or
large area of infarcted myocardium are involved. Meth-
ods that measure LV regional function could therefore be
more sensitive measures than EF to identify systolic
dysfunction, and the assessment of myocardial strain has
been shown to be superior to wall motion analysis in
CAD and is fundamentally a regional technique [9].
In mitral valve incompetence, measures such as ejec-
tion fraction (EF) are load-dependent and the increased
preload may enhance EF despite a subtle decrease in
contractility. By the time EF is low, there may already
have been irreversible myocardial damage [10].
In addition, in the pathophysiology of heart failure,
exercise echocardiography reveals complex abnormali-
ties of both systolic and diastolic ventricular function
Involving Torsion, Untwist, and Longitudinal Motion
[11].
9. Clinical Implication
Although the measure used in this study was made in the
immediate pre-operative period, one could speculate that
such a measure made intra-procedurally could facilitate
selecting an optimal patient for mitral valve surgery and
CABG who are at risk of post operative major cardiac
events.
Additionally, measure of dp/dt may also prove useful
in selecting patients at high risk of post operative severe
left ventricular systolic dysfunction and cardiac death
and need for post-procedural CRT/Defibrillator device
implantation.
10. Limitation
Technical aspects is of crucial importance in the present
study; surgeon experience could affect the results posi-
tively or negatively; complete revascularization and op-
timal mitral valve repair surgery is not a simple proce-
dure for all cardiac surgeon, and if done by expert hands
will improve cardiac function (+ dp/dt & GLPSS) spe-
cially in patients who had a large ischemic although vi-
able myocardium preoperatively.
In addition, the etiology of mitral incompetence and
type of mitral valve surgery play an important role in our
results.
Finally, tachyarrhthymias affect global longitudinal
peak systolic strain values.
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