Full text of DOI:10.1016/S0894-7317(00)70003-4

ORIGINAL ARTICLES
Effects of First Myocardial Infarction on
Left Ventricular Systolic and
Diastolic Function with the Use of
Mitral Annular Velocity Determined by
Pulsed Wave Doppler Tissue Imaging
Mahbubul Alam, MD, PhD, Johan Wardell, BMA, Eva Andersson, BMA,
Bassem A. Samad, MD, PhD, and Rolf Nordlander, MD, FACC, Stockholm, Sweden
This study was undertaken to assess the effect of a
the mean mitral annular motion (r = 0.77, P < .001).
When the patients were divided into 2 different
groups with respect to an ejection fraction ≥0.50 or
<0.50, a cutoff point of mean systolic mitral annular
velocity of ≥7.5 cm/s had a sensitivity of 79% and a
specificity of 88% in predicting a preserved global LV
systolic function. Similar to systolic velocities, the
early diastolic velocity was also reduced, especially at
the infarction sites. The peak mitral annular early
diastolic velocity correlated well with both LV
ejection fraction (r = 0.66, P < .001) and mean systolic
mitral annular motion (r = 0.68, P < .001). However,
no correlation existed between the early diastolic
velocity and conventional diastolic Doppler para-
meters. The reduced peak systolic mitral annular
velocity seems to be an expression of regionally
reduced systolic function. The peak early diastolic
velocity is also reduced, especially at the infarction
sites, and reflects regional diastolic dysfunction.
Thus, quantification of myocardial velocity by Doppler
tissue imaging opens up a new possibility of asses-
sing LV function along its long axis. (J Am Soc Echo-
cardiogr 2000;13:343-52.)
first myocardial infarction (MI) on the systolic and
diastolic velocity profiles of the mitral annulus
determined by pulsed wave Doppler tissue imaging
and thereby evaluate left ventricular (LV) function
after MI. Seventy-eight patients with a first MI were
examined before discharge. Peak systolic, peak early
diastolic, and peak late diastolic velocities were
recorded at 4 different sites on the mitral annulus
corresponding to the septum, anterior, lateral, and
inferior sites of the left ventricle. In addition, the
amplitude of mitral annular motion at the 4 above LV
sites, the ejection fraction, and conventional Doppler
diastolic parameters were recorded. Nineteen age-
matched healthy subjects served as controls. Com-
pared with healthy subjects, the MI patients had a
significantly reduced peak systolic velocity at the
mitral annulus, especially at the infarction sites. A
relatively good linear correlation was found between
the ejection fraction and the mean systolic velocity
from the 4 LV sites (r = 0.74, P < .001). The correlation
was also good when the mean peak systolic mitral
annular velocity was tested against the magnitude of
INTRODUCTION
limitations, especially in cases of unsatisfactory echo
quality. Doppler tissue imaging (DTI) is a new tech-
nique in echocardiography that records the myocar-
dial velocities during the cardiac cycle.1,2 Both the
systolic and diastolic velocities can be recorded
quantitatively by DTI and thereby provide a new way
of assessing left ventricular (LV) function. Assess-
ment of cardiac function by DTI may be more sensi-
tive than traditional methods. However, the method
is still under development, and reference values for
clinical application have not yet been determined.
Most previous studies have compared DTI by
color mapping with other conventional parame-
The conventional echocardiographic methods for
assessing cardiac function are based on endocardial
movement and/or wall thickening and have several
From the Cardiology Division, Karolinska Institute at South
Hospital (Södersjukhuset), Stockholm, Sweden.
Reprint requests: Mahbubul Alam, MD, Cardiology Division,
Södersjukhuset, S-118 83 Stockholm, Sweden (E-mail: mah-
bubul.alam.@medklin.sos.sll.se).
Copyright © 2000 by the American Society of Echocardiography.
0894-7317/2000 $12.00 + 0 27/1/104393
doi:10.1067/mje.2000.104393
343

Journal of the American Society of Echocardiography
May 2000
344 Alam et al
ters.3-6 However, a few studies have used pulsed
wave DTI to assess LV contraction and relaxation
velocities.1,7 The use of pulsed wave DTI at the
mitral annulus allows investigation of the contrac-
tion and relaxation velocities of the left ventricle
along its longitudinal direction.A complete study of
LV function by the pulsed wave DTI technique
requires assessment of myocardial velocity profiles at
different sites of the left ventricle.This is particularly
important in the presence of regional wall motion
abnormalities after an acute myocardial infarction
showed signs of anterior MI,and 45 had inferior MI on the
ECG. Infarction localization was also confirmed by echo-
cardiographic determination of the presence of hypoki-
netic and/or akinetic segments at the respected areas.The
mean value (SD) for maximum creatine kinase–MB was
179 (100) and for s-AST was 5.95 (5.2).
For LV diastolic studies, only 47 patients were included,
that is, those who were previously healthy and without a
history of systemic hypertension, valvular heart disease,
cardiomyopathy, diabetes mellitus, ischemic heart disease,
or other disease that might influence diastolic function.
Twenty-five age-matched healthy subjects without a history
of cardiac disease or systemic hypertension and who had
normal findings on the rest ECG and at echocardiography
served as controls.
(MI).With the use of conventional echocardiography,
we previously reported that the amplitude of LV
atrioventricular plane displacement (ie, the mitral
annular motion) at 4 different sites (septal, anterior,
lateral,and inferior) of the left ventricle can easily be
used to assess LV systolic function.8-10 A previous
study from our laboratory using the same method
during diastole described a feasible method of
assessing diastolic function in healthy subjects.11 It is
easy to record mitral annular motion because it is
devoid of trabeculae, myocardial dropouts, etc,
which could otherwise prevent the assessment of LV
function in a conventional way. However, little is
known about the ability of pulsed wave DTI to assess
LV function during ischemia and MI.12,13 A systemat-
ic study of both systolic and diastolic LV function
after an acute first MI is still missing.
Echocardiography
The patients were examined in the left lateral decubitus
position 2 to 4 days after MI with a Hewlett-Packard Sonos
5500 (Andover, Mass) phased-array system equipped with
DTI technology. Measurements of different cardiac cham-
bers were made according to the recommendations of the
American Society of Echocardiography.14The ejection frac-
tion was calculated as percentage of change in LV chamber
volumes between diastole and systole from apical 4- and 2-
chamber views with Simpson’s method.14 The magnitude
of mitral annular motion at 4 different LV sites (at the sep-
tal,anterior,lateral,and inferior walls) was also recorded by
the method described earlier.8,10
The purpose of the present study is to record with
pulsed wave DTI the effects of a first MI on the
velocity profile of the left ventricle during systole
and diastole on several sites of the mitral annulus
and to compare them with standard echocardio-
graphic parameters.
Doppler Echocardiography
From the apical 4-chamber view, pulsed wave Doppler
mitral flow velocities were recorded by placing the sample
volume between the leaflet tips in the center of the flow
stream.15 Doppler gain and filters were adjusted to obtain
the best spectral recordings and the transmitral peak rapid
filling velocity (E), peak atrial filling velocity (A), E-wave
deceleration time, and E/A ratio were measured.The pul-
monary venous flow was recorded from the apical 4-cham-
ber view by inserting the pulsed wave Doppler sample vol-
ume approximately 1 cm into the right upper pulmonary
vein.16 The pulmonary venous peak systolic (S), diastolic
(D), S/D ratio, and the reverse flow velocity caused by atrial
contraction were recorded at a speed of 100 mm/s. Left
ventricular isovolumic relaxation time (IVRT) was recorded
from the apical 4-chamber view by simultaneous recording
of the mitral and aortic flows17 at a speed of 100 mm/s.
MATERIAL AND METHODS
Subjects
We started with 101 patients with acute MI.Twenty-three
patients were excluded because of previous MIs, presence
of left bundle branch block on the electrocardiogram
(ECG),presence of LV aneurysm,or normal LV wall motion
at echocardiography. Finally, 78 patients (59 men, 19
women) with a first-time acute MI were included to inves-
tigate systolic LV function. All patients were in sinus
rhythm. Twenty-two patients had systemic hypertension,
Mitral Annular Velocity by Doppler Tissue Imaging
12 had diabetes mellitus, and 3 patients had angina pec-
toris.The diagnosis of MI was based on the following cri-
teria:(1) characteristic chest pain,(2) ECG changes,and (3)
diagnostic serial changes in cardiac enzymes. Forty-nine
patients were treated with thrombolysis. Fifty-five patients
developed Q waves on the ECGs. Thirty-three patients
The pulsed wave DTI was performed by activating the DTI
function in the same echocardiographic machine. Images
were acquired by using a variable frequency phased-array
transducer (2.0 to 4.0 MHz).The filter settings were kept
low (50 Hz), and gains were adjusted at the minimal opti-

Journal of the American Society of Echocardiography
Volume 13 Number 5
Alam et al 345
Figure 1 Two-dimensional apical 4-chamber view with the sample volume of the Doppler myocardial
velocity recording at the septal border of the mitral annulus (upper part of figure). The systolic (S) and
early (E) and late (L) diastolic velocities (cm/s) are shown in the lower part of the figure.
mal level to minimize noise and eliminate the signals pro-
duced by the transmitral flow. A 3.5-mm sample volume
was used. Four different sites at the mitral annulus were
selected. In the apical 4-chamber view, the DTI cursor was
placed at the septal side of the mitral annulus in such a
way that the mitral annulus at the septum moved along the
sample volume line. A Doppler velocity range of –20 to 20
cm/s was selected for this study. Three major velocities
were recorded: the positive systolic velocity when the
mitral ring moved toward the cardiac apex, and 2 negative
diastolic velocities when the mitral annulus moved toward
the base away from the apex (one during the early phase
of diastole and another in the late phase of diastole)
ability, measurements of systolic and diastolic DTI were
made at 41 LV sites on 2 different occasions. For interob-
server variability, a second investigator randomly made
measurements at 33 of the above different LV sites without
knowledge of other echocardiographic parameters. The
intraobserver and interobserver variabilities were deter-
mined as the difference between the 2 sets of observations
divided by the mean of the observations and expressed as
a percentage.7
RESULTS
(
Figure 1).The peak systolic and diastolic velocities were
The basic clinical and echocardiographic parameters
for the patients and the healthy subjects are given in
Table 1.The mean mitral annular motion at 4 LV sites
was 9.7 ± 1.9 mm in anterior MI and 10.7 ± 1.6 mm
in inferior MI (P < .01).The intraobserver error was
low: 4.6% ± 4%, 5.8% ± 4.9%, and 6.4% ± 4.9% for
peak systolic, peak early diastolic, and peak late dia-
stolic velocities,respectively.The interobserver varia-
tion for the above velocities was also low: 3.4% ±
3.5%, 6.1% ± 6%, and 6.5% ± 6%, respectively.
measured on-line at a sweep speed of 50 mm/s.By moving
the sample volume at the lateral site of the mitral annulus,
systolic and diastolic velocities of the LV lateral wall were
also recorded. In a similar way, the velocities at the anteri-
or and inferior sites of the mitral annulus were recorded in
the apical 2-chamber view. A mean value from the above 4
sites was used to assess global systolic and diastolic func-
tion. A mean of 3 consecutive cycles was used to calculate
all Doppler echocardiography parameters.
Systolic Myocardial Velocity
Statistics
Results are expressed as the mean and one SD. Compari-
In healthy subjects, the peak systolic mitral annular
velocity at the septum was significantly lower than
that at the lateral and inferior sites (Table 2). Com-
pared with healthy subjects, the MI patients had a
significantly reduced peak systolic velocity at all 4
sites of the mitral annulus (Table 2). Good-quality
echoes for the measurement of ejection fractions
sons of the results were made with the Student t test
(unpaired test between healthy subjects and MI patients,
and paired test between different parameters within the
same group). Linear regression analysis was used for com-
parison of different parameters. A P value <.05 was con-
sidered statistically significant. To test intraobserver vari-

Journal of the American Society of Echocardiography
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346 Alam et al
Figure 2 Correlation between left ventricular ejection fraction and the mean systolic mitral annular
velocity in patients with myocardial infarction. SEE, Standard error of estimate.
Table 1 Basic clinical and echocardiographic parameters
Age
Heart rate (bpm)
LV (mm)
LA (mm)
MAM (mm)
Healthy subjects (n = 25)
Subjects with MI (n = 78)
62 ± 6
64 ± 11
66 ± 10
69 ± 11
46 ± 4
51 ± 6*
34 ± 3
38 ± 4*
14.1 ± 2
10.2 ± 2†
The results are presented as the mean and SD. LV, Left ventricular dimension in end diastole; LA, left atrial dimension; MAM, mean value of the mitral annu-
lar motion; MI, myocardial infarction.
*
P < .01 compared with healthy subjects.
†
P < .001 compared with healthy subjects.
Table 2 Mitral annular peak systolic velocity (S) assessed by Doppler tissue imaging at different sites of the left ventricle
S-Septum (cm/s)
S-Anterior (cm/s)
S-Lateral (cm/s)
S-Inferior (cm/s)
S-Mean (cm/s)
Healthy subjects (n = 25)
8.8 ± 1.3
6.1 ± 1
7.2 ± 1.2
6.7 ± 1.4
9.1 ± 1.6
5.9 ± 1‡
8.7 ± 1.7
7.5 ± 1.9‡
10.4 ± 1.8†
9.8 ± 1.3*
7.8 ± 1.1‡
6.5 ± 1.2
7 ± 1.6‡
9.6 ± 1.1
6.8 ± 1‡
7.8 ± 1.4
7.4 ± 1.3‡
‡
‡
Subjects with anterior MI (n = 33)
Subjects with inferior MI (n = 45)
Total for subjects with MI (n = 78)
7.6 ± 1.2
‡
‡
‡
‡
8.7 ± 2
‡
8.3 ± 2‡
Results are presented as the mean and SD. S-Mean, Mean systolic velocity from 4 LV sites; MI, myocardial infarction.
*
P < .05 compared with septum in healthy subjects.
†
P < .001 compared with septum in healthy subjects.
P < .001 compared with healthy subjects.
‡
were available in 60 patients (77%) with a mean (SD)
value of 48% (9%). A relatively good linear correla-
tion existed between ejection fraction and the mean
systolic myocardial velocity from the 4 LV sites (r =
two different groups with respect to an ejection frac-
tion ≥0.50 or <0.50, a cutoff point of mean systolic
mitral annular velocity of ≥7.5 cm/s had a sensitivity
of 79% and a specificity of 88% in predicting pre-
served global LV systolic function (27 true-positive,3
false-positive, 23 true-negative, and 7 false-negative
results). A previous study has shown that a mean
value of mitral annular motion of 10 mm or more has
high sensitivity and specificity in detecting patients
0.74, P < .001; Figure 2). Recordings of mitral annu-
lar motion and mitral annular velocities by DTI were
possible in all the patients.The correlation was also
good when the mean peak systolic mitral annular
velocity was tested against the magnitude of the
mean systolic mitral annular motion (r = 0.77, P <
9
with an ejection fraction of 0.50 or more. When the
.001; Figure 3).When the patients were divided into
patients were divided into 2 different groups, mitral

Journal of the American Society of Echocardiography
Volume 13 Number 5
Alam et al 347
Figure 3 Correlation between the magnitude of the mean mitral annular motion and the mean systolic
mitral annular velocity in patients with myocardial infarction. SEE, Standard error of estimate; DTI,
Doppler tissue imaging.
Table 3 Mitral annular early diastolic velocity (E) assessed by Doppler tissue imaging at different sites of the left ventricle
E-Septum (cm/s)
E-Anterior (cm/s)
E-Lateral (cm/s)
E-Inferior (cm/s)
E-Mean (cm/s)
Healthy subjects (n = 25)
Subjects with anterior MI (n = 18)
Subjects with inferior MI (n = 29)
10.8 ± 2.3
6.6 ± 1.7
7.5 ± 1.4
11.8 ± 3.4
6.5 ± 1.4§
10 ± 2.9†
13.2 ± 2.9*
8.9 ± 2.1§
10 ± 3.4‡
11.5 ± 3
8.4 ± 1.4§
6.7 ± 1.6§
11.8 ± 2.5
7.6 ± 1.3§
8.5 ± 2.1§
§
§
Results are expressed as the mean and SD. E-Mean, Mean early diastolic velocity from 4 LV sites; MI, myocardial infarction.
*
P < .01 compared with septum in healthy subjects.
†
P < .05 compared with healthy subjects.
P < .01 compared with healthy subjects.
P < .001 compared with healthy subjects.
‡
§
Table 4 Late diastolic mitral annular velocity (L) assessed by Doppler tissue imaging at different sites of the left ventricle
L-Septum (cm/s)
L-Anterior (cm/s)
L-Lateral (cm/s)
L-Inferior (cm/s)
L-Mean (cm/s)
Healthy subjects (n = 25)
Subjects with anterior MI (n = 18)
Subjects with inferior MI (n = 29)
11.9 ± 2.5
10.1 ± 1.6*
9.9 ± 2.6
11.3 ± 2.4
11.3 ± 2.5
11.4 ± 2.8
12.6 ± 3.4
10.5 ± 4.3
12 ± 3.2
12.6 ± 2.6
11.6 ± 2.8
11.2 ± 3
12.2 ± 2.3
10.9 ± 2.5
11 ± 2.6
†
Results are expressed as the mean and SD. L-Mean, Mean late diastolic velocity from 4 left ventricular sites; MI, myocardial infarction.
*
†
P < .05 compared with healthy subjects.
P < .01 compared with healthy subjects.
annular motion ≥10 mm and <10 mm, a cutoff point
of the mean systolic mitral annular velocity of ≥7.5
cm/s had a sensitivity of 72% and a specificity of 93%
in predicting preserved global LV systolic function
patients with anterior MI, the reduced velocity was
more pronounced at the anterior wall than at other
sites (Figure 5). In inferior MI, the mitral annular
velocity at the inferior wall was significantly reduced
compared with that at other LV sites (Figure 5).
(
37 true-positive, 2 false-positive, 25 true-negative
and 14 false-negative results).
Diastolic Myocardial Velocity
When we divided the MI patients into those with
anterior or inferior MIs according to ECG localiza-
tion of the infarction sites,we found a reduced mitral
annular velocity at nearly all sites compared with
that in healthy subjects (Table 2 and Figure 4). In
Two major peak velocities were found during dias-
tole: one during early diastole and the other during
late diastole. In healthy subjects, the early diastolic
mitral velocity at the septum was significantly lower

Journal of the American Society of Echocardiography
May 2000
348 Alam et al
Figure 4 Peak systolic velocity determined by Doppler tissue imaging at different sites of the mitral
annulus in healthy subjects and patients with anterior and inferior myocardial infarction (MI).
***P < .001.
Table 5 Ratio of the early and late diastolic mitral annular velocities assessed by Doppler tissue imaging at different sites
of the left ventricle
Septum
Anterior
Lateral
Inferior
LV-Mean
Healthy subjects (n = 25)
Subjects with anterior MI (n = 18)
Subjects with inferior MI (n = 29)
0.96 ± 0.3
0.66 ± 0.1
0.76 ± 0.2
1.1 ± 0.5
0.65 ± 0.1†
0.88 ± 0.2*
1.1 ± 0.5
0.85 ± 0.3
0.84 ± 0.3
0.96 ± 0.3
0.74 ± 0.2*
0.6 ± 0.2‡
1 ± 0.4
0.74 ± 0.1†
0.77 ± 0.2*
†
Results are expressed as the mean and SD. LV-Mean, Mean value of the ratio of early-to-late diastolic mitral annular velocity from 4 left ventricular sites; MI,
myocardial infarction.
*
P < .05 compared with healthy subjects.
†
P < .01 compared with healthy subjects.
‡
P < .001 compared with healthy subjects.
than at the lateral wall (Table 3).The early diastolic
velocity was lower in both anterior and inferior MIs
compared with that in healthy subjects at all sites
and transmitral E wave, transmitral A wave, E/A ratio,
transmitral E-wave deceleration time, IVRT, or differ-
ent pulmonary venous waves (r values between 0.1
and 0.28; P value was not significant). The ratio
between mitral annular early and late velocity
showed no correlation with any of the transmitral
flow velocities or IVRT.
(Table 3). Similar to systolic velocities, the reduced
early diastolic velocity was more pronounced at
anteroseptal sites in anterior MI and at inferior sites
in inferior MI (Figure 6). The late diastolic mitral
annular velocity was similar to that in healthy sub-
jects at almost all sites (Table 4).However,compared
with that in healthy subjects, the ratio between the
early and late diastolic mitral annular velocity was
reduced, especially at the infarction sites (Table 5).
The conventional Doppler parameters in patients
and healthy subjects are given in Table 6.The peak
mitral annular early diastolic velocity correlated well
with both the LV ejection fraction (r = 0.66,P < .001,
n = 47) and the mean mitral annular motion at sys-
tole (r = 0.68, P < .001, n = 47). However, there was
no correlation between the early diastolic velocity
DISCUSSION
Left ventricular contraction involves both a reduc-
tion of the short-axis diameter and a shortening
along the longitudinal axis of the chamber.1
Previously, the amplitude of the LV shortening along
its long axis has been used to assess both regional
and global LV systolic function.8-10,20 The longitudi-
nal systolic shortening of the left ventricle is reflected
by the motion of the mitral annulus toward the car-
8,19

Journal of the American Society of Echocardiography
Volume 13 Number 5
Alam et al 349
Figure 5 Peak systolic mitral annular velocity at different sites of the left ventricle in patients with ante-
rior and inferior myocardial infarction (MI). S, Septum; A, anterior; L, lateral; I, inferior.
***P < .001.
diac apex in systole,whereas its recoil away from the
apex is the result of diastole. As there is no appre-
ciable motion of the apex in relation to the imaging
transducer, the magnitude of the mitral annular
motion reflects the extent of myocardial shortening
along its longitudinal axis.9,19,20 Recording the mitral
annular motion has the advantage that it is devoid of
trabeculae,myocardial dropouts,etc,and therefore is
independent of echo quality. Further analysis by
quantifying the myocardial velocities with the use of
DTI opens up a new possibility of assessing LV func-
tion along the long axis. The major advantage of
pulsed wave mitral annular velocity measurements is
that the ultrasound beam is parallel to the LV con-
traction. Moreover, it probably measures the trans-
mural myocardial velocity, not only the epicardial or
endocardial velocities. Similar to measurements of
the amplitude of mitral annular motion by conven-
tional echocardiography,the recording of LV velocity
by pulsed wave DTI at different mitral annular sites
is easy. We were able to record it at all the LV sites in
all the patients. In addition, the method is highly
reproducible with low interobserver and intraob-
server variabilities.
Table 6 Conventional Doppler parameters
Subjects with
myocardial
infarction (n = 47)
Healthy
subjects
(n = 25)
Transmitral flow
E-wave (m/s)
A-wave (m/s)
E/A ratio
E-wave deceleration (ms)
IVRT (ms)
0.67 ± 0.2
0.68 ± 0.2
0.98 ± 0.4
198 ± 54
90 ± 22
0.68 ± 0.1
0.66 ± 0.1
1.05 ± 0.3
199 ± 30
86 ± 10
Pulmonary venous waves
Systolic (m/s)
Diastolic (m/s)
Systolic/diastolic
Atrial systole (m/s)
0.57 ± 0.2
0.51 ± 0.2
1.16 ± 0.4
0.31 ± 0.1
0.59 ± 0.1
0.46 ± 0.1
1.3 ± 0.2
0.29 ± 0.1
Results are expressed as the mean and SD. IVRT, Isovolumic relaxation
time.
tion has been confined to the global level with the
use of different Doppler parameters.15-17 Up to now,
there has been no standard method for the assess-
ment of regional diastolic function. Introduction of
pulsed wave DTI at different mitral annular sites of
the left ventricle opens up a new possibility. Thus,
the pulsed wave DTI parameters may be used as an
additional method that could increase the accuracy
of echocardiographic LV studies.
In the assessment of LV systolic function, the con-
cept of global and regional function assessed by con-
ventional echocardiography is an established factor.
On the other hand, assessment of LV diastolic func-

Journal of the American Society of Echocardiography
May 2000
350 Alam et al
Figure 6 Peak early diastolic velocity at different sites on the mitral annulus in patients with anterior and inferi-
or myocardial infarction (MI). S, Septum; A, anterior; L, lateral; I, inferior.
*
*P < .01.
*
**P < .001.
Systolic LV Function by DTI in MI
ventricle along its long axis,22 might have some
action beyond the infarction area.
In the present study, after a first MI, a significant
regional difference was found in the peak systolic
velocity at the mitral annulus related to the infarc-
tion site. Anterior MI patients had lower velocities at
the anterior wall and septum than at other sites.The
reduced velocity at the infarction site is an expres-
sion of myocardial damage after an MI.In inferior MI,
the systolic velocity was not only reduced at the infe-
rior site of the mitral annulus, there was also a sig-
nificantly lower peak systolic velocity at the inter-
ventricular septum compared with the septal velocity
in healthy subjects and to lateral and anterior sites
within the same group of subjects with inferior MIs.
This may be the result of partial damage to the sep-
tum in inferior MIs, as the posterior part of the sep-
tum is usually supplied by the right coronary
artery.21 In addition to the reduced systolic velocity
at the infarction sites in both anterior and inferior
MI, the systolic velocity at the noninfarction sites
was also reduced compared with that in healthy sub-
jects. It is difficult to explain this phenomenon. We
do not know whether the spirally oriented myocar-
dial fiber, which causes the shortening of the left
Although the myocardial velocity and ejection
fraction are two different measurements, our study
demonstrates a relatively good and highly significant
correlation between the mean peak systolic velocity
of the mitral annulus and the LV ejection fraction.
This indicates that systolic velocity plays an impor-
tant role in the pumping function of the left ventri-
cle. In addition, a mean peak systolic velocity of ≥7.5
cm/s predicts a preserved LV ejection fraction
(≥0.50) with relatively high sensitivity and specifici-
ty.In some previous studies using either pulsed wave
7
DTI at lateral sites of the mitral annulus or color M-
mode velocity at 6 different sites on the mitral annu-
lus,23 a significant correlation was found between
the mean peak systolic velocity and ejection frac-
tion. However, in these studies the patients had
mixed diagnoses.
Diastolic LV Function by DTI in MI
The assessment of diastolic function has clinical sig-
nificance.24,25 Although systolic abnormalities are
the most common cause of congestive heart failure,

Journal of the American Society of Echocardiography
Volume 13 Number 5
Alam et al 351
the presence of diastolic filling abnormalities may
lead to inadequate cardiac output even though the
ejection fraction is normal or near-normal.26 Left
ventricular diastolic dysfunction may occur after
MI.24,25 Other associated diseases (eg, systemic
hypertension, valvular heart disease, cardiomyopa-
thy, diabetes mellitus) may also influence diastolic
function. To assess the effects of a first MI on the
myocardial diastolic velocities, we included only
patients without a history of previous disease. The
peak early diastolic velocity of the left ventricle
along its long axis was significantly decreased in
both anterior and inferior MI compared with that in
healthy subjects. Similar to the systolic velocity, the
decrease in the early diastolic velocity was more pro-
nounced at the infarction sites (ie,at the anterior site
in anterior MI and at the inferior site in inferior MI).
The ratio of early-to-late diastolic velocity was signif-
icantly lower, especially at the infarction sites, com-
pared with that in healthy subjects. This is the result
of a significant decrease in the early diastolic veloci-
ties in this patient population. In a previous study
with old MIs or dilated cardiomyopathy and with LV
dysfunction,a decreased peak early diastolic velocity
ence of pseudonormalization of the transmitral flow
velocity or with an elevated LV end-diastolic pres-
sure.
Limitation
This study analyzes the possibilities of assessing LV
function by using the myocardial velocity along the
long axis. No consideration was taken of the con-
traction of the left ventricle along its short axis
caused by circumferential fiber. For this study, we
divided the MI patients into anterior and inferior
groups. Anterior MI with infarction only near the
apex may result in a different velocity at the annulus
compared with an infarction near the annulus and
vice versa. Another limitation is that we used LV
ejection fraction determined by echocardiography as
the reference method. No isotope studies were per-
formed to assess LV function. However, on compar-
ing the peak systolic mitral annular velocity with LV
ejection fraction, only the high-quality recordings
were accepted.We also compared the peak systolic
mitral annular velocity with the mean value of the
mitral annular motion assessed by M-mode echocar-
diography. Previous studies have shown a good cor-
relation between the LV ejection fraction deter-
mined by radionuclide angiography and the mean
mitral annular motion recorded by M-mode echocar-
diography.9,30 Another limitation is that coronary
and LV angiography were not performed during the
acute phase of the infarction to localize and evaluate
the extent of LV wall asynergy. However, the infarc-
tion sites were determined by both ECG and 2-
dimensional echocardiography.
5
was noted with the use of color-coded DTI. In
another study, the early diastolic velocity could also
be induced during balloon occlusion at percuta-
neous transluminal coronary angioplasty.13
In our study,the peak early diastolic mitral annular
velocity correlated well with the LV ejection frac-
tion. It probably reflects the circumstance that the
diastolic dysfunction is related to the systolic dys-
function after MI. However, the early diastolic mitral
annular velocity did not correlate with any of the
conventional Doppler diastolic parameters. The
transmitral flow velocities and the IVRT are depen-
dent on LV relaxation and on left atrial pressure.27,28
After MI, patients may develop different degrees of
diastolic dysfunction. With conventional Doppler
parameters, these changes may be detected by the
development of abnormal LV relaxation, pseudonor-
malization, or a restrictive pattern, depending on the
extent of the myocardial damage.Therefore conven-
tional Doppler parameters may fail to identify dia-
stolic dysfunction after MI. However, the early dia-
stolic mitral annular velocity measured by DTI has
been postulated to be independent of the filling
pressure.7,29This may be the reason for the good cor-
relation between the early diastolic velocity deter-
mined by DTI and the LV ejection fraction, but not
with the conventional Doppler parameters, in the
present study. Thus,by using the mitral annular peak
early diastolic velocity, it may be possible to assess
the diastolic dysfunction after MI, even in the pres-
Conclusion
Mitral annular velocities can readily be recorded by
pulsed wave DTI after MI.The reduced peak systolic
velocity seems to be an expression of regionally
reduced systolic function. The mean peak systolic
velocity from 4 LV sites correlated well with the LV
ejection fraction.The peak early diastolic velocity is
also reduced, especially at the infarction sites, and
reflects regional diastolic dysfunction.Thus, quantifi-
cation of the myocardial velocity by DTI opens up a
new possibility of assessing LV function in patients
with MI.
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