Echocardiography was conducted by experienced sonographers using the Vivid E95 ultrasound system (GE Vingmed Ultrasound, Horten, Norway). Images in cine loop format were analyzed offline using the EchoPAC software (EchoPAC 204, GE Vingmed Ultrasound). All indices were measured according to ASE guidelines [15 , 16 (link)]. Pulse Doppler imaging was used to measure the mitral valve peak early (E) and late (A) diastolic velocities, E/A ratio, and LV isovolumic relaxation time (IVRT). LVEF was calculated using the biplane Simpson’s method. LV global longitudinal strain (GLS) was defined as the average peak longitudinal strains obtained from three apical views [17 (link)]. Peak strain dispersion (PSD) was the standard deviation of the time-to-peak longitudinal strains for all segments [18 (link)].
According to the criteria of ASE [19 (link)], the cut-offs for abnormal LV diastolic performance were, as follows: (1) septal mitral annular e′ velocity of < 7 cm/s or lateral mitral annular e′ velocity of < 10 cm/s; (2) average E/e′ ratio of > 14; (3) LAVI of > 34 ml/m2; (4) peak tricuspid regurgitation velocity of > 2.8 m/s. The patients were diagnosed, as follows: LVDD, when > 50% of the indexes met the above criteria; indeterminate LVDD, when merely 50% of the criteria were positive; with risk of developing LVDD but not LVDD yet, when < 50% of the indexes met the above criteria [19 (link)]. For patients with LVDD, the severity of LVDD was defined according to the 2016 EACVI criteria [19 (link), 20 (link)], as follows: mild, when E/A ≤ 0.8 and E ≤ 50 cm/s or ≥ 2 negative criteria (LAVI > 34 ml/m2, average E/e’ > 14, or TR > 2.8 m/s); moderate, when E/A ≤ 0.8 and E > 50 cm/s or 0.8 < E/A < 2 + ≥ 2 positive criteria (LAVI > 34 ml/m2, average E/e’ > 14, or TR > 2.8 m/s); severe, when E/A ≥ 2. Based on the above two criteria, the patients in the present study were categorized into three subgroups: patients with risks for LVDD but without LVDD (n = 237), patients with indeterminate or mild LVDD (n = 113), and patients with moderate or severe LVDD (n = 98). Among these patients, three patients met the criteria for mild LVDD, and seven patients met the criteria for severe LVDD.
According to the criteria of ASE [19 (link)], the cut-offs for abnormal LV diastolic performance were, as follows: (1) septal mitral annular e′ velocity of < 7 cm/s or lateral mitral annular e′ velocity of < 10 cm/s; (2) average E/e′ ratio of > 14; (3) LAVI of > 34 ml/m2; (4) peak tricuspid regurgitation velocity of > 2.8 m/s. The patients were diagnosed, as follows: LVDD, when > 50% of the indexes met the above criteria; indeterminate LVDD, when merely 50% of the criteria were positive; with risk of developing LVDD but not LVDD yet, when < 50% of the indexes met the above criteria [19 (link)]. For patients with LVDD, the severity of LVDD was defined according to the 2016 EACVI criteria [19 (link), 20 (link)], as follows: mild, when E/A ≤ 0.8 and E ≤ 50 cm/s or ≥ 2 negative criteria (LAVI > 34 ml/m2, average E/e’ > 14, or TR > 2.8 m/s); moderate, when E/A ≤ 0.8 and E > 50 cm/s or 0.8 < E/A < 2 + ≥ 2 positive criteria (LAVI > 34 ml/m2, average E/e’ > 14, or TR > 2.8 m/s); severe, when E/A ≥ 2. Based on the above two criteria, the patients in the present study were categorized into three subgroups: patients with risks for LVDD but without LVDD (n = 237), patients with indeterminate or mild LVDD (n = 113), and patients with moderate or severe LVDD (n = 98). Among these patients, three patients met the criteria for mild LVDD, and seven patients met the criteria for severe LVDD.
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