J Cardiol 2007 Sep; 50（3）: 159 – 166

Mitral Annulus Displacement
Measured by Tissue-Tracking
Method With Doppler-Tissue
Images is a Useful Marker of the
Severity of Heart Failure
Koji ITO, MD
Mitsuru NOMA, MD
Masahiro MOHRI, MD
Kohtaro ABE, MD
Umpei YAMAMOTO, MD
Kan KIKUCHI, MD
Kenji MIYATA, MD
Hideki ORIGUCHI, MD
Hideo YAMAMOTO, MD
Tsukasa TAJIMI, MD
Yutaka KIKUCHI, MD
Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
Objectives. This study investigated whether the measurement of mitral annulus displacement by the tissue-tracking method with Doppler-tissue images can provide more accurate information on the severity ofheart failure compared to conventional methods, such as left ventricular ejection fraction（LVEF）.
Background. Impaired left ventricular function is an important predictor of poor prognosis. Although
LVEF has been used to assess left ventricular function, such indicators do not necessarily correlate well toclinical variables such as New York Heart Association（NYHA）
functional class or plasma brain natriuretic
peptide（BNP）concentration.
Methods. In 90 subjects with or without various heart diseases, mitral annulus displacement was measured by the tissue-tracking method with Doppler-tissue images and the correlations evaluated with NYHA
functional class, plasma BNP concentration, left ventricular mass index and Tei index.
Results. Mitral annulus displacement by the tissue-tracking method with Doppler-tissue images waswell correlated with NYHA functional class and plasma BNP concentration. LVEF was also correlatedwith these clinical variables, but significantly more weakly. Furthermore, mitral annulus displacement by
the tissue-tracking method with Doppler-tissue images was correlated with left ventricular mass index andTei index, which indicate left ventricular systolic and diastolic function.
Conclusions. The present study suggests that mitral annulus displacement measured by our technique isa useful and reliable method for assessing the severity of heart failure.
──────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2007 Sep; 50（3）: 159−166

Key Words■ Echocardiography（Doppler-tissue images, tissue-tracking）■ Heart failure（mitral annulus）

──────────────────────────────────────────────
九州厚生年金病院 循環器内科 : 〒 806−8501 北九州市八幡西区岸の浦 1−8−1
Department of Cardiology, Kyushu Kosei-Nenkin Hospital, Kitakyushu
Address for correspondence : NOMA M, MD, Department of Cardiology, Kyushu Kosei-Nenkin Hospital, Kishinoura 1−8−1,
Yahatanishi-ku, Kitakyushu 806−8501 ; E-mail : mitsuru.noma@qkn-hosp.jp
Manuscript received March 14, 2007 ; revised June 14, 2007 ; accepted June 18, 2007

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Ito, Noma, Mohri et al

INTRODUCTION
Impaired left ventricular function is an important
predictor of poor prognosis.1−3）There is no doubtthat the evaluation of left ventricular function isimportant in various heart diseases. Left ventricularfunction is commonly evaluated using the left ventricular ejection fraction（ LVEF）determined bycineangiography or echocardiography. Echocardiography is noninvasive and less time-consuming
compared to other diagnostic modalities, so is usually used. The modified biplane Simpson method ispreferable, 4）but needs skill to reduce measurement
errors. Furthermore, LVEF could represent mainly
the left ventricular systolic function, and so LVEF
sometimes does not correlate with the clinical factors of heart failure such as New York Heart
Association（NYHA）functional class.
Echocardiographic M-mode tracing of mitralannulus motion is correlated with LVEF 5−10）and
mortality. 11,12）However, whether mitral annulus
motion indicates the clinical status of heart failuresuch as NYHA functional class or plasma BNP
concentration remains unknown. Furthermore,echocardiac M-mode tracing of mitral annulus
motion cannot measure the displacement at theidentical point during a cardiac cycle.
The tissue-tracking method using Doppler-tissue
imaging exactly reflects myocardial velocity anddisplacement.9,13,14）Therefore, this tracking method
can evaluate mitral annulus displacement moreaccurately than the M-mode method.
The present study investigated whether the measurement of mitral annulus displacement by the tissue-tracking method with Doppler-tissue images
can provide more accurate information on theseverity of heart failure than conventional methods
such as LVEF, and assessed the correlation with
NYHA functional class as an index of heart failure.
SUBJECTS AND METHODS
Study population
This study included 90 consecutive subjects
referred for echocardiographic examination at the
Kyushu Kosei-Nenkin Hospital between October2005 and May 2006（Table 1）. Exclusion criteria
included right-sided heart failure caused by primary
pulmonary hypertension or severe tricuspid regurgitation. All participating subjects provided informed
consent before the study.


（yr）

          − 

Etiology of heart failure
Ischemic heart disease
Hypertensive heart disease
Non-ischemic dilated cardiomyopathy
Hypertrophic cardiomyopathy
Valvular heart disease






Lone atrial brillation
OthersNormal（no heart disease）



RhythmSinus
Atrial brillation
Pacemaker



Echocardiographic analysis
The present study used a Vivid 7 digital ultrasound system（GE Medical Systems, BT05）.
Scanning was performed longitudinally from theapex to acquire the apical four-chamber view andthe two-chamber view, and from the left sternalborder to acquire the parasternal long-axis view
with a M4S transducer. Gain, filter, pulse repetitivefrequency, sector size, and depth were adjusted tothe optimum conditions and to reach the highest
frame rate as possible（ ＞ 100 frames/sec）. The
Doppler-tissue imaging data with two-dimensional
images were stored on hard disc and analyzed offline. The analysis software built into the Vivid （7 Qanalysis）was used to determine the tissue displacement at several locations. Measurements were done
at two differential points : the hinge of the mitralvalve at the lateral wall, and the hinge of the mitralvalve at the septum in the apical four-chamberview. The sampling area size was 4 × 4 mm, andthe sampling area was maintained at the identicalarea of the tissue during the entire cardiac cycle bymanual tracking. Positive peak values of mitralannulus displacement were determined by the tissue-tracking method with Doppler-tissue images at
each point（Fig. 1）. LVEF was calculated by themodified biplane Simpson method using the apicalfour- and two-chamber views. Left ventricular mass
was calculated by the following equation : 15）
Left ventricular mass（g）＝ 1.04 × 0.8 （LVDd[
3＋ PWT ＋ IVST）− LVDs3]＋ 0.6
where LVDd ＝ left ventricular diastolic dimension
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Mitral Annulus Displacement and Heart Failure

161

Fig. 1 Representative profiles of mitral annulus displacement measured by the tissue-tracking
method with Doppler-tissue images
Left panel illustrates a patient with heart failure subject and right panel shows a normal subject. The circle
at the mitral annulus in the apical four-chamber view is the region of interest, at the septal side（yellow）andthe lateral side
（green）. X-axis is the time course in cycle lengths and Y-axis mitral annulus displacement.
ROI ＝ region of interest ; AVO ＝ aortic valve opening ; AVC ＝ aortic valve closing.

（cm）, LVDs ＝ left ventricular systolic dimension（cm）, PWT ＝ posterior wall thickness（ cm）and
IVST ＝ interventricular septal thickness（ cm）at
end-diastole and systole in two-dimensional images
from the parasternal long-axis view. Left ventricular mass index was also calculated from the bodysurface area.
The Tei index was measured as the sum of isovolumic contraction and relaxation intervals divided
by ejection time as previously reported. Briefly, left
ventricular inflow and outflow velocity profiles
were determined in the apical four-chamber andapical three-chamber views. The time interval
between the end and the onset of left ventricular
inflow was designated as A , and the ejection time
derived from the duration of left ventricular outflow
velocities as B . Tei index was calculated as follows : Tei index ＝（A − B）/B.16,17）
Three consecutive beats were analyzed for all
measurements, and the values were averaged.
Meaurement of plasma brain natriuretic peptide
concentration
This part of the study excluded patients withJ Cardiol 2007 Sep; 50（3）: 159 – 166

chronic renal failure（ serum creatinine level ＞
2.0 mg/dl）to avoid the effects of renal dysfunction
on plasma brain natriuretic peptide（BNP）clearance.18）Blood samples for measuring plasma BNP
concentrations were collected from peripheral veins
within 7 days of echocardiographic examination.
Statistical analysis
Data are expressed as mean value ± standard
deviation. Statistical analysis used Dr SPSSII for
Windows（SPSS Inc. 2001）. Analysis of variance
was used to compare differences between the various values such as mitral annulus displacement
measured by the tissue-tracking method with
Doppler-tissue images, plasma BNP concentrations
or LVEF, and NYHA functional class. Comparisons
between mean values were performed with Fisher scorrelation for multiple comparisons. The Pearson
correlation coefficient was used for analysis of linear correlation between different variables. A pvalue ＜ 0.05 was considered statistically significant.

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Ito, Noma, Mohri et al

Fig. 2 Relationships between mitral annulus displacement measured by tissue-tracking method with
Doppler-tissue images and other factors
A : The relationship with NYHA functional class. The value of mitral annulus displacement is significantly
different between neighboring NYHA functional classes.
＊
p ＜ 0.05 vs neighboring NYHA functional class.
B : The relationship with plasma BNP concentration. There is a statistically significant, inverse correlation
between mitral annulus displacement and plasma BNP concentration.
C : The relationship between plasma BNP concentration and NYHA functional class.
＊p ＜ 0.05 vs neighboring NYHA functional class.
MAD ＝ mitral annulus displacement ; NYHA ＝ New York Heart Association ; BNP ＝ brain natriuretic
peptide.

RESULTS
Measurement of mitral annulus displacement by
tissue-tracking method with Doppler-tissue
imagesRepresentative recordings of mitral annulus displacement by the tissue-tracking method with
Doppler-tissue images in a normal subject and apatient with heart failure are shown in Fig. 1. The
peak values of the displacement were measured atboth septal and lateral sides of the mitral annulus.
Relationship between mitral annulus displacement and NYHA functional class
Fig. 2−A shows the relationship between mitralannulus displacement measured by the tissue-tracking method with Doppler-tissue images and NYHA
functional class. Mitral annulus displacement wassignificantly inversely correlated with NYHA functional class（n ＝ 90, r ＝− 0.85, mean value ± SD ;normal subjects（n ＝ 16）: 24.4 ± 3.7 mm, NYHA
Ⅰ（n ＝ 27）: 18.9 ± 4.7 mm, NYHA Ⅱ（n ＝ 22）:13.7 ± 3.8 mm, NYHA Ⅲ（ n ＝ 18）: 10.3 ±2.3 mm, NYHA Ⅳ（n ＝ 7）: 5.7±1.8 mm）. Furthermore, the value of mitral annulus displacement ineach NYHA functional class was significantly
different from that in the neighboring classes.
Relationship between mitral annulus displacement and plasma BNP concentration
Mitral annulus displacement measured by the tissue-tracking method with Doppler-tissue images
was inversely correlated with plasma BNP concentration（ n ＝ 57, r ＝− 0.63 ; Fig. 2−B）. Plasma
BNP concentration was also correlated with NYHA
functional class（Fig. 2−C）.
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Mitral Annulus Displacement and Heart Failure

163

Fig. 3 Relationships between LVEF and other factors
A : The relationship with NYHA functional class. Significant difference is noted only between NYHA
functional classes Ⅰ and Ⅱ.
＊
p ＜ 0.05 vs NYHA functional class Ⅰ.
B : The relationship with plasma BNP concentration.
LEEF ＝ left ventricular ejection fraction. Other abbreviations as in Fig. 2.

Relationship between LVEF and severity ofheart failure
Fig. 3−left shows the relationship between
LVEF and NYHA functional class（ n ＝ 90, r ＝− 0.57）and Fig. 3−right shows the relationshipbetween LVEF and plasma BNP concentrations（n ＝ 57, r ＝− 0.46）. The relationships between
LVEF and these values were weaker than thosewith mitral annulus displacement by the tissuetracking method with Doppler-tissue images.
Relationships between mitral annulus displacement and LVEF, left ventricular mass index, andTei index
Mitral annulus displacement measured by the tissue-tracking method with Doppler-tissue images
was correlated with LVEF in all patients（n ＝ 90,r ＝ 0.67 ; Fig. 4）. Mitral annulus displacement wasalso correlated with left ventricular mass index,
which indicated both left ventricular dilation andleft ventricular hypertrophy（n ＝ 90, r ＝− 0.61 ;Fig. 5−left）. Furthermore, mitral annulus displacement had a statistically significant correlation with
the Tei index, a marker of global left ventricularfunction incorporating both left ventricular systolicand diastolic function（n ＝ 47, r ＝− 0.47 ; Fig. 5−
right）.

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Fig. 4 Relationship between LVEF and mitral annulus
displacement measured by the tissue-tracking
method with Doppler-tissue images
Abbreviations as in Figs. 2, 3.

DISCUSSION
Previous studies showed mitral annulus motion isuseful to evaluate left ventricular systolic function
using two-dimensional image-guided M-mode
echocardiography. The present study evaluatedmitral annulus displacement by the tissue-tracking
method with Doppler-tissue imaging, which provides accurate assessment of mitral annulus displacement. We found that mitral annulus displacement measured by the tissue-tracking method with

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Ito, Noma, Mohri et al

Fig. 5 Relationships between mitral annulus displacement measured by the tissue-tracking methodwith Doppler-tissue images and other factors
Left : There is a statistically significant, inverse correlation with left ventricular mass index.
Right : There is a statistically significant, inverse correlation with the Tei index.
Abbreviations as in Fig. 2.

Doppler-tissue images was a more powerful indicator of NYHA functional class as a subjective marker of heart failure severity compared with LVEF,
was also correlated with plasma BNP concentration
which is another marker of heart failure severity,
and was correlated with the left ventricular massindex and Tei index. These results indicate that thismethod is useful and reliable to evaluate the severity of heart failure.
LVEF is commonly applied as a useful and reliable index of left ventricular systolic function.1−3,19,20）
However, we occasionally encounter patients withovert heart failure but preserved LVEF. In fact,
heart failure may be caused not only by systolic
dysfunction but also by diastolic dysfunction. 21,22）Furthermore, LVEF does not correlatewith NYHA functional class. 12） Therefore, we
aimed to investigate whether mitral annulus displacement measured by the tissue-tracking methodwith Doppler-tissue images can provide a reliable
and objective indicator of heart failure severity and
NYHA functional class.
The present study showed that mitral annulus
displacement measured by the tissue-tracking
method with Doppler-tissue images was correlatedwith both NYHA functional class and plasma BNP
concentration. LVEF had weak relationships with
NYHA functional class and plasma BNP concentration. These results suggest that mitral annulus
displacement by tissue-tracking method with
Doppler-tissue images has the potential to be amore useful and reliable indicator to assess heart
failure severity rather than conventional methods
such as LVEF.
In addition, the present study revealed a significant relationship between mitral annulus displacement by the tissue-tracking method with Dopplertissue images and the Tei index, a marker of global
left ventricular function including diastolic function.16,17,23）This result suggests that mitral annulus
displacement by the tissue-tracking method with
Doppler-tissue images reflects both left ventricularsystolic and diastolic function. The mechanisms
involved are beyond the scope of the present study.
The tissue-tracking method with Doppler-tissue
images detects the motion of the mitral annulus atboth septal and lateral wall sides, which allows us
to measure the actual displacement of the mitralannulus independent of angle. Furthermore, the values measured by this technique may reflect the displacement of the identical point in the mitral annulus during a cardiac cycle. Therefore, it is likelythat such measurement of mitral annulus displacement can provide more accurate measurements ofmitral annulus motion compared to M-mode tracing, thus providing better correlation with severityof heart failure.
Measurement of mitral annulus displacement by
the tissue-tracking method with Doppler-tissue
images was correlated well with NYHA functionalclass in patients with divergent etiologies of heart
failure. Therefore, this method provides a simple
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Mitral Annulus Displacement and Heart Failure

approach to evaluate global left ventricular function
in various heart diseases.
In conclusion, we suggest that mitral annulus
displacement measured by the tissue-tracking
要165

method with Doppler-tissue images is a useful andreliable marker of the severity of heart failurecaused by various heart diseases.

約

Dopper-Tissue Image を用いた Tissue-Tracking 法による僧帽弁輪移動距離測定は心不全重症度マーカーとして有用である

目

伊藤

浩司

野 間

充

毛利

正博

阿部弘太郎

山本

雲平

菊 池

幹

宮田

健二

折口

山本

英雄

多治見

司

菊 池

裕

秀樹

的 : 心機能評価では，一般に左室駆出率の測定が行われる．M-mode 法による僧帽弁輪の収縮期移動距離（僧帽弁輪移動距離）は左室駆出率と相関があることが示されている．しかし，左室駆出率は必ずしも心不全の重症度とは相関しないとされており，僧帽弁輪移動距離においても心不全の重症度との相関は明らかではない．本研究では，tissue-tracking 法を用いて測定した僧帽弁輪移
動距離と心不全重症度（NYHA class，血清脳性ナトリウム利尿ペプチド濃度）との相関を検討した．
さらに，左室駆出率や Tei index との関連についても検討した．
方

法 : さまざまな心疾患が疑われ心エコー図を行った連続 90 症例で，心エコー図検査時のNYHA class，左室駆出率（MOD 法），左室心筋重量，tissue-tracking 法による僧帽弁輪移動距離（中隔側＋側壁側），心エコー図検査日前後 1 週間以内での血清脳性ナトリウム利尿ペプチド濃度の測定を行った．
結果 : 平均年齢 67 歳，男性 55 例，女性 35 例，洞調率 63 例，心房細動 16 例，ペースメーカー

調律 11 例であった．基礎心疾患は，虚血性心疾患 20 例，拡張型心筋症 13 例，肥大型心筋症 11 例，
高血圧性心疾患 5 例，弁膜症 14 例，正常（明らかな心疾患なし）16 例，不整脈（心房細動）6 例，その他 5 例であった．僧帽弁輪移動距離は NYHA class，血清脳性ナトリウム利尿ペプチド濃度と有意な負の相関を示した．その相関は左室駆出率よりも強い相関を示した．僧帽弁輪移動距離は左室心筋
重量や Tei index とも有意な負の相関を示した．
結論 : Tissue-tracking による僧帽弁輪移動距離測定は，さまざまな心疾患における心不全重症度の有用なマーカーとなりうると考えられる．

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