title: Pre-Load-Induced Changes in Forward LV Stroke and Functional Mitral Regurgitation: Echocardiographic Detection of the Descending Limb of Starling's Curve.
abstract: The purpose of this study was to clarify the prognostic significance of diagnosing whether the failing heart is functioning on the descending limb of the Starling curve by using echocardiography with passive leg lifting (PLL).
  
  
  
  Patients with advanced heart failure can shift to the descending limb of the Starling curve, in which pre-load does not lead to an expected increase in forward left ventricular stroke volume (LVSV).
  
  
  
  Thirty-five consecutive patients with left ventricular (LV) ejection fraction of <40% underwent echocardiography at rest during baseline and during PLL to increase pre-load.
  
  
  
  Despite PLL, a paradoxical decrease in forward LVSV was observed in 15 (43%) patients. Changes in forward LVSV inversely correlated with those in functional mitral regurgitation (r = -0.56). The primary endpoint of cardiac death or hospitalization due to worsening heart failure occurred in 15 (43%) patients during follow-up (2.8 ± 2.2 years). There were a number of significant predictors of the primary endpoint in the univariate Cox analysis: baseline E/A ratio (p = 0.0002), paradoxical decrease in LVSV despite PLL (hazard ratio: 4.44; 95% confidence interval: 1.41 to 14.0; p = 0.011), baseline LV end-systolic volume (p = 0.023), and baseline LV ejection fraction (p = 0.034). In the bivariate Cox analysis, an addition of the paradoxical decrease in LVSV significantly enhanced the predictive power of all other univariate predictors.
  
  
  
  Heart failure patients with LV systolic dysfunction on the descending limb of the Starling curve can be recognized by the paradoxical decrease in LVSV despite PLL, and the prognostic predicting power is additive to the other traditional echocardiographic predictors. Also, our results suggest that functional mitral regurgitation is an important reason for the descending limb of the Starling curve, which is clinically recognized as the pre-load-induced decrease in forward LVSV.
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan. Electronic address: abeyukio@aol.com.
authors.forename: Yukio
authors.initials: Y
authors.lastname: Abe
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Kanako
authors.initials: K
authors.lastname: Akamatsu
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Atsuko
authors.initials: A
authors.lastname: Furukawa
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Kazato
authors.initials: K
authors.lastname: Ito
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Matsumura
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Haze
authors.affiliation: Department of Cardiology, Osaka City General Hospital, Osaka, Japan.
authors.forename: Takahiko
authors.initials: T
authors.lastname: Naruko
authors.affiliation: Department of Internal Medicine and Cardiology, Osaka City University Medical School, Osaka, Japan.
authors.forename: Minoru
authors.initials: M
authors.lastname: Yoshiyama
authors.affiliation: Department of Cardiology, Nishinomiya-Watanabe Cardiovascular Center, Nishinomiya, Japan.
authors.forename: Junichi
authors.initials: J
authors.lastname: Yoshikawa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D008955:Models, Cardiovascular; D056888:Patient Positioning; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D016277:Ventricular Function, Left
keywords: Starling curve; echocardiography; heart failure; mitral regurgitation; passive leg lifting