Doppler Echocardiography Yields Dubious Estimates of Left Ventricular Diastolic Pressures

Abstract

Quantification of left ventricular (LV) diastolic function is necessary to diagnose heart failure (HF) when LV systolic function is normal.1–4 Furthermore, repetitive assessment of LV filling pressures is an important guide for titration of diuretic treatment and can predict survival of HF patients.5 Because of patient discomfort and the risks involved in invasive procedures, a noninvasive estimate of diastolic LV function and pressures is highly desirable. In current cardiological practice, noninvasive evaluation of diastolic LV function is based on Doppler echocardiographic visualization of LV inflow and/or LV tissue reextension. LV inflow and LV tissue reextension, however, are only indirectly related to LV filling pressures through laws of physics such as the Bernoulli principle and Laplace law. Noninvasive estimates of LV filling pressures can therefore be offset not only by limitations of the imaging technique but also by shortcomings inherent to derivation of pressures from inflow or reextension signals. As a result of these problems with noninvasive estimates of LV diastolic function and pressures, the cardiological community has witnessed over the past 20 years repetitive cycles in which a Doppler echocardiographic index was first proposed as robust and shortly thereafter discredited by contradictory evidence. The latest of such cycles involved the ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/E′). The value of the E/E′ ratio as a reliable estimate of LV filling pressures was demonstrated in a variety of cardiac diseases6–10 and endorsed by European and American consensus statements on diastolic HF4 and diastolic LV dysfunction11 before being seriously questioned both in hypertrophic12 and dilated cardiomyopathy.13 This continuing uncertainty14 surrounding the value of noninvasive estimates of LV filling pressures and diastolic LV dysfunction asks for a reappraisal of physiological assumptions linking LV filling pressures to myocardial reextension …