Estimation of Left Ventricular Filling Pressure with Exercise by Doppler Echocardiography in Patients with Normal Systolic Function: A Simultaneous Echocardiographic–Cardiac Catheterization Study

Abstract

Doppler echocardiography is now used to evaluate left ventricular filling pressures in patients at rest. However, the clinical use of Doppler echocardiography in the determination of filling pressures with exercise has been less well studied. The aim of this prospective study was to confirm the validity of an accepted Doppler parameter (ratio of transmitral E velocity to Doppler tissue annular e' velocity [E/e']) as a measure of filling pressure in patients with normal systolic function during rest and exercise. Twelve patients who presented with symptoms of dyspnea and ejection fraction greater than 50% underwent an exercise right heart catheterization during a symptom-limited bicycle exercise test. Simultaneous Doppler assessment of transmitral flow and tissue Doppler annulus motion was recorded. The transmitral E velocity increased from 0.88 +/- 0.2 to 1.29 +/- 0.4 cm/s whereas the mitral annular e' velocity increased from 0.08 +/- 0.02 to 0.11 +/- 0.06 with exercise. The E/e' ratio increased from 11.7 +/- 0.5 to 14.4 +/- 0.6. Pulmonary artery wedge pressure (PAWP) increased from 14 +/- 4 to 23 +/- 10 mm Hg at peak exercise. The sensitivity of an E/e' of 15 or less as a predictor for a normal PAWP during exercise was 89%. Conversely, in all cases where the E/e' was greater than 15, the PAWP was elevated during exercise. Noninvasively obtained Doppler of mitral and mitral annulus velocities provides a reliable estimation of PAWP not only at baseline, but also with exercise. Specifically, an E/e' ratio of greater than 15 during exercise is associated with a significantly elevated PAWP of greater than 20 mm Hg.