Impact of inotropic drugs on the validity of left ventricular filling pressure echocardiographic assessment in end-stage heart failure patients

Abstract

Purpose: Several studies found that the ratio of early diastolic transmitral flow velocity to tissue Doppler mitral annular early diastolic velocity E/e$'$ correlated well with the mean pulmonary capillary wedge pressure (PCWP). Recently, the validity of E/e' ratio in predicting PCWP was challenged in patients with decompensated end-stage systolic heart failure. In the latter study, influence of inotropic drugs was not taken into consideration. We hypothesize that inotropes modify relaxation properties and may have impaired the validity of E/e' as a surrogate of filling pressure in this setting. Methods and results: Hemodynamic and echocardiographic data were gathered prospectively in 37 patients with decompensated end stage heart failure (EF≤35%, NYHA≥III, LVTDD>31 mm/m2). Those patients (Mean age 56yo, PCWP 22±8 mmHg, septal E/e' 17±5) were admitted for ventricular assist device implantation or heart transplantation. For 11 patients, we had at least two points of evaluation, before and after introduction of inotropes. In the overall study (n=49), E/e' ratio (lateral,septal,mean) was not or poorly correlated to PCWP (r=0,35, p<0,01 for septal E/e'). In examinations performed without inotropic drugs (n=17), correlation between septal E/e' and PCWP was good (r=0,66; p<0,01) while no correlation was found in examinations during inotropes use (n=28). Lateral and mean E/e' were not or poorly correlated to PCWP in both cases. ![Figure][1] PCWP-E/e' correlation-linear regression Conclusions: In decompensated patients with advanced systolic heart failure, the E/e' ratio for assessing left ventricular filling pressure is accurate in the absence of inotropes but unreliable when inotropic drugs are used. [1]: pending:yes