Elevation Of Filling Pressure Research Articles

Left ventricular to left arial volume ratio in the assessment of filling pressure in patients with dyspnoea and preserved ejection fraction.

Assessing filling pressure (FP) remains a clinical challenge despite advancements in non-invasive imaging techniques. This study investigates the utility of echocardiographic left ventricular (LV) to left atrial (LA) volume ratio in estimating the resting FP in patients with dyspnoea and preserved ejection fraction (EF). This study is a prospective, single-centre analysis of 53 consecutive patients with dyspnoea (New York Heart Association grade 2 or 3) and LVEF of ≥50% (mean age 71 ± 10 years) who underwent cardiac catheterisation, including direct measurement of LA pressure at rest using retrograde technique. Echocardiographic data were obtained 1.5 ± 1.0 h after cardiac catheterisation. The patients were divided into two groups: Group 1 consisted of individuals with elevated FP, indicated by a mean LA pressure or mean pulmonary capillary wedge pressure of >12 mmHg, and Group 2 comprised of patients with normal FP. The LV and LA volumes were measured at three specific points: the minimum volume (LVES, LAmin), the volume during diastasis (LVdias, LAdias), and the maximum volume (LVED, LAmax). The corresponding LV/LA volume ratios were analysed: end-systole (LVES/LAmax), diastasis (LVdias/LAdias), and end-diastole (LVED/LAmin). The patients in Group 1 exhibited lower LV/LA volume ratios compared with those in Group 2 (LVES/LAmax 0.44 ± 0.12 vs. 0.60 ± 0.23, P = 0.0032; LVdias/LAdias 1.13 ± 0.30 vs. 1.56 ± 0.49, P = 0.0007; LVED/LAmin 2.71 ± 1.57 vs. 4.44 ± 1.70, P = 0.0004). The LV/LA volume ratios correlated inversely with an increased FP (LVES/LAmax, r = -0.40, P = 0.0033; LVdias/LAdias, r = -0.45, P = 0.0007; LVED/LAmin, r = -0.55, P < 0.0001). Among all the measurements, the LVdias/LAdias ratio demonstrated the highest discriminatory power to distinguish patients with elevated FP from normal FP, with a cut-off value of ≤1.24 [area under the curve (AUC) = 0.822] for the entire group, encompassing both sinus rhythm and atrial fibrillation. For patients in sinus rhythm specifically, the cut-off value was ≤1.28 (AUC = 0.799), with P < 0.0001 for both. The LVdias/LAdias index demonstrated non-inferiority to the E/e' ratio [ΔAUC = 0.159, confidence interval (CI) = -0.020-0.338; P = 0.0809], while surpassing the indices of LA reservoir function (ΔAUC = 0.249, CI = 0.044-0.454; P = 0.0176), LA reservoir strain (ΔAUC = 0.333, CI = 0.149-0.517; P = 0.0004), and LAmax index (ΔAUC = 0.224, CI = 0.043-0.406; P = 0.0152) in diagnosing patients with elevated FP. The study presents a straightforward and reproducible method for non-invasive estimation of FP using routine TTE in patients with dyspnoea and preserved EF. The LVdias/LAdias index emerges as a promising indicator for identifying elevated FP, demonstrating comparable or even superior performance to established parameters.

Bending Saturation Index – A Novel Index of Old Symptom a Marker of Elevated Filling Pressure in Heart Failure

Objectives: Bendopnea is a symptom in patients with heart failure (HF) defined as shortness of breath when bending forward. It is mediated by increased ventricular filling pressure during bending forward. Qualification of bendopnea and its correltion with other symptoms and parameters of HF is not a much explored area. In this study, we studied the frequency of bendopnea in patients admitted with HF and a index of difference between sitting and bending saturations and its correlation with clinical, laboratory, and echocardiographic and short-term mortality. Material and Methods: We conducted a study of 150 patients admitted with DHF in the span of 5 month and followed for 1 month. Bendopnea is defined as subjective sensation of worsening shortness of breath after bending for 1 min or more. Saturations after bending for 1 min are also recorded for each patient. Bendopnea saturation index (BOSI) is calculated as difference between saturations at baseline and after bending over, its percentage over baseline saturation (SaO2 sitting - SaO2 bending/SaO2 sitting*100). Results: It was present in 61 patients (40.7%). Among 150 patients, 11 patientns (7.3%) expired. Orthopnea was more frequent in patients with bendopnea compared to patients without (59% of patients with bendopnea also had orthopnea and 34.8% of patients without bendopnea had orthopnea, and the difference was statistically significant (P = 0.03). Paroxysmal nocturnal dyspnea (PND) was present in 29.5% of patients with bendopnea and 11% of patients without bendopnea (P = 0.05). The patients with bendopnea had higher right ventricular systolic pressure (RVSP) (49.9 ± 1.6) compared to patients without bendopnea (33.5 ± 0.9). Average NT pro BNP values were 8717 ± 950 pg/mL in patients with bendopnea and 1110 ± 99 pg/mL in patients without bendopnea (P &lt; 0.005). Mean BOSI was 4.4 (±2.9) in patients with bendopnea and 0.4 (±0.09) in patients without bendopnea. There was a negative correlation between BOSI and left ventricular ejection fraction (LVEF), and positive correlation between BOSI and RVSP. Among patients with bendopnea, six patients expired, when compared with patients who were alive after 1 month using t-test, patients who expired have higher average BOSI (P &lt; 0.005). Conclusion: Bendopnea and falling of desaturation on bending is a sign of significance in HF patients. The presence of bendopnea correlated with increased pulmonary arterial pressure and with other symptoms of respiratory variation, namely – orthopnea and PND, and higher values of biomarker (NTproBNP). BOSI, but not bendopnea had significant positive correlation with RVSP, and negative correlation with LVEF. BOSI also correlated with short-term mortality.

Diastolic function evaluation in children with ventricular arrhythmia

Premature ventricular contractions (PVC) are frequently seen in children. We evaluated left ventricular diastolic function in PVC children with normal left ventricular systolic function to detect whether diastolic function disturbances affect physical performance. The study group consisted of 36 PVC children, and the control group comprised 33 healthy volunteers. Echocardiographic diastolic function parameters such as left atrial volume index (LAVI), left atrial strains (AC-R, AC-CT, AC-CD), E wave, E deceleration time (Edt), E/E’ ratio, and isovolumic relaxation time (IVRT) were measured. In the cardiopulmonary exercise test (CPET), oxygen uptake (VO2 max) was registered. Evaluation of diastolic function parameters revealed statically significant differences between the patients and controls regarding Edt (176.58 ± 54.8 ms vs. 136.94 ± 27.8 ms, p < 0.01), E/E’ (12.6 ± 3.0 vs. 6.7 ± 1.0, p < 0.01), and IVRT (96.6 ± 19.09 ms. vs. 72.86 ± 13.67 ms, p < 0.01). Left atrial function was impaired in the study group compared to controls: LAVI (25.3 ± 8.2 ml/m2 vs. 19.2 ± 7.5 ml/m2, p < 0.01), AC-CT (34.8 ± 8.6% vs. 44.8 ± 11.8%, p < 0.01), and AC-R-(6.0 ± 4.9% vs. −11.5 ± 3.5%, p < 0.01), respectively. VO2 max in the study group reached 33.1 ± 6.2 ml/min/kg. A statistically significant, moderate, negative correlation between VO2 max and E/E’ (r = −0.33, p = 0.02) was found. Left ventricular diastolic function is impaired and deteriorates with the arrhythmia burden increase in PVC children. Ventricular arrhythmia in young individuals may be related to the filling pressure elevation and drive to exercise capacity deterioration.

P800 Effect of Valsalva Maneuver on echocardiographic systolic and diastolic parameters in patients with acute coronary syndrome, a comparison between normal and high ventricular filling pressures

Abstract Funding Acknowledgements Nil OnBehalf Nil Introduction Echocardiography is used as a useful and common method for the assessments of left and right ventricular (LV &amp; RV) systolic and diastolic functions. Valsalva Maneuver (VM) with the increase in the intra-thoracic and intra-abdominal pressure is often used as a simple, inexpensive and non-invasive method to diagnose some clinical conditions such as heart murmurs. However, in terms of echocardiography, the use of VM is limited to a few parameters for many years. On the other hand, blood level of N-Terminal Pro–B-Type Natriuretic Peptide (NT Pro–BNP) indirectly discriminates normal or high ventricular filling pressure (FP). Purpose The purposes of this research is to provide a comprehensive review of the technique and to compare the effect of VM in ACS patients, with and without elevated FP on either RV and LV diastolic and systolic echocardiographic parameters. Methods Thirty-eight patient, who were diagnosed with possible ACS; Unstable Angina Pectoris, NSTEMI and STEMI, underwent coronary angiography enrolled in this double–blinded clinical trial study. The mild Coronary Artery Disease (CAD) with normal levels of NT Pro–BNP were included in study group one and patients with significant CAD and high level of NT Pro–BNP who underwent PCI were included in study group two. All the systolic and diastolic indicators of both ventricles, totally twenty-four parameters those had mentioned in the academic literature previously, have been evaluated; once before Valsalva and once during stage 2 of the maneuver. Echocardiography is performed by an advanced echo machine and by an expert cardiologist- echocardiographer, which the recorded images were reviewed by the second echocardiographer separately. Results Between the two groups, LV parameter analysis showed significant difference in LV EF pre and post VM. However, there was statistically insignificant difference regarding other systolic as well as diastolic parameters. Between the two groups, RV parameters analysis showed no significant difference in systolic and diastolic parameters pre and post VM. Conclusion To the best of our knowledge, this is the first report assessing post VM changes in four chambers as well as mitral and tricuspid valves parameters in ACS patients with normal versus high level of FP. Previously, LV diastolic dysfunction and Doppler mitral inflow pattern correlation with VM were approved. In the present study, in addition to those known findings from before, except the LV ejection fraction (LVEF) that showed there was statistically significant difference in pre– and post-VM, other systolic parameters, as well as diastolic indicators in either RV and LV, were identical. Therefore, we do not recommend conducting Valsalva maneuver on the rest of the other parameters to diagnose systolic and diastolic dysfunction in ACS patients with mild versus significant CAD who were assumed to have normal or elevated filling pressures.

Variable Hemodynamic Responses during Diastolic Stress Echocardiography in Patients Who Have Relaxation Abnormality with Possible Elevated Filling Pressure.

Background and ObjectivesThe clinical characteristics of patients with diastolic dysfunction characterized by a relaxation abnormality with possible elevated filling pressure is remain to be determined. We sought to test whether diastolic stress echocardiography (DSE) is useful for characterization of these patients.MethodsA total of 120 patients (58 men, mean age of 64±7 years) with E/A ratio <1.0 (mean±SD, 0.7±0.1) and 10≤ E/e' <15 at rest echocardiography was enrolled prospectively for supine bicycle exercise up to 50 W.ResultsDuring exercise, 47 patients (39%) showed high left ventricular filling pressure (E/e' >15, hLVFP) and 40 (30%) developed exercise-induced pulmonary hypertension (systolic pulomary arterial pressure >50 mmHg, EiPH) without hLVFP. The remaining 33 patients did not show hLVFP or EiPH. The incidence of EiPH with hLVFP was 21% (25/120). By multivariate analysis, age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.00–1.13; p=0.039) and systolic pulmonary artery pressure at rest (OR, 1.14; 95% CI, 1.02–1.27; p=0.02) were associated with EiPH, whereas late diastolic transmitral velocity (OR, 1.04; 95% CI, 1.00–1.08; p=0.03) and diastolic blood pressure (OR, 0.94; 95% CI, 0.90–0.99; p=0.02) were associated with hLVFP during exercise.ConclusionsPatients with relaxation abnormality and possibly hLVFP showed markedly heterogeneous hemodynamic changes during low-level exercise and DSE was useful to characterize these patients.

0540: Relationship between functional capacity and diastolic function in chronic heart failure patients

Dyspnea is the frequent cause of exercise intolerance and physical inactivity among chronic heart failure patients. Diastolic dysfunction has shown significant correlation with exercise capacity. The aim is to study whether there is interaction between left ventricular diastolic dysfunction and functional capacity in our CHF patients. 1613 consecutive ambulatory patients with chronic heart failure were enrolled from 2006 to 2013 and registered in the therapeutic unit of chronic heart failure. Clinical, echocardiographic and biological data were investigated. We divided our patients into 2 groups as follow: group 1with reducing filling pressure (64 years, 67% were male), group 2 with elevated filling pressure (EFP) (69 years, 61% were male). We analyzed New York heart association (NYHA) status and the 6 minutes’ walk test. Assessment of diastolic function as determined by Doppler-derived mitral and pulmonary venous flow velocities recorded by transthoracic pulsed Doppler echocardiography. There was no significant difference in baseline characteristic and ejection fraction. The mean of 6 minutes’ walk in groups were 349 and 212m respectively. Group 2 (EFP) was significantly associated with more NYHA grade III/IV (p<0.00001), inversely associated with NYHA grade I/II (p<0.0001). The 6 minutes’ walk test was shorter in EFP patients than others (P<0.01). There was a significant correlation between diastolic dysfunction and cardiac decompensation (p=0.00001), right ventricular dysfunction (p=0.00001), pulmonary hypertension (p=0.00001), dilated vena cava and higher doses of diuretics (p=0.00001). Also, beta-blockers were inversely associated (P<0.0001). Diastolic dysfunction is significantly associated with impaired functional capacity and dyspnea among CHF patients.

Abstract 17499: Addition of Myocardial Parameters to the Diagnosis of Stage B Heart Failure

Introduction: Stage B heart failure (BHF, asymptomatic structural heart disease) is diagnosed in the presence of myocardial scar or impaired LVEF. However, the insensitivity of LVEF may lead to under-recognition of BHF in non-ischemic heart disease. This may be important, as BHF may precede the onset of HF symptoms, and necessitates the initiation of treatment. We sought the implications of using additional LV assessment to identify BHF in pts at risk of HF (stage A HF, AHF). Methods: We studied 510 asymptomatic pts (age 58±12yrs) with AHF (diabetes, hypertension or obesity), but no history of ischemic heart disease and a normal stress echo. All pts underwent echocardiography (including assessment of strain and diastolic dysfunction) and cardiopulmonary exercise testing. Results: BHF was defined as the presence of at least one of; reduced LV longitudinal strain (&lt;18%), increased LV filling pressure (E/e’&gt;13) or moderate-to-severe LV hypertrophy (LV mass index ≥109 g/m 2 in women and 132 g/m 2 in men) in 243 patients (47%). Reduced exercise capacity (peakVO 2 and METS) was identified in BHF compared with other AHF (Table). Using this definition, BHF was associated with lower peak VO 2 (β=-0.20, p&lt;0.00001) and METS (β=-0.21, p&lt;0.0001), independent of higher BMI, insulin resistance, older patient age, male sex and treatment with beta-blockers. Conclusions: LV hypertrophy, elevated LV filling pressure elevation and abnormal myocardial deformation independently contribute to lower exercise capacity in pts at risk of HF. Given the association of exercise capacity with outcome, these factors should be considered grounds for the diagnosis of BHF.

Diastolic tolerance to systolic pressures closely reflects systolic performance in patients with coronary heart disease

In animal experiments, elevating systolic pressures induces diastolic dysfunction and may contribute to congestion, a finding not yet translated to humans. Coronary surgery patients (63±8years) were studied with left ventricular (LV) pressure (n=17) or pressure-volume (n=3) catheters, immediately before cardiopulmonary bypass. Single-beat graded pressure elevations were induced by clamping the ascending aorta. Protocol was repeated after volume loading (n=7). Consecutive patients with a wide range of systolic function were included. Peak isovolumetric LV pressure (LVP(iso)) ranged from 113 to 261mmHg. With preserved systolic function, LVP elevations neither delayed relaxation nor increased filling pressures. With decreasing systolic function, diastolic tolerance to afterload progressively disappeared: relaxation slowed and filling pressures increased (diastolic dysfunction). In severely depressed systolic function, filling pressures increased even with minor LVP elevations, suggesting baseline load-dependent elevation of diastolic pressures. The magnitude of filling pressure elevation induced in isovolumetric heartbeats was closely and inversely related to systolic performance, evaluated by LVP(iso) (r=-0.96), and directly related to changes in the time constant of relaxation τ (r=0.95). The maximum tolerated systolic LVP (without diastolic dysfunction) was similarly correlated with LVP(iso) (r=0.99). Volume loading itself accelerated relaxation, but augmented afterload-induced upward shift of filling pressures (7.9±3.7 vs. 3.0±1.5; P<0.01). The normal human response to even markedly increased systolic pressures is no slowing of relaxation and preservation of normal filling pressures. When cardiac function deteriorates, the LV becomes less tolerant, responding with slowed relaxation and increased filling pressures. This increase is exacerbated by volume loading.

Use of Pulmonary Artery Systolic Pressure To Reveal Unsuspected Mismatch in Right-Left Sided Filling Pressure Elevation

Use of Pulmonary Artery Systolic Pressure To Reveal Unsuspected Mismatch in Right-Left Sided Filling Pressure Elevation

Echocardiographic Assessment of Structural and Functional Cardiac Remodeling in Patients with Predialysis Chronic Kidney Disease

Cardiac remodeling has been demonstrated in patients on hemodialysis and in predialysis patients with chronic kidney disease (CKD). Using functional echocardiographic parameters to study the association of hemodynamic status and predialysis CKD has not yet been established. From November 2007 to September 2008, ninety-six patients (50 men and 46 women) with different stages of CKD were enrolled consecutively to undergo echocardiography. Group 1 consisted of 27 patients with mild CKD (CKD stages 1 and 2) and group 2 consisted of 69 patients with moderate/severe CKD (CKD stages 3-5). Higher values were observed for the products of serum calcium and phosphorus, serum phosphorus, and intact parathyroid hormone; lower values were observed for hematocrit and serum albumin in group 2 patients. Higher mitral E and A velocities, longer isovolumic relaxation time, more prevalence of moderate-to-severe left ventricular (LV) diastolic dysfunction and higher mitral E/Em value were noted in group 2 patients. Eccentric left ventricular hypertrophy (LVH) had effects on systolic contraction disturbance in group 2 patients. CKD severity without LVH had effects on LV filling pressure elevation and relaxation impairment. Among biochemical and echocardiographic parameters, mitral E/Em was most independently associated with a diagnosis of moderate/severe CKD (odds ratio = 1.29, P = 0.023) and it was the most predictive variable with sensitivity and specificity values for a cutoff value of > or =13 of 64% and 74%, respectively. CKD severity without LVH increased LV filling pressure and impaired LV relaxation. Mitral E/Em was significantly associated with moderate/severe CKD.

Assessment of diastolic dysfunction in elderly hypertensive patients using integrated Doppler echocardiography

The aim of this study was to assess the different stages of diastolic dysfunction (DD) in elderly, asymptomatic, hypertensive patients with preserved systolic function, and to investigate the role of Tissue Doppler imaging (TDI) and Pulmonary venous (PV) flow added to the routine echocardiographic assessment. Patients. 322 patients (age: 70.8±9.1 years) were enrolled. Methods. Mitral inflow pattern, TDI (Ea: early diastolic velocity) and PV flow was assessed to evaluate diastolic function. Deceleration time of mitral E velocity < 150ms, E/Ea≥7 and/or S/D< 1 of PV flow indicated elevated filling pressure (EFP). Patients were divided into four groups: no DD, mild DD, moderate DD and severe DD. Results. In 63 cases we found no DD, mild DD was present in 150 cases, moderate DD in 86 cases and severe DD in 23 cases. Compared with patients without DD, the Ea was decreased in mild and moderate DD (14.8±2.3 vs 12.2±2.4 cm/s, p<0.001; vs 13.3±2.6 cm/s, p=0.005). Normal mitral inflow pattern was found in 149 patients, 86 of them had EFP (58%). Conclusions. One third of elderly hypertensive patients with preserved systolic function had moderate-to-severe asymptomatic DD. More than half of the patients had EFP with normal mitral inflow pattern.

Angiotensin receptor blockade and angiotensin-converting-enzyme inhibition limit adverse remodeling of infarct zone collagens and global diastolic dysfunction during healing after reperfused ST-elevation myocardial infarction

To determine whether therapy with the angiotensin II type 1 receptor blocker (ARB) candesartan and the comparator angiotensin-converting-enzyme inhibitor (ACEI) enalapril during healing after reperfused ST-elevation myocardial infarction (RSTEMI) limit adverse remodeling of infarct zone (IZ) collagens and left ventricular (LV) diastolic dysfunction, we randomized 24 dogs surviving anterior RSTEMI (90-min coronary occlusion) to placebo, candesartan, and enalapril therapy between day 2 and 42. Six other dogs were sham. We measured regional IZ and non-infarct zone (NIZ) collagens (hydroxyproline; types I/III; cross-linking), transforming growth factor-beta (TGF-beta) and topography at 6 weeks, and hemodynamics, LV diastolic and systolic function, and remodeling over 6 weeks. Compared to sham, placebo-RSTEMI differentially altered regional collagens, with more pronounced increase in TGF-beta, hydroxyproline, and type I, insoluble, and cross-linked collagens in the IZ than NIZ, and increased IZ soluble and type III collagens at 6 weeks, and induced persistent LV filling pressure elevation, diastolic and systolic dysfunction, and LV remodeling over 6 weeks. Compared to placebo-RSTEMI, candesartan and enalapril limited adverse regional collagen remodeling, with normalization of type III, soluble and insoluble collagens and decrease in pyridinoline cross-linking in the IZ at 6 weeks, and attenuation of LV filling pressure, diastolic dysfunction, and remodeling over 6 weeks. The results suggest that candesartan and enalapril during healing after RSTEMI prevent rather than worsen adverse remodeling of IZ collagens and LV diastolic dysfunction, supporting the clinical use of ARBs and ACEIs during subacute RSTEMI.

Plasma N-Terminal Pro-Brain Natriuretic Peptide is a sensitive marker of functional severity in hypertrophic cardiomyopathy

Objectives: This study sought to determine the diagnostic utility of measurement of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with hypertrophic cardiomyopathy (HCM), and the capacity of the method to assess the severity of left ventricular (LV) dysfunction. Background: Plasma BNP is useful in heart failure and HCM. Plasma NT-proBNP has been increasingly used in cardiac diseases but there is no report of NT-proBNP measurement in HCM. Methods: We studied 70 ambulatory patients (mean age 32.6±11.4 years) with HCM (septal thickness >15mm, a non-dilated LV with normal ejection fraction). 15 (21.4%) patients had a resting outflow gradient >30mmHg (obstructive) and 55 did not have (non- obstructive). A control group of 20 normal volunteers age and sex matched were enrolled. The pts were examined by Doppler echocardiography and a blood sample was drawn for NT-proBNP measurement (electrochemiluminescence immunoassay Roche). Comparisons were made between HCM and normals, and between subgroups of HCM. Correlations were verified between levels of NT-proBNP and echocardiographic variables. Results: In the HCM group, the mean plasma NT-proBNP was 1312±1364 pg/ml, versus 41.2±28.3 pg/ml in the control group (p<0.0001). The levels of the peptide were correlated with LA diameter (r=0.39; p=0.001), septal thickness (r=0.24; p=0.04). There was no linear correlation with obstruction but there were differences in the concentrations of NT-proBNP between obstructive (2116±1812 pg/ml) and non-obstructive (1103±1176 pg/ml) HCM groups (p=0.02). Patients with Doppler derived signs of LV filling pressure elevation presented higher levels of NT-proBNP than the others. Conclusions: Measurement of plasma NT-proBNP in HCM pts is a sensitive method for diagnosis and functional evaluation. Further studies are necessary to verify the prognostic value of the test in HCM.

Importance of hemodynamic response to therapy in predicting survival with ejection fraction ≤ 20% secondary to ischemic or nonischemic dilated cardiomyopathy

To identify patients with left ventricular ejection fractions ≤ 20% who are likely to survive on tailored medical therapy after referral to transplantation, this study of 152 patients addressed the hypotheses that (1) severely elevated filling pressures initially measured at referral would not necessarily predict poor outcome, (2) survival would be best when low pulmonary wedge pressures could be achieved with therapy tailored for hemodynamic goals, and (3) coronary artery disease would be an independent risk factor for early mortality. Despite an average initial ejection fraction of 0.15, cardiac index of 2.0 liters/min/m 2 and pulmonary artery wedge pressure of 28 mm Hg, the actuarial survival with tailored therapy was 63% at 1 year, with 34 of 41 (83%) deaths occurring suddenly. Survival was not related to initial filling pressure elevation, but was best predicted by the pulmonary artery wedge pressures during therapy; patients achieving pressure of ≤ 16 mm Hg had 1-year survival of 83 vs 38% (p = 0.0001). The other independent predictors were serum sodium and coronary artery disease. Patients with high filling pressures during therapy and coronary artery disease had 21% survival at 1 year. Survival after referral to transplantation with an ejection fraction ≤ 20% is better than previously described. Patients in whom left ventricular filling pressures cannot be adequately reduced by tailored therapy, particularly if coronary artery disease is present, should be considered for early transplantation.