Estimation 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.

Echo-Doppler and strain assessment of filling pressures in adults with congenitally corrected transposition and systemic right ventricles.

Systolic dysfunction of the systemic right ventricle (sRV) is common in adults with transposition of the great arteries and sRV. In acquired disease, diastology analysis for assessment of filling pressures (FP) is paramount in patient care. Retrospective analysis of 47 adults with sRV without prior systemic tricuspid valve surgery undergoing catheterization and echocardiography within 7 days (median -2 [-1, -3]) from January 2000 to February 2021 at our institution. Median age was 48 (31, 55) years, and 16 (34.0%) patients were female. FPs were normal in 21 patients (44.7%). Left atrial size was enlarged in most patients (83.0%) with mean indexed value 58.3 ± 23.4 mL/m2. Tissue Doppler e' was not significantly different between those with high FPs vs. normal (medial 0.07 ± 0.03 vs. 0.08 ± 0.03 m/s, P = 0.63; lateral 0.08 ± 0.04 vs. 0.08 ± 0.04 m/s, P = 0.88). E velocity and subpulmonic mitral regurgitant velocity were higher in those with high FPs (0.9 ± 0.3 vs. 0.6 ± 0.2 m/s, P = 0.005; 3.8 ± 1.1 vs. 2.8 ± 0.9 m/s, P = 0.004). Left atrial reservoir strain, sRV global longitudinal strain, and subpulmonic left ventricular strain were worse in those with high FP (18.0 ± 7.6 vs. 27.9 ± 10.2%, P = 0.0009; -13.0 ± 4.4 vs. -17.9 ± 5.0%, P = 0.002; -16.8 ± 5.7 vs. -23.0 ± 3.8%, P = 0.001). Despite the complex anatomy, FPs can be assessed non-invasively in adults with sRV without prior systemic tricuspid valve surgery. The current guideline algorithm for diastolic dysfunction in acquired heart disease has limited applicability in this population. Given the limitations of Doppler in this heterogeneous population, strain analysis can be a helpful adjunct for estimation of FPs.

Novel Estimation of Left Ventricular Filling Pressure Using 3-D Speckle-Tracking Echocardiography: Assessment in a Decompensated Systolic Heart Failure Model

E/e′ allows for the non-invasive estimation of left ventricular (LV) filling pressure; however, Doppler malalignment can make the estimation unreliable, especially in dilated systolic failing hearts. The ratio of peak early diastolic filling rate to peak early diastolic global strain rate (FRe/SRe), which is a parameter derived from 3-D speckle-tracking echocardiography to estimate filling pressure, may be better applied in dilated systolic failing hearts because it can be obtained without the Doppler method. We investigated whether FRe/SRe could provide a better estimation of filling pressure than E/e′ in 23 dogs with decompensated systolic heart failure induced by microembolization. FRe/SRe had better correlation coefficients with LV end-diastolic pressure (0.75–0.90) than did E/e′ (0.40). The diagnostic accuracy of FRe/SRe in distinguishing elevated filling pressure was significantly higher than that of E/e′. This study indicates that FRe/SRe may provide a better estimation of LV filling pressure than E/e′ in dilated systolic failing hearts.

Abstract 13798: Influence of Advanced Pulmonary Vascular Remodeling on Accuracy of Echocardiographic Parameters of Left Ventricular Filling Pressure

Introduction: Evaluation of left ventricular (LV) filling pressure (FP) plays an important role in the clinical management of pulmonary hypertension (PH). However, the accuracy of echocardiographic parameters for the estimation of LV FP in the presence of pulmonary vascular lesions has not been fully addressed. Methods: We investigated 87 patients diagnosed with PH due to pulmonary vascular lesions (non-cardiac PH; PH NC ) (PH NC group) and 117 patients with ischemic heart disease without reduced LV ejection fraction (&lt;40%) (control group). Mean pulmonary arterial wedge pressure (PAWP) and pulmonary vascular resistance (PVR) were obtained by right heart catheterization. As echocardiographic parameters of LV FP, the ratio of early- (E) to late-diastolic transmitral flow velocity (E/A), ratio of E to early-diastolic mitral annular velocity (E/e'), and left atrial volume index (LAVI) were measured. The PH NC group was subdivided into non-severe and severe groups according to median PVR (5.3 Wood units). Results: PAWP was 12±5 mmHg in controls, 9±4 mmHg in non-severe PH NC , and 8±3 mmHg in severe PH NC . In the control and non-severe PH NC groups, positive correlations were observed between PAWP and E/A (R=0.66 and R=0.41, respectively), E/e' (R=0.36 and R=0.33), and LAVI (R=0.38 and R=0.62). In contrast, in the severe PH NC group, PAWP was only correlated with LAVI (R=0.41, p=0.006). In the control group, PAWP determined E (β=0.45, p&lt;0.001) but PVR did not, whereas both PAWP and PVR were independent determinants of E (β=0.32, p=0.001; and β=-0.35, p&lt;0.001, respectively) in the PH NC group. Conclusions: In the presence of advanced pulmonary vascular lesions, conventional Doppler echocardiographic parameters may not accurately reflect LV FP. Importantly, elevated PVR would lower the E value, even when PAWP is elevated, resulting in blunting of these parameters for the detection of elevated LV FP. LAVI might be a reliable parameter for estimating LV FP in patients with severe non-cardiac PH.

Novel Echocardiographic Approach to Hemodynamic Phenotypes Predicts Outcome of Patients Hospitalized With Heart Failure.

Although in clinical practice heart failure (HF) patients are classified using left ventricular ejection fraction (LVEF), this categorization is insufficient for prognosis, especially when LVEF is preserved or there is a concomitant right ventricular (RV) dysfunction. We hypothesized that a combined noninvasive evaluation of LV forward flow, filling pressure, and RV function would be better than LVEF in predicting all-cause mortality of hospitalized patients with HF. Transthoracic echocardiographic examinations of 603 patients hospitalized with HF were analyzed. In a subsample of 200 patients with HF, LV stroke volume index, LV filling pressure estimation, tricuspid annular plane systolic excursion, and systolic pulmonary artery pressure were combined to determine 4 hemodynamic profiles: normal flow-normal pressure, normal flow-high pressure, low flow without RV dysfunction, and low flow with RV dysfunction profile. This model was then applied in a validation cohort (n=403). Prognosis worsened from the normal flow-normal pressure profile to the low flow with right ventricular dysfunction profile. At the multivariate survival analysis, the model showed independent high risk-stratification capability (P<0.001), even in subgroups of patients with LVEF < or ≥50% (P=0.011 and P<0.001, respectively) and < or ≥40% (P=0.044 and P<0.001, respectively). LVEF and HF classification based on LVEF did not predict outcome. Echocardiographic-derived profiling of LV forward flow, filling pressure, and RV function allowed categorization of patients hospitalized with HF and predicted all-cause mortality independently of LVEF. This model is based on conventional echocardiography, is easy to apply, and is, therefore, suggested for clinical practice.

Right atrial pressure is under estimated by echocardiography in HFpEF patients

The estimation of right atrial pressure (RAP) is important for pulmonary pressure and right ventricular filling pressure estimation. The accuracy of the inferior vena cava study to evaluate RAP has been tested in a few studies, and never in patients with heart failure with preserved ejection fraction (HFpEF) Our study investigated whether the study of inferior vena cava (IVC) size and collapsibility was accurate in a cohort of patients with heart failure with preserved ejection fraction (HFpEF). Between January 2014 and December 2018, 142 patients with suspected HFpEF and pulmonary hypertension (PH), underwent right heart catheterization (RHC) and transthoracic echocardiography within 5 days in our referral centre. The estimating RAP according to IVC size and collapsibility were retrospectively determined. Patients were classified in 3 groups according to the current guidelines: ≤ 2.1 cm that collapses > 50% with a sniff suggested a normal RAP of 3 mm Hg, an IVC diameter > 2.1 cm that collapses < 50% with a sniff suggested a high RAP of 15 mm Hg. A RAP of 8 mmHg was suggested for the other patients. A total of 118 patients (83%) had a possible and complete IVC analysis. Mean RAP estimation by right heart catheterism was 13 ± 5 mmHg. Inferior vena cava at end expiration was 19 ± 7 mm. Thirty-eight patients had an echo estimate RAP of 3 mmHg, whereas hemodynamic RAP in this group was 10 ± 5 mmHg. Forty patients had an echo estimate RAP of 8 mmHg, whereas hemodynamic RAP in this group was 14 ± 5 mmHg. 37 patients had an echo estimate RAP of 15 mmHg, whereas hemodynamic RAP in this group was 17 ± 5 mmHg. The RAP difference estimation of echo and hemodynamics was > 5 mmHg in respectively 66%, 40% and 39% of the patients in each group ( Fig. 1 ). In HFpEF patients, RAP is high. The study of the IVC is feasible in most cases but the estimation of the RAP is hazardous. This could have consequence in the evaluation of pulmonary pressure.

Left-ventricular filling pressure estimation in HFpEF, is echocardiography reliable?

Echocardiography is frequently used for the left-ventricular filling pressure (LVFP) measurement in heart failure with preserved ejection fraction (HFpEF), however invasive measurements remain the gold standard. We aimed to evaluate the diagnostic value of different echocardiographic parameters taken individually and the 2016 echocardiographic grading algorithms for predicting LVFP. Invasive hemodynamic and echocardiographic measurements were simultaneously performed in 90 patients with heart failure New York Heart Association class ≥ II, left-ventricular ejection fraction (LVEF) ≥ 50%, enrolled prospectively in our center for pulmonary hypertension evaluation. Mean age of the study patients was 70 ± 8 years, 64% were female, mean LVEF was 63 ± 5%, and 39% had atrial fibrillation at the time of measurement. Mean PAWP and mPAP were 19 ± 6 and 37 ± 11 mmHg, respectively. Taken individually, PAWP was correlated with E/E’ mean ( r = 0.23; P = 0.04), E pick ( r = 0.36; P = 0.0009), left-ventricular mass ( r = 0.27; P = 0.008), tricuspid regurgitation (tr) jet velocity ( r = 0.27, P = 0.02) and left atrial volume (LAVi) ( r = 0.24; P = 0.03). Correlation coefficients were higher in patients without atrial fibrillation. The area under the curve for classifying elevated LVFP by ASE/EACVI algorithm taking into account E/e’ mean, TR velocity and LAVi algorithm was 0.72. Echocardiographic parameters, including the E/e’ ratio, have a poor to moderate predictive value for the estimation of invasively acquired PAWP especially in patient with atrial fibrillation. Using the 2016 recommendations ASE/EACVI algorithm to evaluate LVFP has to be used with caution.

Management of acute heart failure: Contribution of daily bedside echocardiographic assessment on therapy adjustment with impact measure on the 30-day readmission rate (JECICA).

There are currently one million heart failure (HF) patients in France and the rate is progressively increases due to population aging. Acute decompensation of HF is the leading cause of hospitalization in people over 65 years of age with a 25% re-hospitalization rate in the first month. Expenses related to the management of HF in France in 2013 amounted to more than one billion euros, of which 65% were for hospitalizations alone. The management of acute decompensation is a challenge, due to the complexity of clinical and laboratory evaluation leading to therapeutic errors, which in turn leads to longer hospitalization, high early re-hospitalization and complications. Therapeutic adjustment, especially diuretic, in the acute phase (during hospitalization) affects early re-hospitalization rates (within 30 days). These adjustments can be based on clinical estimation and laboratory parameters, but echocardiography has been shown to be superior in estimating filling pressures (FP) compared to clinical and laboratory parameters.We hypothesize that a simple daily bedside echocardiographic assessment could provide a reproducible estimation of FP with an evaluation of mitral inflow and the inferior vena cava (IVC). This could allow a more reliable estimate of the true blood volume of the patient and thus lead to a more suitable therapeutic adjustment. This in turn should lead to a decrease in early re-admission rate (primary endpoint) and potentially decrease six-month mortality and rate of complications.

P3737Left ventricular filling pressure estimation in HFpEF, is echocardiography reliable?

P3737Left ventricular filling pressure estimation in HFpEF, is echocardiography reliable?

Noninvasive assessment of left ventricular end-diastolic pressure by deceleration time of early diastolic mitral annular velocity in patients with heart failure.

To examine the diagnostic ability of the deceleration time of early mitral annular velocity (e'DT) as determined by tissue Doppler velocity image, a method for assessing LV filling pressure. Estimation of LV filling pressure by Doppler echocardiography requires a combination of various parameters. Therefore, there remains a need for a simple index in LV filling pressure estimation. The e' is known to be reduced and delayed with increased LV filling pressure during development of heart failure. Thus, we hypothesized that e'DT would be shortened as LV filling pressure is increased. Simultaneous LV end-diastolic pressure (LVEDP) measurement and Doppler echocardiography were performed in 94 patients who were admitted to our hospital for heart failure. Exclusion criteria were atrial fibrillation, mitral valve surgery, and acute coronary syndrome. The e'DT in 31 patients with LVEDP >16mmHg (68±13ms) was significantly shorter than that in 63 patients with LVEDP ≤16mmHg (103±27ms). Both e'DT and early transmitral flow velocity (E)/e' were significantly correlated with LVEDP. In 30 patients with 10-14 E/e', significance of correlation in e'DT was remained, while E/e' was not. The area under the ROC curve for prediction of LVEDP >16mmHg for e'DT was greater than that for E/e' (0.91 vs 0.74, P=.046). The e'DT is useful to assess LV filling pressure, especially in 10-14 E/e'. This simple tissue Doppler index may be a potential parameter for easily distinguishing between mild and severe heart failures.

Assessment of central venous physiology of Fontan circulation using peripheral venous pressure

ObjectiveElevated central venous pressure is a major cause of morbidity and mortality after the Fontan operation. The difference between mean circulatory filling pressure and central venous pressure, a driving force of venous return, is important in determining dynamic changes in central venous pressure in response to changes in ventricular properties or loading conditions. Thus, noninvasive central venous pressure and mean circulatory filling pressure estimation may contribute to optimal management in patients undergoing the Fontan operation. We tested the hypothesis that central venous pressure and mean circulatory filling pressure in those undergoing the Fontan operation can be simply estimated using peripheral venous pressure and arm equilibrium pressure, respectively. MethodsThis study included 30 patients after the Fontan operation who underwent cardiac catheterization (median 8.6, 3.4-42 years). Peripheral venous pressure was measured at the peripheral vein in the upper extremities. Mean circulatory filling pressure was calculated by the changes of arterial pressure and central venous pressure during the Valsalva maneuver. Arm equilibrium pressure was measured as equilibrated venous pressure by rapidly inflating a blood pressure cuff to 200 mm Hg. ResultsCentral venous pressure and peripheral venous pressure were highly correlated (central venous pressure = 1.6 + 0.68 × peripheral venous pressure, R = 0.86, P < .0001). Stepwise multivariable regression analysis showed that only peripheral venous pressure was a significant determinant of central venous pressure. Central venous pressure was accurately estimated using regression after volume loading by contrast injection (R = 0.82, P < .0001). In addition, arm equilibrium pressure measurements were highly reproducible and robustly reflected invasively measured mean circulatory filling pressure (mean circulatory filling pressure = 9.1 + 0.63 × arm equilibrium pressure, R = 0.88, P < .0001). ConclusionsCentral venous pressure and mean circulatory filling pressure can be noninvasively estimated by peripheral venous pressure and arm equilibrium pressure, respectively. This should help clarify unidentified Fontan pathophysiology and the mechanisms of Fontan failure progression, thereby helping construct effective tailor-made approaches to prevent Fontan failure.

Functional deficiency of natural killer cells in acute coronary syndrome is related to ineffective degranulation

pressure, and (2) to the impairment of the LV longitudinal function by reducing coronary flow reserve. In asymptomatic patients with moderate to severe AS and preserved LV ejection fraction, BNP release is mainly determined by LV end-diastolic volume, LV filling pressure estimation (diastolic burden) and exercise LV longitudinal strain (subclinical LV dysfunction). Further studies are needed to clarify the role of those determinants in risk stratification of asymptomatic patients with AS. P.L. This work was supported by the Belgian National Fund for Scientific Research (F.R.S-FNRS T.0028.14). C.H. received grants from the Montreal Heart Institute Foundation (Bourse du Bal du Cœur), and the Department of Medicine of the University of Montreal and the Association des Cardiologues du Quebec.

Young Investigator Award session - Clinical: 11/12/2013, 12:45-13:45 * Location: Bursa

Young Investigator Award session - Clinical: 11/12/2013, 12:45-13:45 * Location: Bursa

Use and Limitations of E/e' to Assess Left Ventricular Filling Pressure by Echocardiography

Measurement of left ventricular (LV) filling pressure is useful in decision making and prediction of outcomes in various cardiovascular diseases. Invasive cardiac catheterization has been the gold standard in LV filling pressure measurement, but carries the risk of complications and has a similar predictive value for clinical outcomes compared with non-invasive LV filling pressure estimation by echocardiography. A variety of echocardiographic measurement methods have been suggested to estimate LV filling pressure. The most frequently used method for this purpose is the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), which has become central in the guidelines for diastolic evaluation. This review will discuss the use the E/e' ratio in prediction of LV filling pressure and its potential pitfalls.

Letter by Ogunyankin Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure”

To the Editor: I read with interest the article by Mullens et al1 about patients with severe heart failure, and I agree with their important warning that using annular tissue Doppler velocity indices as the sole predictors of elevated left ventricular (LV) filling pressure is inaccurate. Some points in the article deserve additional clarification. The authors cite published data on the ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) with pulmonary capillary wedge pressure (PCWP) in a wide range of cardiac patients. However, the strength of the correlation in the validation articles2,3 may not justify the use of the …

Letter by Dokainish Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure”

HomeCirculationVol. 120, No. 7Letter by Dokainish Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Dokainish Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure” Hisham Dokainish, MD Hisham DokainishHisham Dokainish Baylor College of Medicine, Houston, Tex Search for more papers by this author Originally published18 Aug 2009https://doi.org/10.1161/CIRCULATIONAHA.109.854547Circulation. 2009;120:e47To the Editor:In their recent article, Mullens et al1 tested the ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) in 106 patients with left ventricular ejection fraction (LVEF) ≤30% on admission and after treatment for decompensated heart failure. They found no correlation between E/Ea and pulmonary capillary wedge pressure (PCWP), particularly in patients with larger LV volumes, more impaired cardiac indexes, and cardiac resynchronization therapy. This study tested previously validated and commonly used echo Doppler variables in the real-world setting, especially in patients with severe systolic heart failure requiring intravenous therapy, where such variables have diagnostic and therapeutic importance.These findings are of particular interest because they contrast with correlations between E/Ea and PCWP found in prior investigations using similar patients.2,3 Commendably, the authors divided the population into patients with cardiac resynchronization therapy and those without to account for the impact of cardiac pacing on myocardial longitudinal velocities, particularly in the septum. Nonetheless, the authors did not find a correlation between E/Ea and PCWP in these patients, and they found weak correlations between mitral deceleration time, mitral E/late diastolic velocity ratio (A), and left atrial volume and PCWP. Weak correlations of such conventional echo Doppler variables with PCWP (in particular, of mitral deceleration time) also contrast with findings by previous investigators4 and add to the uniqueness of the current article.One of the main reasons that this study discovered different findings than prior investigations is likely technical: As seen in Figure 5, the lateral Ea was interpreted as 14.8 cm/s,1 a value much too high for a patient with LVEF ≤30% (who normally would have a lateral Ea ≤8 cm/s).2 The apparent overinterpretation of the Ea value appears to be due to spectral broadening, resulting in an overestimation of Ea and an underestimation of E/Ea. Thus, one wonders whether such measurement issues were systemic in this study. Similarly, it is curious that, in Figure 5, a patient with such an elevated E/late diastolic ratio and rapid mitral deceleration time had a simultaneous PCWP of only 14 mm Hg,1 which is in stark contrast to the findings of prior studies.4 Therefore, the true simultaneity of the PCWP with respect to the Doppler measurements, including E/Ea, could potentially be questioned.I commend the authors on such a thought-provoking study of Doppler indices in the real world of severe systolic heart failure. As recommended by experts in the field,5 no single echo-Doppler measure should ever be used in isolation for the assessment of LV filling pressures. Rather, a constellation of findings (eg, mitral inflow, tissue Doppler, left atrial size, and pulmonary venous measurements, the latter of which were not reported in this study and are of particular use in this patient population) should be used for the accurate estimation of LV filling pressures, which echo-Doppler readily and reproducibly provides.DisclosuresNone. References 1 Mullens W, Borowski AG, Curtin RJ, Thomas JD, Tang WH. Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure. Circulation. 2009; 119: 62–70.LinkGoogle Scholar2 Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol. 1997; 30: 1527–1533.CrossrefMedlineGoogle Scholar3 Dokainish H, Zoghbi WA, Al-Bakshy FA, Dhir M, Quinones MA, Nagueh SF. Optimal noninvasive assessment of LV filling pressures: a comparison of tissue Doppler echocardiography and BNP in patients with pulmonary artery catheters. Circulation. 2004; 109: 2432–2439.LinkGoogle Scholar4 Nishimura RA, Appleton CP, Redfield MM, Ilstrup DM, Holmes DR Jr, Tajik AJ. Noninvasive Doppler echocardiographic evaluation of left ventricular filling pressures in patients with cardiomyopathies: a simultaneous Doppler echocardiographic and cardiac catheterization study. J Am Coll Cardiol. 1996; 28: 1226–1233.CrossrefMedlineGoogle Scholar5 Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelisa A. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009; 22: 107–133.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 18, 2009Vol 120, Issue 7 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.854547PMID: 19687366 Originally publishedAugust 18, 2009 PDF download Advertisement SubjectsCongenital Heart DiseaseEchocardiography

Letter by Nagueh et al Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure”

To the Editor: We read with interest the article by Mullens et al,1 which reported that, in patients with decompensated systolic heart failure, the early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) ratio may not be reliable in predicting filling pressures, especially in patients with larger left ventricular volumes, lower cardiac indices, and cardiac resynchronization therapy pacing. We want to express caution in interpreting these results because they contradict abundant data previously published and validated.2 Our concern is that the conclusions proffered may convey the wrong message about the use of E/Ea as a noninvasive estimate of filling pressures in patients with heart failure and left ventricular systolic dysfunction, in whom the ratio generally works well. The first major issue is the composition of …

Left Ventricular Filling Pressure Estimation at Rest and During Exercise in Patients With Severe Aortic Valve Stenosis: Comparison of Echocardiographic and Invasive Measurements

The Doppler index of left ventricular (LV) filling (E/e') is recognized as a noninvasive measure for LV filling pressure at rest but has also been suggested as a reliable measure of exercise-induced changes. The aim of this study was to investigate changes in LV filling pressure, measured invasively as pulmonary capillary wedge pressure (PCWP), at rest and during exercise to describe the relation with E/e' in patients with severe aortic stenosis. Twenty-eight patients with an aortic valve areas<1 cm(2) performed a multistage supine bicycle exercise test until exhaustion. PCWP, E/e'(septal), and E/e'(lateral) were determined simultaneously by echocardiography at rest and at maximal tolerated workload. PCWP increased significantly from 18+/-8 mm Hg at rest to 39+/-10 mm Hg at peak exercise (P < .0001). E, e'(septal), and e'(lateral) increased with exercise, whereas E/e'(septal) remained unchanged (19+/-6 vs 19+/-6; P=NS), and only minimal changes were observed in E/e'(lateral) (14+/-4 vs 15+/-4; P=.05). E/e'(septal) and E/e'(lateral) were significantly correlated with PCWP at rest (r=0.72, P < .0001, and r=0.67, P < .0001, respectively) as well as at peak exercise (r=0.66, P=.0003, and r=0.47, P=.02, respectively), with nearly similar slopes of the linear regression lines. The intercepts, however, increased by 18 mm Hg (P=.01) and by 19 mm Hg (P=.01) at peak exercise, respectively. Changes in E/e'(septal) and E/e'(lateral) were not related to changes in PCWP with exercise (P=NS). Instead, the ratio of E velocity during exercise to e'(septal) at rest (E(exercise)/e'(septal, rest)) was correlated with PCWP during exercise (r=0.61, P=.001), and furthermore, E(exercise)-E(rest)/e'(septal, rest) was related to changes in PCWP (r=0.45, P=.02). The results for the lateral side were r=0.50 (P=.01) and r=0.44 (P=.03), respectively. E/e' is well correlated with PCWP at rest. However, E/e' cannot be used to detect exercise-induced changes in PCWP in patients with severe aortic stenosis. Using the ratio of E during exercise to e' at rest may result in a better estimate of the increase in PCWP during exercise.

Abstract 4726: How Reliable is Left Atrial Volume in Estimating Left Atrial Pressure in Advanced Heart Failure Patients? Three-Dimensional Echocardiographic and Catheterization Studies

Previous work has suggested that left atrial (LA) size reflects LA pressure but direct correlative studies of pressure and volume are scant. Furthermore, evaluation of LA size has typically been based on 1-dimensional measures or 2D echo-derived LA area or volume. The aim of this study was to explore whether 3D LA volume could accurately indicate LA pressure in advanced heart failure (HF) patients, in whom filling pressure estimation is clinically relevant. We studied 32 patients with advanced HF both with 3D echo (3DE) performed simultaneously or close to the time of pulmonary capillary wedge pressure (PCWP) measurement by cardiac catheterization. From full volume 3D data sets of the left heart, maximum LA volume (MaxLAV) and minimum LA volume (MinLAV), and volumes indexed to body surface area (MaxMAVI and MinLAVI) were calculated. Mean PCWP was obtained from standard invasive recordings. Results: The mean LVEF was 23±8. The MaxLAV was 101±38 ml with a range of 34 to 173. MaxLAVI was 50±16 ml/m2 with a range of 19 to 81. MinLAV was 76±37 with a range of 19 to 145. MinLAVI was 38±16 ml/m2, with a range of 12 to 72. The PCWP (mm Hg) was 21±8 with a range of 2 to 34. The correlation between PCWP, and MaxLAV, MaxLAVI, MinLAV and MinLAVI were respectively r=0.193, p=0.28; r=0.25, p=0.16; r=0.24, p=0.17; and r=0.31, p=0.08. Within the group, there were some patients with normal or low PCW but with larger LA volumes (&gt;median) while some patients with high filling pressures did not necessarily have higher LA volumes. Conclusion: In advanced HF patients, maximum or minimum LA volumes do not correlate with PCWP. LA remodeling and depletion of LA volume reserve in these patients is most likely responsible for the lack of correlation. Thus, in advanced HF patients, LA volume cannot be used to assess left heart filling pressure.

Usefulness of B-Type Natriuretic Peptide Levels to Predict Left Ventricular Filling Pressures in Patients With Body Mass Index >35, 31 to 35, and ≤30 kg/m 2

Noninvasive left ventricular (LV) pressure estimation in obese patients has not been well described. Simultaneous B-type natriuretic peptide (BNP) and echocardiographic Doppler examinations were performed in patients with dyspnea undergoing cardiac catheterization. Patients were divided into body mass index (BMI) >35 (markedly obese), 31 to 35 (obese), and < or =30 kg/m2 (nonobese). BNP levels and mitral early diastolic/tissue Doppler annular velocity (E/Ea) were compared with invasively measured LV end-diastolic and pre-atrial (pre-A) pressures. Seventy-two patients were studied. Except for BMI, LV mass index, and LV diastolic dimension, there were no significant differences in baseline, echocardiographic Doppler, or hemodynamic characteristics among the groups. However, BNP was significantly lower in markedly obese compared with obese and nonobese patients (116 +/- 187 vs 241 +/- 674 and 277 +/- 352 pg/ml, respectively; p = 0.03). BNP did not correlate with LV pre-A pressure in markedly obese patients (R = 0.13, p = 0.47), whereas BNP significantly correlated with this variable in the obese (R = 0.64) and nonobese (R = 0.58) groups. Mitral E/Ea significantly correlated with LV pre-A and LV end-diastolic pressures in all BMI groups. In markedly obese patients with dyspnea, BNP did not correlate with invasively measured LV filling pressure, whereas this correlated in obese and nonobese patients. However, mitral E/Ea significantly correlated with LV filling pressures in all BMI groups. In conclusion, BNP is not recommended for LV filling pressure estimation in ambulatory patients with dyspnea with BMI >35 kg/m2.