Left Ventricular Filling Research Articles

Abstract We105: cBIN1 Gene Therapy Improves Left Ventricular Filling Pressure in a Canine Model of Ischemic Dilated Cardiomyopathy

Introduction: In heart failure patients, increased left ventricular end diastolic pressure (LVEDP) is pathognomonic of myocardial dysfunction. Previously, we presented that gene therapy with exogeneous cardiac bridging integrator 1 (cBIN1), a membrane scaffolding protein that organizes T-tubule microdomains and is decreased in failing hearts, recovers systolic function in a canine model of chronic ischemic dilated cardiomyopathy (IDCM). The effect of catheter-based delivery of cBIN1 gene therapy on increased LVEDP is unclear. Hypothesis: We tested the hypothesis that cBIN1 gene therapy improves LVEDP in a canine model of IDCM. Methods: Twelve healthy dogs (30±2 kg) underwent left anterior descending artery ligation and developed IDCM with LVEF <40% and NT-proBNP >900 pmol/L over 3–4 months. Animals received a single application at 20 subendocardial LV sites of either AAV9-GFP (control, n=6) or AAV9-cBIN1 (n=6) using a MyoStar catheter-based injection. Pressure-volume loops were acquired in vivo, including measurement of LVEDP, end-systolic pressure-volume relation (ESPVR), isovolumic relaxation time (IVRT) and isovolumetric contraction time (IVCT). Measurements were performed on the day prior to administering the therapy ( pre-therapy ) and 5–8 weeks post-intramyocardial injection ( post-therapy ). For statistics, student t-test was used, and p<0.05 refers as significant. Results are reported as mean±SD. Results: In AAV9-GFP control-treated dogs, compared with pre-therapy, post-therapy LVEDP elevated significantly (13±1 vs. 17±1 mmHg, p=0.002, Figure A ), whereas in the cBIN1-treated cohort, elevated LVEDP improved significantly (13±4 vs. 11±3 mmHg, p=0.042). With control therapy, ESPVR exhibited a significant decrease in contractility (1.40±0.44 vs. 1.81±0.49 mmHg/mL, p=0.001, Figure B ), whereas cBIN1 therapy caused a substantial improvement in ESPVR (1.54±0.71 vs. 1.34±0.43 mmHg/mL, p=0.022, Figure B ). At the post-therapy time-point, compared with control therapy, cBIN1 therapy improved IVRT (96±10 vs. 72±8 ms, p<0.001, Figure C ) and IVCT (49±4 vs. 40±3 ms, p=0.009, Figure D ). Conclusion: cBIN1 gene therapy reduces elevated LV filling pressure and improves overall hemodynamics in a canine model of chronic IDCM.

Characterization and Mortality Risk of Impaired Left Ventricular Filling in COPD.

In COPD, impaired left ventricular (LV) filling might be associated with coexisting HFpEF or due to reduced pulmonary venous return indicated by small LV size. We investigate the all-cause mortality associated with small LV or HFpEF and clinical features discriminating between both patterns of impaired LV filling. We performed transthoracic echocardiography (TTE) in patients with stable COPD from the COSYCONET cohort to define small LV as LVEDD below the normal range and HFpEF features according to recommendations of the European Society of Cardiology. We assessed the E/A and E/e' ratios, NT-pro-BNP, hs-Troponin I, FEV1, RV, DLCo, and discriminated patients with small LV from those with HFpEF features or no relevant cardiac dysfunction as per TTE (normalTTE). The primary outcome was all-cause mortality after four and a half year. In 1752 patients with COPD, the frequency of small LV, HFpEF-features, and normalTTE was 8%, 16%, and 45%, respectively. Patients with small LV or HFpEF features had higher all-cause mortality rates than patients with normalTTE, HR: 2.75 (95% CI: [1.54 - 4.89]) and 2.16 (95% CI: [1.30 - 3.61]), respectively. Small LV remained an independent predictor of all-cause mortality after adjusting for confounders including exacerbation frequency and measures of RV, DLCo, or FEV1. Compared to normalTTE, patients with small LV had reduced LV filling, as indicated by lowered E/A. Yet in contrast to patients with HFpEF-features, patients with small LV had normal LV filling pressure (E/e') and lower levels of NT-pro-BNP and hs-Troponin I. In COPD, both small LV and HFpEF-features are associated with increased all-cause mortality and represent two distinct patterns of impaired LV filling.

Association of Impaired Left Ventricular Mitral Filling from 4D Flow Cardiac MRI and Prognosis of Hypertrophic Cardiomyopathy.

Purpose To investigate whether the peak early filling rate normalized to the filling volume (PEFR/FV) estimated from four-dimensional (4D) flow cardiac MRI may be used to assess impaired left ventricular (LV) filling and predict clinical outcomes in individuals with hypertrophic cardiomyopathy (HCM). Materials and Methods Cardiac MRI with a 4D flow sequence and late gadolinium enhancement (LGE), as well as echocardiography, was performed in 88 individuals: 44 participants with HCM from a French prospective registry (ClinicalTrials.gov; NCT01091480) and 44 healthy volunteers matched for age and sex. In participants with HCM, a composite primary end point was assessed at follow-up, including unexplained syncope, new-onset atrial fibrillation, hospitalization for congestive heart failure, ischemic stroke, sustained ventricular arrhythmia, septal reduction therapy, and cardiac death. A Cox proportional hazard model was used to analyze associations with the primary end point. Results PEFR/FV was significantly lower in the HCM group (mean age, 51.8 years ± 18.5 [SD]; 29 male participants) compared with healthy volunteers (mean, 3.35 sec-1 ± 0.99 [0.90-5.20] vs 4.42 sec-1 ± 1.68 [2.74-11.86]; P < .001) and correlated with both B-type natriuretic peptide (BNP) level (r = -0.31; P < .001) and the ratio of pulsed Doppler early transmitral inflow to Doppler tissue imaging annulus velocities (E/E'; r = -0.54; P < .001). At a median follow-up of 2.3 years (IQR, 1.7-3.3 years), the primary end point occurred in 14 (32%) participants. A PEFR/FV of 2.61 sec-1 or less was significantly associated with occurrence of the primary end point (hazard ratio, 9.46 [95% CI: 2.61, 45.17; P < .001] to 15.21 [95% CI: 3.51, 80.22; P < .001]), independently of age, BNP level, E/E', LGE extent, and LV and left atrial strain according to successive bivariate models. Conclusion In HCM, LV filling evaluated with 4D flow cardiac MRI correlated with Doppler and biologic indexes of diastolic dysfunction and predicted clinical outcomes. Keywords: Diastolic Function, Left Ventricular Filling, Hypertrophic Cardiomyopathy, Cardiac MRI, 4D Flow Sequence Clinical trial registration no. NCT01091480 Supplemental material is available for this article. © RSNA, 2024.

Predisposing Risk Factors Affecting Reversibility of Left Ventricular Diastolic Filling Pattern in Patients with Preserved Ejection Fraction

Predisposing Risk Factors Affecting Reversibility of Left Ventricular Diastolic Filling Pattern in Patients with Preserved Ejection Fraction

CMR 2-77 - Assessment of Left Ventricular Filling Pressure by Cardiac Magnetic Resonance Imaging as a Predictor of Adverse Outcomes in Patients with Non-ischemic Cardiomyopathy

CMR 2-77 - Assessment of Left Ventricular Filling Pressure by Cardiac Magnetic Resonance Imaging as a Predictor of Adverse Outcomes in Patients with Non-ischemic Cardiomyopathy

HeartWare Left Ventricular Assist Device Exercise Hemodynamics With Speed Adjustment Based on Left Ventricular Filling Pressures.

Functional capacity remains limited in heart failure patients with left ventricular assist devices (LVADs) due to fixed pump speed and inability to offload the left ventricle adequately. We hypothesized that manually adjusting LVAD speed during exercise based on pulmonary capillary wedge pressures would increase total cardiac output and maximal oxygen consumption. Two participants with a HeartWare LVAD underwent an invasive ramp study at rest followed by an invasive cardiopulmonary stress test exercising in two randomized phases: fixed speed and adjusted speed. In the latter phase, speed was adjusted every 1 minute during exercise at ±20 rpm/1 mm Hg change from baseline pulmonary capillary wedge pressure. There was no difference in maximal oxygen consumption between the two phases, with a modest increase in total cardiac output during speed adjustment. Filling pressures were initially controlled during speed adjustment until speed was capped at 4,000 rpm, at which point filling pressures increased. Blood pressure was variable. The pressure across the head of the pump (ΔP) was higher with speed adjustment. Contrary to our hypothesis, LVAD speed adjustment during exercise did not improve total cardiac output and functional capacity. This variable response may be attributed to the native cardiac reserve and baroreceptor response; however, additional studies are needed.

Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients

Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied. We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients' early diastolic mitral inflow (E), septal mitral annulus relaxation (e'), and peak tricuspid regurgitation velocity before and immediately after exercise. Over a mean follow-up of 3.3±3.4years, patients with E/e' ≥15 with exercise (n=1,323; 9.2%) had lower exercise capacity (7.3±2.1 vs 9.1±2.4 metabolic equivalents, P<.0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P<.0001). Approximately 6% (n=837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e' ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P<.0001) compared with those with poststress E/e' ≤ 8. Those with an E/e' of 9 to 14, while at lower risk than the E/e' ≥15 cohort (hazard ratio [HR]= 0.58 [0.48-0.69]; P<.0001), had higher risk than if E/e' ≤8 (HR= 1.56 [1.37-1.78], P<.0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e' ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P<.0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e' ≤ 15 after exercise, patients with E/e' ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR= 8.99 [4.7-17.3], P<.0001). Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.

The Left Atrial Area Derived Cardiovascular Magnetic Resonance Left Ventricular Filling Pressure Equation Shows Superiority over Integrated Echocardiography.

Background and objectives: Evaluating left ventricular filling pressure (LVFP) plays a crucial role in diagnosing and managing heart failure (HF). While traditional assessment methods involve multi-parametric transthoracic echocardiography (TTE) or right heart catheterisation (RHC), cardiovascular magnetic resonance (CMR) has emerged as a valuable diagnostic tool in HF. This study aimed to assess a simple CMR-derived model to estimate pulmonary capillary wedge pressure (PCWP) in a cohort of patients with suspected or proven heart failure and to investigate its performance in risk-stratifying patients. Materials and methods: A total of 835 patients with breathlessness were evaluated using RHC and CMR and split into derivation (85%) and validation cohorts (15%). Uni-variate and multi-variate linear regression analyses were used to derive a model for PCWP estimation using CMR. The model's performance was evaluated by comparing CMR-derived PCWP with PCWP obtained from RHC. Results: A CMR-derived PCWP incorporating left ventricular mass and the left atrial area (LAA) demonstrated good diagnostic accuracy. The model correctly reclassified 66% of participants whose TTE was 'indeterminate' or 'incorrect' in identifying raised filling pressures. On survival analysis, the CMR-derived PCWP model was predictive for mortality (HR 1.15, 95% CI 1.04-1.28, p = 0.005), which was not the case for PCWP obtained using RHC or TTE. Conclusions: The simplified CMR-derived PCWP model provides an accurate and practical tool for estimating PCWP in patients with suspected or proven heart failure. Its predictive value for mortality suggests the ability to play a valuable adjunctive role in echocardiography, especially in cases with unclear echocardiographic assessment.

Cardiac Magnetic Resonance Left Ventricular Filling Pressure Is Associated with NT-proBNP in Patients with New Onset Heart Failure.

Background and Objectives: Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping and estimating left ventricular (LV) filling pressure (LVFP). The N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is released from cardiac myocytes in response to mechanical load and wall stress. This study sought to investigate if CMR-derived LVFP is associated with the serum levels of NT-proBNP and, in addition, if it provides any incremental prognostic value in heart failure (HF). Materials and Methods: This study recruited 380 patients diagnosed with HF who underwent same-day CMR and clinical assessment between February 2018 and January 2020. CMR-derived LVFP was calculated, as previously, from long- and short-axis cines. During CMR assessment, serum NT-proBNP was measured. The pathological cut-offs were defined as follows: NT-proBNP ≥ 125 pg/mL and CMR LVFP > 15 mmHg. The incidence of HF hospitalisation was treated as a clinical outcome. Results: In total, 305 patients had NT-proBNP ≥ 125 pg/mL. Patients with raised NT-proBNP were older (54 ± 14 vs. 64 ± 11 years, p < 0.0001). Patients with raised NT-proBNP had higher LV volumes and mass. In addition, CMR LVFP was higher in patients with raised NT-proBNP (13.2 ± 2.6 vs. 15.4 ± 3.2 mmHg, p < 0.0001). The serum levels of NT-proBNP were associated with CMR-derived LVFP (R = 0.42, p < 0.0001). In logistic regression analysis, this association between NT-proBNP and CMR LVFP was independent of all other CMR variables, including LV ejection fraction, LV mass, and left atrial volume (coefficient = 2.02, p = 0.002). CMR LVFP demonstrated an independent association with the incidence of HF hospitalisation above NT-proBNP (hazard ratio 2.7, 95% confidence interval 1.2 to 6, p = 0.01). Conclusions: A CMR-modelled LVFP is independently associated with serum NT-proBNP levels. Importantly, it provides an incremental prognostic value over and above serum NT-proBNP levels.

Routine Non-Invasive Cardiac Imaging Indices Cannot Reliably Detect Elevated Left Ventricular Filling Pressure

Routine Non-Invasive Cardiac Imaging Indices Cannot Reliably Detect Elevated Left Ventricular Filling Pressure

Elevated Left Ventricular Filling Pressure as an Early Predictor of Progression of White-coat Hypertension to Sustained Hypertension

Background: White-coat hypertension is commonly observed in subjects presenting with elevated office blood pressure measurements. Although white-coat hypertension does not require medication long-term, studies have observed progression to sustained hypertension in about 30% of individuals. Left ventricular diastolic abnormalities have been described in some individuals with white-coat hypertension and early hypertension. Objective: The present study is a prospective study of follow-up of individuals with white-coat hypertension and the correlation of left ventricular diastolic parameters as determinants of the development of sustained hypertension. Materials and Methods: Individuals diagnosed to have white-coat hypertension based on elevated office blood pressure measurements and normal ambulatory blood pressure measurements were included in the study and were evaluated by echocardiography for left ventricular diastolic function and filling pressures (E/A ratio, E wave deceleration time, E/E’ ratio). They were followed up for 1-year to assess for the development of sustained hypertension and to correlate with the initial echocardiographic parameters. Results: A total number of 32 individuals with white coat hypertension were followed up for 1 year period. Moreover, 25 (78.12%) subjects remained to be normotensive and 7 (21.88%) subjects developed sustained hypertension. There was no significant correlation between E/A, and E wave deceleration time in all the subjects. E/E’ ratio had a positive correlation (R-value 0.77) in subjects who developed sustained hypertension over a 1-year follow-up. Conclusion: Echocardiographic evaluation of left ventricular filling pressure by E/E’ ratio can be considered as an early predictor for the development of sustained hypertension in white-coat hypertension in a long-term follow-up.

Bendopnea Is Due To Elevated Left Ventricular Filling Pressures Rather Than Elevated Pulmonary Artery Pressures

Bendopnea Is Due To Elevated Left Ventricular Filling Pressures Rather Than Elevated Pulmonary Artery Pressures

Abstract WP182: Diastolic Dysfunction With Elevated Left Ventricular Filling Pressures Is Associated With Embolic Stroke Of Undetermined Source And Atrial Fibrillation Detection After Ischemic Stroke

Introduction: Diastolic dysfunction, particularly with elevated left ventricle filling pressure (LVFP) is known to be a strong independent predictor of all-cause mortality and major cardiac events. There is limited data on the role of diastolic function in ischemic stroke. We hypothesize that diastolic dysfunction with elevated LVFP is more likely to be present in patients with Embolic stroke of undetermined source (ESUS) compared to non-cardioembolic stroke and is associated with AF on cardiac monitoring in the ESUS group. Methods: This is a single center retrospective study that included adult patients with a diagnosis of acute ischemic stroke from 2014 to 2016. We excluded patients with confirmed cardioembolic stroke and those with indeterminate diastolic function. ESUS was defined as no ipsilateral stenoses ≥ 50%, cardiac telemetry for at least two weeks without evidence of atrial fibrillation or atrial flutter, and a LVEF ≥ 30%. A transthoracic echocardiogram was performed and interpreted by cardiologists. Baseline patient characteristics and clinical variables were compared among patients with and without diastolic dysfunction. Potential associations between diastolic dysfunction, ESUS and AF detection in ESUS patients were assessed using logistic regression. Results: There were 509 patients, the mean age was 64.19, 54.81% were male, and 146 had LVFP data. Diastolic dysfunction overall was not associated with ESUS (adjusted OR 1.44, 95% CI 0.91-2.28, p = 0.125) or AF detection on cardiac monitoring (adjusted OR 1.87, 95% CI 0.75-4.70, p = 0.183). However, diastolic dysfunction and elevated LVFP was associated with ESUS subtype (adjusted OR 2.26, 95% CI 1.03-4.93, p = 0.041) and AF detection on cardiac monitoring (adjusted OR 3.58, 95% CI 1.07-12.01, p = 0.039). Conclusion: Our study suggests that diastolic dysfunction with elevated LVFP is associated with ESUS stroke subtype and AF detection on cardiac monitoring. Therefore, the presence of diastolic dysfunction with elevated LVFP may identify a population of stroke patients more likely to have ESUS, particularly in the setting of occult AF. Studies are needed to confirm our findings and test the safety and efficacy of anticoagulation in patients with ESUS and diastolic dysfunction with elevated LVFP.

The Additive Effect of Left Ventricular Filling Pressure and Renal Function on Long-Term Prognosis of High-Risk Patients Undergoing Coronary Angiography

Introduction: Impaired relaxation is the earliest manifestation of ischemic cascade. Risk factors and renal function abnormalities are associated with coronary disease and diastolic dysfunction as well. We aimed to study the association of noninvasive assessment of left ventricular filling pressures and renal function with mortality in high-risk patients undergoing coronary angiography. Patients and Methods: An observational prospective study of 564 consecutive patients undergoing coronary angiography was conducted. The median follow-up was 2,293 days. Patients were categorized into 2 groups according to presence of significant diastolic dysfunction: group 1, 382 patients, with normal and group 2, 182 patients, with elevated filling pressure. Renal insufficiency was determined as calculated glomerular filtration rate <60 mL/min. Patients demographic, clinical, echocardiography, laboratory, and angiographic data were prospectively collected. Results: Fifty-three percent of patients underwent angiography due to acute coronary syndrome (ACS), 85.5% had coronary artery disease, 53.4% had reduced (<50%) left ventricular ejection fraction (LVEF), and 47.4% had abnormal renal function. The mortality during the follow-up period was 30.0%. Patients with elevated filling pressure had significantly higher mortality (50.5% vs. 20.2%, p < 0.0001). Impaired renal failure as well, was associated with higher mortality (48% vs. 15%, p < 0.001). The association remained significant in subgroups of patients with and without ACS and reduced and preserved LVEF. In Cox regression model which combined elevated filling pressure, renal insufficiency, age, diabetes mellitus, hypertension, presence of atrial fibrillation, LVEF, and anemia, elevated filling pressure and renal function impairment were independently associated with higher mortality (HR: 3.717, CI: 1.623–8.475, p < 0.0001 and HR: 0.972, CI: 0.958–0.985, p = 0.0001, respectively). There was an incremental prognostic value of elevated filling pressures and renal function impairment on mortality. Conclusions: Advanced diastolic dysfunction and impaired renal function are signals toward worse outcomes and are associated with mortality in high-risk patients undergoing coronary angiography.

Role of Left Atrial Functions for The Assessment of Left Ventricular Filling Pressure in Patients with Acute Coronary Syndrome.

Role of Left Atrial Functions for The Assessment of Left Ventricular Filling Pressure in Patients with Acute Coronary Syndrome.

Persistence of Stress Related Left Ventricular Filling Abnormality in Treated Hypertensive Patients

Hypertension is associated with impaired left ventricular (LV) diastolic function. However, the impact of stress on LV filling of treated hypertensive individuals is unclear. Fourteen hypertensive patients (mean age 55 years) and 14 age-sex matched normotensive controls underwent Doppler echocardiographic studies at rest and one minute following supine ergometer bicycle.

Correlation between Echocardiographic Diastolic Parameters and Invasive Measurements of Left Ventricular Filling Pressure in Patients with Takotsubo Cardiomyopathy

The extent of diastolic dysfunction is of clinical importance in the risk stratification and management of patients with Takotsubo cardiomyopathy (TC). Standard echocardiographic indices of diastolic dysfunction have robust predictive ability in assorted disease states, but have not been validated in TC. The aim of this study was to compare Doppler metrics of diastolic function against catheterization-measured filling pressures in TC. Patients with TC who met inclusion and exclusion criteria were evaluated using echocardiography and catheterization performed within 24hours. Both left ventricular (LV) end-diastolic pressure and LV pre-A diastolic pressure were obtained from catheterization tracings. The echocardiographic parameters for diastolic function were extracted using the American Society of Echocardiography recommendations and a previously validated regression equation for mean left atrial pressure (mLAP). A total of 51 patients with TC were included. Patients were predominantly women (72.5%), with a mean age of 58±13years and a mean ejection fraction of 24±10 %. E/e' ratio (septal, average, and lateral) and calculated mLAP correlated positively with catheterization LV pre-A, with fair to moderate correlation (coefficient range, 0.38-0.44). The t-test mean difference between LV pre-A pressure and calculated mLAP was 0.77±7.34mm Hg (95% CI, ±14.68mm Hg) suggesting inconsistent measures. mLAP also exhibited poor diagnostic ability to discriminate elevated LV pre-A diastolic pressure, with an area under the receiver operating characteristic curve of 0.69 (95% CI, 0.50-0.88). Commonly used echocardiographic parameters for diastolic function demonstrated less-than-optimal correlation, with poor sensitivity and specificity, compared with invasively measured LV end-diastolic pressure or LV pre-A wave diastolic pressure in patients with TC. Precise characterization of LV filling pressure in patients with TC using contemporary noninvasive echocardiographic parameters appears challenging. Invasive measurements of filling pressure should remain the gold standard for optimal risk stratification and management of patients with TC.

Abstract 12714: Impact of Reduced Left Ventricular Filling Pressure on Diastolic Function During Exercise in Patients With HFpEF

Background: During exercise, patients with heart failure with preserved ejection fraction (HFpEF) have an exaggerated increase in pulmonary capillary wedge pressure (PCWP) and left atrial-left ventricular pressure gradient (E wave velocity), as well as a blunted increase in early diastolic recoil (e’ velocity). It is unknown if non-invasive markers of diastolic function improve when exercise PCWP is acutely ameliorated. Methods: Patients with invasively proven HFpEF (n = 34, 71±6 years, 59% female, PCWP &gt; 25 or Δ15 mm hg at peak exercise) underwent 2 seated cycle exercise tests with sublingual nitroglycerin (NTG) and placebo (PLB) in a cross-over design. PCWP (right heart catheter), tissue Doppler velocities of the mitral annulus (e’) and mitral inflow velocities (E) were measured at rest and during 20-watt submaximal steady state exercise. Differences between placebo and GTN conditions were assessed by repeated measures mixed model. Results: PCWP was 7.6±3.9 mmHg at rest and 21.1±7.8 mmHg with sub-maximal exercise and was decreased by 14% and 24% respectively by NTG (Drug effect p &lt; 0.001, Figure ). Mean E’ was 6.2±1.5 cm/sec at rest and 8.8±1.7 cm/sec during exercise and was decreased by 6% and 8% respectively by NTG (p = 0.003), but augmentation during exercise was unchanged (NTG +36%, PLB +41%, p = 0.211). The E wave velocity was 69.6±21.2 cm/sec rest and 101.9±31.3 cm/sec during exercise and was decreased by 12% and 11% with NTG respectively (p &lt;0.001), but augmentation during exercise was unchanged (NTG +48%, PLB +46%, p = 0.507). Conclusions: NTG significantly and acutely lowered exercise PCWP in patients with HFpEF but did not improve diastolic function as assessed by echocardiography. The symmetrical slowing of E wave velocity and e’ with reduced PCWP demonstrate that higher preload helps maintain diastolic recoil and early diastolic filling for patients with HFpEF. Therapies that reduce preload in HFpEF may result in apparently worsened markers of diastolic function.

Reproducibility of the 2016 American Society of Echocardiography-European Association of Cardiovascular Imaging Algorithm for Estimation of Left Ventricular Filling Pattern: Not Perfect but Good Enough.

The 2016 American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines for the evaluation of left ventricular diastolic function reported a new algorithm to assess diastolic function and to estimate left ventricular filling pressure (LVFP). At least five to six different parameters were necessary to conclude, each of them with their own inter-observer variability. This article examines the reproducibility of each parameter of the algorithm and its influence on the final decision of the clinician. Echocardiographic exams of 12 non-selected patients without any known cardiac disease or follow-up but addressed to the hospital for symptoms were analyzed by two readers (one junior and one senior) in five French cardiologic tertiary centers. Inter-observer reproducibility at each step of the algorithm and final decision were analyzed. There was mild agreement on the final decision. The main reasons of discrepancy were disagreement on the significance of mitral annular calcifications and measured values that are just around the cut-off (despite good reproducibility, a slight variation could lead to misclassification of a dichotomous choice between a normal measure and a pathologic measure). Without considering performance, this multicentric French study puts forward limits to the actual algorithm recommended for LVFP pattern assessment. Agreement is excellent in caricatural (easy) cases (left ventricular pressure clearly normal or clearly elevated) but a great discordance exists in the gray zone. Improvement in the algorithm and in the method for LVFP determination is proposed.

Association Between Preexisting Elevated Left Ventricular Filling Pressure and Clinical Outcomes of Future Acute Myocardial Infarction.

Because no data were available regarding the effect of preexisting left ventricular filling pressure (LVFP) on clinical outcomes in patients with acute myocardial infarction (AMI), we evaluated whether preexisting high LVFP can determine outcomes of subsequent AMI events.Methods and Results:Among 399,613 subjects who underwent echocardiography for various reason from August 2004 to June 2019, 231 had experienced subsequent AMI and were stratified according to preexisting LVFP: low LVFP (E/e' ≤14) and high LVFP (E/e' >14). The primary outcome was cardiac death at 30 days and 1 year after AMI. Overall, 19.5% had high LVFP prior to AMI events. Preexisting high LVFP was associated with an increased risk of cardiac death at 30 days (3.8% vs. 11.6%; adjusted hazard ratio (HR) 4.56, 95% confidence interval (CI) 1.20-17.24, P=0.026) and 1 year after AMI (7.9% vs. 35.9%; adjusted HR 4.14, 95% CI 1.79-9.57, P<0.001). Preexisting E/e' as a continuous value was significantly associated with 1-year risk of cardiac death (adjusted HR 1.08, 95% CI 1.02-1.15, P=0.007). Follow-up echocardiography showed that patients with high LVFP did not show improvement in systolic or diastolic function. Preexisting high LVFP was associated with poor clinical course and 1-year cardiac death after subsequent AMI, as well as no improvement in systolic or diastolic function.