Ventricular End-diastolic Pressure In Patients Research Articles

A prospective analysis of the correlation between ultrasonic B-lines, cardiac tissue doppler signals and left ventricular end-diastolic pressure in patients with severe aortic stenosis

BackgroundThe development of heart failure is a turning point in the natural course of aortic stenosis (AS). Pulmonary oedema and elevated left ventricular pressure (LVP) are cardinal features of heart failure. Evaluating pulmonary oedema by lung ultrasound involves taking the upper hand with a bedside noninvasive tool that may reflect LVP.AimWe sought to assess the correlation between sonographic pulmonary congestion, invasive LV pre-A pressure, and echocardiographic LV end-diastolic pressure (LVEDP) in symptomatic AS patients receiving transcatheter aortic valve replacement.MethodsForty-eight consecutive patients with severe AS and planned transcatheter aortic valve implantation (TAVI) were enrolled. LVEDP was estimated to be normal or elevated using the ASE/EACVI algorithm and transmitral Doppler indices, the E/A ratio, the E/e′, and the left atrial volume index. Invasive LV pre-A pressure was used as a reference, with > 12 mm Hg defined as elevated.ResultsForty-eight patients (25 women (52%), mean age 75 years, standard deviation (SD) ± 7.7 years) were enrolled in the study. We detected severe B-lines (≥ 30) in 13 (27%) patients and moderate B-lines (15–30) in 33 (68.6%) patients. The number of B-lines increased significantly with the severity of New York Heart Association (NYHA) functional classes (Fig. 1). The B-line count was 14 ± 13 in NYHA class I patients, 20 ± 20 in class II patients, and 44 ± 35 in class III patients (p < 0.05, rho = 0.384). The number of B-lines was correlated with the E/E’ ratio (R = 0.664, p < 0.0001) and the proBNP level (R = 0. 882, p < 0.008). We found no significant correlation with the LVEDP or LVEF. The LVEDP correlated well with the E/E’ ratio (R = 0.491, p < 0.001) but not at all with E/A, DT, or LAVI. All patients had an elevated LVEDP > 12, with a mean pressure of 26 mmHg, a minimum of 13 mmHg, and a maximum of 45 mmHg, with an SD of 7.85.ConclusionAssessing lung ultrasonic B-lines is a straightforward and practical approach to identifying pulmonary oedema in AS patients. The number of B-lines correlated with the E/E’ ratio and the functional status of patients but did not correlate with invasive LVEDP or LVEF. All patients had elevated LVEDP that correlated with E/E’.

Correlation of left atrial strain with left ventricular end-diastolic pressure in patients with coronary artery disease and preserved left ventricular ejection faction

Abstract Funding Acknowledgements Type of funding sources: None. Background Elevated left ventricular (LV) filling pressures are the main physiologic consequence of LV diastolic dysfunction. Left atrial (LA) strain was recently found useful to predict elevated LV filling pressures noninvasively. However, there are few reports on the role of LA strain when predicting LV filling pressure in patients with coronary artery disease (CAD). The aim of this study was to explore the correlation between LA strain and LV end-diastolic pressure (LVEDP) in patients with CAD and preserved LV ejection fraction. Methods Fifty-four patients with stable CAD were enrolled. Global atrial longitudinal strain was measured by averaging all atrial segments. Resorvoir (S-LAs), conduit (S-LAe), and contractile (S-LAa) phase strain were obtained. LVEDP was invasively obtained by left heart catheterization. Results Patients were divided into two groups: elevated LVEDP group (LVEDP &amp;gt; 15mmHg group: n = 23) and normal LVEDP group (LVEDP ≤ 15mmHg group: n = 31). Elevated LVEDP group showed significantly decreased S-LAs and S-LAa (S-LAs: 21.3 ± 7.2% vs. 27.5 ± 7.8%, p &amp;lt; 0.005; S-LAa: 9.7 ± 3.3% vs. 14.6 ± 3.4%, p &amp;lt; 0.0001). However, E/Ea and S-LAe were not significantly different between the two groups. LVEDP significantly correlated with S-LAa (r=-0.596, p &amp;lt; 0.0001) and S-LAs (r=-0.431, p &amp;lt; 0.001). Receiver operating characteristics curve analysis showed that S-LAa could predict elevated LVEDP (AUC = 0.84) and a cut-off value of S-LAa &amp;lt; 11.6% was able to most accurately identify patients with elevated LVEDP. Conclusions LA strain, especially S-LAa, provided additional diagnostic value for the noninvasive assessment of LV filling pressure in CAD patients with preserved LV ejection fraction.

Long-term Implications of Post-Procedural Left Ventricular End-Diastolic Pressure in Patients Undergoing Transcatheter Aortic Valve Implantation

Current risk models have only limited accuracy in predicting transcatheter aortic valve Implantation (TAVI) outcomes and there is a paucity of clinical variables to guide patient management after the procedure. The prognostic impact of elevated left ventricular end-diastolic pressure (LVEDP) in TAVI patients is unknown. The aim of the present study was to evaluate the prognostic value of after-procedural LVEDP in patients who undewent TAVI. Consecutive patients with severe symptomatic aortic stenosis who undewent TAVI were divided into 2 groups according to after-procedural LVEDP above and below or equal 12 mm Hg. Collected data included baseline clinical, laboratory and echocardiographic variables. We evaluated the impact of elevated vs. normal LVEDP on in-hospital outcomes, short- and long-term mortality. Eight hundred forty-five patients were included in the study with complete in-hospital and late mortality data available for all survivors (median follow-up 29.5 months [IQR 16.5 to 48.0]). The mean age (±SD) was 82.3±6.2 years and mean Society of Thoracic Surgery score was 4.0%±3.0%. Patients with LVEDP>12 mm Hg (n = 591, 70%) and LVEDP≤12 mm Hg (n = 254, 30%) had a 6-months mortality rate of 6.8% and 2%, respectively (P=0.004) and a 1-year mortality rate of 10.1% vs 4.9%, respectively (p = 0.017). By multivariable analysis, after-procedural LVEDP>12 mm Hg was independently associated with all-cause mortality (HR 2.45, 95% CI 1.58 to 3.76, p <0.001) during long-term follow-up. In conclusion, elevated after-procedural LVEDP in patients who undewent TAVI is an independent predictor of mortality following TAVI. Further research regarding the use of LVEDP as a tool for after-procedural medical management is warranted.

Wire Crossing Time Correlate with Left Ventricular End-Diastolic Pressure in Patients with ST Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Backgrounds: Mortality and morbidity in acute myocardial infarction depend on the extent of the infarct area. Rapid recovery of coronary artery blood flow with primary percutaneous coronary intervention (pPCI) can limit the extent of infarction and improve left ventricular function. Acute myocardial infarction reduce diastolic function, which in the early stage of diastolic dysfunction, there is an increase in left ventricular end-diastolic pressure (LVEDP). The non-invasive marker of E/e’ ratio is an accurate parameter of increased LVEDP.Methods: This was a cross-sectional study enrolled consecutive patients with ST Segment Elevation Myocardial Infarction (STEMI) who underwent pPCI at Dr. Sardjito Hospital. The wire crossing time was calculated from the onset of chest pain until the guidewire crossed the infarct-related artery during the pPCI procedure. The E/e’ ratio was determined by transthoracic echocardiography which performed within 48 hours after the primary PCI. Correlation between the wire crossing time and the E/e’ ratio was assessed by the Pearson correlation test. The value of p &lt;0.05 was considered statistically significant.Results: A total of 40 patients were enrolled in this study. The mean wire crossing time was 12.73±5.22 hours. The median value of the E/e’ ratio was 8.36 (range: 4.71-22.00). There was a moderate strength and significant correlation between the wire crossing time and the E/e’ ratio (r = 0.572; p &lt;0.001). Patients with E/e’ ratio &gt;15 had significantly longer wire crossing time than in patient with E/e’ ratio ≤15 (20.21±2.5 hours vs. 11.41±4.39 hours; p &lt;0.001; respectively). The wire crossing time was independently associated the E/e’ ratio (r = 0.463; p = 0.003).Conclusion: There was a moderate strength and significant positive correlation between the wire crossing time and increased LVEDP, an earlier marker of diastolic dysfunction, measured by E/e’ ratio using TTE in patients with STEMI underwent pPCI.

Clinical factors affecting left ventricular end-diastolic pressure in patients with acute ST-segment elevation myocardial infarction.

An association between left ventricular end-diastolic pressure (LVEDP) and outcomes of ischemic heart diseases has been reported. The present study aimed to investigate the LVEDP patterns and the effecting factors in patients with acute ST-segment elevation myocardial infarction (STEMI). A total of 515 STEMI patients receiving immediate percutaneous coronary intervention (PCI) were divided into two groups according to their LVEDP before left ventricular angiography: LVEDP of 15 mmHg or less (group A, n=145) and LVEDP above 15 mmHg (group B, n=370). Blood samples were collected before and within 24 hours after PCI, and an ultrasonic cardiogram was conducted to measure left ventricular ejection fraction (EF%) and to evaluate ventricular structure changes. The narrowness of each artery was measured with coronary angiography. In comparison with group A, patients in group B had a more infarction-related artery (IRA) descending branch and regional wall motion abnormality, a larger left atrial end-diastolic diameter (LAEDd) and a left ventricular end-diastolic diameter (LVEDd), a smaller EF%, a higher level of myocardial necrosis markers, and a higher heart failure rate. Furthermore, LVEDP level was found to be positively correlated with Gensini score, LAEDd, LVEDd, N-terminal pro b-type natriuretic peptide, troponin T, uric acid, creatine kinase (CK), CK myocardial band, low-density lipoprotein cholesterol and fasting blood glucose, and negatively correlated with glomerular filtration rate and EF%. LVEDP elevation has a higher incidence of heart failure and a higher risk of death, which is associated with the criminal blood vessels.

Correlation of left atrial strain with left ventricular end-diastolic pressure in patients with normal left ventricular ejection fraction

Left ventricular diastolic dysfunction (LVDD) remains challenging to be assessed by echocardiography. We sought to explore the relationship between left atrial strain and left ventricular (LV) diastolic function in patients with normal left ventricular ejection fraction (LVEF) by invasive left-heart catheterization. 55 consecutive individuals with LVEF > 50% underwent LV catheterization. Standard transthoracic echocardiography was performed during 12 h before or after the procedure. Left atrial (LA) strain were obtained by speckle tracking echocardiography. When LVEF ≥ 50%, the group with elevated left ventricular end-diastolic pressure (LVEDP) (n = 35) showed decreased left atrial reservoir strain (LASr) (35.2 ± 7.7% vs 21.3 ± 7.2%, p < 0.001), left atrial conduit strain (LASct) (17.6 ± 6.3% vs 11.9 ± 4.1%, p < 0.001), left atrial contraction strain (LAScd) (16.6 ± 7.2% vs 9.5 ± 5.0%, p < 0.001) and increased E/e′ ration(8.9 ± 2.6 vs 10.1 ± 3.5, p = 0.17). LVEDP negatively correlated with LASr (R = 0.662, p < 0.001), LASct (R = 0.575, p < 0.001) and LAScd (R = 0.456, p < 0.001), but not with E/e′. LASr, LASct and LAScd were all independent predictors of elevated LVEDP (p < 0.05), with a higher C-statistic for the model including LASr (0.95, 0.86 and 0.93 respectively). The area under the curve (AUC) for LASr is 0.914 (cutoff value is 26.7%, sensitivity is 90%, specificity is 82.9%). In patients with normal LV ejection fraction, left atrial strain presented good correlation with LVEDP, and LASr was superior to LASct and LAScd to predict LVEDP. LA strain demonstrated better agreement with the invasive reference than E/e′.

Correlations between invasively measured aortic pressures and left ventricular end-diastolic pressure in patients undergoing coronary angiography.

Data on ventricular-arterial coupling using invasive hemodynamic studies are limited. This study was performed to clarify the interaction between aortic pressures and left ventricular end-diastolic pressure (LVEDP) using invasive catheterization. A total of 104 consecutive stable patients (mean age, 65.8 ± 10.0 years; 56% men) undergoing invasive coronary angiography (ICA) were prospectively evaluated. LVEDP and central aortic pressures [systolic blood pressure (aSBP) and diastolic blood pressure (aDBP)] were sequentially measured using a pigtail catheter before ICA. Aortic pulse pressure (aPP) was defined by the difference between aSBP and aDBP. A total of 82 patients (79%) had obstructive coronary artery disease (≥50% stenosis). The mean LVEDP value was 18.7 ± 6.4 mmHg. Univariable analyses showed that aSBP (r = 0.309, P = 0.001) and aPP (r = 0.286, P = 0.003) significantly correlated with LVEDP, whereas aDBP was not correlated with LVEDP (P > 0.05). Multivariable analysis revealed that aSBP (β = 0.345, P = 0.001) and aPP (β = 0.276, P = 0.018) remained independent predictors of LVEDP even after controlling for potential confounders. Invasively measured aSBP and aPP were independently associated with invasively measured LVEDP in patients undergoing ICA. This result provides additional evidence of a close interaction between central aortic pressure and LV diastolic function in this population.

E/e` ratio is superior to speckle tracking for detecting elevated left ventricular end-diastolic pressure in patients with coronary artery disease and preserved ejection fraction.

A weak correlation has been reported between left ventricular filling pressures and the traditional echocardiographic tools for the evaluation of diastolic function in patients with coronary artery disease (CAD) and preserved left ventricular ejection fraction (LVEF). On the other hand, studies that compared invasive measurements with speckle tracking echocardiography have shown promising results, but they were not exclusively targeted on this specific population. Immediately before the left heart catheterization, a comprehensive two-dimensional Doppler echocardiography and speckle tracking analysis was prospectively performed in outpatients referred for coronary angiography. Left ventricular end-diastolic pressure (LVEDP) was measured before any contrast exposure. Eighty-one patients with coronary artery disease were studied, and the group with high LVEDP (n=40) showed increased left atrial volume index (22±6mL/m2 vs 26±8.26mL/m2 , P=0.04), E-wave velocity (65±15cm/s vs 78±20cm/s, P=0.02), E/e` (average) ratio (8.14±2.0 vs 11.54±2.7, P=0.03), and E/global circumferential strain rate E peak ratio (E/GCSRE ) (39cm vs 46cm, P<0.01). There was a positive correlation between LVEDP and E/e` (ρ=0.56; P=0.03), and between LVEDP and E/GCSRE ratio (ρ=0.43; P<0.01). The area under the receiver operating characteristics (ROC) curve was 0.83 and 0.73, respectively (P<0.05). E/e` and E/GCSRE were both independent predictors of elevated LVEDP (P<0.05), with a higher C-statistic for the model including E/e` (0.89 vs 0.85). The E/e` ratio was able to identify elevated LVEDP in CAD patients with preserved LVEF with more accuracy than the E/GCSRE ratio.

Usefulness of Echocardiography/Doppler to Reliably Predict Elevated Left Ventricular End-Diastolic Pressure in Patients With Pulmonary Hypertension

The ability of echocardiography (echo)/Doppler to predict elevated left ventricular (LV) end-diastolic pressure (EDP) specifically among patients with pulmonary hypertension is not well defined. This was a retrospective analysis of 161 patients referred to a specialized pulmonary hypertension clinic. A model based on an American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE) joint statement was evaluated, and a new model was developed using univariate linear regression and multivariable logistic regression for potentially better prediction of elevated LVEDP. The study cohort had a median pulmonary arterial pressure was 34.0mm Hg and pulmonary vascular resistance was 3.7 Wood units; 81 patients (51%) had LVEDP >15mm Hg on invasive testing. Doppler E/A, E/e' (septal, lateral, and average), e'/a' (lateral and average), and left atrial volume and diameter all had significant correlation with LVEDP (p <0.05). The ASE/EAE model performed poorly (sensitivity 54% and specificity 66%) for detecting elevated LVEDP. Only echo/Doppler grade 3 diastolic dysfunction had an LVEDP significantly different from other grades (grade 0 to 2, median 15mm Hg, interquartile range 13 to 22mm Hg; grade 3, median 22mm Hg, interquartile range 19 to 32mm Hg; p <0.01). An experimental model was statistically significant in its prediction of elevated LVEDP (area under the receiver operating characteristic curve 0.7, p <0.001) but demonstrated poor performance (sensitivity 67% and specificity 61%). In conclusion, numerous echo/Doppler measurements correlate with elevated LV filling pressure. However, both the ASE/EAE model and our experimental model had poor test performance that did not permit confident identification of elevated LVEDP.

Noninvasive Estimation of Ventricular Filling Pressures in Patients with Single Right Ventricles

Increased ventricular end-diastolic pressure (VEDP) is a known risk factor for morbidity and mortality in patients with single-ventricle physiology. Spectral Doppler tissue imaging (DTI) has been shown to modestly correlate with direct measurement of VEDP. Strain rate (SR) values, obtained via myocardial deformation, have not yet been compared with VEDP in this patient population. The goal of this study was to evaluate which of these imaging techniques correlates best with VEDP in patients with single-RV (RV) physiology. Patients with single-RV physiology who underwent simultaneous echocardiography and catheterization were evaluated. Echocardiographic data included global longitudinal SR early diastolic wave (SRe) and SR late diastolic wave (SRa), DTI early diastolic wave (e') and DTI late diastolic wave (a') of the right ventricular free wall, and right atrioventricular valve inflow velocities (E and A waves). E/SRe and E/e' ratios were calculated. VEDP was obtained from the catheterization report. Twenty-seven studies were performed on patients with single-RV physiology. The median age at the time of catheterization was 11.4 months (range, 0-132 months). The mean VEDP was 9.9 ± 4.5 mm Hg. VEDP correlated significantly with E/SRe ratio (r = 0.88), global SRe (r = -0.52), SRe/SR late diastolic wave ratio (r = -0.42), and valve A velocity (r = 0.48). There were no significant correlations between VEDP and DTI measurements. Receiver operating characteristic curve analysis using an E/SRe cutoff of 150 cm showed 87.5% sensitivity and 78.9% specificity for predicting VEDP > 10 mm Hg. In patients with single-RV physiology, VEDP correlated strongly with SR but not with DTI measurements. SR measurements should be considered as a possible means to estimate VEDP in this complex patient population rather than DTI.

The validity of a global tissue Doppler index in estimating left ventricular end-diastolic pressure in patients with coronary artery disease

Background The left ventricular end diastolic pressure (LVEDP) is an important parameter in cardiac patients. There are few data on adding tissue Doppler derived mitral annular peak systolic velocity (S′) wave to the ratio of early mitral inflow to mitral annular velocity (E/E′) for the estimation of left ventricular end diastolic pressure (LVEDP) in patients with preserved LV ejection fraction. Objectives To assess the validity of E/(E′A ∼ S′) in estimating LVEDP in patients with CAD and intermediate E/E′. Methods Sixty-five subjects underwent echocardiography and TDI of the mitral annulus in less than 30 min of cardiac catheterization. Echocardiographic variables including E/E′ and E/(E′A ∼ S′) were compared to invasively measured LVEDP. Results Based on coronary angriography, 49 subjects showed significant CAD (group I) while 16 subjects showed no evidence of CAD (control group). The E/E′ and the E/(E′X S′) were significantly higher in CAD patients than in the control group ( P r = 0.785, P r = 0.274, P > 0.05). ROC analysis yielded an optimal E/(E′A ∼ S′) cutoff value of 1.43 for prediction of LVEDP >12 mmHg with a sensitivity of 90.9%, a specificity of 57.1%, a positive predictive value of 76.9% and a negative predictive value of 80.0% (AUC 0.88, 95% CI 0.71–1.00, P 12 mmHg with a sensitivity of 72.7%, a specificity of 28.6%, a positive predictive value of 61.5% and a negative predictive value of 40.0% (AUC 0.68, 95% CI 0.44–0.93, P > 0.05). Conclusions E/(E′A ∼ S′) correlates well with LVEDP and can be used as a simple andaccurate estimate ofLVEDP in coronary artery disease patients with intermediate E/E′.

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Prognostic Utility of Left Ventricular End-Diastolic Pressure in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Measurement of left ventricular end-diastolic pressure (LVEDP) is readily obtainable in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, the prognostic utility of LVEDP during primary PCI has never been studied. LVEDP was measured in 2,797 patients during primary PCI in the Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial. Outcomes were assessed at 30 days and 2 years stratified by medians of LVEDP. Multivariable analysis was performed to determine whether LVEDP was an independent determinate of adverse outcomes. The median (interquartile range) for LVEDP was 18 mm Hg (12 to 24). For patients with LVEDP >18 mm Hg versus those with ≤18 mm Hg, hazard ratios (95% confidence intervals) for death and death or reinfarction at 30 days were 2.00 (1.20 to 3.33, p = 0.007) and 1.84 (1.24 to 2.73, p = 0.002), respectively, and at 2 years were 1.57 (1.12 to 2.21, p = 0.009) and 1.45 (1.14 to 1.85, p = 0.002), respectively. Patients in the highest quartile of LVEDP (≥24 mm Hg) were at the greatest risk of mortality. Only a weak correlation was present between LVEDP and left ventricular ejection fraction (LVEF; R(2) = 0.03, p <0.01). By multivariable analysis increased LVEDP was an independent predictor of death or reinfarction at 2 years (hazard ratio 1.20, 95% confidence interval 1.02 to 1.42, p = 0.03) even after adjustment for baseline LVEF. In conclusion, baseline increased LVEDP is an independent predictor of adverse outcomes in patients with STEMI undergoing primary PCI even after adjustment for baseline LVEF. Patients with LVEDP ≥24 mm Hg are at the greatest risk for early and late mortality.

Noninvasive Prediction of Left Ventricular End-Diastolic Pressure in Patients With Coronary Artery Disease and Preserved Ejection Fraction

Background The aim of this study was to compare 3 different available methods for estimating left ventricular end-diastolic pressure (LVEDP) noninvasively in patients with coronary artery disease and preserved left ventricular ejection fraction (EF). Methods We used 3 equations for noninvasive estimation of LVEDP: The equation of Mulvagh et al., LVEDP 1 = 46 − 0.22 (IVRT) − 0.10 (AFF) − 0.03 (DT) − (2 ÷ E/A) + 0.05 MAR; the equation of Stork et al., LVEDP 2 = 1.06 + 15.15 × Ai/Ei; and the equation of Abd-El-Aziz, LVEDP 3 = [0.54 (MABP) × (1 − EF)] − 2.23. (Abbreviations: A, A-wave velocity; AFF, atrial filling fraction; Ai, time velocity integral of A wave; DT, deceleration time; E, E-wave velocity; Ei, time velocity integral of E wave; IVRT, isovolumic relaxation time; MABP, mean arterial blood pressure; MAR, time from termination of mitral flow to the electrocardiographic R wave; Ti, time velocity integral of total wave.) Results LVEDP measured by catheterization was correlated with LVEDP 1 ( r = 0.52, P < 0.001), LVEDP 2 ( r = 0.31, P < 0.05), and LVEDP 3 ( r = 0.81, P < 0.001). Conclusions The equation described by Abd-El-Aziz, LVEDP = [0.54 MABP × (1 − EF)] − 2.23, appears to be the most accurate, reliable, and easily applied method for estimating LVEDP noninvasively in patients with preserved left ventricular ejection fraction and an LVEDP < 20 mm Hg.

Lack of Diastolic Reserve in Patients With Heart Failure and Normal Ejection Fraction

The genesis of symptoms in patients with heart failure (HF) and normal ejection fraction (HFNEF) is unclear. Most investigations of HFNEF have focused on cardiac function at rest although most of these patients are breathless only on exercise. Stress-induced impairment in systolic or diastolic function could result in these symptoms. Method and Result- Forty-one patients with HFNEF and 29 controls underwent dobutamine stress echocardiography with color tissue Doppler imaging. Wall motion score index and regional myocardial systolic velocity (Sm) were measured at and peak stress. Systolic (Sa), early diastolic (Ea), and late diastolic (Aa) mitral annular velocities were averaged over the 6 periannular sites. Mitral annular long-axis velocity was lower in the HFNEF than controls at rest. Global, regional, and long-axis systolic function did not worsen with stress in the HFNEF group. The Ea decreased and the E/Ea increased with stress in the HFNEF but not in controls. The 6-minute walk distance was shorter and negatively correlated to the E/EA ratio at rest and stress in the HFNEF group. Impaired diastolic reserve results in stress-induced increase in the left ventricular end-diastolic pressure in patients with HFNEF giving rise to exercise intolerance.

Tissue Doppler Imaging: a reliable method for estimation of the left ventricular end-diastolic pressure in patients with chronic heart failure

Tissue Doppler Imaging: a reliable method for estimation of the left ventricular end-diastolic pressure in patients with chronic heart failure

Abstract 1770: Left Ventricular Filling Curve Variables are Superior to Resting Lung to Heart Ratios in Predicting Left Ventricular End-diastolic Pressure in Patients with Preserved Systolic Function Undergoing Gated Myocardial Perfusion Imaging

Introduction: There is a 4–5 fold increase in morbidity and mortality when diastolic dysfunction is present in patients with coronary artery disease (CAD). Thallium-201 lung/heart ratio (TLHR) at stress has been proven to capture this increased risk. Most laboratories however use technetium-99m agents for stress myocardial perfusion imaging (MPI) which prevents access to stress TLHR. Method: This is a retrospective study of 52 consecutive patients (age 58±11 years, 73% had CAD) who underwent MPI and cardiac catheterization within 15 days, without interval change in medication or intervention. All patients had ejection fraction ≥45% and normal sinus rhythm. Left ventricular end-diastolic pressure (LVEDP) at cardiac catheterization was recorded. From MPI, peak filling rate (PFR), time to peak filling rate (TPFR), filling rate during first 1/3 of diastole (1/3FR) were obtained using 4D-MSPECT (University of Michigan) and rest TLHR was calculated manually. Results: PFR, TPFR and 1/3FR correlated significantly with LVEDP (r= −0.53, 0.45, −0.45 and p =0.00005, 0.0008, 0.0009 respectively). Rest TLHR did not correlate with PFR, TPFR and 1/3FR (r=0.11, 0.06, 0.09 and p =0.47, 0.68, 0.55 respectively) or with LVEDP (r=0.10, p =0.49). These variables had excellent negative predictive value (NPV) of ≥90% but modest positive predictive value (PPV) of ≥54%. Since PFR did not correlate with 1/3FR (r=0.18, p =0.19), we combined these 2 variables. This combination had a NPV of 84% and improved PPV to 86% and specificity to 94%. Conclusions: Our study validates diastolic filling variables from 4D-MSPECT showing excellent correlation with LVEDP at cardiac catheterization ( p ≤0.0009). PFR, TPFR and 1/3FR are superior to rest TLHR and they have excellent sensitivity (≥82%) and specificity (≥63%) for detecting LVEDP ≥18mmHg. Hence, a valid methodology of combining the risk of perfusion defects with diastolic impairment can be achieved by adding PFR, TPFR and 1/3FR to MPI results. Receiver Operated Characteristic Curve Analysis

The importance of pulmonary venous flow measurement for evaluating left ventricular end-diastolic pressure in patients with coronary artery disease in the early stage of Diastolic Dysfunction

Transmitral flow pattern assessed by pulsed Doppler echocardiography is widely used to evaluate left ventricular end-diastolic pressure (LVEDP). A restrictive mitral flow pattern is well recognized as a finding of severely elevated LVEDP. On the other hand, an abnormal relaxation pattern can be interpreted many ways. For example, some patients who display an abnormal relaxation pattern have a mild impairment of left ventricular (LV) relaxation as a result of aging, and others have severely impaired LV diastolic function. To evaluate LVEDP in patients with abnormal relaxation mitral filling patterns, we studied 55 patients who had coronary artery disease with abnormal relaxation pattern who underwent elective cardiac catheterization. We recorded the transmitral and pulmonary venous flow velocity curves and measured the duration of the mitral A wave (MAd) and pulmonary venous reversal wave during atrial contraction (PAd). Positive correlations were found between PAd and LVEDP (r = 0.65, P <.01) and between PAd-MAd and LVEDP (r = 0.7, P <.0001); however, MAd was not significantly correlated with LVEDP. In conclusion, PAd must be measured for an accurate evaluation of LV end-diastolic pressure in patients with an abnormal relaxation pattern in the transmitral flow velocity curve.

Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction

Background: Plasma atrial natriuretic peptide (ANP), mainly from the atrium, brain natriuretic peptide (BNP), mainly from the ventricle, norepinephrine (NE), and endothelin-1 (ET-1) levels are increased with the severity of congestive heart failure (CHF). Although a close correlation between the left ventricular end-diastolic pressure (LVEDP) and plasma ANP in patients with left ventricular dysfunction has been reported, it is not yet known which cardiac natriuretic peptide is a better predictor of high LVEDP in patients with CHF. Methods: To investigate the biochemical predictors of the high LVEDP in patients with left ventricular dysfunction, we measured plasma ANP, BNP, NE, and ET-1 levels and the hemodynamic parameters in 72 patients with symptomatic left ventricular dysfunction. Stepwise multivariate regression analyses were also used to determine whether the plasma levels of ANP, BNP, NE, and ET-1 could predict high LVEDP. Results: Although significant positive correlations were found among the plasma levels of ANP, BNP, ET-1, and NE and the LVEDP, only BNP (p = 0.0001) was an independent and significant predictor of high LVEDP in patients with CHF. In all eight patients with severe CHF measured for hemodynamics before and after the treatments, the plasma BNP levels decreased in association with the decrease of LVEDP, whereas other factors increased in some patients despite the decrease of LVEDP. Conclusions: These findings suggest that plasma BNP is superior to ANP as a predictor of high LVEDP in patients with symptomatic left ventricular dysfunction. (Am Heart J 1998;135:825-32.)

Doppler echocardiographic evaluation of left ventricular end-diastolic pressure in patients with coronary artery disease

Pulmonary venous flow velocity recordings have been found to be useful in complementing the information obtained from the mitral flow velocity and improving the assessment of left ventricular diastolic pressures. This study was undertaken to evaluate the accuracy of mitral flow and pulmonary venous flow variables, recorded by transthoracic Doppler echocardiography, in estimating left ventricular end-diastolic pressure (LVEDP) in 101 consecutive patients with coronary artery disease undergoing diagnostic left-sided heart catheterization. Patients were assigned to three groups according to the values of LVEDP (group 1, ≤12 mm Hg; group 2, between 13 and 19 mm Hg; and group 3, ≥20 mm Hg). LVEDP correlated most strongly with systolic fraction of pulmonary venous flow ( r = −0.76), isovolumic relaxation time ( r = −0.76), E/A ratio ( r = 0.74), deceleration time of early mitral flow ( r = −0.74), and mitral A wave duration/pulmonary venous A wave duration (AD/PVAD) ratio ( r = −0.70) ( p < 0.01 for each correlation). Discriminant analysis demonstrated that deceleration time, AD/PVAD ratio, and isovolumic relaxation time were major determinants of LVEDP, with 87.1% of patients correctly assigned to study groups; 97% of patients of group 1 and 95% of patients of group 3 were identified, whereas the accuracy in identifying the patients of group 2 was lower (41%). Deceleration times of 140 msec or less and AD/PVAD ratios of 0.9 or less were the best cutoff points in predicting an LVEDP of 20 mm Hg or greater. Multiple linear regression analysis demonstrated that the combination of mitral flow and pulmonary venous flow velocity variables provided a better estimation of LVEDP compared with that obtained from mitral flow velocity recordings alone ( r = 0.88 versus 0.79; F test, 20.6). We conclude that combined analysis of mitral flow and pulmonary venous flow velocity provides, in patients with coronary artery disease, a noninvasive estimation of LVEDP with an accurate prediction of pressures of 12 mm Hg or less and 20 mm Hg or greater and less accurate prediction of intermediate values.