Tissue Doppler for Estimating LV Filling Pressure
Abstract & Commentary
With Comments by Michael H. Crawford, MD, Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco, Editor, Clinical Cardiology Alert.
Synopsis: E/E´ is useful for detecting elevated LV filling pressures in patients with heart failure and may be especially useful for excluding high filling pressures in those with diastolic dysfunction.
Source: Bruch C, et al. Am J Cardiol. 2005;95:892-895.
Tissue doppler imaging (TDI) has been shown to be useful for estimating left ventricular (LV) filling pressure in patients with systolic LV dysfunction, but little information is known about its accuracy in those with diastolic dysfunction. Thus, Bruch and colleagues from Germany, studied 74 patients with clinical evidence of heart failure undergoing cardiac catheterization who were not in atrial fibrillation and did not have valvular disease. LV ejection fraction (EF) was > 45% by echocardiography in 28, who also had evidence of diastolic dysfunction by Doppler. LV EF was < 45% in 46 patients. Right and left heart catheterization were done within 4 hours of the echo/Doppler. For this study, TDI was done at septal and lateral LV sites and averaged for each patient to determine the early systolic velocity (E´). Mitral Doppler early velocity (E) was obtained in the standard fashion.
Results: Most of the patients with systolic heart failure had coronary artery disease, whereas only 50% of the diastolic heart failure group did. No one in the diastolic group had dilated cardiomyopathy. Mitral Doppler E was similar in both groups but A was higher in the diastolic group (80 vs 43 m/s, P < .01), resulting in a lower E/A in the diastolic group (1.1 vs 2.2, P < .01). Also, E deceleration and isovolumic relaxation time were increased in the diastolic group. Doppler/TDI E/E´ was not significantly different between the 2 groups. LV end diastolic pressure (EDP) and pulmonary capillary wedge pressure (PCWP) were significantly lower in the diastolic heart failure group (17 vs 23 and 14 vs 21 mmHg, respectively). In the diastolic heart failure group, E/E´ correlated significantly with LV EDP (r = .68) and PCWP (r = .56); and an E/E´ > 11 identified patients with LV EDP > 15 mmHg with a positive predictive value of 94% and a negative predictive value of 91%. In those with systolic heart failure, E/E´ also correlated significantly with LV EDP (r = .54) and PCWP (r = .47). E/E´ > 14 identified those with an LV EDP > 15 mmHg with a positive predictive value of 100%, but a negative predictive value of 39% due to a relatively low sensitivity (71%). Bruch et al concluded that E/E´ is useful for detecting elevated LV filling pressures in patients with heart failure and may be especially useful for excluding high filling pressures in those with diastolic dysfunction.
Comments
Commonly, mitral valve and pulmonary vein Doppler flow velocities are used to estimate diastolic function and filling pressures. However, changes in these parameters due to age and heart rate, and the difficulties with measuring pulmonary vein velocities in some limit their usefulness. This study and others suggest that TDI us a useful addition to the determination of filling pressures. Because of the high specificity of E/E´ in patients with and without systolic dysfunction (100 and 90%, respectively), the positive predictive value is high in both groups (100 and 94%, respectively). Although sensitivity and negative predictive values are strong in the diastolic dysfunction group, the lower sensitivity in the systolic dysfunction group markedly lowers the negative predictive value in this group. Thus, a high E/E´ is useful for identifying high filling pressures in all patients, but a normal E/E´ may be falsely negative in those with systolic dysfunction.
One difficulty with applying this information to patient care is the different E/E´ cut points in this study. The best separation between those with LV EDP > 15 mmHg and those with normal filling pressure was an E/E´ of 11 in the diastolic dysfunction group and 14 in the systolic dysfunction group. Also, the study did not provide cut points for mean PCWP, which is what is usually used in the intensive care unit. Prior studies using PCWP have come up with different cut points. Thus, the exact cut point has not been determined and this study suggests that it may be different for different hemodynamic problems. Until this is clarified further, I view 10-15 as the gray zone and above 15 high filling pressures are almost certain. A low E/E´ is less useful.
E/E´ is useful for detecting elevated LV filling pressures in patients with heart failure and may be especially useful for excluding high filling pressures in those with diastolic dysfunction.
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