Doppler tissue imaging: a reliable method for estimation of left ventricular filling pressure in patients with mitral regurgitation.
ABSTRACT Doppler of mitral and pulmonary vein flows are used to estimate left ventricular (LV) filling pressure. Mitral regurgitation (MR) makes unreliable these parameters by inducing changes of both mitral inflow and pulmonary vein flow.
To evaluate whether Doppler tissue imaging (DTI) diastolic indices obtained at the level of LV lateral mitral annulus can provide accurate estimation of LV filling pressure in patients with MR.
Forty-three patients (age 55 +/- 11 years) with severe MR and mean LV ejection fraction (EF) 58 +/- 13 were enrolled, 10 (23%) with LV EF < 50% and 33 (77%) with LV EF > 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and DTI indices of the lateral mitral annulus were obtained. LV end-diastolic pressure (LVEDP) was measured invasively with fluid-filled catheter.
In the overall population, the majority of standard Doppler and DTI indices correlated with LVEDP, but the multivariate analysis showed that the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/Em ratio) (beta = .87, P = .0001) was independent predictor of LVEDP (R2 = 0.74, SE = 4, P = .0001). An E/Em ratio > 10 predicted an LVEDP > 15 mm Hg (sensitivity 90%, specificity 83%). In both groups with LV EF > 50% (beta = .77, P = .005; cumulative R2 = 0.73, SE = 2.5, P = .0001) and < 50% (beta = .89, P = .002; cumulative R2 = 0.77, SE = 2.1, P = .002), multivariate analysis underscored again only E/Em ratio as independent predictor of LVEDP.
The combination of DTI indices of the mitral annulus and mitral inflow velocities provides reliable parameters to predict LV filling pressure in patients with MR both in patients with LV EF > 50% and < 50%.
- SourceAvailable from: Cristian Mornoş[show abstract] [hide abstract]
ABSTRACT: The early diastolic transmitral velocity/early mitral annular diastolic velocity ratio (E/Ea) reflects left ventricular (LV) filling pressure in a variety of cardiac diseases. The value of this parameter in patients with significant mitral regurgitation (MR) remains controversial. It has been hypothesized that, by combining the index of diastolic function (E/Ea) and a parameter that explores LV systolic performance (Sa, mitral annulus peak systolic velocity), a close prediction of the LV end-diastolic pressure (LVEDP) can be provided. Hence, the study aim was to assess the relationship between a new parameter, E/(EaxSa), and LVEDP in patients with severe MR. A total of 55 consecutive patients with severe MR, in sinus rhythm, who had been referred for heart catheterization, was analyzed. Echocardiography was performed simultaneously with LVEDP measurements. Both, E/Ea and E/(EaxSa) were calculated, using the average of the velocities of the septal and lateral mitral annulus. A significant linear correlation was demonstrated between E/(EaxSa) and LVEDP (r = 0.81, p < 0.001); this was superior to E/Ea (r = 0.73, p < 0.001), Sa (r = -0.59, p = 0.004), pulmonary artery systolic pressure (r = 0.57, p = 0.007), E-wave (r = 0.45, p = 0.009), Ea (r = -0.31, p = 0.01), and left atrial volume (r = 0.28, p = 0.02). No significant relationships could be demonstrated between LVEDP and the LV ejection fraction. The area under the receiver-operating characteristic (ROC) curve for prediction of LVEDP > 15 mmHg was greatest for E/(EaxSa) (AUC = 0.87, p < 0.001), followed by the E/Ea ratio (AUC = 0.81, p < 0.001). A statistical comparison of the ROC curves indicated that E/(EaxSa) was more accurate than E/Ea (p = 0.02). The optimal E/(EaxSa) cut-off to predict a LVEDP > 15 mmHg was 1.95 (85% sensitivity, 83% specificity). E/(EaxSa) correlates strongly with LVEDP, and can serve as a simple and accurate echocardiographic index for the estimation of LVEDP in patients with severe MR.The Journal of heart valve disease 09/2010; 19(5):576-83. · 1.07 Impact Factor
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ABSTRACT: BACKGROUND: Patients with severe sepsis or septic shock often exhibit significant cardiovascular dysfunction. We sought to determine whether severity of diastolic dysfunction assessed by transthoracic echocardiography (TTE) predicts 28-day mortality. METHODS: In this prospective, observational study conducted in 2 intensive care units at a tertiary-care hospital, 78 patients (age 53.2 +/- 17.1; 51% Female; Mean APACHE II score 23.3 +/- 7.4) with severe sepsis or septic shock underwent TTE within 6 hours of intensive care unit (ICU) admission, after 18 to 32 hours, and after resolution of shock. LV diastolic dysfunction was defined according to modified American Society of Echocardiography 2009 guidelines, using E, A, and e' velocities; E/A and E/e'; and E deceleration time. Systolic dysfunction was defined as an ejection fraction (EF) < 45%. RESULTS: Twenty-seven patients (36.5%) had diastolic dysfunction on initial echocardiogram, while 47 (61.8%) patients had diastolic dysfunction on at least one echocardiogram. Overall mortality was 16.5%. The highest mortality (37.5%) was observed among patients with grade I diastolic dysfunction, an effect that persisted after controlling for age and APACHE II score. At time of initial TTE central venous pressure (CVP) (11+/-5 mmHg) did not differ among grades 1-3, although patients with grade I received less intravenous fluid. CONCLUSIONS: LV diastolic dysfunction is common in septic patients. Grade I diastolic dysfunction, but not Grades II and III, was associated with increased mortality. This finding may reflect inadequate fluid resuscitation in early sepsis, despite an elevated CVP, suggesting a possible role for TTE in sepsis resuscitation.Critical ultrasound journal 05/2012; 4(1):8.
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ABSTRACT: The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity (E/Ea) is a widely used noninvasive tool to estimate left ventricular end diastolic pressure (LVEDP). The aim of this study was to explore whether E/Ea ratio was a reliable index for the estimation of LVEDP in patients with mitral regurgitation (MR). Sixteen patients with nonischemic MR (primary MR group; 6 male, 58 ± 12 years) 51 patients with ischemic MR (secondary MR group; 29 male, 63 ± 9 years) and 29 patients without MR (control group; 19 male, 53 ± 10 years) were consecutively included. The peak transmitral flow and mitral annular velocities during early diastole were measured. LVEDP was determined invasively by left heart catheterization. Primary and secondary MR groups had significantly higher E/Ea ratios and LVEDP than control group. LVEDP significantly correlated with E/Ea ratio in patients with primary MR, but not in patients with secondary MR. Multiple regression analysis revealed that E/Ea ratio was an independent predictor of LVEDP in patients with primary MR. Ten patients with primary MR had LVEDP ≥15 mmHg. ROC analysis demonstrated cutoff values for E/Ea ratios as >10.5 for lateral mitral annulus (sensitivity: 80%, specificity: 66%, PPV: 80%, NPV: 66%) and as >14 for medial mitral annulus (sensitivity: 90%, specificity: 83%, PPV: 90%, NPV: 83%) to predict primary MR patients with LVEDP ≥15 mmHg. E/Ea ratio is still reliable in estimation of LVEDP in primary MR patients while it is not predictive for LVEDP in secondary MR patients.Echocardiography 07/2011; 28(6):633-40. · 1.26 Impact Factor