Doppler Estimation of Left Ventricular Filling Pressures in Patients With Mitral Valve Disease

Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
Circulation (Impact Factor: 14.43). 07/2005; 111(24):3281-9. DOI: 10.1161/CIRCULATIONAHA.104.508812
Source: PubMed


Conventional Doppler measurements have limitations in the prediction of left atrial pressure (LAP) in patients with mitral valve disease (MVD), given the confounding effect of valve area, left ventricular (LV) relaxation, and stiffness. However, the time interval between the onset of early diastolic mitral inflow velocity (E) and annular early diastolic velocity (Ea) by tissue Doppler imaging (TDI), T(E-Ea), which is well related to the time constant of LV relaxation (tau) in canine and clinical studies, is not subject to these variables. We therefore undertook this study to test its usefulness in a patient population.
Two-dimensional Doppler and TDI echocardiography were performed simultaneously with right-heart catheterization in 51 consecutive patients (mean+/-SD age, 64+/-11 years) with MVD: 35 with moderately severe to severe mitral regurgitation (MR) and 16 with moderate to severe mitral stenosis (MS). Among several Doppler measurements, only the mitral E/A ratio, isovolumetric relaxation time (IVRT), and pulmonary venous Ar duration had significant relations with mean pulmonary capillary wedge pressure (PCWP). The ratio of IVRT to T(E-Ea) (for MR, r=-0.92; for MS, r=-0.88; both P<0.001) and the ratio of IVRT to tau (for MR, r=-0.74; for MS, r=-0.85; both P<0.001) had the best correlations with PCWP. In 54 repeat studies, including those performed after MV repair or replacement, these ratios tracked well the changes in PCWP and readily identified changes in mean PCWP by > or =5 mm Hg. A similar correlation was noted in 13 patients with atrial fibrillation (r=-0.92, P<0.01) and in a prospective group of 14 patients with MR (r=-0.93, P<0.001).
The ratio of IVRT to T(E-Ea) or to tau can be readily applied for estimating mean PCWP in patients with MVD and can track changes in PCWP after valve surgery.

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Available from: Michael Reardon, Jul 27, 2014
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    • "Current ultrasound systems have tissue Doppler presets for assessing mitral annular velocities [5] and the ratio of the peak early mitral inflow (E) velocity to the peak early mitral annular velocity (E′) is most widely used for estimating the PCWP in the clinical setting. However, several publications have recently raised concerns about the reliability of E/E′, especially in patients with preserved LV ejection fraction (EF), mainly because E′ is affected by LV morphology, regional function, and mitral annular structure, resulting in an erroneous PCWP estimation [6, 7]. "
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    ABSTRACT: We aimed to identify the clinical utility of a simple echocardiographic approach for estimating the pulmonary capillary wedge pressure (PCWP) on the basis of the combined assessment of mitral inflow and tissue Doppler mitral annular velocities. We retrospectively enrolled 165 patients who underwent both echocardiographic examination and right heart catheterization, and determined the diagnostic accuracy of echocardiography-derived parameters for estimating PCWP >18 mmHg. Eighty-three patients had preserved left ventricular (LV) ejection fraction ≥50% (the PEF group) and 82 patients had reduced LVEF <50% (the REF group). The PEF group had higher peak early mitral annular velocity (E') compared with the REF group. Eight patients in the PEF group but none in the REF group had normal LV diastolic function, represented as E' >8 cm/s, and all of these patients had normal inflow pattern. The mean PCWP had the strongest correlation with the ratio of the peak early mitral inflow velocity (E) to the peak late diastolic mitral inflow velocity during atrial contraction (E/A) in both groups, followed by the left atrial diameter and E/E' in both patient groups. Receiver operating characteristic (ROC) analysis demonstrated that the combination of abnormal E' ≤8 and elevated E/A had high diagnostic accuracy compared with E/E' in both patient groups with different cutoff values of E/A (1.81 in the PEF group and 1.16 in the REF group) for predicting mean PCWP >18 mmHg. After excluding patients with normal diastolic function using E', conventional E/A is a reliable marker for predicting high PCWP and is superior to E/E'.
    Full-text · Article · Mar 2013 · Journal of Echocardiography
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    • "Information on left ventricular end diastolic pressure (LVEDP) is essential when one considers the presence or absence of clinical symptoms in patients with mitral regurgitation (MR).1 Supposedly, patients with pulmonary disease and significant MR but with cardiac compensation may have dyspnea because of a pulmonary rather than a cardiac cause. "
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    ABSTRACT: Conventional Doppler measurements, including mitral inflow and pulmonary venous flow, are used to estimate left ventricular end diastolic pressure (LVEDP). However, these parameters have limitations in predicting LVEDP among patients with mitral regurgitation. This study sought to establish whether the correlation between measurements derived from tissue Doppler echocardiography and LVEDP remains valid in the setting of severe mitral regurgitation. THIRTY PATIENTS (MEAN AGE: 57.37 ± 13.29 years) with severe mitral regurgitation and a mean left ventricular ejection fraction (EF) of 46.0 ± 14.95 were enrolled; 16 (53.4%) patients were defined to have EF < 50% and 14 (46.6%) patients had EF ≥ 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and Doppler tissue imaging indices were obtained, and LVEDP was measured invasively through cardiac catheterization. The majority of the standard Doppler and Doppler tissue imaging indices were not significantly correlated with LVEDP in the univariate analysis. In the multiple linear regression, however, early (E) transmitral velocity to annular E' (E/E') ratio (β = 1.09, p value < 0.01), E wave velocity to propagation velocity (E/Vp) ratio (β = 7.87, p value < 0.01), and isovolumic relaxation time (β = 0.21, p value = 0.01) were shown as independent predictors of LVEDP (R(2) = 91.7%). The ratio of E/Vp and E/E' ratio and also the isovolumic relaxation time could be applied properly to estimate LVEDP in mitral regurgitation patients even in the setting of severe mitral regurgitation.
    Full-text · Article · Aug 2010
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    • "The left atrial pressure may be assessed in the presence of mitral valve regurgitation but with an unacceptable level of approximation. However, in a recent article Diwan and coworkers [12] reported a noninvasive way to determine left ventricular filling pressure in patients with mitral valve disease, using the isovolumetric relaxation time, and the time interval between the onset of early diastolic mitral inflow velocity and annular early diastolic velocity (assessed using tissue Doppler imaging). Furthermore, they demonstrated that the indices obtained with this approach are predictive of pulmonary capillary wedge pressure (PCWP). "
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    ABSTRACT: The use of pulmonary artery catheters (PACs) during cardiac surgery varies considerably depending on local policy, ranging from use in 5-10% of the patient population to routine application. However, as in other clinical fields, recent years have witnessed a progressive decline in PAC use. One of the reasons for this is probably the increasing use of transoesophageal echocardiograpy, even though careful analysis of the information provided by PAC and transoesophageal echocardiograpy indicates that the two tools should be considered subsidiary rather than alternatives. The principal categories of cardiac patients who can benefit from PAC monitoring are those with present and those with possible haemodynamic instability. On this basis we can identify five groups: patients with impaired left ventricular systolic function; those with impaired right ventricular systolic function; those with left ventricular diastolic dysfunction; those with an acute ventricular septal defect; and those with a left ventricular assist device. This review highlights the specific role of PAC-derived haemodynamic data for each category.
    Full-text · Article · Feb 2006 · Critical care (London, England)
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