Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure

Abstract

Background: The ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) has been correlated with pulmonary capillary wedge pressure (PCWP) in a wide variety of cardiac conditions. The objective of this study was to determine the reliability of mitral E/Ea for predicting PCWP in patients admitted for advanced decompensated heart failure.

Methods and results: Prospective consecutive patients with advanced decompensated heart failure (ejection fraction < or =30%, New York Heart Association class III to IV symptoms) underwent simultaneous echocardiographic and hemodynamic evaluation on admission and after 48 hours of intensive medical therapy. A total of 106 patients were included (mean age, 57+/-12 years; ejection fraction, 24+/-8%; PCWP, 21+/-7 mm Hg; mitral E/Ea ratio, 20+/-12). No correlation was found between mitral E/Ea ratio and PCWP, particularly in those with larger left ventricular volumes, more impaired cardiac indexes, and the presence of cardiac resynchronization therapy. Overall, the mitral E/Ea ratio was similar among patients with PCWP >18 and < or =18 mm Hg, and sensitivity and specificity for mitral E/Ea ratio >15 to identify a PCWP >18 mm Hg were 66% and 50%, respectively. Contrary to prior reports, we did not observe any direct association between changes in PCWP and changes in mitral E/Ea ratio.

Conclusions: In decompensated patients with advanced systolic heart failure, tissue Doppler-derived mitral E/Ea ratio may not be as reliable in predicting intracardiac filling pressures, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac resynchronization therapy.

Figures

Figure 1

Relation between mitral E/Ea and pulmonary capillary wedge pressure at baseline (Upper panel) and relation between changes (baseline-follow-up) in mitral E/Ea and changes (baseline-follow-up) in pulmonary capillary wedge pressure (Lower panel)

Figure 2

Mitral E/Ea in all patients and stratified to previous CRT-D implantation or not.

Figure 3

Receiver operator characteristic curves for the prediction of pulmonary capillary wedge pressure > 18 mmHg (upper panel) and > 15 mmHg (lower panel) for mitral E/Ea.

Figure 4

Relation between mitral E/Ea and pulmonary capillary wedge pressure (PCWP) to LV end-diastolic volume and cardiac index. The p-value represents t-test between concordant and disconcordant PCWP and mitral E/Ea. Error bars represent standard deviation.

Figure 5

Example of two patients with discordant pulmonary capillary wedge pressure (PCWP) and mitral E/Ea. Upper panel shows patient with low PCWP and high mitral E/Ea and lower panel shows patient with high PCWP and low mitral E/Ea.

Figure 6

Example of changes in pulmonary capillary wedge pressure (PCWP) and mitral E/Ea in one patient from baseline (Upper panel) to follow-up (Lower panel). Note the discordant PCWP and mitral E/Ea at baseline and at follow-up, and the reduction in PCWP (−5 mmHg) which is associated with an increase in mitral E/Ea (+ 2).