Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study

Abstract

Background: Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e' and E/e' for identification and grading of diastolic dysfunction pre-operatively.

Methods: Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e'-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC).

Results: Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e' and E/e', diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e'-velocities (mean < 9 cm s- 1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78.

Conclusions: The results of this study indicate that a simplified approach with tissue Doppler e'-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e' ratio the severity of diastolic dysfunction may be overestimated.

Trial registration: Clinicaltrials.gov, Identifier: NCT03349593 . Date of registration 21/11/2017. https://clinicaltrials.gov .

Keywords: Diastole; Left ventricular dysfunction; Point-of-care ultrasound; Prospective studies; Risk assessment; Tissue Doppler; Transthoracic echocardiography.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1

The study flow diagram. *The first patients of each study day were excluded due to the surgery schedule. Abbreviations: TTE = transthoracic echocardiography

Fig. 2

The illustration of the diagnostic test e’. The illustration made by Tomi Myrberg. LA indicates the left atrium; LV, the left ventricle; RA, the right atrium; RV, the right ventricle; TDI e’, tissue Doppler peak velocity of the mitral annulus during early filling of the left ventricle

Fig. 3

Simplified assessment of diastolic dysfunction by Lanspa et al. Crit Care. 2016;20(1):243. Three categories are established with suspected left ventricular diastolic dysfunction (LVDD) based on mean e’ values and E/e’ ratio: i) e’ − 1 + E/e’ ≤ 8 = LVDD grade I and normal filling pressures, ii) e’ < 9 cm s− 1 + E/e’ 8 to 14 = LVDD grade II and elevated filling pressures, and iii) e’ < 9 cm s− 1 + E/e’ ≥ 14 = LVDD grade III and elevated filling pressures

Fig. 4

The ROC curve for e’ mean velocities to discriminate diastolic dysfunction. AUROC (95%CI): 0.901 (0.840–0.962), p < 0.001. The dashed lines are pointing out the cut-off value 8.75 cm s− 1