`
`
`
`
`
`
`
`
`
`
`
`doi:l0.1053/euje.200l.0l36, available online at http://www.idealibra1y.com on liiE¢.l§’
`
`
`
`
`
`
`TEACHING CORNER: REVIEW
`
`
`
`
`
`
`
`Non-invasive Estimation of Left Ventricular Filling
`
`
`
`
`Pressures by Doppler Echocardiography
`
`
`
`
`
`
`
`
`
`
`
`M. Pozzoli‘, E. Traversiz and J. R. T. C. Roelandt3
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`‘Department of Cardiology, A. Manzoni Hospital, Lecco, Italy; 2Department of Cardiology, S. Maugeri
`
`
`
`
`
`
`
`Foundation, IRCCS, Centro Medico, Montescano, Italy; 3Department of Cardiology, Thoraxeenter,
`
`
`
`Erasmus University Medical Center, Rotterdam, The Netherlands
`
`
`
`
`
`
`
`
`
`
`
`
`Besides being complicated reality,
`
`
`
`
`
`
`in my experience, is odd .
`. ..
`
`
`
`
`
`
`Of course anyone can be simple
`if he has no facts to bother about
`
`
`
`
`
`
`
`
`C. S. Lewis
`
`
`
`
`
`
`
`
`
`
`Heart
`failure is haemodynamically characterized by
`
`
`
`
`
`
`elevated left. ventricular filling pressure.
`Its determi-
`
`
`
`
`
`
`
`
`nation is important
`in order to optimize unloading
`
`
`
`
`
`therapy,
`interpret equivocal symptoms, predict prog-
`
`
`
`
`
`
`
`nosis and the follow-up of treatments“. Invasive tech-
`
`
`
`
`
`
`niques are impractical
`for
`repeated measurements.
`Therefore there is a need for more comfortable and less
`
`
`
`
`
`
`
`
`
`expensive methods of measurement.
`
`
`
`
`
`
`
`
`
`
`
`Over the past 10 years, pulsed-wave Doppler echo-
`
`
`
`
`
`
`
`
`cardiography has emerged as a practical
`tool for the
`
`
`
`
`
`
`non-invasive estimation of left ventricular filling pres-
`sures and several indices derived from transmitral and
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`pulmonary venous flow velocity recordings have been
`
`
`
`
`
`
`
`validated for estimating left ventricular filling pressures
`
`
`
`
`
`
`
`
`
`in various subsets of patients with both systolic and
`
`
`
`
`
`
`
`diastolic left ventricular dysfunction, excluding those in
`
`
`
`
`
`
`
`
`whom left ventricular filling is affected by extrinsic
`
`
`
`
`
`
`
`
`factors such as mitral stenosis or pericardial constraint.
`
`
`
`
`
`
`
`
`
`
`The basic principle of all these methods is that blood
`flow is driven from the left atrium into the left ventricle
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`by the instantaneous pressure gradient across the mitral
`
`
`
`
`
`
`
`
`
`valve and that mitral flow velocity therefore reflects the
`
`
`
`
`
`
`
`
`level of left atrial pressurelml. However, since the trans-
`
`
`
`
`
`
`
`mitral pressure gradient (and flow velocity) is deter-
`
`
`
`
`
`
`
`
`
`
`mined not only by left atrial pressure, but depends also
`on ventricular factors such as relaxation rate and com-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`pliance, the correlations between Doppler variables and
`
`Address correspondence to: Massimo Pozzoli, Department of
`
`
`
`
`
`
`
`Cardiology, A. Manzoni Hospital, Via della Filanda, Lecco, Italy.
`
`
`
`
`
`
`
`
`
`Tel: +39-0343-489111; E-mail: maxpozz@libero.it
`
`
`
`
`Received 2 July 2001,‘ revised manuscript received I5 November
`
`
`
`
`
`
`
`
`200i; accepted 20 November 200i.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`left atrial pressure are too weak for an accurate estima-
`
`
`
`
`
`
`
`
`
`tion and may vary between different subsets of patients.
`In fact, the rate of left ventricular relaxation affects left
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ventricular pressure fall
`in early diastole and conse-
`
`
`
`
`
`
`
`
`
`quently plays an important role in determining the E
`
`
`
`
`
`
`
`
`
`wave velocity. Thus, when the rate of left ventricular
`
`
`
`
`
`
`
`
`
`relaxation is high (such as in normal young subjects
`
`
`
`
`
`
`
`
`and in hyperthyroid patients) the early diastolic wave
`
`
`
`
`
`
`
`
`
`
`velocity (E) and its deceleration may be increased even if
`
`
`
`
`
`
`
`
`the left atrial pressure is low. Conversely, when relaxa-
`
`
`
`
`
`
`
`
`
`tion is markedly impaired (such as in patients with
`
`
`
`
`
`
`
`severe left ventricular hypertrophy and diastolic heart
`
`
`
`
`
`
`
`
`
`
`failure) E wave velocity and its deceleration rate may be
`
`
`
`
`
`
`
`
`
`
`relatively low even in the presence of elevated left atrial
`
`
`
`
`
`
`
`
`
`pressure. The opposite effects of left atrial pressure and
`
`
`
`
`
`
`
`
`impaired left ventricular relaxation may make it difficult
`
`
`
`
`
`
`
`
`to estimate left ventricular filling pressure in a given
`patients on the basis of transmitral flow velocity wave
`
`
`
`
`
`
`
`
`
`alone.
`
`
`
`
`
`
`
`
`
`To overcome the confounding effects of the multiple
`
`
`
`
`
`
`
`interacting factors that affect transmittal flow velocities,
`
`
`
`
`
`
`
`
`several strategies are followed. First of all Doppler
`indices should be considered in the context of the clinical
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`picture (age, heart rate, etiology of the disease, etc.) and
`
`
`
`
`
`the M-mode and two-dimensional echocardiographic
`findings (left atrium and left ventricular dimensions and
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`systolic function). For example,
`in a patient with a
`
`
`
`
`
`
`
`
`dilated left ventricle and poor systolic function we
`
`
`
`
`
`
`
`know that
`left ventricular
`relaxation is
`impaired.
`
`
`
`
`
`
`
`Consequently, a high amplitude E wave with rapid
`
`
`
`
`
`
`
`
`
`
`deceleration must be due to high left atrial pressure and
`a non—co1npliant left ventricle. On the other hand, in a
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`patient with poor systolic function and a delayed or
`
`
`
`
`
`
`
`
`reduced E wave followed by a slow deceleration and
`an increased late diastolic A wave velocity left ventricu-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`lar
`filling pressures are normal or mildly elevated.
`Consequently,
`several
`studies have shown that
`in
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`patients with severe systolic dysfunction and normal
`
`
`
`
`
`
`
`sinus rhythm the correlation between simple variables,
`
`1525-2l 67/02/010075-{~05 $35.00/0
`
`
` (cid:9)
`
`((3 2002 Published by Elsevier Science Ltd on behalf of The European Society of Cardiology
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`O75
`
`PRAXAIR ET AL. 1015
`
`
`
`075
`
`
`
`76 M. Pozzoli et a1.
`
`
`
`
`
`
`
`
`
`such as EIA and deceleration time, and left ventricular
`
`
`
`
`
`
`
`
`
`
`
`
`
`filling pressure are excellent[“’7].
`
`
`
`
`
`
`
`
`The estimation of left ventricular filling pressures in
`conditions where left ventricular dysfunction is
`less
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`apparent can be improved by the analysis of the pul-
`
`
`
`
`
`
`
`
`monary vein flow velocity pattern. The pulmonary vein
`
`
`
`
`
`
`
`
`flow velocity pattern mirrors
`the changes of
`the
`
`
`
`
`
`
`
`
`
`left atrial pressure. When the left atrium pressure is
`
`
`
`
`
`
`
`
`elevated and, particularly, when there is a high V-wave
`
`
`
`
`
`
`
`because of a non-compliant
`left atrium,
`the systolic
`
`
`
`
`
`
`
`
`forward flow velocity (S wave) decreases While the
`
`
`
`
`
`
`
`diastolic velocity (D Wave) increases. Although systolic
`
`
`
`
`
`
`
`pulmonary venous
`flow velocity is determined by
`
`
`
`
`
`
`multiple _factors (including left ventricular systolic func-
`
`
`
`
`
`
`tion, left atrium relaxation, right ventricular vis a tergo
`
`
`
`
`
`
`
`
`and mitral
`regurgitation),
`the systolic forward flow
`
`
`
`
`
`
`
`velocity in patients with left ventricular systolic dysfunc-
`
`
`
`
`
`
`
`
`
`tion is strongly and inversely related to the left ventricu-
`
`
`
`
`
`
`
`lar filling pressures. In particular, a systolic fraction
`
`
`
`
`
`
`
`
`<40“/o is a reliable index of a pulmonary artery wedge
`
`
`
`
`
`
`
`pressure >18 mmHg[3”"”. However,
`in young normal
`
`
`
`
`
`
`
`subjects, in patients with eccentric mitral regurgitation
`
`
`
`
`
`
`
`
`
`and in those with a cardiac allograft a blunted S wave
`
`
`
`
`
`
`
`
`may be present even when left ventricular filling pres-
`
`
`
`
`
`
`
`
`
`sures are low. Conversely,
`in patients with good left
`
`
`
`
`
`
`ventricular systolic function and vigorous displacement
`
`
`
`
`
`
`
`
`
`
`
`of the mitral annulus, the S wave can be relatively high
`
`
`
`
`
`
`in spite of high filling pressures.
`
`
`
`
`
`
`
`Another useful index for estimating left ventricular
`
`
`
`
`
`
`
`
`
`filling pressure is the difference between the duration of
`
`
`
`
`
`
`
`
`
`
`the reverse pulmonary vein flow wave (Ar) and of the
`
`
`
`
`
`
`
`
`
`
`mitral forward A wave (Fig. 1). In normal subjects the
`
`
`
`
`
`
`
`
`
`duration of these two waves is almost equal. When
`
`
`
`
`
`
`
`
`the left atrium contracts against a stiff ventricle,
`the
`
`
`
`
`
`
`
`
`
`
`forward fiow across the mitral valve stops early while the
`
`
`
`
`
`
`
`
`reversed flow into the pulmonary veins increases. Thus,
`
`
`
`
`
`
`
`
`
`
`an Ar wave duration longer than that of the transmitral
`
`
`
`
`
`
`
`
`
`A wave is an accurate sign of a left ventricular end-
`
`
`
`
`
`
`
`
`
`diastolic pressure >15 mmHg“”. This index has the
`
`
`
`
`
`
`
`
`additional advantage of being independent of age, mitral
`
`
`
`
`
`
`
`regurgitation and left ventricular systolic function. It
`should be noted that although this index is strongly
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`correlated with left ventricular end—diastolic pressure, its
`
`
`
`
`
`
`
`correlation with pulmonary wedge pressure is rather
`
`
`
`
`
`
`
`
`
`poor. The fact that patients with a high left ventricular
`
`
`
`
`
`
`end-diastolic pressure may occasionally have mildly
`
`
`
`
`
`
`
`
`elevated or even normal early diastolic left atrium pres-
`
`
`
`
`
`
`
`
`sures accounts for this discrepancy. Other limitations of
`
`
`
`
`
`
`
`
`
`this index are:
`the difficulty of recording Ar wave
`
`
`
`
`
`
`
`
`duration in patients with dilated left atrium and pul-
`
`
`
`
`
`
`
`
`monary veins; its dependence on atrial systolic function
`
`
`
`
`
`
`
`
`
`and its merge with the diastolic forward flow when
`
`
`
`
`
`
`
`
`
`
`
`the heart rate is high and/or the PR interval is long.
`Technical details on how to obtain and correctly
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`measure this and other
`transmitral and pulmonary
`
`
`
`
`
`
`
`
`venous flow vardiables can be found in a comprehensive
`
`
`
`
`review published by Appleton ['2].
`
`
`
`
`
`
`
`Despite these limitations, the analysis of pulmonary
`vein flow in combination of transmitral fiow in order to
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`differentiate normal from pseudonormal velocity pat-
`
`
`
`Eur J Echocardiography, Vol. 3, issue 1, March 2002
`
`
`
`
`
`
`
`
`
`076
`
`
`
`
`
`
`
`
`
`terns improves the estimation of left ventricular filling
`
`
`
`
`
`
`
`pressures in patients with moderately impaired function
`and dilated left ventricles.
`
`
`
`
`
`
`
`
`
`
`
`There remains, however, a sizeable number of patients
`
`
`
`
`
`
`
`
`
`in whom even this method is not
`reliable enough:
`
`
`
`
`
`
`
`
`patients with a single transmitral flow wave due to
`
`
`
`
`
`
`
`
`tachycardia and /or a prolonged PR interval; patients in
`
`
`
`
`
`
`
`atrial fibrillation, those who have isolated diastolic dys-
`
`
`
`
`
`
`
`
`function; those with a cardiac allograft and those with
`
`
`
`
`
`
`
`inadequate Doppler recordings of pulmonary vein flow.
`
`
`
`
`
`
`
`
`Two methods have been recently proposed to estimate
`
`
`
`
`
`
`
`left ventricular filling pressures. The first method com-
`
`
`
`
`
`
`
`
`bines transmitral E wave velocity with its propagation
`
`
`
`
`
`
`
`
`
`velocity (Pv) into the left ventricular recorded by colour
`
`
`
`
`
`
`M-mode Doppler. The second method combines trans-
`
`
`
`
`
`
`
`
`
`
`mitral E wave velocity with the early diastolic velocity of
`
`
`
`
`
`
`
`
`the mitral annulus motion recorded by pulse-wave tissue
`
`
`
`
`
`
`
`
`
`Doppler. Both of these methods are based on the
`
`
`
`
`
`
`
`
`concept that normalizing transmitral E wave velocity by
`an index that reflects the rate of left ventricular relaxa-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`tion which is independent from pre—load reduces the
`
`
`
`
`
`
`
`
`confounding eflfect of the relaxation rate and improves
`
`
`
`
`
`
`
`
`
`the correlation with left atrial pressure. It has been
`
`
`
`
`
`
`
`
`
`
`shown by several studies that the wavefront of the early
`
`
`
`
`
`
`
`
`diastolic inflow velocity reaches the left ventricular apex
`
`
`
`
`
`
`
`
`almost instantaneously when the relaxation rate is high,
`
`
`
`
`
`
`
`
`while it takes longer when relaxation is impaired[”’‘‘”.
`The Pv of this wavefront can be assessed by color
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`M-mode in the apical four-chamber View with the beam
`
`
`
`
`
`
`
`
`
`
`aligned with the centre of the left ventricular inflow. The
`
`
`
`
`
`
`
`
`
`
`
`
`slope of the first colour aliasing (set at 45 cm/s) from the
`mitral annulus to 4 cm into the left ventricular is then
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`identified, either visually or by isovelocity mapsm]. This
`measurement is strongly related to the time constant
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`(tau) of the left ventricular pressure decay and the E /Pv
`
`
`
`
`
`
`ratio With pulmonary wedge pressure. Recent observa-
`
`
`
`
`
`
`
`
`
`tions, however, suggest that this method is more reliable
`
`
`
`
`
`
`
`
`
`in patients with dilated ventricles while its accuracy is
`
`
`
`
`
`
`
`
`limited in patients with normal systolic function and
`
`small left ventricles[‘3"4].
`
`
`
`
`
`
`
`
`
`
`
`Like Pv, the velocity of early diastolic mitral annulus
`
`
`
`
`
`
`
`
`
`
`
`
`motion (E') has also been found to be related to tau and
`
`
`
`
`
`
`
`
`to be relatively independent of left atrial pressure“5"5].
`
`
`
`
`
`
`
`
`
`Again the E/E’ ratio has been successfully applied to
`
`
`
`
`
`
`
`
`estimate left ventricular filling pressures in subsets of
`
`
`
`
`
`
`
`including those with atrial fibrillation, sinus
`patients,
`
`
`
`
`
`
`tachycardia, cardiac allograft and normal
`systolic
`
`
`
`
`
`
`
`
`function“7‘2°‘. An early study indicated that a E/E’ ratio
`
`
`
`
`
`
`
`
`>10 is a reliable index to estimate a pulmonary wedge
`
`
`
`
`
`
`
`
`
`pressure >12 mmHg“5’. A more recent study showed
`
`
`
`
`
`
`
`
`
`that an E/E’ ratio <8 accurately identifies patients with a
`
`
`
`
`
`
`
`
`
`
`normal pressure and a ratio >15 those with an elevated
`
`
`
`
`
`
`pulmonary wedge pressurelm.
`In patients with inter-
`
`
`
`
`
`
`
`mediate values (>8 and <15) pulmonary wedge pres-
`
`
`
`
`
`
`
`
`
`sures may vary widely and the other Doppler flow
`methods can be used. It remains unresolved whether
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`better results can be obtained using the lateral or the
`
`
`
`
`
`
`
`
`
`
`septal E’. In patients with ischaemic heart disease it is
`
`
`
`
`
`
`
`
`
`probably best to average the values obtained from the
`
`
`
`
`
`
`
`
`lateral, septal, anterior and inferior mitral annulus. The
`
`
`
`
`
`076
`
`
`
`Non-invasive Estimation of Left Ventricular Filling Pressures
`
`
`
`
`
`
`
`
`
`77
`
`
`IRP
`
`DT
`
`Adur
`
`ECG
`
`
`
`
`PVF
`
`
`TDI
`
`
`COLOR
`M-mode
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Figure 1. Parameters used for the estimation of left ventricular filling
`pressures.
`
`
`
`
`
`
`
`
`
`
`Pulsed Doppler of transmitral flow (MVF): isovolumic relaxation period
`
`
`
`
`
`
`
`
`
`
`
`(IRP); early diastolic (E) and late diastolic (A) wave amplitude; deceleration
`
`
`
`
`
`
`
`
`
`time (DT);
`late diastolic wave duration (Adur). Derived measurements:
`
`
`
`
`
`
`
`
`
`
`ratio between early diastolic and late diastolic wave amplitude (E/A);
`
`
`
`
`
`
`
`
`
`
`deceleration rate (E/DT). Pulsed Doppler of pulmonary vein flow (PVF):
`
`
`
`
`
`
`
`
`
`
`systolic forward flow wave amplitude (S) ; diastolic forward flow wave
`
`
`
`
`
`
`
`
`amplitude (D); diastolic reverse flow duration (Ardur). Derived measure-
`
`
`
`
`
`
`
`
`
`ments: systolic fraction (S/S+D); difference between diastolic reverse flow
`
`
`
`
`
`
`
`
`
`
`
`duration of pulmonary venous flow and late diastolic wave duration of
`
`
`
`
`
`
`
`
`
`
`flow (Ar-A duration). Tissue Doppler of mitral annulus (TDI):
`mitral
`
`
`
`
`
`
`
`
`
`
`
`
`amplitude of early diastolic wave 03'); amplitude of late diastolic wave (A’);
`
`
`
`
`
`
`
`
`
`Derived measurements: ratio between early diastolic wave amplitude of
`
`
`
`
`
`
`
`
`
`
`transmitral flow and early diastolic wave amplitude of mitral annulus
`
`
`
`
`
`
`
`
`
`(E/E’). Colour M-mode Doppler of transmitral inflow: propagation velocity
`
`
`
`
`
`
`
`
`
`
`
`
`
`of early diastolic fiow (Pv) calculated as the slope of the first aliasing
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`(45 cm /s) from the mitral valve plain to 4 cm into the left ventricle. Derived
`
`
`
`
`
`
`
`
`
`measurements: ratio between early diastolic wave amplitude of transmitral
`
`
`
`
`
`
`
`
`
`
`flow and its propagation velocity into the left ventricule (E/Pv).
`
`Eur J Echocardiography, Vol. 3, issue 1, March 2002
`
`
`
`
`
`
`
`
`
`077
`
`077
`
`
`
`78 M. Pozzoli et al.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Table 1. Parameters for identification of patients with an
`
`
`
`
`
`
`
`elevated left ventricular filling pressure.
`
`- Enlarged left atrium size
`
`
`
`
`
`E/A ratio >2
`
`
`
`
`DT <150 msec
`
`
`
`
`SF of pulmonary vein flow <40%
`
`
`
`
`
`
`E/E’ ratio >15
`
`
`
`
`E/Pv >2
`
`
`
`
`cocoa
`
`
`
`DT: deceleration time of early diastolic wave of transmitral flow;
`
`
`
`
`
`
`
`
`
`
`E/A: ratio between early diastolic and late diastolic wave amplitude
`
`
`
`
`
`
`
`
`
`
`of transmitral flow; E/E’: ratio ratio between early diastolic wave
`
`
`
`
`
`
`
`
`
`
`amplitude oftransmitral flow and early diastolic wave amplitude of
`
`
`
`
`
`
`
`
`
`
`mitral annulus; E/Pvt ratio between early diastolic wave amplitude
`
`
`
`
`
`
`
`
`
`of transmitral
`flow and its propagation velocity into the left
`
`
`
`
`
`
`
`
`
`
`ventricular. LA: left atrium. SF: systolic fraction.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Table 2. Proposed formulas for the estimation of left
`
`
`
`ventricular filling pressure.
`
`MFV and PVF (for patients in sinus rhythm-Heft ventricular
`
`
`
`
`
`
`
`
`
`systolic dysfunction)
`
`
`PCWP=1-85 >< deceleration rate — 0-1 X SF+ 10-9”“?
`
`
`
`
`
`
`
`MFV and colour M—mode (for patients in sinus rhythm and
`
`
`
`
`
`
`
`
`
`
`various cardiac conditions)
`
`
`
`PCWP=5‘27 X (E/Pv)+4-66“-‘7
`
`
`
`MFV and TDl mitral annulus (for patients in sinus rhythm and
`
`
`
`
`
`
`
`
`
`
`
`various cardiac conditions)
`
`
`
`PCWP= l~9+1-24 X (E/E')““3
`
`
`
`
`MFV and TDI mitral annulus (for patients with single transmitral
`
`
`
`
`
`
`
`
`
`
`flow wave due to tachycardia)
`
`
`
`
`
`PCWP=1~S5+1-47 >< (E./E')“73
`
`
`
`MFV and TDl mitral annulus (for patients in atrial fibrillation)
`
`
`
`
`
`
`
`
`
`
`PCWP=6'489+0‘82l X (E/E’)l2"l
`
`
`
`MFV: mitral flow velocity; PVF: pulmonary vein flow; PCWP:
`
`
`
`
`
`
`
`
`
`pulmonary artery wedge pressure; TDI: tissue Doppler. See Table
`
`
`
`
`
`
`
`
`
`l for the other abbreviations.
`
`
`
`
`
`
`parameters used for the estimation of left ventricular
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`filling pressure are summarized in Fig. 1. Table 1 shows
`
`
`
`
`
`
`
`
`
`
`parameters that can be used to identify patients with an
`
`
`
`
`
`
`
`
`
`elevated left ventricular filling pressure. The next step in
`
`
`
`
`
`
`
`
`
`
`the analysis of patients is to use formulas which provide
`
`
`
`
`
`
`
`
`
`an estimate of the actual filling pressure (Table 2).
`
`
`
`
`
`
`
`
`Two questions arise: (1) should left ventricular filling
`
`
`
`
`
`
`pressures be routinely estimated during the echocardio-
`
`
`
`
`
`
`
`graphic examination of patients with known or sus-
`
`
`
`
`
`
`
`
`
`pected heart failure? and (2), what indices should be
`
`
`
`
`
`
`
`
`
`used in a given patient? To answer the first question
`
`
`
`
`
`
`
`additional studies specifically designed to assess the
`
`
`
`
`
`
`
`practical impact of this non-invasive measurement on
`treatment and outcome are needed. We should realize,
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`however, that in everyday practice we try to assess the
`
`
`
`
`
`
`
`
`haemodynamic status on the basis of symptoms and
`
`
`
`
`
`
`
`
`
`
`clinical signs despite the fact that the sensitivity of these
`
`
`
`
`
`
`
`
`indices in identifying patients with a high filling pressure
`
`
`
`
`
`
`
`is, at best, 60°/om]. Doppler echocardiography is far
`
`
`
`
`
`
`
`
`more accurate and reproducible, provided that an
`
`
`
`
`appropriate methodology is applied.
`As far as the method and the indices are concerned,
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`we think that two concepts should be kept in mind. The
`
`
`
`
`
`
`
`
`first
`is that because of the complex pathophysiologic
`
`Eur J Echocardiography, Vol. 3, issue 1, March 2002
`
`
`
`
`
`
`
`
`
`078
`
`
`
`
`
`
`
`
`mechanisms that govern the relation between Doppler
`
`
`
`
`
`
`echocardiographic variables and left atrial pressures,
`
`
`
`
`
`
`
`
`
`
`no single variable can be used to assess left ventricular
`
`
`
`
`
`
`
`filling pressures in a given patient. Second, different
`
`
`
`
`
`
`
`
`methods should be applied in different subsets of
`
`
`
`
`
`
`
`
`patients, taking into consideration factors such as the
`
`
`
`
`
`
`
`
`
`etiology of the disease, heart rate and rhythm, and
`
`
`
`
`
`
`
`
`systolic function. We suggest beginning the evaluation of
`
`
`
`
`
`
`
`
`left ventricular filling pressure by looking at dimensions
`
`
`
`
`
`
`
`
`
`
`and function of the left ventricular by standard M- and
`B-mode echo. As stated above, if the left ventricle is
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`dilated and its systolic function depressed the trans-
`
`
`
`
`
`
`
`mitral flow velocity parameters alone”) or in combina-
`
`
`
`
`
`
`
`tion with pulmonary venous fiow parameterslml (Table
`
`
`
`
`
`
`
`
`
`2, first equation) are usually sufficient for estimating left
`
`
`
`
`
`
`
`
`
`ventricular filling pressure. If there are still doubts, or
`
`
`
`
`
`
`
`the pulmonary venous flow recording is
`technically
`
`
`
`
`
`
`
`
`
`
`inadequate, E/Pv or E/E’ ratios can also be caclulated. If
`
`
`
`
`
`
`
`
`
`the left ventricular systolic function is normal or mildly
`
`
`
`
`
`
`
`
`
`
`depressed, the E/E’ ratio is the measurement of choice. It
`
`
`
`
`
`
`
`
`allows differentiation of patients with normal (low left
`
`
`
`
`
`
`ventricular filling pressure) from those with pseudo-
`
`
`
`
`
`
`
`
`normal (high left ventricular filling pressure) mitral flow
`
`
`
`
`
`
`
`
`
`
`velocity pattern, those in whom an impaired filling is due
`to ‘restriction’
`from those in whom this is due to
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`‘constriction’[23]. In addition, E/E’ ratio incorporated in
`
`
`
`
`
`
`
`
`dififerent equations (Table 2) can be used to quantita-
`
`
`
`
`
`
`
`
`tively estimate left ventricular filling pressure in various
`
`
`
`
`
`
`
`
`
`subsets of patients such as those with a single transmitral
`
`
`
`
`
`
`flow due to sinus tachycardia, hypertrophic cardio-
`
`
`
`
`
`myopathy, cardiac allograft and atrial fibrillation“7'2"].
`
`
`
`
`
`
`
`
`
`The concepts presented will be exemplified by several
`
`
`
`
`
`
`patients who underwent simultaneous invasive and
`
`
`
`Doppler echocardiographic assessment.
`
`[4]
`
`[5]
`
`References
`
`[1] Stevenson LW. Therapy tailored for symptomatic heart
`
`
`
`
`
`
`
`
`failure. Heart Failure 1995; 87~107.
`
`
`
`
`
`[2] Nishimura RA, Tajik AJ. Evaluation of diastolic filling of left
`
`
`
`
`
`
`
`
`
`
`
`ventricle in health and disease: Doppler echocardiography is
`
`
`
`
`
`
`
`
`the clinician’s Rosetta stone. J Am Coll Cardiol l997; 30: 8~l8.
`
`
`
`
`
`
`
`
`
`
`[3] Oh JK, Appleton CP, Hatle L, Nishimura RA, Seward
`
`
`
`
`
`
`
`
`
`
`J8, Tajik 11. The noninvasive assessment of left ventricular
`
`
`
`
`
`
`
`
`
`diastolic
`function with
`two-dimensional
`and Doppler
`
`
`
`
`
`
`echocardiography. J Am Soc Echocardiogr 1997; 10: 246~270.
`
`
`
`
`
`
`
`Mulvagh S, Quinones ME, Kleiman NS. Estimation of left
`
`
`
`
`
`
`
`
`
`
`ventricular end—diastolic pressure from Doppler transmitral
`
`
`
`
`
`
`flow velocity in cardiac patients independent of systolic
`
`
`
`
`
`
`
`
`performance. J Am Coll Cardiol 1992; 20: 112—119.
`
`
`
`
`
`
`
`Appleton CP, Galloway JM, Gonzales MS, Graballa M,
`
`
`
`
`
`
`
`
`
`Basnight MA et al. Estimation of left ventricular filling
`
`
`
`
`
`
`
`
`
`pressures using two-dimensional and Doppler echocardiogra-
`
`
`
`
`
`phy in adult patients with cardiac disease. J Am Coll Cardiol
`
`
`
`
`
`
`
`
`
`
`
`1993; 22: 1972-1982.
`
`
`
`Giannuzzi P,
`lmparato A, Temporelli PL et al. Doppler-
`
`
`
`
`
`
`
`
`
`derived mitral deceleration time of early filling is a strong
`
`
`
`
`
`
`
`
`
`predictor of pulmonary capillary wedge pressure in post-
`
`
`
`
`
`
`
`infarction patients with left ventricular systolic dysfunction. J
`
`
`
`
`
`
`
`Am Coll Cardiol l994; 23: 16304637.
`
`
`
`
`
`
`Vanoverschelde JLJ, Robert AR, Gerbaux A, Michel X,
`
`
`
`
`
`
`
`
`
`Hanet C, Wijns W. Noninvasive estimation of pulmonary
`
`
`
`
`
`
`
`
`arterial wedge pressure with Doppler transmitral flow velocity
`
`
`
`
`
`
`
`
`pattern in patients with known heart disease. Am J Cardiol
`
`
`
`
`
`
`
`
`
`1996; 75: 383—389.
`
`
`
`
`161
`
`078
`
`
`
`Non-invasive Estimation of Left Ventricular Filling Pressures
`
`
`
`
`
`
`
`
`
`79
`
`
`[8] Kuecherer HF, Kusumoto FM, Muhiudeen IA, Cahalan MK,
`
`
`
`
`
`
`
`
`
`Schiller NB. Pulmonary venous flow patterns by transesopha-
`
`
`
`
`
`
`
`geal pulsed Doppler echocardiography: relation to parameters
`
`
`
`
`
`
`
`of left ventricular systolic and diastolic function. Am Heart J
`
`
`
`
`
`
`
`
`
`1991; 122: 1683-1693.
`
`
`
`[9] Brunazzi MC, Chirillo F, Pasqualini M, et :21. Estimation of
`
`
`
`
`
`
`
`
`
`
`
`left ventricular diastolic pressures from precordial pulsed-
`
`
`
`
`
`
`Doppler analysis of pulmonary venous and mitral flow. Am
`
`
`
`
`
`
`
`
`
`Heart J 1994; 128: 293-300.
`
`
`
`
`:10] Pozzoli M, Capomolla S, Pinna G, Cobelli F, Tavazzi L.
`
`
`
`
`
`
`
`
`
`
`
`
`Doppler echocardiography reliably predicts pulmonary artery
`
`
`
`
`
`
`wedge pressure in patients with chronic heart failure with and
`
`
`
`
`
`
`
`
`
`
`without mitral regurgitation. J Am Coll Cardiol 1996; 27:
`
`
`
`
`
`
`
`
`
`883-893.
`
`ll] Rossvoll O, Hatle LK. Pulmonary flow velocities recorded by
`
`
`
`
`
`
`
`
`
`
`transthoracic Doppler ultrasound: relation to left ventricular
`
`
`
`
`
`
`
`diastolic. J Am Coll Cardiol 1993; 21: 1687-1696.
`
`
`
`
`
`
`
`
`:12] Appleton CP, Jensen JL, Hatle LK, Oh JK. Doppler evalu-
`
`
`
`
`
`
`
`
`
`
`ation of left and right ventricular diastolic function: a techni-
`
`
`
`
`
`
`
`
`cal guide for obtaining optimal flow velocity recordings. J Am
`
`
`
`
`
`
`
`
`
`
`Soc Echocardiogr 1997; 10: 271-291.
`
`
`
`
`
`:13] Garcia MJ, Ares MA, Asher C, Rodriguez L, vandervoort P,
`
`
`
`
`
`
`
`
`
`
`
`
`Thomas JD. An index of early left ventricular filling that
`
`
`
`
`
`
`
`
`
`
`combined with pulsed Doppler peak E velocity may estimate
`
`
`
`
`
`
`
`
`
`capillary wedge pressure. J Am Coll Cardiol 1997; 29:448-454.
`
`
`
`
`
`
`
`
`
`
`:14] Garcia MJ, Smedira MG, Greenberg NL et
`:21. Color
`
`
`
`
`
`
`
`
`
`
`M—Mode Doppler flow propagation velocity is a preload
`
`
`
`
`
`
`
`insensitive index of left ventricular relaxation: animal and
`
`
`
`
`
`
`
`
`human validation. J Am Coll Cardiol 2000; 35: 201-208.
`
`
`
`
`
`
`
`
`
`:15] Nagueh SF, Sun H, Kopelen HA, Middleton KJ, Khoury DS.
`
`
`
`
`
`
`
`
`
`
`
`Hemodynamic determinants of the mitral annulus diastolic
`
`
`
`
`
`
`
`velocities by tissue Dopplcr. J Am Coll Cardiol 2001; 37:
`
`
`
`
`
`
`
`
`
`
`278-285.
`
`
`:16] Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA,
`
`
`
`
`
`
`
`
`
`Quinones MA. Doppler tissue imaging: a noninvasive tech-
`
`
`
`
`
`
`nique for evaluation of left ventricular
`relaxation and
`
`
`
`
`
`
`
`
`estimation of filling pressures. J Am Coll Cardiol 1997; 30:
`
`
`
`
`
`
`
`
`
`
`1527-1533.
`
`:17] Nagueh SF, Mikati I, Kopelen HA, Middleton KJ, Quinones
`
`
`
`
`
`
`
`
`
`
`MA, Zoghbi WA. Doppler estimation of left ventricular filling
`
`
`
`
`
`
`
`
`
`pressure in sinus tachycardia. A new application of tissue
`
`
`
`
`
`
`
`
`
`Doppler imaging. Circulation 1998; 98: 1644-1650.
`
`
`
`
`
`
`:18] Nagueh SF, Lakkis NM, Middleton KJ, Spencer WH, Zoghbi
`
`
`
`
`
`
`
`
`
`
`WA, Quinones MA. Doppler estimation of left ventricular
`
`
`
`
`
`
`
`
`filling pressures in patients with hypetrophic cardiomyopathy.
`
`
`
`
`
`
`
`Circulation 1999; 99: 254-261.
`
`
`
`
`19] Sundereswaran LS, Nagueh SF, Vardan S et al. Estimation of
`
`
`
`
`
`
`
`
`
`
`
`left and right ventricular filling pressures after heart transplan-
`
`
`
`
`
`
`
`
`tation by tissue Doppler imaging. Am J Cardiol 1998; 82:
`
`
`
`
`
`
`
`
`
`
`352-357.
`
`:20] Sohn DW, Song JM, Zo JH et al. Mitral annulus velocity in
`
`
`
`
`
`
`
`
`
`
`
`
`
`the evaluation of left ventricular diastolic function in atrial
`
`
`
`
`
`
`
`
`
`fibrillation. J Am Soc Echocardiogr 1999; 12: 927-931.
`
`
`
`
`
`
`
`
`21] Ommen SR, Nishimura RA, Appleton CP et al. Clinical utility
`
`
`
`
`
`
`
`
`
`
`
`of Doppler echocardiography and tissue Doppler imaging in
`
`
`
`
`
`
`
`
`the estimation of left ventricular filling pressures. A compara-
`
`
`
`
`
`
`
`
`tive simultaneous Doppler eatheterization study. Circulation
`
`
`
`
`
`
`2000; 102: 1788-1794.
`
`
`
`[22] Stevenson LW, Perlotf JK. The limited reliability of physical
`
`
`
`
`
`
`
`
`
`
`signs for estimating hemodynamies in chronic heart failure.
`
`
`
`
`
`
`
`
`JAMA 1989; 261: 884-888.
`
`
`
`
`[23] Garcia MG, Rodriguez L, Arcs M, Griffin BP, Thomas JD,
`
`
`
`
`
`
`
`
`
`
`
`Klein AL. Differentiation of constrictive pcriearditis from
`
`
`
`
`
`
`
`restrictive cardiomyopathy: assessment of left ventricular
`
`
`
`
`
`
`diastolic velocities in longitudinal axis by Doppler tissue
`
`
`
`
`
`
`
`
`imaging. J Am Coll Cardiol 1996; 27: 108-114.
`
`
`
`
`
`
`
`
`
`
`
`Eur J Echocardiography, Vol. 3, issue 1, March 2002
`
`
`
`
`
`
`
`
`
`
`079
`
`079