Download Assessment of Diastolic Function in Heart Failure and Atrial Fibrillation

Assessment of Diastolic Function in Heart Failure and Atrial
Fibrillation
S. CARERJ, S. RAFFA, C. ZITO
In the past three decades, Doppler echocardiography has emerged as a noninvasive alternative to cardiac catheterisation for evaluating haemodynamic
variables [1]. A well-performed Doppler examination is able to provide as
accurate data as conventional cardiac catheterisation does.
Diastolic function of the left ventricle (LV) plays a relevant role in producing the signs and symptoms of heart failure (HF) in cardiac diseases, the
end result of which is the elevation of left ventricular pressure per unit volume of blood entering the LV [2–5]. This elevated filling pressure increases
left atrial pressure, which is reflected back to the pulmonary circulation and
causes symptoms of shortness of breath and signs of pulmonary congestion.
Because of the complexity of the multiple interrelated events that comprise
diastolic filling of the heart, assessment of LV diastolic function was in the
past limited to the catheterisation laboratory, where complex measurements
of pressure–volume relations and rates of decrease in pressure from highfidelity pressure curves were used [6].
It has been speculated that Doppler echocardiography could be used to
assess diastolic filling and function of the LV non-invasively [7, 8].
Kitabatake et al. [9] in 1982 described the different flow velocity curves that
occur in different disease states from Doppler interrogation of transmitral
flow. Multiple investigations in both animals and humans followed and provided insight into the interpretation of these flow velocity patterns [10, 11].
The mitral flow velocity curves can be viewed as determined by the relative
driving pressure across the mitral valve from the left atrium to the LV. There
is an initial rapid acceleration of flow as left ventricular pressure drops
rapidly below left atrial pressure during ventricular relaxation (measured as
the E wave velocity). As the LV fills in early diastole, there is a rise in pres-
Division of Cardiology, University of Messina, Italy
182
S. Carerj et al.
sure that exceeds the left atrial pressure, causing a deceleration of flow. The
rate of deceleration of flow is measured as the mitral E wave deceleration
time and is dependent mainly upon the effective operating compliance of the
LV. During mid-diastole there is equilibration of left ventricular and left atrial pressures, with a low velocity of forward flow as a result of inertial forces.
Finally, at atrial contraction there is a re-acceleration of transmitral flow as
left atrial pressure rises above left ventricular pressure (measured as the A
wave velocity). These flow velocity curves are dependent on multiple intrinsic factors that include the rate of left ventricular relaxation and elastic
recoil (diastolic suction), left atrial and left ventricular compliance, and left
atrial pressure, as well as varying patient conditions such as load, age, and
heart rate [10, 11].
It has already been shown in experimental models of HF [12] that there is
also a progression of abnormal diastolic patterns that occurs over time with
cardiac diseases. In the early stage of dysfunction, impaired relaxation of the
LV dominates, which decreases early diastolic filling although filling pressures remain normal in the rest state. This is reflected by a decrease in the
initial E wave velocity, prolongation of E wave deceleration time, and
increased proportion of filling due to atrial contraction. With disease progression, left atrial pressure rises, which increases the driving pressure
across the mitral valve. This is accompanied by a gradual increase in E wave
velocity and a decrease in effective operating compliance of the LV, which
shortens the mitral E wave deceleration time. In advanced stages of disease,
there will be even higher pressures, a higher E/A ratio, and a very abbreviated mitral deceleration time. This concept of a progression of the mitral flow
velocity curves with worsening disease has a clinical application: the prognosis of patients with either dilated or infiltrative cardiomyopathy is indicated by a short mitral deceleration time, with values below 140 ms indicating a
poor outcome, independently of the degree of systolic dysfunction [13, 14].
Furthermore, non-invasive assessment of left ventricular filling pressures in
HF patients would be of great value in assessing their degree of left ventricular dysfunction and monitoring the effect of unloading therapies. Previous
studies have shown that this can be estimated by combining various Doppler
echocardiographic variables [10, 15–17]. Patients with atrial fibrillation (AF)
have, however, been excluded from these studies, limiting the applicability of
such estimates to patients in sinus rhythm.
It has been shown that in patients with HF and sinus rhythm elevated left
atrial pressures can compensate for delayed left ventricular relaxation, thus
increasing early diastolic mitral flow velocity and its deceleration and
decreasing isovolumic relaxation time. High left atrial pressure before atrial
contraction together with a stiff LV shortens and reduces mitral flow velocity
wave at atrial contraction. This leads to the so-called pseudo-normal and
Assessment of Diastolic Function in Heart Failure and Atrial Fibrillation
183
restrictive patterns that in HF patients are reliable indexes of elevated left
ventricular filling pressures. Pulmonary venous flow in sinus rhy thm
patients shows a triphasic pattern which is predominantly related to left atrial function and reflects the oscillations of left atrial pressures [18]. Thus, the
systolic forward flow velocity is determined by the combined backward
effect of the decrease in left atrial pressure, due to both left atrial relaxation
and mitral annulus descent, and the forward propagation of systolic right
ventricular pressure [19]. The diastolic forward flow velocity, which occurs
when the mitral valve is open and the left atrium behaves as a passive conduit, slightly follows and is closely related to early diastolic mitral flow velocity. The reverse diastolic flow velocity wave is determined by atrial contraction and its duration depends mainly on left ventricular compliance. In
patients with HF and sinus rhythm, when the left atrial pressure is high (and
left atrial compliance is reduced) the systolic flow velocity is blunted; the
diastolic forward flow velocity is high and its deceleration is rapid; the
reverse flow is prolonged and its duration exceeds that of forward mitral
flow at atrial contraction.
Unfortunately, approximately 20% of patients with chronic HF have AF
[20, 21]. When AF is present, the loss of atrial contraction and of ventricular
rate control affects both mitral and pulmonary venous flow and the relationship between Doppler variables and left ventricular filling pressure becomes
more complicated. When AF occurs, the active atrial contraction is lost, so
that the whole blood volume filling the LV is detected in a monophasic E
wave. At the same time Doppler recording of pulmonary venous flow shows a
loss of the late diastolic reverse flow. Loss of the active left atrial relaxation
causes the disappearance of the first component of the systolic forward flow
velocity. Besides these effects on left ventricular and atrial filling due to the
loss of an active atrial contraction, irregular cardiac cycle lengths produce
marked beat-to-beat variations in both mitral and pulmonary venous flow
velocities.
Despite all these differences between Doppler echocardiographic findings
in patients with sinus rhythm and AF, a relatively accurate estimation of pulmonary capillary wedge pressure (PCWP) can be achieved in HF patients
who are in AF. In particular, in patients with AF, indexes of early left ventricular diastolic filling, i.e. isovolumic relaxation time, deceleration time, and
deceleration rate, and the systolic fraction of pulmonary venous flow are
almost as strongly correlated with PCWP as they are in patients with sinus
rhythm [22, 23]. Temporelli et al. [24] have recently found that a value of 120
ms in E wave deceleration time seems to be the best cut-off point in predicting high values of PCWP in HF patients with AF, the sensitivity and specificity of a mitral E wave deceleration time below 120 ms in predicting PCWP
above 20 mmHg being 100% and 96%, respectively.
184
S. Carerj et al.
AF is characterised by an irregular heart rate that produces beat-to-beat
variations in contractility, preload, after-load, and mitral regurgitation,
which leads to increased variability in Doppler measurements. To minimise
this problem it would be preferable to investigate patients when they are
receiving optimal medical therapy including medications that are able to
reduce sufficiently (and synchronise as much as possible) their ventricular
heart rate. Moreover, short cardiac cycles (< 600 ms) should not be analysed
because they are often associated with fusion of pulmonary venous flow
waves. The optimal number of beats to be analysed and averaged for Doppler
measurements of diastolic function in AF should be approximately three
times that necessary in sinus rhythm, i.e. from 5 to 10.
Problems related to variability of haemodynamic conditions in HF
patients with AF may constitute a limit of flow Doppler; furthermore, to
obtain meaningful data, a strict and time-consuming methodology must be
followed, which may limit the everyday application of this parameters in a
busy clinical practice.
In order to limit the load dependence of flow Doppler measurements on
left ventricular diastolic function, new methods have recently been introduced. Nagueh et al. [25] found that peak acceleration of the E wave (PkAcc),
isovolumic relaxation time, deceleration time of the E wave, and the ratio of
E velocity to propagation velocity (E/Vp) were strongly related to left ventricular filling pressure. In particular, the velocity of propagation of the early
inflow from the LV base to the apex (Vp), determined using colour M-mode,
correlated well with the time constant of isovolumetric left ventricular relaxation (τ) [26]. In patients with abnormal left ventricular relaxation and elevated left ventricular end-diastolic pressure, filling flow propagation is
rapidly attenuated in spite of the increased early transmitral velocity.
Therefore, as the severity of HF increases, the E/Vp also increases and may
be a more sensitive index than E velocity or Vp alone. Recently Oyama et al.
[27] found that a cut-off value of E/Vp of 1.7 was able to predict with acceptable accuracy the presence of high PCWP (> 15 mmHg) in HF patients with
AF.
Tissue Doppler imaging has recently become a common tool of modern
ultrasound systems. This allows the recording of myocardial contraction and
relaxation velocities. The early diastolic mitral annular velocity (Ea) has
been shown to be a relatively load-independent measure of myocardial
relaxation in patients with cardiac disease [28]. When tissue Doppler imaging is combined with pulsed Doppler transmitral flow in early diastole (E),
the resultant E/Ea ratio has been correlated with left ventricular filling pressure measured invasively in patients with sinus rhythm [29]. E/Ea values
above 15 have been shown to be highly predictive (sensitivity 92%, specificity 90%) of a PCWP greater than 15 mmHg in patients with depressed ejec-
Assessment of Diastolic Function in Heart Failure and Atrial Fibrillation
185
tion fraction and sinus rhythm [30]. In conclusion, Doppler echocardiography is now well accepted as a reliable and reproducible method for assessing
diastolic function in various cardiac diseases. Several studies have demonstrated that left ventricular pressure and mean PCWP can be estimated from
variables of mitral and pulmonary venous flow. In particular, an excellent
inverse correlation has been found between the deceleration time of transmitral E wave and PCWP in patients with severe left ventricular dysfunction
and sinus rhythm. In the case of HF patients with AF, however, few data have
been published so far. The presence of irregular rhythm associated with high
variability of haemodynamic conditions and absence of atrial contraction
constitute an obstacle to the accurate evaluation of left ventricular diastolic
function by means of flow Doppler imaging. Tissue Doppler imaging could
be of great utility in this particular clinical setting thanks to its relative loadindependence. Further clinical studies are needed in order to assess the value
of tissue Doppler variables in estimating left ventricular filling pressures and
to compare them to flow Doppler parameters in HF patients with AF.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Nishimura RA, Tajik AJ (1994) Quantitative hemodynamics by Doppler echocardiography: a noninvasive alternative to cardiac catheterization. Prog Cardiovasc
Dis 36:309–342
Grossman W, Barry WH (1980) Diastolic pressure-volume relations in the diseased
heart. Fed Proc 39:148–155
Levine HJ, Gaasch WH (1978) Diastolic compliance of the left ventricle: chamber
and muscle stiffness, the volume/mass ratio and clinical implications. Mod
Concepts/Cardiovasc Dis 47:99–102
Gaasch WH, Levine HJ, Quinones MA et al (1976) Left ventricular compliance:
mechanisms and clinical implications. Am J Cardiol 38:645–653
Grossman W, McLaurin LP (1976) Diastolic properties of the left ventricle. Ann
Intern Med 84:316–326
Mirsky I (1984) Assessment of diastolic function: suggested methods and future
considerations. Circulation 69:836–841
DeMaria AN, Wisenbaugh T (1987) Identification and treatment of diastolic
dysfunction: role of transmitral Doppler recordings. J Am Coll Cardiol 9:1106–1107
Labovitz AJ, Pearson AC (1987) Evaluation of left ventricular diastolic function: clinical relevance and recent Doppler echocardiographic insights. Am Heart J
114:836–851
Kitabatake A, Inoue M, Asao M et al (1982) Transmitral blood flow reflecting diastolic behaviour of the left ventricle in health and disease – a study by pulsed
Doppler technique. Jpn Circ J 46:92–102
Appleton CP, Hatle LK, Popp RL (1988) Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coll Cardiol 12:426–440
Appleton CP, Hatle LK, Popp RL (1988) Demonstration of restrictive ventricular
186
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
S. Carerj et al.
physiology by Doppler echocardiography. J Am Coll Cardiol 11:757–768
Ohno M, Cheng CP, Little WC (1994) Mechanism of altered filling patterns of left
ventricular filling during the development of congestive heart failure. Circulation
89:2241–2250
Rihal CS, Nishimura RA, Hatle LK et al (1994) Systolic and diastolic dysfunction in
patients with clinical diagnosis of dilated cardiomyopathy: relation to symptoms
and prognosis. Circulation 90:2772–2779
Xie GY, Berk MR, Smith MD et al (1994) Prognostic value of Doppler transmitral
flow patterns in patients with congestive heart failure. J Am Coll Cardiol
24:132–139
Pozzoli M, Capomolla S, Opasich C et al (1992) Left ventricular filling pattern and
pulmonary wedge pressure are closely related in patients with recent anterior myocardial infarction and left ventricular dysfunction. Eur Heart J 13:1067–1073
Brunazzi MC, Chirillo F, Pasqualini M et al (1994) Estimation of left ventricular
diastolic pressures from precordial pulsed-Doppler analysis of pulmonary venous
and mitral flow. Am Heart J 128:293–300
Appleton CP, Galloway JM, Gonzales MS et al (1993) Estimation of left ventricular
filling pressures using two-dimensional and Doppler echocardiography in adult
patients with cardiac diseases. Additional value of analyzing left atrial size, left
atrial ejection fraction, and the difference in duration of pulmonary venous and
mitral flow velocity at atrial contraction. J Am Coll Cardiol 22:1972–1982
Keren G, Sherez J, Megidish R, Levitt B, Laniado S (1985) Pulmonary venous flow
pattern: its relationship to cardiac dynamics. Circulation 71:1105–1112
Smiseth OA, Thompson CR, Lohavanichbutr K et al (1999) The pulmonary venous
systolic flow pulse: its origin and relationship to left atrial pressure. J Am Coll
Cardiol 34:802–809
Kopecky SI, Gersh BJ, McGoon MD et al (1987) The natural history of lone atrial
fibrillation: a population-based study over three decades. New Engl J Med
317:669–674
Kannel WB, Abbott RD, Savane DD et al (1982) Epidemiologic features of chronic
atrial fibrillation. N Engl J Med 306:1018–1022
Traversi E, Corbelli F, Pozzoli M (2001) Doppler echocardiography reliably predicts
pulmonary artery wedge pressure in patients with chronic heart failure even when
atrial fibrillation is present. Eur J Heart Fail 3:173–181
Pozzoli M, Capomolla S, Pinna G et al (1996) Doppler echocardiography reliably
predicts pulmonary artery wedge pressure in patients with chronic heart failure
with and without mitral regurgitation. J Am Coll Cardiol 27:883–893
Temporelli PL, Scapellato F, Corrà U et al (1999) Estimation of pulmonary wedge
pressure by transmitral Doppler in patients with chronic heart failure and atrial
fibrillation. Am J Cardiol 83:724–727
Nagueh SF, Kopelen HA, Quinones MA (1996) Assessment of left ventricular filling
pressure by Doppler in the presence of atrial fibrillation. Circulation 94:2138–2145
Brun P, Tribouilloy C, Duval AM et al (1992) Left ventricular flow propagation
during early filling is related to wall relaxation: a color M-mode Doppler analysis. J
Am Coll Cardiol 20:420–432
Oyama R, Murata K, Tanaka N et al (2004) Is the ratio of transmitral peak E-wave
velocity to color flow propagation velocity useful for evaluating the severity of
heart failure in atrial fibrillation. Circ J 68:1132–1138
Nagueh SF, Middleton KJ, Kopelen HA et al (1997) Doppler tissue imaging: a
noninvasive technique for evaluation of left ventricular relaxation and estimation
Assessment of Diastolic Function in Heart Failure and Atrial Fibrillation
29.
30.
187
of filling pressures. J Am Coll Cardiol 30:1527–1533
Ommen S, Nishimura RA, Appleton CP et al (2000) Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study.
Circulation 102:1788–1794
Dokainish H, Zoghbi WA, Lakkis NM et al (2004) Optimal noninvasive assessment
of left ventricular filling pressures: a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.
Circulation 109:2432–2439