Download Left ventricular diastolic function and filling pressure.

Left ventricular diastolic function
and filling pressure in patients with
dilated cardiomyopathy
Bogdan A. Popescu
University of Medicine and Pharmacy
Bucharest, Romania
My conflicts of interest:
I have nothing to declare
Why bother?
ESC Guidelines for HF. Eur Heart J 2008;29:2388-2342
Dilated cardiomyopathy
LV diastolic dysfunction
• present / not
LV filling pressures
• elevated / not
• reversibly elevated / not
• grading LV diastolic dysfunction
Left ventricular diastolic function by echo
Relaxation
Compliance
E/A ratio, E deceleration time
Isovolumic relaxation time
Flow propagation velocity
Myocardial Ve, Se, SRe
Short duration A wave
Increased PV reversed flow
E/e’ ratio
Left atrial volume
Courtesy: A. Fraser
Eur J Echocardiogr 2009;10:165-193.
Nagueh S, et al. Eur J Echocardiogr 2009;10:165-193
LV filling by transmitral PW Doppler
E/A ratio
Relaxation
very good
Filling pressure
very, very bad
restrictive filling
good
pseudonormal
bad
impaired relaxation
Disease severity
Mitral EDT
The single most important variable of mitral inflow
Clinical applications of mitral inflow parameters
in patients with DCM
PW Doppler mitral inflow variables and
filling pattern correlate better with
• LV filling pressure
• functional class
• prognosis
E
restrictive filling
A
IVRT
than LV ejection fraction
Mitral EDT is a strong predictor of PCWP
• 140 postinfarct pts in SR
• LV ejection fraction < 35%
• EDT < 120 ms best predictor
of PCWP > 20 mm Hg
• 35 pts with HF and A Fib
• Mean LVEF 22 ± 5%
• EDT < 120 ms best predictor
of PCWP > 20 mm Hg
Giannuzzi P, et al. J Am Coll Cardiol 1994
Temporelli PL, et al. Am J Cardiol 1999
EDT relation to filling pressures
depends on LVEF
LVEF ≤ 50%
LVEF > 50%
Yamamoto K, et al. J Am Coll Cardiol 1997;30:1819-26.
Persistence of Restrictive Filling Pattern in DCM:
an ominous prognostic sign
Free of TX or Death
Nonrestrictive FP
Reversible RFP
>115msec >115msec
<115msec >115msec
Persistent RFP
<115msec <115msec
Pinamonti B, et al. J Am Coll Cardiol 1997;29:604-612
EDT and survival in patients with systolic HF
• 13 studies
• 2046 pts
Thohan V. Curr Opinion Cardiol 2004;19:238-249
Systolic and diastolic dysfunction in patients
with clinical diagnosis of dilated cardiomyopathy.
Relation to symptoms and prognosis
Rihal CS, et al. Circulation 1994;90:2772-2779
Mitral inflow - limitations
• U-shaped relation with LV diastolic function
(normal vs pseudonormal)
• Sinus tachycardia & first degree AV block
(fusion of the E and A waves)
• Arrhythmias: atrial flutter
(LV filling influenced by rapid atrial contractions)
1st degree
AV block
Atrial
flutter
F F
F
Unmasking of impaired relaxation in
pseudonormalization by reducing transmitral filling
pressure using the Valsalva maneuver
baseline
Valsalva
or
restrictive
filling
pattern
pseudonormalization
normal
impaired
relaxation
pattern
normal
pattern
A wave velocity change during Valsalva
as a predictor of increased LVEDP
Schwammenthal E, et al. Am J Cardiol 2000;86:169-74.
Pulmonary vein
flow PW-Doppler
A systolic fraction <40%
reliably predicts a
PCWP >18 mm Hg
(in pts with systolic dysfunction)
Brunazzi MC, et al. Am Heart J 1994;128:293.
Kuecherer H, et al. Am Heart J 1991;122:1683.
Pozzoli M, et al. J Am Coll Cardiol 1996;27:883.
Pulmonary venous Flow Pattern and Filling Pressure
S
D
S
A
D
LA
AR
AR
AR
• AR dur >A predicts a LVEDP > 15 mm Hg with a sensitivity
of 85% and a specificity of 79%
• Independent of LV ejection fraction
Rossvoll and Hatle, J Am Coll Cardiol 1993
• Age-independent
Klein et al, J Am Soc Echocardiogr 1997
Courtesy of E. Schwammenthal
Progression of diastolic indices
Amplitude
E
E’
Time / severity of disease
Courtesy: A. Fraser
Assessment of LV filling pressures
by combined Tissue Doppler
and PW echocardiography
E ≈ pw/tau
E’ ≈ 1/tau
E/E’ ≈ pw
Nagueh SF, et al.
J Am Coll Cardiol 1997;30:1527-33.
Impact of LVEF on estimation of LVFP by TDI
Patients
with EF < 50%
Patients
with EF ≥ 50%
Rivas-Gotz C, et al. Am J Cardiol 2003;91:780-4.
Estimation of filling pressures
in patients with preserved EF
Nagueh S. et al. Eur J Echocardiogr 2009;10:165-193
Assessing LVFP by E/E’
• E/E’ <8 likely normal
• E/E’ >15 likely elevated
• E/E’ of 8-15 unclear
Ommen SR, et al. Circulation 2000;102:1788-1794
• 108 pts w CHF, follow-up: 351 ± 252 days
• 4 groups were defined
Group I: EF >40% and E/E’ ratio <15
Group II: EF >40% and E/E’ ratio ≥15
Group III: EF ≤40% and E/E’ ratio <15
Group IV: EF ≤40% and E/E’ ratio ≥ 15
• primary end point: combined risk of cardiac mortality
or rehospitalization for HF
Am J Cardiol 2009;103:1275-79.
In terms of cardiac death,
group IV and age were
independent prognostic
predictors.
Hirata K, et al.
Am J Cardiol 2009;103:1275-1279
Problems with E/E’ in LVFP assessment
• Uses a regional parameter (E’) to assess LVFP
• With poor LV relaxation very low velocities of E’
are measured, and small variations in
measurements will strikingly affect
calculations of E/E’ (denominator)
• Cut-off values are different for different sites
• Relatively wide overlap in the middle range
(E/E’ between 8-15)
• 106 pts with EF ≤ 30%
• NYHA class III-IV
• simultaneous echo
and right heart cath
No correlation was found
between E/E’ ratio and PCWP,
especially in pts with larger LV
volumes, more impaired CI,
CRT
PCWP > 18 mmHg
PCWP > 15 mmHg
Mullens W, et al. Circulation 2009;119:62-70
Correspondence on Mullens’ study
• concerns regarding:
– technical aspects of echo and PCWP
measurements
– the inclusion of pts with significant MR and
of pts with CRT
– the cut-off used for average E/E’
– the potentially greater utility of transmitral
flow parameters (eg EDT) in this population
• 79 pts - decompensated
systolic HF (DCM and CAD),
including large LV vol and
CRT
• simultaneous echo and
right heart catheterization
• noninvasive measurements
of pulmonary artery systolic
and diastolic pressure, mean
right atrial pressure and
stroke volume had significant
correlations with invasive
measurements
Several Doppler
indices had
good accuracy
in identifying
pts with PCWP
> 15 mm Hg
Nagueh S, et al. Circ Cardiovasc Imag 2011;4:220-227
Assessment of the ASE-EAE guidelines for
diastolic function in pts with depressed EF
• retrospective study
• 62 pts, LVEF < 50%
• echo ≤ 20’ of left
heart cath
• correlations with LV
pre-A pressure:
– E/e’ R=0.43
– E/A R=0.52
– EDT R=-0.51
– LAVi R=0.50
(all significant)
54 of 62 pts accurately classified using the algorithm
Dokainish H, et al. Eur J Echocardiogr 2011;12:857-864
Conclusions
• Assessment of diastolic function and filling
pressure has clinical and prognostic value in
patients with DCM
• No single echo parameter is enough for all
situations
• An integrated algorithm is more useful in
identifying patients with normal and elevated
LV filling pressures
Thank you!