Estimating LV Filling Pressure by Echocardiography

Study Questions:

What is the feasibility and accuracy of identifying patients with elevated left ventricular (LV) filling pressure using echocardiography/Doppler?

Methods:

A multicenter study was conducted to review the records of 450 patients with a variety of cardiac diseases referred for clinically indicated right- and/or left-sided heart catheterization and echocardiography/Doppler performed either during or immediately after the procedure. Clinical data were extracted from chart review and retrospectively assigned to show or not show “heart failure” (based on symptoms [e.g., dyspnea], physical exam [e.g., S3, rales, pedal edema], and testing [e.g., pulmonary infiltrates, elevated biomarkers]). Left atrial volume index (threshold >34 ml/m2), tricuspid regurgitation (threshold Vmax > 2.8 m/s) and mitral inflow velocities, and septal mitral annular tissue velocity (threshold E/e’[s] >14) were used to estimate LV filling pressure using an algorithm based on the 2016 American Society of Echocardiography / European Association of Echocardiography / European Association of Cardiovascular Imaging (ASE/EAE/EACI) recommendations. Invasively measured pressure (pulmonary artery wedge pressure [PCWP] or pre-A-wave LV end-diastolic pressure >12 mm Hg) was used as the gold standard.

Results:

Mean LV ejection fraction (LVEF) was 47%; LVEF was <50% in 209 patients. Invasive measurements showed elevated LV filling pressure in 58% of the patients. Echo/Doppler data acquisition was feasible in 419 patients (93.1%); testing the ASE/EAE/EACI recommendations used 320 patients (after further excluding patients with mitral regurgitation, paced rhythm, or atrial fibrillation). Clinical assessment had an accuracy of 72% (95% confidence interval [CI], 67-76%) in identifying patients with elevated filling pressure, whereas echocardiography had an accuracy of 87% (95% CI, 84-91%; p < 0.001 vs. clinical assessment). The combination of clinical and echocardiographic assessment was incremental, with a net reclassification improvement of 1.5 versus clinical assessment (p < 0.001).

Conclusions:

The authors concluded that the echocardiographic assessment of LV filling pressure is feasible and accurate; and, when combined with clinical data, leads to a more accurate diagnosis, regardless of LVEF.

Perspective:

Used among a group of patients with known cardiac disease; and after excluding patients in whom all echo/Doppler data were not available, and patients with mitral regurgitation, paced rhythm, or atrial fibrillation (29% of the initial cohort); the 2016 ASE/EAE/EACI recommendations for assessment of LV diastolic function performed fairly well. Assessment of the clinical utility of this algorithm in an unselected patient population remains of interest.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound

Keywords: Biological Markers, Blood Pressure, Cardiac Catheterization, Cardiac Imaging Techniques, Diastole, Dyspnea, Echocardiography, Echocardiography, Doppler, Edema, Heart Failure, Pulmonary Wedge Pressure, Stroke Volume, Tricuspid Valve Insufficiency, Ventricular Function, Left


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