Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease

Accuracy of peak mitral e-wave velocity in the diagnosis of heart failure with preserved ejection fraction in older patients with acute dyspnea

BACKGROUND

The diagnosis of heart failure with preserved ejection fraction is characterized by its complexity, especially for physicians without great experience in comprehensive transthoracic Doppler echocardiography. Peak mitral E-wave (E) velocity has been successfully correlated to invasive left ventricular diastolic pressures in patients with structural heart disease. The aim of the study was to address the accuracy of E in the diagnosis of heart failure with preserved ejection fraction in elderly patients with acute dyspnea.

METHODS

This prospective study included 29 consecutive patients ≥70 years of age with heart failure with preserved ejection fraction and acute dyspnea and 29 controls ≥70 years of age. The final diagnosis was supported by the 2016 ASE/EACVI recommendations.

RESULTS

Mean age of the overall population was 85±7 years. E was strongly correlated with left atrial volume index (r=0.72, P<0.001) and with peak velocity of tricuspid regurgitation (r=0.77, P<0.001). E >85cm/s was 90% sensitive and 93% specific in the diagnosis of heart failure with preserved ejection fraction (AUC, 0.95). E/e' (0.95) and E/(e'xs') (0.92) did not perform better.

CONCLUSION

E/e' and E/(e'xs') provide essential diagnostic and prognostic information in heart failure with preserved ejection fraction and deserve to be included in every report of comprehensive transthoracic Doppler echocardiography. E velocity is a very simple and user-friendly parameter that can be used for the sole diagnostic purpose in elderly patients with acute dyspnea by operators without great deal of experience, such as cardiologists without formal training, emergency physicians, intensive care anesthetists, internists and geriatricians.

Doppler Echocardiographic Indices Are Specific But Not Sensitive to Predict Pulmonary Artery Occlusion Pressure in Critically Ill Patients Under Mechanical Ventilation

OBJECTIVES

The objective of this study was to prospectively evaluate the ability of transthoracic echocardiography to assess pulmonary artery occlusion pressure in mechanically ventilated critically ill patients.

DESIGN

In a prospective observational study.

SETTING

Amiens University Hospital Medical ICU.

PATIENTS

Fifty-three mechanically ventilated patients in sinus rhythm admitted to our ICU.

INTERVENTION

Transthoracic echocardiography was performed simultaneously to pulmonary artery catheter.

MEASUREMENTS AND MAIN RESULTS

Transmitral early velocity wave recorded using pulsed wave Doppler (E), late transmitral velocity wave recorded using pulsed wave Doppler (A), and deceleration time of E wave were recorded using pulsed Doppler as well as early mitral annulus velocity wave recorded using tissue Doppler imaging (E'). Pulmonary artery occlusion pressure was measured simultaneously using pulmonary artery catheter. There was a significant correlation between pulmonary artery occlusion pressure and lateral ratio between E wave and E' (E/E' ratio) (r = 0.35; p < 0.01), ratio between E wave and A wave (E/A ratio) (r = 0.41; p < 0.002), and deceleration time of E wave (r = -0.34; p < 0.02). E/E' greater than 15 was predictive of pulmonary artery occlusion pressure greater than or equal to 18 mm Hg with a sensitivity of 25% and a specificity of 95%, whereas E/E' less than 7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 32% and a specificity of 81%. E/A greater than 1.8 yielded a sensitivity of 44% and a specificity of 95% to predict pulmonary artery occlusion pressure greater than or equal to 18 mm Hg, whereas E/A less than 0.7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 19% and a specificity of 94%. A similar predictive capacity was observed when the analysis was confined to patients with EF less than 50%. A large proportion of E/E' measurements 32 (60%) were situated between the two cut-off values obtained by the receiver operating characteristic curves: E/E' greater than 15 and E/E' less than 7.

CONCLUSIONS

In mechanically ventilated critically ill patients, Doppler transthoracic echocardiography indices are highly specific but not sensitive to estimate pulmonary artery occlusion pressure.

The Association between Five Genetic Variants in MicroRNAs (rs2910164, rs11614913, rs3746444, rs11134527, and rs531564) and Cervical Cancer Risk: A Meta-Analysis

The objective of this study was to conduct a meta-analysis to systematically summarize and investigate the association of miRNA-124 rs531564, miRNA-218 rs11134527, miRNA-146a rs2910164, miRNA-196a2 rs11614913, and miRNA-499 rs3746444 polymorphisms with cervical cancer. A systematic review was performed to identify relevant studies using Embase and PubMed databases. A chi-square-based Q-test combined with the inconsistency index (I 2) was used to check the heterogeneity between studies. A total of six case-control studies on rs2910164 and rs11614913, 4 studies on rs3746444 and rs11134527, and three studies on rs531564 were included. No evidence of association was found between miR-146a rs2910164, miR-196a2 rs11614913, miRNA-499 rs3746444, and miR-218 rs11134527 polymorphisms and cervical cancer risk in all the genetic models. The miR-124 rs531564 polymorphism was associated with a statistically increased risk of cervical cancer in a homozygote model (CC vs. GG: OR = 2.87, 95% CI: 1.40-5.91, P H = 0.887), dominant model (GC/CC vs. GG: OR = 1.38, 95% CI: 1.07-1.80, P H = 0.409), and recessive model (CC vs. GC/GG: OR = 2.26, 95% CI: 1.58-3.23, P H = 0.979). However, this finding should be interpreted with caution for limited samples and heterogeneity. Large-scale and well-designed studies are needed to validate our result.

A novel echocardiographic method for estimation of pulmonary artery wedge pressure and pulmonary vascular resistance

Aims

This study aimed to evaluate a novel echocardiographic algorithm for quantitative estimation of pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance (PVR) in patients with heart failure and pulmonary hypertension (PH) scheduled to right heart catheterization (RHC).

Methods and results

In this monocentric study, 795 consecutive patients (427 men; age 68.4 ± 12.1 years) undergoing echocardiography and RHC were evaluated. Multiple regression analysis was performed to identify echocardiographic predictors of PAWP and PVR measured by RHC in the derivation group (the first 200 patients). The diagnostic accuracy of the model was then tested in the validation group (the remaining 595 patients). PH was confirmed by RHC in 507 (63.8%) patients, with 192 (24.2%) cases of precapillary PH, 248 (31.2%) of postcapillary PH, and 67 (8.4%) of combined PH. At regression analysis, tricuspid regurgitation maximal velocity, mitral E/e′ ratio, left ventricular ejection fraction, right ventricular fractional area change, inferior vena cava diameter, and left atrial volume index were included in the model (R = 0.8, P < 0.001). The model showed a high diagnostic accuracy in estimating elevated PAWP (area under the receiver operating characteristic curve = 0.97, 92% sensitivity, and 93% specificity, P < 0.001) and PVR (area under the receiver operating characteristic curve = 0.96, 89% sensitivity, and 92% specificity, P < 0.001), outperforming 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations (P < 0.001) and Abbas' equation (P < 0.001). Bland–Altman analysis showed satisfactory limits of agreement between echocardiography and RHC for PAWP (bias 0.7, 95% confidence interval −7.3 to 8.7) and PVR (bias −0.1, 95% confidence interval −2.2 to 1.9 Wood units), without indeterminate cases.

Conclusions

A novel quantitative echocardiographic approach for the estimation of PAWP and PVR has high diagnostic accuracy in patients with heart failure and PH.

EVALUATION OF LEFT VENTRICULAR FILLING PRESSURE USING NUMERICAL MODELING

The main objective of this work is to study the effect of blood pressure and viscosity on flow in a pathological and healthy anatomy. The method chosen for this project is the numerical simulation of fluid dynamics. First, a radiological database from Tlemcen hospital was studied in order to select a patient whose aortic anatomy is representative of the pathology studied in this research project. The left ventricle was segmented using SolidWork software. The exported data made it possible to model this geometry on Comsol software. The geometry has been idealized to make it comparable to a given healthy left ventricle geometry and present the main parameters which influence the ventricular hemodynamics. A first series of numerical simulations made it possible to highlight the hemodynamic disturbances associated with the pathology of interest and described extensively in the literature. A second series of numerical simulations made it possible to model the effect of blood viscosity on flow. All the results obtained, the modeling of the left ventricle, must be valid experimentally. This study therefore does not completely justify the treatment of ventricular dilation with a flow modulator but constitutes an important first step towards a proof of concept.

Relationship between transesophageal echocardiography-derived pulmonary artery systolic pressure measurements and early morbidity in patients undergoing coronary artery bypass grafting

Context:

We studied the relationship between intraoperative transesophageal echocardiography-derived (TEE-derived) pulmonary artery systolic pressure (PASP) measurements with early morbidity in on-pump coronary artery bypass grafting (CABG) surgery.

Aims:

The objective of the study was to assess whether TEE-derived elevated PASP is independently predictive of significant morbidity.

Settings and Design:

Prospective observational study in a university hospital.

Materials and Methods:

Around 54 patients who underwent CABG under cardiopulmonary bypass (CPB) were divided into two groups; with PASP ≥35 mmHg and PASP <35 mmHg, assessed by intraoperative TEE. Outcomes studied were poor coronary revascularization, postoperative arrhythmias, myocardial infarction, respiratory failure, intra-aortic balloon pump use, pacemaker dependence, significant inotrope use, prolonged intensive care unit stay, and the total length of stay in the hospital. Mortality analysis was not a part of this study since expected sample sizes were low.

Results:

Patients with PASP ≥35 mmHg had a higher risk of respiratory failure, increased inotrope use and prolonged hospital stay, although multivariate analysis failed to demonstrate an independent association of PASP with these outcomes. Diabetes mellitus (DM), peripheral vascular disease, low cardiac output and elevated mitral annular E/e’ ratio were significantly associated with higher pulmonary arterial pressures. Multivariate analysis showed that PASP was independently associated with higher mitral annular E/e’ ratio.

Conclusions:

Our study, therefore, suggests that higher PASP may predict higher left ventricular filling pressures, and although elevated PASP ≥35 mmHg may be associated with DM; peripheral vascular disease, lower intraoperative cardiac output, postoperative respiratory failure, higher inotrope use, and delayed hospital discharge, it is not an independent predictor of any of these variables.

Contribution of Levosimendan in Weaning from Mechanical Ventilation in Patients with Left Ventricular Dysfunction: A Pilot Study

Purpose

Mechanically ventilated patients with left ventricular (LV) dysfunction are at risk of weaning failure. We hypothesized that optimization of cardiovascular function might facilitate the weaning process. Therefore, we investigated the efficacy of levosimendan in difficult-to-wean patients with impaired LV performance.

Materials and Methods

Nineteen mechanically ventilated patients, with LV ejection fraction (LVEF) 34 ± 8%, difficult-to-wean from the ventilator, were assessed by transthoracic echocardiography before the start and at the end of a spontaneous breathing trial (SBT) (first SBT). Eight patients successfully weaned. The remaining 11 failed-to-wean patients received a 24-hour infusion of levosimendan, and they were reassessed during a second SBT.

Results

After levosimendan administration, LVEF increased from 30 ± 10 to 36 ± 3% (p=0.01). End-SBT peak e′ velocity increased from 7 to 9 cm/s (p=0.02). E/e′ increased from 10.5 to 12.9 during the first SBT, whereas it remained constant at 10 throughout the second SBT (p=0.01). During the second SBT, partial pressure of arterial oxygen and central venous oxygen saturation improved, compared to the first one (93 ± 34 vs. 67 ± 28 mmHg, p=0.03, and 66 ± 11% vs. 57 ± 9%, p=0.02, respectively). Nine of the 11 patients were successfully weaned from the ventilator.

Conclusions

In difficult-to-wean from mechanical ventilation patients with LV dysfunction, levosimendan might contribute to successful weaning by improving both systolic and diastolic LV function.

Evaluation of Hypertrophic Cardiomyopathy: Newer Echo and MRI Approaches

PURPOSE OF REVIEW

This review discusses the basic and evolving echocardiographic and cardiac magnetic resonance (CMR) approaches in the diagnosis and management of patients with hypertrophic cardiomyopathy (HCM).

RECENT FINDINGS

Newer imaging technologies and techniques in both echocardiography and CMR have proved to add incremental value to our understanding of HCM. 3D reconstruction in echocardiography and CMR allows for more accurate morphological and volumetric assessment of the left ventricle. Echocardiographic and CMR-based left atrial assessment, including for its mechanical properties, has been shown to be correlated to outcomes and development of atrial fibrillation. Tissue characterization and scar burden quantification by late gadolinium enhancement on CMR has revolutionized our understanding of fibrotic processes in HCM and their contribution to disease severity and clinical outcomes. Cardiac imaging plays a crucial role in HCM patients. Using echocardiography and CMR as complementary modalities allows for improved diagnostics, optimization of treatment, and better prognostication.

Association between a miRNA-146a polymorphism and susceptibility to head and neck squamous cell carcinoma in Chinese patients: A meta-analysis of 8 case-control studies

A closer association has been found between the microRNA-146a rs2910164 polymorphism and the risk of head and neck carcinoma in some molecular epidemiological studies. Recently two meta-analyses were performed to explore the relationship between miRNA-146a polymorphisms and the susceptibility of squamous cell carcinoma of the head and neck (SCCHN); however, they yielded conflicting results in susceptibility regarding ethnic variations. Hence, the present study was performed to explain the relationship between the miRNA-146a rs2910164 polymorphism and the risk of SCCHN development of Chinese patients. We retrieved databases and screened eligible papers up to March 10, 2017 and then we extracted the essential data. The subgroup analyses were also performed based on the tumor site, region, and genotyping means. Crude odds ratios (OR) at 95% confidence intervals (CI) were chosen to describe the strength of the association. As a result, 6 publications were included in our study which involved 8 independent case-control studies. A significant association was found between miR-146a rs2910164 polymorphisms and the risk of SCCHN in Chinese patients according to the overall data [CC+CG vs. GG: OR = 1.13; 95%CI = 1.00-1.29; CC vs. GG: OR = 1.19; 95%CI = 1.03-1.38]. According to the subgroup analysis based on tumor site, the risk of cancer was significantly increased among laryngeal cancer (dominant model: OR = 1.76, 95%CI = 1.26~2.46, P = 0.001; homozygote model: OR = 1.83, 95%CI = 1.25~2.67, P = 0.002) and nasopharyngeal carcinoma (homozygote model: OR = 1.41, 95%CI = 1.05~1.90, P = 0.022). In summary, variant alleles of miR-146a rs2910164 alleles may have an association with the increased risk of SCCHN in Chinese patients, and these associations differed based on tumor site. Further studies including a larger sample size will be necessary to clarify these results.

Doppler Assessment of Diastolic Function Reflect the Severity of Injury in Rats With Chronic Heart Failure

OBJECTIVE

For chronic heart failure (CHF), more emphasis has been placed on evaluation of systolic as opposed to diastolic function. Within the study of diastology, measurements of left ventricular (LV) longitudinal myocardial relaxation have the most validation. Anterior wall radial myocardial tissue relaxation velocities along with mitral valve inflow (MVI) patterns are applicable diastolic parameters in the differentiation between moderate and severe disease in the ischemic rat model of CHF. Myocardial tissue relaxation velocities correlate with traditional measurements of diastolic function (ie, hemodynamics, Tau, and diastolic pressure-volume relationships).

METHODS AND RESULTS

Male Sprague-Dawley rats underwent left coronary artery ligation or sham operation. Echocardiography was performed at 3 and 6 weeks after coronary ligation to evaluate LV ejection fraction (EF) and LV diastolic function through MVI patterns (E, A, and E/A) and Doppler imaging of the anterior wall (e' and a'). The rats were categorized into moderate or severe CHF according to their LV EF at 3 weeks postligation. Invasive hemodynamic measurements with solid-state pressure catheters were obtained at the 6-week endpoint. Moderate (N = 20) and severe CHF (N = 22) rats had significantly (P < .05) different EFs, hemodynamics, and diastolic pressure-volume relationships. Early diastolic anterior wall radial relaxation velocities as well as E/e' ratios separated moderate from severe CHF and both diastolic parameters had strong correlations with invasive hemodynamic measurements of diastolic function.

CONCLUSION

Radial anterior wall e' and E/e' can be used for serial assessment of diastolic function in rats with moderate and severe CHF.

Influence of Diaphragmatic Motion on Inferior Vena Cava Diameter Respiratory Variations in Healthy Volunteers

BACKGROUND

The collapsibility index of inferior vena cava (cIVC) is widely used to decide fluid infusion in spontaneously breathing intensive care unit patients. The authors hypothesized that high inspiratory efforts may induce false-positive high cIVC values. This study aims at determining a value of diaphragmatic motion recorded by echography that could predict a high cIVC (more than or equal to 40%) in healthy volunteers.

METHODS

The cIVC and diaphragmatic motions were recorded for three levels of inspiratory efforts. Right and left diaphragmatic motions were defined as the maximal diaphragmatic excursions. Receiver operating characteristic curves evaluated the performance of right diaphragmatic motion to predict a cIVC more than or equal to 40% defining the best cutoff value.

RESULTS

Among 52 included volunteers, interobserver reproducibility showed a generalized concordance correlation coefficient (ρc) above 0.9 for all echographic parameters. Right diaphragmatic motion correlated with cIVC (r = 0.64, P < 0.0001). Univariate analyses did not show association between cIVC and age, sex, weight, height, or body mass index. The area under the receiver operating characteristic curves for cIVC more than or equal to 40% was 0.87 (95% CI, 0.81 to 0.93). The best diaphragmatic motion cutoff was 28 mm (Youden Index, 0.65) with sensitivity of 89% and specificity of 77%. The gray zone area was 25 to 43 mm.

CONCLUSIONS

Inferior vena cava collapsibility is affected by diaphragmatic motion. During low inspiratory effort, diaphragmatic motion was less than 25 mm and predicted a cIVC less than 40%. During maximal inspiratory effort, diaphragmatic motion was more than 43 mm and predicted a cIVC more than 40%. When diaphragmatic motion ranged from 25 to 43 mm, no conclusion on cIVC value could be done.

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine

OBJECTIVE

Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

METHODS

The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact.

RESULTS

Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring.

CONCLUSIONS

This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.

Interatrial septum motion but not Doppler assessment predicts elevated pulmonary capillary wedge pressure in patients undergoing cardiac surgery

BACKGROUND

Left atrial pressure and its surrogate, pulmonary capillary wedge pressure (PCWP), are important for determining diastolic function. The role of transthoracic echocardiography (TTE) in assessing diastolic function is well established in awake subjects. The objective was to assess the accuracy of predicting PCWP by TTE and transesophageal echocardiography (TEE) during coronary artery surgery.

METHODS

In 27 adult patients undergoing on-pump coronary artery surgery, simultaneous echocardiographic and hemodynamic measurements were obtained immediately before anesthesia (TTE), after anesthesia and mechanical ventilation (TTE and TEE), during conduit harvest (TEE), and after separation from cardiopulmonary bypass (TEE).

RESULTS

Twenty patients had an ejection fraction (EF) of 0.5 or greater. With the exception of E/e' and S/D ratios, echocardiographic values changed over the echocardiographic studies. In patients with low EF, E velocity, deceleration time, pulmonary vein D, S/D, and E/e' ratios correlated well with PCWP before anesthesia. After induction of anesthesia using TTE or TEE, correlations were poor. In normal EF patients, correlations were poor for both TEE and TTE at all five stages. The sensitivity and specificity of echocardiographic values were not high enough to predict raised PCWP except for a fixed curve pattern of interatrial septum (area under the curve 0.89 for PCWP ≥ 17, and 0.98 for ≥ 18 mmHg) and S/D less than 1 (area under the curve 0.74 for PCWP ≥ 17, and 0.78 for ≥ 18 mmHg).

CONCLUSION

Doppler assessment of PCWP was neither sensitive nor specific enough to be clinically useful in anesthetized patients with mechanical ventilation. The fixed curve pattern of the interatrial septum was the best predictor of raised PCWP.

Usefulness of tissue Doppler imaging to evaluate pulmonary capillary wedge pressure during exercise in patients with reduced left ventricular ejection fraction

The early diastolic transmitral velocity/tissue Doppler imaging mitral annular early diastolic velocity (E/e') ratio is used to estimate left ventricular (LV) filling pressures at rest. However, there are only limited data that validate its use during exercise. Accordingly, the aim of this study was to test the ability of E/e' to estimate pulmonary capillary wedge pressure (PCWP) during symptom-limited exercise in patients with LV systolic dysfunction. Forty patients with severe LV dysfunction and heart failure symptoms (54 ± 12 years, 28 men) underwent simultaneous Doppler assessment of E/e' and right-sided cardiac catheterization at rest and during a symptom-limited exercise test, at steady state levels of 30%, 60%, and 90% of their maximal exercise capacity. During exercise, all 40 patients successfully completed stage 1, yielding 40 pairs of data for comparison. Eighteen patients also successfully completed stage 2, and 5 patients also made it through stage 3, yielding 23 additional data pairs. In total, there were thus 63 pairs of data available during exercise. With exercise, heart rate increased from 77 ± 14 to 112 ± 21 beats/min. Septal E/e' at rest correlated well with PCWP at rest (r = 0.75, p <0.01). PCWP at rest also correlated with resting mitral deceleration time (r = 0.32, p <0.01) and with the transmitral E/A ratio (r = 0.74, p <0.01). During exercise, the correlation between septal E/e' and PCWP was weaker (r = 0.57, p <0.01) and was shifted to the right. This rightward shift was observed in patients with both separated or merged E and A velocities. In conclusion, in patients with severe LV dysfunction, although E/e' allows accurate estimation of PCWP at rest, it appears less reliable for estimating LV filing pressure during exercise.

Weaning-induced cardiac dysfunction: where are we today?

INTRODUCTION

The concept of weaning-induced cardiac dysfunction emerged 26 years ago with the publication of a clinical study conducted by François Lemaire and collaborators.

OBJECTIVES

One objective of this article is to remember the results and the historical context under which our pivotal study was conducted. Another objective is to review some of the subsequent studies that aimed to analyze the underlying mechanisms, to noninvasively detect the cardiac origin of weaning failure, and to propose specific therapies enabling weaning success.

CONCLUSION

Weaning-induced cardiac dysfunction has become an established cause of weaning failure. Underlying mechanisms may differ from one patient to another. Important progress has already been made in its diagnosis thanks to relevant clinical research studies. Ongoing and future technological advances in ultrasonography and in biomarker research should certainly help in diagnosing weaning induced-pulmonary edema and in identifying the main mechanisms responsible for its development. Progress on appropriate therapeutic options on an individual basis is still expected.

Preoperative fasting does not affect haemodynamic status: a prospective, non-inferiority, echocardiography study

BACKGROUND

The link between preoperative fasting and hypovolaemia remains unclear. We tested the hypothesis that preoperative fasting does not significantly increase the proportion of patients with hypovolaemia according to transthoracic echocardiography (TTE) criteria.

METHODS

Patients of ASA status I-III and without bowel preparation were included in a non-inferiority, prospective, single-centre trial. Patients underwent passive leg raising (PLR) test and TTE at admission (Day 0) and after 8 h fasting (Day 1). The primary hypothesis was that an 8 h preoperative fasting does not increase the proportion (margin=5%) of patients with a positive PLR test ('functional approach'). The secondary hypothesis was that echocardiographic filling pressures or stroke volume (margin 10%) are not affected by preoperative fasting ('static approach').

RESULTS

One hundred patients were included and 98 analysed. After an 8 h fasting, the change in the proportion of responders to PLR was -6.1% [95% confidence interval (CI)=-16.0 to 3.8] of responders to PLR test on Day 0 when compared with Day 1. Because 95% CI was strictly inferior to 5%, there was no significant increase in the proportion of PLR responders on Day 1 when compared with Day 0. The 95% CI changes of static variables were always fewer than 10%, meaning that preoperative fasting induced significantly no relevant changes in static variables.

CONCLUSION

Preoperative fasting did not alter TTE dynamic and static preload indices in ASA I-III adult patients. These results suggest that preoperative fasting does not induce significant hypovolaemia. Clinical trial registration NCT 01258361.

The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics

Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.

Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use

INTRODUCTION

To investigate whether respiratory variation of inferior vena cava diameter (cIVC) predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure (ACF).

METHODS

Forty patients with ACF and spontaneous breathing were included. Response to fluid challenge was defined as a 15% increase of subaortic velocity time index (VTI) measured by transthoracic echocardiography. Inferior vena cava diameters were recorded by a subcostal view using M Mode. The cIVC was calculated as follows: (Dmax - Dmin/Dmax) × 100 and then receiver operating characteristic (ROC) curves were generated for cIVC, baseline VTI, E wave velocity, E/A and E/Ea ratios.

RESULTS

Among 40 included patients, 20 (50%) were responders (R). The causes of ACF were sepsis (n = 24), haemorrhage (n = 11), and dehydration (n = 5). The area under the ROC curve for cIVC was 0.77 (95% CI: 0.60-0.88). The best cutoff value was 40% (Se = 70%, Sp = 80%). The AUC of the ROC curves for baseline E wave velocity, VTI, E/A ratio, E/Ea ratio were 0.83 (95% CI: 0.68-0.93), 0.78 (95% CI: 0.61-0.88), 0.76 (95% CI: 0.59-0.89), 0.58 (95% CI: 0.41-0.75), respectively. The differences between AUC the ROC curves for cIVC and baseline E wave velocity, baseline VTI, baseline E/A ratio, and baseline E/Ea ratio were not statistically different (p = 0.46, p = 0.99, p = 1.00, p = 0.26, respectively).

CONCLUSION

In spontaneously breathing patients with ACF, high cIVC values (>40%) are usually associated with fluid responsiveness while low values (< 40%) do not exclude fluid responsiveness.

Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a systemic disease with a rising incidence. Cardiac dysfunction may occur as an early complication of AP. B type natriuretic factor (BNP) is a diagnostic and prognostic indicator of cardiac disorders. Therefore, in this study we aimed to assess the relationship between serum BNP concentrations and severity of AP.

METHODS

Patients with AP who were admitted to gastroenterology clinic of our center, were included in this study. BNP measurements were performed twice, once on admission to the hospital and another after clinical and laboratory remission of the disease. All patients underwent echocardiography, abdominal ultrasonography and/or computed tomography chest X-ray and routine biochemical assays. Disease severity was determined by Ranson, Balthazar and Glasgow scoring systems.

RESULTS

A total of 55 patients with AP (33 male, 60%) were enrolled in the study. Causes of AP were biliary in 32 patients (58%), alcoholic in 10 (18%), idiopathic in 8 (15%), hyperlipidemic in 4 (7%) and ERCP related in one patient (2%), respectively. Serum BNP levels in first 2 days of admission and after the clinical and laboratory remission of disease were 444 ± 295.9 and 124 ± 109.5 pg/ml, respectively (p<0.001). Increased serum BNP levels were positively correlated with severity of the disease (p<0.001). We could not find a difference between serum BNPe levels of edematous and necrotizing patients (P = 0.683).

CONCLUSION

Increased serum BNP levels might be a plausible indicator of severity of AP during the course of the disease.

The Utility of Tissue Doppler Imaging for the Noninvasive Determination of Left Ventricular Filling Pressures in Patients With Septic Shock

Background: Pulmonary artery wedge pressure (PAWP) is an important indicator of volume status in septic patients. Although it requires invasive pulmonary artery catheterization (PAC), a noninvasive method to assess PAWP would be clinically useful in this select patient population. Diastolic indices using transthoracic echocardiography (TTE) may provide an accurate estimate of PAWP. Objective: To determine whether echocardiographic Doppler assessment is accurate in estimating PAWP in patients with septic shock. Methods: A retrospective chart review was performed of 320 patients admitted with a diagnosis of septic shock from 2007-2008. Of the total patient population, 40 patients fulfilled the inclusion criteria, having undergone both TTE and PAC within 4 hours. Spectral Doppler indices including peak early (E) and late (A) transmitral velocities, E/A ratio, and E-wave deceleration time were measured. Tissue Doppler indices including S’, E’ and A’ velocities were determined. Pulmonary artery wedge pressure values measured invasively were compared to the dimensionless index of E/E’ in each patient. Results: The mean age was 68 ± 12 years with 28 males (70%). On echo assessment, 28% of patients had evidence of mild left ventricular diastolic dysfunction while 17% of patients had moderate diastolic dysfunction. Pulmonary artery wedge pressures ranged from 7 to 31 mm Hg with a mean of 18 ± 5 mm Hg. The mean E/E’ was 11 ± 8. Linear regression analysis between PAWP and E/E7apos; demonstrated a strong correlation (r = .84, P < .05). Conclusion: Tissue Doppler indices using TTE is a feasible and strong predictor of PAWP in patients with septic shock.

Assessment of abnormal left atrial relaxation by transesophageal pulsed Doppler echocardiography of pulmonary venous flow velocity

BACKGROUND

Several studies on left ventricular relaxation have been undertaken in the past; however, left atrial (LA) relaxation has not been fully evaluated.

HYPOTHESIS

The purpose of this study was to assess abnormalities in LA relaxation by evaluating pulmonary venous flow velocity and interatrial septal motion using transesophageal echocardiography.

METHODS

The subjects were 56 untreated patients in sinus rhythm, including 25 with previous myocardial infarction, 9 with hypertrophic cardiomyopathy, 11 with dilated cardiomyopathy, as well as 11 with chest pain syndrome as controls. Peak first systolic velocity (PVS1), peak atrial systolic velocity (PVA), and their time-velocity integrals (PVS1-I and PVA-I, respectively) were calculated from the pulmonary venous flow velocity.

RESULTS

The PVS1 and PVS1-I correlated negatively with the maximum LA dimension and mean pulmonary capillary wedge pressure, and correlated positively with the amplitude of the interatrial septal motion during LA relaxation and percent fractional LA relaxation. The PVA and PVA-I did not correlate with the mean pulmonary capillary wedge pressure. There was a weak positive correlation between PVA and PVS1, and a close positive correlation between the ratio of PVA to PVS1 and mean pulmonary capillary wedge pressure. Multiple regression analysis indicated that the PVS1 was most closely related to percent fractional LA relaxation, followed by mean pulmonary capillary wedge pressure.

CONCLUSION

The PVS1 determined from the pulmonary venous flow velocity is closely related to parameters of LA relaxation which may be determined by transesophageal M-mode echocardiography, and the ratio of PVA to PVS1 is useful for noninvasive evaluation of LA pressure.

Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation

BACKGROUND

The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling.

HYPOTHESIS

The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation.

METHODS

We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm.

RESULTS

Mean pulmonary capillary wedge pressure, V-wave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V-wave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy.

CONCLUSION

Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.

Echocardiographic assessment of pulmonary artery occlusion pressure in ventilated patients: a transoesophageal study

Background

Non-invasive evaluation of left ventricular filling pressure has been scarcely studied in critically ill patients. Accordingly, we prospectively assessed the ability of transoesophageal echocardiography (TEE) Doppler to predict an invasive pulmonary artery occlusion pressure (PAOP) ≤ 18 mmHg in ventilated patients.

Methods

During two consecutive 3-year periods, TEE Doppler parameters were compared to right heart catheterisation derived PAOP used as reference in 88 ventilated patients, haemodynamically stable and in sinus rhythm (age: 63 ± 14 years; simplified acute physiologic score (SAPS) II: 45 ± 12). During the initial period (protocol A), threshold values of pulsed-wave Doppler parameters to predict an invasive PAOP ≤ 18 mmHg were determined in 56 patients. Derived Doppler values were prospectively tested during the subsequent period (protocol B) in 32 patients.

Results

In protocol A, Doppler parameters had similar area under the receiver operating characteristic (ROC) curve. In protocol B, mitral E/A ≤ 1.4, pulmonary vein S/D > 0.65 and systolic fraction > 44% best predicted an invasive PAOP ≤ 18 mmHg. Lateral E/E' ≤ 8.0 or E/Vp ≤ 1.7 predicted a PAOP ≤ 18 mmHg with a sensitivity of 83% and 80%, and a specificity of 88% and 100%, respectively. Areas under ROC curves of lateral E/E' and E/Vp were similar (0.91 ± 0.07 vs 0.92 ± 0.07: p = 0.53), and not significantly different from those of pulsed-wave Doppler indices.

Conclusion

TEE accurately predicts invasive PAOP ≤ 18 mmHg in ventilated patients. This further increases its diagnostic value in patients with suspected acute lung injury/acute respiratory distress syndrome.

Accuracy of the isovolumic relaxation time in the emergency diagnosis of new-onset congestive heart failure with preserved left ventricular systolic function in the setting of B-type natriuretic peptide levels in the mid-range

Despite the fact that B-type natriuretic peptide (BNP) is a useful diagnostic complement to clinical and radiographic data in the emergency diagnosis of acute congestive heart failure, levels of BNP in the mid-range (100-500 pg/ml) are acknowledged to be inconclusive for the diagnosis. We assessed the diagnostic value of the pulsed Doppler-derived isovolumic relaxation time (IVRT) by bedside Doppler echocardiography in the emergency diagnosis of new-onset congestive heart failure with preserved systolic function in 43 patients presenting with acute severe dyspnea and inconclusive BNP levels. A short IVRT <50 ms was a good predictor of acute congestive heart failure in this clinical setting, with a positive predictive value of 94%.

A Novel Method to Estimate Pulmonary Artery Wedge Pressure Using the Downslope of the Doppler Mitral Regurgitant Velocity Profile

Continuous-wave (CW) Doppler recording of mitral regurgitation (MR) is a reflection of the left ventriculoatrial pressure gradient. Accordingly, this jet may yield information about pulmonary artery wedge pressure (PAWP). In this study, we derived and then evaluated a novel method for prediction of PAWP. Patients (n=80) with moderate to severe MR and left ventricular dysfunction were included in the study. Transthoracic echocardiography was performed in patients during pulmonary artery pressure monitoring. A satisfactory CW Doppler recording of MR was obtained in 63/80 (78%). On the late descending portion of the CW recording, the time from a velocity of 4 m/sec to the end of the jet was defined as t1, and from 3 m/sec to the end of the jet as t2. Mathematical derivation of t1/t2 as a predictor of PAWP, was performed based on Weiss' derivation. If t1/t2 was <1.30, the PAWP was normal. If t1/t2 > 1.44, the PAWP was > 16 mmHg. With this new mathematical derivation, it appears that the downslope of the CW Doppler MR waveform may be able to distinguish a normal from elevated PAWP.

Assessment of left ventricular systolic and diastolic function by doppler tissue imaging in patients with preinfarction angina

BACKGROUND

The aim of this study was assessment of left ventricular (LV) systolic and diastolic function by pulsed wave Doppler tissue imaging (DTI) in patients with or without preinfarction angina in acute myocardial infarction.

METHODS

We prospectively evaluated 31 consecutive patients (4 women, 27 men; age 58 +/- 10 years) with a first acute myocardial infarction. LV systolic and diastolic function was assessed by classic methods and DTI on the third day during acute myocardial infarction. Patients were divided into 2 groups according to the presence (group 1; n = 10) or absence (group 2; n = 21) of preinfarction angina. Mitral inflow velocities and early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), peak systolic mitral annular velocity, Em/Am, the ratio of early diastolic mitral inflow velocity (E) to Em, and myocardial performance index were calculated by DTI.

RESULTS

Group 1 had significantly higher Em and Em/Am than group 2 (11.3 +/- 3.34 cm/s vs 7.4 +/- 2.07 cm/s, P <.0001; 1.01 +/- 0.38 cm/s vs 0.6 +/- 0.2 cm/s, P =.001, respectively). The E/Em ratio and myocardial performance index were significantly lower in group 1 than in group 2 (5.1 +/- 2.92 vs 8.10 +/- 3.15, P=.018; 0.49 +/- 0.15 vs 0.65 +/- 0.24, P =.042, respectively). Wall-motion score index was lower in those with preinfarction angina than in those without (1.6 +/- 0.36 vs 1.9 +/- 0.39; P =.04, respectively). Peak systolic mitral annular velocity and Am were not statistically different between groups (9.4 +/- 1.84 vs 8.3 +/- 2.03, P =.172; 11.7 +/- 3.07 vs 12.1 +/- 3.34, P =.72, respectively). There were no significant differences between the 2 groups regarding transmitral E velocity, atrial contraction mitral inflow velocity (A), E/A ratio, isovolumetric relaxation time, and deceleration time of the mitral E wave (P =.91, P =.08, P =.58, P =.81, and P =.71, respectively).

CONCLUSION

LV diastolic function was better in patients with preinfarction angina than in patients without. This condition could not be detected by conventional mitral inflow Doppler velocities, but could be detected by DTI. This preliminary evidence shows that DTI is better than conventional mitral Doppler indices in the assessment of a favorable LV diastolic function in patients with preinfarction angina.

Doppler echocardiographic estimation of left ventricular end-diastolic pressure after MI in rats

The spectral Doppler mitral flow pattern, alone or combined with tissue Doppler mitral annulus velocity, can be used to predict left ventricular (LV) filling pressure in humans, whereas invasive hemodynamic measurements are still required in the rat. This study was undertaken to assess whether LV end-diastolic pressure (LVEDP) can be estimated using Doppler echocardiography in the rat after myocardial infarction (MI). Thirty-seven rats (23 rats with MI after left coronary artery ligation and 14 sham-operated rats) were evaluated 3 mo after surgery with echo-Doppler and invasive hemodynamic measurements. Pulse wave spectral Doppler at the mitral valve tip was used to measure the E wave, the E wave deceleration time (DT), and the A wave; spectral Doppler tissue imaging was used to measure the early diastolic lateral mitral annulus velocity (E(a)). We found weak correlations between LVEDP and the peak velocity of the early mitral inflow (E), E/peak velocity of the late mitral inflow, and DT, and strong correlations with E(a) and especially with E/E(a) [R(2) = 0.89, LVEDP (in mmHg) = 0.987E/E(a) - 4.229]. Longitudinal followup of a subgroup of rats with MI revealed a marked rise of E/E(a) between days 7 and 21 in rats with heart failure only. We conclude that Doppler echocardiography can be used for serial assessment of LV diastolic function in rats with MI.

Use of echocardiography for hemodynamic monitoring

OBJECTIVE

To assess the accuracy of echocardiography for hemodynamic monitoring.

DATA SOURCES

A computerized MEDLINE search was used with the following search headings: monitoring (physiologic and intra-operative) and both echocardiography and transesophageal echocardiography. A number of studies were obtained from the reference lists of cardiology reviews and textbooks.

STUDY SELECTION

Studies that were designed to assess the accuracy of hemodynamic monitoring.

DATA EXTRACTION

From the selected studies, the accuracy of different techniques for measuring preload and cardiac output was compared.

DATA SYNTHESIS

Hypovolemia can be detected accurately by measuring left ventricular end-diastolic area. At high preload, Doppler-based methods are more accurate, although further studies in critical care patients are needed. Cardiac output is best measured by measuring Doppler flow, preferably across the aortic valve.

CONCLUSIONS

Echocardiography can be used to make accurate hemodynamic measurements; however, training is required. Further studies are needed to validate these methods in the management of critically ill patients.

Restrictive left ventricular filling and preserved ventricular function: a limitation in the noninvasive estimation of pulmonary wedge pressure by Doppler echocardiography

Pulmonary wedge pressure (PWP) can be estimated from the ratio of transmitral early peak flow velocity to flow propagation velocity measured by Doppler. Discrepancies observed in the application of the method prompted us to design this prospective study, aimed at detecting potential limitations of the method. We studied a total of 32 patients admitted to a cardiac intensive care unit, using a Swan-Ganz catheter. Correlation between invasive- and Doppler-estimated PWP was fairly good (r = 0.58). Analysis of discrepant cases led to the identification of a subgroup of 6 patients in whom PWP was largely underestimated because of unexpectedly high values of flow propagation velocity (71 +/- 15 cm/s vs 37 +/- 10 cm/s in the rest of the group; P =.0001). All of them had in common a restrictive Doppler filling pattern and preserved left ventricular systolic function. Exclusion of this group showed an improvement in the correlation coefficient to r = 0.72. In conclusion, PWP can be estimated by the Doppler early peak flow velocity to flow propagation velocity ratio, although a significant underestimation of PWP may be observed in patients with a restrictive filling pattern and preserved ventricular function.

Effect of the isolated left bundle branch block on systolic and diastolic functions of left ventricle

BACKGROUND

We planned this study to evaluate the effects of left bundle branch block (LBBB) on systolic and diastolic functions of left ventricle (LV) that have not previously been investigated in detail.

MATERIAL AND METHODS

Forty-five cases diagnosed as isolated LBBB according to the standard electrocardiographic criteria (group I, mean age: 60 +/- 12 years) were taken as the case group and 65 cases with normal conduction system (group II, mean age 58 +/- 14 years) were taken as the control group. Echocardiography was performed to all patients and coronary angiography was performed to 21 patients in group I and 35 patients in group II. In addition to standard systolic and diastolic function parameters, isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and ejection time (ET) were measured by echocardiography, and the myocardial performance index (MPI) [(IRT+ICT)/ET] was calculated. LV end-diastolic pressure was calculated for the patients undergoing coronary angiography.

RESULTS

In group I, LV end-systolic diameter was greater (3.1 +/- 0.4 cm vs 2.8 +/- 0.4 cm, P <.001) and ejection fraction was lower (64% +/- 6% vs 68% +/- 6%, P <.001) than those of group II. Rapid filling deceleration time and rate was markedly different in group I (respectively, 133 +/- 50 ms vs 166 +/- 24 ms, P <.001; 608 +/- 291 cm/s(2) vs 383 +/- 116 cm/s(2), P <.001). In addition, it was found that LBBB caused shortening of LV diastolic period and ET markedly (respectively, 347 +/- 116 ms vs 394 +/- 106 ms, P =.03; 255 +/- 40 ms vs 294 +/- 21 ms, P <.001) and prolongation of IRT and ICT (respectively; 124 +/- 36 ms vs 91 +/- 16 ms, 96 +/- 35 ms vs 38 +/- 9 ms, P <.001). The MPI was predominantly higher in group I (0.89 +/- 0.29 vs 0.40 +/- 0.06, P <.001). Invasively determined LV end-diastolic pressure was found higher in group I (14 +/- 3 mm Hg vs 10 +/- 3 mm Hg, P <.001).

CONCLUSION

A marked elevation of the LV MPI and end-diastolic pressure, parallel to changes of conventional echocardiographic parameters, in patients with isolated LBBB points out that LBBB causes marked deterioration on LV systolic and diastolic functions.

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Feasibility and accuracy of transthoracic Doppler echocardiographic estimation of pulmonary capillary wedge pressure applying different methods

BACKGROUND

Pulmonary wedge pressure (PWP) is an established index of cardiac function and an essential component in the management of patients with congestive heart failure and in critically ill patients.

AIM

To evaluate feasibility and accuracy of non-invasive prediction of PWP by Doppler echocardiography in daily clinical practice.

METHODS

Agreement was assessed between values predicted by Doppler vs. invasively measured PWP. Forty-five consecutive patients [mean (S.D.) age 62 (10) years] with CAD (44%), DCMP (40%) and without structural heart disease (16%) were studied (EF< or =40% in 58% of the patients). Doppler transmitral and pulmonary venous flow velocity profiles were recorded. For binary and quantitative prediction of PWP, four different methods and five different linear equations, suggested previously in the literature, were evaluated.

RESULTS

Predictive values to identify elevated PWP were highest for pulmonary venous flow reversal exceeding the duration of forward mitral flow during atrial systole (PPV 1 and NPV 0.96). Likewise, agreement with measured PWP was highest for equations comprising both transmitral and pulmonary venous flow variables (relative mean difference 0.11, S.D.+/-4.01 mmHg for the most accurate equation). Feasibility was slightly, but not statistically, lower when pulmonary venous flow was considered vs. transmitral flow parameters alone for binary prediction (87 vs. 93%) as well as for quantitative assessment (82 vs. 93%).

CONCLUSION

Semiquantitative prediction of elevated PWP by Doppler echocardiography is feasible as well as accurate in daily clinical practice. However, accuracy of numeric estimates is limited. Hence, invasive measurement of PWP is still necessary in certain clinical settings.

Noninvasive cardiac absolute pressure sensing: a fundamentally new approach

Noninvasive cardiac pressure sensing using an imaging modality to ascertain changes in absolute pressure would be of immense benefit as a replacement for the Swan-Ganz catheter in current use. However, very little research has been published in this area. This paper reviews the small number of relevant studies to date, points out the many gaps in the research record, and discusses possible new avenues of approach in solving the problem.

Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis

BACKGROUND

The early diastolic velocity of the mitral annulus (E') is reduced in patients with diastolic dysfunction and increased filling pressures. Because transmitral inflow early velocity (E) increases progressively with higher filling pressures, E/E' has been shown to have a strong positive relationship with pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure. However, previous studies have primarily involved patients without a pericardial abnormality. In constrictive pericarditis (CP), E' is not reduced, despite increased filling pressures. This study evaluated the relationship between E/E' and PCWP in patients with CP.

METHODS AND RESULTS

We studied 10 patients (8 men; mean age, 64+/-7 years) with surgically confirmed CP. Doppler echocardiography was performed to measure early and late diastolic transmitral flow velocities. Tissue Doppler echocardiography was performed to measure E'. PCWP was measured with right heart catheterization. All patients were in sinus rhythm. Mean E and E' were 91+/-15 cm/s and 11+/-4 cm/s, respectively. Mean PCWP was 25+/-6 mm Hg. E' was positively correlated with PCWP (r=0.69, P=0.027). There was a significant inverse correlation between E/E' and PCWP (r=-0.74, P=0.014). Despite high left ventricular filling pressures, E/E' (mean, 9+/-4) was <15 in all but 1 patient.

CONCLUSIONS

Paradoxical to the positive correlation between E/E' and PCWP in patients with myocardial disease, an inverse relationship was found in patients with CP.