Echocardiographic assessment of simultaneously measured left ventricular filling pressures in patients with normal left ventricular ejection fraction

Non-invasive assessment of left ventricular filling pressure in aortic stenosis

BACKGROUND

The assessment of left ventricular (LV) filling pressure (FP) is important for the management of aortic stenosis (AS) patients. Although, it is often restricted for predict LV FP in AS because of mitral annular calcification and a certain left ventricular hypertrophy. Thus, we tested the predictive ability of the algorithm for elevated LV FP in AS patients and also applied a recently-proposed echocardiographic scoring system of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score.

METHODS

We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LV FP. LV diastolic dysfunction (DD) was graded according to the ASE/EACVI guidelines. The VMT score was defined as follows: time sequence of opening of mitral and tricuspid valves was scored to 0-2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava was dilated, one point was added and VMT score was finally calculated as 0-3.

RESULTS

Of the 116 patients, 29 patients showed elevated PAWP. Ninety patients (93%) and 67 patients (63%) showed increased values for left atrium volume index (LAVI) and E/e', respectively when the cut-off values recommended by the guidelines were applied and thus the algorism predicted elevated PAWP with a low specificity and positive predictive value (PPV). VMT ≥ 2 predicted elevated PAWP with a sensitivity of 59%, specificity of 90%, PPV of 59%, and negative predictive value of 89%. An alternative algorithm that applied tricuspid regurgitation velocity and VMT scores was tested, and its predictive ability was markedly improved.

CONCLUSION

VMT score was applicable for AS patients. Alternative use of VMT score improved diagnostic accuracy of guideline-recommended algorism.

Clinical relevance of spectral tissue Doppler-derived E/e' in older patients with preserved ejection fraction

BACKGROUND

The E/e' index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e' is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e' in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature.

METHODS

A total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e'.

RESULTS

The mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e' was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e'>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e'xs') (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e'. The existing literature offers large body of evidence that E/e' provides essential diagnostic and prognostic information in older patients with cardiovascular disease.

CONCLUSION

E/e' is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.

Current clinical applications of spectral tissue Doppler echocardiography (E/e' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved ejection fraction. Revisited 15 years later

It is currently well established that more than half of heart failure patients have preserved ejection fraction. The diagnosis of heart failure with preserved ejection fraction is complex in clinical practice despite ESC recommendations issued in 2019. In this context, the demonstration of increased left ventricular filling pressures at rest or during exercise allows a definite diagnosis of heart failure with preserved ejection fraction in patients with signs and/or symptoms compatible with the diagnosis and a preserved ejection fraction. The spectral tissue Doppler-derived E/e' ratio by transthoracic Doppler echocardiography has been validated in the noninvasive assessment of left ventricular diastolic pressures at rest and during exercise. Several studies report the validity of E/e' in the diagnosis of heart failure with preserved ejection fraction in patients with both isolated exertional and acute dyspnea, as well as in risk stratification. In light of the current literature, E/e' deserves to be included on every transthoracic Doppler echocardiography report in patients with suspected heart failure with preserved ejection fraction. This updated review provides an overview of the diagnostic relevance of E/e' in patients in its two modes of clinical presentation, isolated exertional dyspnea and the decompensated congestive form.