Ratio of Early Transmitral Velocity to Lateral Mitral Annular Early Diastolic Velocity Has the Best Correlation With Wedge Pressure Following Cardiac Surgery

Correlation Between Tissue Doppler Imaging Method (E/e') and Invasive Measurements of Left Ventricular Filling Pressures: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES

Evaluation of pulmonary capillary wedge pressure (PCWP) through right heart catheterization can indirectly provide an estimation of the filling pressure of the left ventricle. Echocardiography can estimate left ventricular compliance using mitral annular tissue Doppler imaging (TDI). The E/e' ratio refers to the correlation between the peak mitral inflow (E-wave) velocity and early diastolic tissue Doppler mitral annular velocity (e'). The main purpose of this systematic review was to establish the correlation between echocardiographic E/e' ratio and PCWP. The correlation between E/e' and left ventricular end-diastolic pressure (LVEDP) was evaluated as a secondary objective.

DESIGN

A systematic review and meta-analysis of observational studies was conducted. The search was based on Medline (PubMed), Scopus, and Web of Science.

SETTING

Intensive care unit or cardiac intensive care unit.

PARTICIPANTS

Adult patients.

INTERVENTIONS

Any study comparing the left ventricular filling pressure obtained by cardiac catheterization (reference) and echocardiographic evaluation, in particular TDI analysis (intervention), were included.

MEASUREMENTS AND MAIN RESULTS

The pooled analysis included 94 studies from the initially identified 7,304 records. The correlation was 0.48 (95% CI 0.42-0.54, Q = 420.52, I2 = 84.8%) for PCWP and 0.50 (95% CI 0.38-0.60, Q = 210.91, I2 = 89.1%) for LVEDP.

CONCLUSIONS

The E/e' ratio moderately correlated with PCWP/LVEDP. The correlation was stable irrespective of the sites where e' was measured, but each site has its own limitations for specific patient subpopulations. The correlation was weak in patients with heart failure with a preserved ejection fraction.

Comparison of the prognostic value of lateral versus septal early mitral annulus velocity in patients with acute decompensated heart failure

Mitral annular early diastolic velocity (e') measured using Doppler echocardiography is important for the noninvasive estimation of left ventricular filling pressure (LVFP). However, it remains unknown whether lateral or septal e' is prognostically more reliable. Accordingly, here, we compared the prognostic utility of lateral e' with that of septal e' in patients hospitalized for acute decompensated heart failure (HF). We retrospectively analyzed the data of 193 consecutive patients with acute decompensated HF. According to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, the cut-off values of high lateral e' and septal e' were 10 cm/s and 7 cm/s, respectively. Kaplan-Meier survival curves and log-rank tests were used to compare 90-day mortality between groups. For the entire cohort, 90-day mortality was 15.5%. Lateral e' <10 was significantly correlated with higher 90-day mortality (log-rank, P = 0.026), whereas septal e' <7 was not significantly associated with 90-day mortality (log-rank, P = 0.405). Receiver operating characteristic curve analyses revealed that the best cut-off values for lateral e' and septal e' in this cohort were 10 cm/s and 6 cm/s, respectively. However, septal e' <6 was also not associated with 90-day mortality (log-rank, P = 0.141). This study demonstrated that, when comparing lateral e' with septal e', the former provides better prognostic utility for patients with acute decompensated HF. If a dissociation between lateral e' and septal e' is detected, the value measured at the lateral site may be more credible for determining LVFP in HF.

What Is the Evidence That the Tissue Doppler Index E/e' Reflects Left Ventricular Filling Pressure Changes After Exercise or Pharmacological Intervention for Evaluating Diastolic Function? A Systematic Review

Background

Noninvasive echocardiographic tissue Doppler assessment (E/e′) in response to exercise or pharmacological intervention has been proposed as a useful parameter to assess left ventricular (LV) filling pressure (LVFP) and LV diastolic dysfunction. However, the evidence for it is not well summarized.

Methods and Results

Clinical studies that evaluated invasive LVFP changes in response to exercise/other interventions and echocardiographic E/e′ were identified from PubMed, Scopus, Embase, and Cochrane Library databases. We grouped and evaluated studies that included patients with preserved LV ejection fraction (LVEF), patients with mixed/reduced LVEF, and patients with specific cardiac conditions. Overall, we found 28 studies with 9 studies for preserved LVEF, which was our primary interest. Studies had differing methodologies with limited data sets, which precluded quantitative meta‐analysis. We therefore descriptively summarized our findings. Only 2 small studies (N=12 and 10) directly or indirectly support use of E/e′ for assessing LVFP changes in preserved LVEF. In 7 other studies (cumulative N=429) of preserved LVEF, E/e′ was not useful for assessing LVFP changes. For mixed/reduced LVEF groups or specific cardiac conditions, results similar to preserved LVEF were found.

Conclusions

We find that there is insufficient evidence that E/e′ can reliably assess LVFP changes in response to exercise or other interventions. We suggest that well‐designed prospective studies should be conducted for further evaluation.

Left ventricular filling pressure by septal and lateral E/e' equally predict cardiovascular events in the general population

PURPOSE

There exists no consensus on the site of E/e' measurement. This study aimed to evaluate the predictive value of septal and lateral E/e' along with the importance of their intra-individual difference.

METHODS

In 1775 persons from the general population, peak early diastolic velocity (e') was obtained by color tissue Doppler at the septal and lateral mitral annular sites. The endpoint was combined of cardiovascular death or admission due to heart failure or acute myocardial infarction.

RESULTS

During a median follow-up of 10.9 years, the endpoint occurred in 227 participants. E/e'_septal and E/e'_lateral were equally strong predictors of cardiac events; in age- and sex-adjusted models they did not differ in AUC (septal: 0.8385, lateral: 0.8389; p = 0.94) or in continuous NRI (p = 0.84). Models using E/e'_average did not improve AUC or NRI, and the intra-individual difference between sites had no predictive value (p = 0.79). E/e'_septal was generally higher than E/e'_lateral, thus age- and sex-specific normal values were reported for both sites for a population free of cardiac events during 10 years of follow-up.

CONCLUSIONS

Septal and lateral E/e' are equally useful in predicting cardiac events in the general population. Measuring both sites provides no further predictive value than measuring a single site.

Noninvasive assessment of exercise tolerance using mitral annular velocities

PURPOSE

To investigate the feasibility of evaluating exercise tolerance using lateral and septal mitral annular velocities in patients with preserved left ventricular ejection fraction (LVEF) and those with reduced LVEF.

METHOD

We studied 36 patients with LVEF ≥50% and 36 with LVEF <50%. We measured peak early diastolic velocity of transmitral flow (E) and peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus. The ratios of E to LEa (E/LEa) and E to SEa (E/SEa) were calculated. We measured peak oxygen consumption [Formula: see text] and anaerobic threshold (AT) by cardiopulmonary exercise testing.

RESULTS

In patients with LVEF ≥50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.69 and r = -0.74, respectively; p < 0.001); E/SEa correlated modestly (r = -0.59 and r = -0.60, respectively; p < 0.001). In patients with LVEF <50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.72 and r = -0.76; respectively, p < 0.001); E/SEa correlated modestly (r = -0.63 and r = -0.63, respectively; p < 0.001).

CONCLUSION

E/LEa may be more useful than E/SEa for the noninvasive estimation of exercise tolerance, throughout a wide range of LVEF.

Impact of milrinone on mitral annular velocity in patients with congestive heart failure

PURPOSE

The purpose of this study is to assess the impact of milrinone on mitral annular velocity in patients with congestive heart failure.

METHOD

We studied 27 patients with congestive heart failure. All patients underwent transthoracic echocardiography both before and after administration of milrinone. We measured the early transmitral velocity (E) and the mitral annular early diastolic velocity (Ea). The ratio of E to Ea (E/Ea) was calculated. After the baseline echocardiography, milrinone was administered as a continuous infusion at a rate of 0.25 μg/kg/min. Echocardiographic measurements were repeated 4 h after milrinone was begun.

RESULTS

After administration of milrinone, Ea was significantly increased, while E/Ea was significantly decreased. The population of 27 patients was divided into 20 (74 %) with left ventricular ejection fraction (LVEF) <50 % and seven (26 %) with LVEF ≥50 %. Ea was significantly increased in both groups, while E/Ea was significantly decreased.

CONCLUSION

Even low-dose milrinone produced an improvement in left ventricular (LV) diastolic function, as evidenced by an increase in Ea, and falls in LV filling pressures, as determined by a decrease in E/Ea, in patients with congestive heart failure throughout a wide range of LV systolic function.

Contribution of ventricular diastolic dysfunction to pulmonary hypertension complicating chronic systolic heart failure

OBJECTIVES

The aim of the study is to clarify the clinical role of Doppler-echocardiographic parameters of left ventricular diastolic dysfunction (LVDD) as determinants of pulmonary hypertension in patients experiencing left ventricular systolic dysfunction (LVSD) with and without the presence of functional mitral valve regurgitation (FMR).

BACKGROUND

Pulmonary hypertension (pulmonary venous or mixed pulmonary venous-arterial hypertension) complicating LVSD is associated with poor outcomes beyond that of LVSD alone. The view of the contribution of LVDD as a determinant of pulmonary hypertension is controversial and not well defined as a tool in clinical practice.

METHODS

Data from patients with LVEF ≤40% undergoing Doppler-echocardiography evaluations during the period from August 2001 to December 2004 were analyzed. Pulmonary systolic pressure (PSP), parameters of diastolic function (mitral valve [MV] transmitral flow velocity [E]/mitral annular diastolic velocity [e'] ratio, MV deceleration time [DT]), quantitated effective regurgitant orifice area (EROA) of FMR, and clinical characteristics were evaluated. Pulmonary hypertension was defined as an estimated PSP ≥45 mm Hg.

RESULTS

Criteria were met in 1,541 patients; one-third (n = 533) demonstrating PSP ≥45 mm Hg (58 ± 10 mm Hg, range 45 to 102 mm Hg). Patients with pulmonary hypertension were older with higher E/e' ratio, EROA, and lower DT and LVEF. In multivariate analysis, pulmonary hypertension was independently predicted not only by severity of FMR (EROA ≥20 mm(2), odds ratio: 3.8, p < 0.001) but also by parameters of LVDD (E/e' ratio ≥15, odds ratio: 3.31, p < 0.001; DT ≤150 ms, odds ratio: 3.8, p < 0.001). Receiver-operating characteristics curve analysis showed that EROA, E/e' ratio, and DT provided significant incremental value in predicting pulmonary hypertension (c-statistic 0.830, p < 0.001).

CONCLUSIONS

Patients with LVSD commonly have secondary pulmonary hypertension, which is largely determined by the severity of LVDD even with adjustment for FMR and low LVEF. Thus, measures of LVDD in routine clinical practice where PSP may not be estimated are important physiologic descriptors of hemodynamic status and are cumulatively linked in the prediction of pulmonary hypertension.

Prognostic value of tissue Doppler-Derived E/e' on early morbid events after cardiac surgery

BACKGROUND

The tissue Doppler-derived surrogate for left ventricular diastolic pressure, E/e', has been used to prognosticate outcome in a variety of cardiovascular conditions. In this study, we determined the relationship of intraoperative E/e' to the use of inotropic support, duration of mechanical ventilation (MV), length of intensive care unit stay (ICU-LOS), and total hospital stay (H-LOS) in patients requiring cardiac surgery. The records of 245 consecutive patients were retrospectively reviewed to obtain 205 patients who had intraoperative transesophageal echocardiography examinations prior to coronary artery bypass grafting and/or valvular surgery. Cox proportional hazards and logistic regression models were used to analyze the relation between intraoperative E/e' or LVEF and early postoperative morbidity (H-LOS, ICU-LOS, and MV) and the probability that a patient would require inotropic support. With adjustments for other predictors (female gender, hypertension, diabetes, history of myocardial infarction, emergency surgery, renal failure, procedure type, and length of aortic cross-clamp time), an elevated E/e' ratio (>or=8) was significantly associated with an increased ICU-LOS (49 versus 41 median h, P = 0.037) and need for inotropic support (P = 0.002) while baseline LVEF was associated with inotropic support alone (P < 0.0001). These data suggest that the tissue Doppler-derived index of left ventricular diastolic filling pressure may be a useful indicator for predicting early morbid events after cardiac surgery, and may even provide additional information from that of baseline LVEF. Further, patients with elevated preoperative E/e' may need more careful peri- and postoperative management than those patients with E/e' <8.

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.

Diastolic dysfunction, cardiovascular aging, and the anesthesiologist

As the number of persons aged 65 years and older continues to increase, the anesthesiologist will more frequently encounter this demographic. Cardiovascular changes that occur in this patient population present difficult anesthetic challenges and place these patients at high risk of perioperative morbidity and mortality. The anesthesiologist should be knowledgeable about these age-related cardiovascular changes, the pathophysiology underlying them, and the appropriate perioperative management. Whether presenting for cardiac or general surgery, the anesthesiologist must identify patients with altered physiology as a result of aging or diastolic dysfunction and be prepared to modify the care plan accordingly. With a directed preoperative assessment that focuses on certain aspects of the cardiovascular system, and the assistance of powerful echocardiographic tools such as tissue Doppler, this can be achieved.