- Email: [email protected]
Impact of left ventricular ejection fraction on estimation of left ventricular filling pressures using tissue Doppler and flow propagation velocity
described 2 cases of aneurysm formation after resolution of the IMH at 1 and 27 months after initial presentation, and 1 case of dissection 1 month after hematoma resolution. The number of patients in group II with significant complications (79%) was higher than that in previous studies, and 57% developed either a significant aneurysm or dissection.7 Earlier studies may have included different acute aortic syndromes with different pathologic bases. Our study concurs with previous studies in demonstrating medical management of type B IMH (i.e., aggressive management of hypertension unless complications develop).8 This study demonstrates that IMH of the descending thoracic aorta is not as benign as was previously thought. Larger IMHs and aortic diameters at diagnosis are associated with higher complication rates, and resolution of the IMH may be followed by aneurysm formation.
FIGURE 5. Aortic ratio at diagnosis (group 1, no aneurysm/dissection/death; group 2, aneurysm/dissection/death).
required during long-term follow-up. They concluded from their results that disappearance of the IMH suggested a good prognosis. Ide et al,6 in their series, found the descending aorta diameter (after resolution of the IMH) increased in 26% of patients. They also
1. Gore I. Pathogenesis of dissecting aneurysm of the aorta. Arch Pathol 1952; 53:142–153. 2. Wilson S, Hutchins G. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med 1982;106:175–180. 3. Hirst A, Johns V, Kime S. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217–219. 4. Ferguson JD, Moore N, Banning AP. Intramural aortic haematoma causing ischaemia of the spinal cord. Heart 1996;75:533. 5. Nishigami K, Tsuchiya T, Shono H, Horibata Y, Honda T. Disappearance of aortic intramural hematoma and its significance to the prognosis. Circulation 2000;102(suppl III):III-243–III-7. 6. Ide K, Uchida H, Otsuji H, Nishimine K, Tsushima J, Ohishi H, Kitamura S. Acute aortic dissection with intramural hematoma: possibility of transition to classic dissection or aneurysm. J Thorac Imaging 1996;11:46 –52. 7. Song JK, Kim HS, Kang DH, Lim TH, Song MG, Park SW, Park SJ. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol 2001;37:1604 –1610. 8. Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol 2000;86:664 –668.
Impact of Left Ventricular Ejection Fraction on Estimation of Left Ventricular Filling Pressures Using Tissue Doppler and Flow Propagation Velocity Carlos Rivas-Gotz,
MD,
Michael Manolios, MD, Vinay Thohan, Sherif F. Nagueh, MD
N
oninvasive estimation of left ventricular (LV) filling pressures is currently utilized in several laboratories using Doppler echocardiography. Previous studies have shown the accuracy of transmitral and pulmonary venous flow velocities1–5 in patients with a reduced ejection fraction (EF) and the limited From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas. Dr. Nagueh’s address is: Section of Cardiology, 6550 Fannin Street, SM-1246, Houston, Texas 77030-2717. E-mail: [email protected]. Manuscript received September 19, 2002; revised manuscript received and accepted November 11, 2002.
780
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 91 March 15, 2003
MD,
and
role they play in patients with normal EF.6 Recently, other ultrasound modalities have been described and include tissue Doppler (TD) imaging7–11 and color M-mode– derived flow propagation velocity (FPV).12–15 Because mitral peak E velocity is dependent on relaxation and preload, and FPV and mitral annular early diastolic velocity by TD (Ea) are related to LV relaxation, the ratio of E to FPV or Ea has been used to predict filling pressures. However, there is a paucity of data on the impact of LVEF on their accuracy. Furthermore, for Ea, the potential advantage—if any— of using the anterior, inferior, or average of all 0002-9149/03/$–see front matter doi:10.1016/S0002-9149(02)03433-1
FIGURE 1. Mitral inflow, FPV, and TD at the septal and lateral sides of the mitral annulus in a patient with EF of 20% and dilated cardiomyopathy. Notice that all Doppler indexes, i.e., mitral inflow, E/FPV, and E/Ea at either corner provide concordant information consistent with increased wedge pressure >15 mm Hg. Mean wedge pressure was 25 mm Hg.
velocities, especially in patients with segmental dysfunction, is unknown. This study was undertaken to prospectively evaluate the accuracy of TD imaging using all 4 areas of the mitral annulus, and FPV for predicting LV filling pressures in patients with and without normal EF, including those with segmental wall motion abnormalities. •••
The institutional review board of Baylor College of Medicine approved the protocol and all patients provided written informed consent. The study population comprised 2 parallel groups of consecutive patients (not included in previous studies): 54 patients with EF ⬍50% and 55 subjects with EF ⱖ50%. These patients were undergoing right-sided cardiac catheterization in the cardiac catheterization laboratory (n ⫽ 40) or the intensive care unit (n ⫽ 69). Inclusion criteria were sinus rhythm (60 to 100 beats/min), satisfactory Doppler and pressure recordings, and absence of mitral stenosis or prosthetic mitral valve. Patients had simultaneous echocardiographic and hemodynamic measurements. Patients were imaged in the supine position. After acquiring parasternal and apical views, pulsed-Doppler was used to record transmitral and pulmonary venous flow in the apical 4-chamber view as previously described.1,2 In the apical 4-chamber view, with the use of color Doppler, the M-mode cursor was aligned along the mitral inflow stream to record the early flow propagation velocity into the left ventricle as previously reported.12,14 Baseline shift was per-
FIGURE 2. Mitral inflow, FPV, and TD at the septal and lateral corners of the mitral annulus in a patient with EF of 20% and ischemic cardiomyopathy. Septal infarction was present and the basal segment of the lateral wall had normal function. Mean wedge pressure was 20 mm Hg. Notice that although septal E/Ea predicts a pressure >25 mm Hg, use of lateral Ea resulted in an estimated pressure of <15 mm Hg. An average of septal and lateral Ea (velocities 8.25, E/Ea ratio 14.5) provided the best estimate of the actual wedge pressure.
formed as needed to obtain a distinct border of the propagation velocity into the LV cavity. TD imaging (Figures 1 to 3) was applied in the pulsed-Doppler mode to record mitral annulus velocities at their septal, lateral, inferior, and anterior areas. Analysis was performed without knowledge of hemodynamic data. Two-dimensional measurements were obtained per the recommendations of the American Society of Echocardiography16 and included LV volumes, EF, and left atrial maximum volume. All Doppler values represent the average of 3 to 5 beats. Mitral inflow, pulmonary venous flow, and TD velocities were analyzed as previously described.1,2,9 –11 FPV was measured as the slope of the linear component of the color border produced by propagation of E velocity into the left ventricle past the mitral valve tips.12,14 The early diastolic (Ea) and late diastolic (Aa) TD velocities at the 4 areas of the mitral annulus were measured, and the dimensionless parameters— E/FPV14,15 and E/Ea9 –11—were computed. For patients in the intensive care unit, the chest x-ray was used to verify the position of the pulmonary artery catheter, whereas fluoroscopy was used in the cardiac catheterization laboratory. Medex transducers were balanced before the acquisition of hemodynamic data, with the zero level at the midaxillary line. Pressure measurements were acquired at end expiration and represent the average of 5 cycles. Cardiac output BRIEF REPORTS
781
dynamic variables were significantly related to FPV and Ea. Both velocities had an inverse, but weak, correlation with wedge pressure (r ⫽ ⫺0.25 to 0.37, p ⬍0.01), and both related positively to EF, stroke volume, and cardiac output (range for stroke volume of r ⫽ 0.33 with lateral Ea to r ⫽ 0.43 with FPV, both p ⬍0.01). In patients with EF⬍50%, several parameters derived from mitral inflow and pulmonary venous flow (recorded in 35 patients) were significantly related to wedge pressure (Table 2). A previous regression equation from our laboratory2 that uses isovolumetric relaxation time and E/A ratio well predicted mean wedge pressure (r ⫽ 0.79, p ⬍0.01). The correlation of E/FPV and E/Ea to wedge pressure are shown in Figure 4, and their most optimum values for the prediction of wedge pressure ⬎15 mm Hg are listed in Table 3. Patients with EF⬍50% were divided into 2 subgroups based on the presence or absence of regional dysfunction (Table 4). Patients with segmental dysfunction (n ⫽ 26) were older (66 ⫾ 3 vs 59 ⫾ 3 years, p ⫽ 0.07) and had a higher EF (37 ⫾ 1% vs 28 ⫾ 2%, FIGURE 3. Mitral inflow, FPV, and TD at the septal and lateral p ⫽ 0.012). Wedge pressure, FPV, and Ea (p ⬎0.1) corners of the mitral annulus in a patient with hypertension, LV were all similar in the 2 subgroups. In general, Ea hypertrophy, and EF of 55%. Notice that although mitral inflow showed a trend toward lower values in the wall inand E/Ea at either side provide concordant information consisvolved with infarction versus the contralateral sites tent with increased wedge pressure (24 mm Hg), the ratio of (septal: 4.1 ⫾ 0.3 vs 5.3 ⫾ 0.6 cm/s, p ⫽ 0.06; E/FPV is suggestive of filling pressures of <15 mm Hg. inferior: 5.1 ⫾ 0.6 vs 6.7 ⫾ 0.7 cm/s, p ⫽ 0.16, lateral: 4 ⫾ 1 vs 7.9 ⫾ 0.5 cm/s, p ⫽ 0.03; anterior: 4.4 ⫾ 0.4 TABLE 1 Demographic and Hemodynamic Characteristics of the Two Groups vs 6 ⫾ 0.6 cm/s, p ⫽ 0.1). The avEF ⬍50% EF ⱖ50% erage of septal and lateral Ea veloc(n ⫽ 54) (n ⫽ 55) ities resulted in a better relation to wedge pressure only in patients with Age (yrs) 62 ⫾ 2 64 ⫾ 2 Men/women 41/13 36/19 segmental dysfunction. In both subEjection fraction (%) 34 (22.5–40)* 65 (58–67) groups, the inclusion of Ea at other Heart rate (beats/min) 81 ⫾ 2 84 ⫾ 2 areas did not result in a better preSystolic blood pressure (mm Hg) 120 ⫾ 3 124 ⫾ 4 diction than that achieved by averagDiastolic blood pressure (mm Hg) 64 ⫾ 2 65 ⫾ 2 Pulmonary artery systolic pressure (mm/Hg) 44 ⫾ 2 44 ⫾ 3 ing Ea velocity at only the septal and Pulmonary artery diastolic pressure (mm/Hg) 23 ⫾ 1 21 ⫾ 1 lateral sites. Mean right atrial pressure (mm/Hg) 12 ⫾ 1 12 ⫾ 1 In patients with normal EF, mitral Stroke volume (ml) 48 ⫾ 2* 69 ⫾ 2 inflow and TD velocities were satisCardiac output (L/min) 4.4 ⫾ 0.2* 5.4 ⫾ 0.2 factorily recorded from all patients; Pulmonary capillary wedge pressure (mm/Hg) 20 (14–28)* 16 (11–20) End-diastolic volume (ml) 152 (110–191)* 112 (99–131) however, pulmonary venous flow End-systolic volume (ml) 89 (66–140)* 42 (33–57) was obtained in 32 and FPV in 46 patients. E/FPV had the weakest cor*p ⬍0.01 versus patients with EF ⱖ50%. Data are expressed as mean ⫾ SEM or median (25th to 75th percentile) where appropriate. relation with wedge pressure and lateral E/Ea had the best relation (although weaker than in patients with was derived by the thermodilution technique, averag- EF⬍50% [Figure 5]). ing 3 cardiac cycles with ⬍10% variation. ••• Data are presented as mean ⫾ SEM or median This study shows the impact of LVEF on the (25th to 75th percentile) where appropriate. Unpaired accuracy of wedge pressure prediction using the availStudent’s t and Mann-Whitney rank-sum tests were able Doppler parameters. Novel findings include the used to compare LV volumes, EF, and hemodynamics strong impact of EF on the accuracy of predicting between the 2 groups. Linear regression analysis was filling pressures using the ratio of E/FPV. When using applied to examine the relation between wedge pres- this ratio in patients with a reduced EF, a higher cutoff sure and Doppler parameters. A p value ⱕ0.05 was is needed to detect elevated filling pressures than considered significant. when using a lower ratio in patients with normal EF. Table 1 lists demographic and hemodynamic char- TD Ea was useful irrespective of LVEF. E/Ea ratio at acteristics of patients in both groups. Several hemo- the lateral side of the mitral annulus was the best 782 THE AMERICAN JOURNAL OF CARDIOLOGY姞
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lower ratio should be used. In the presence of regional dysfunction, the combination of septal and lateral Ea EF ⬍50% EF ⱖ50% appears to be most accurate. Although the pulmonary venous Left atrial maximal volume (ml) 0.5* 0.36† Peak E velocity (cm/s) 0.6* 0.5* atrial reversal velocity duration miE/A ratio 0.65* 0.41* nus the mitral A velocity duration Isovolumetric relaxation time (ms) ⫺0.72* ⫺0.41* had the strongest relation to mitral Pulmonary venous systolic filling fraction ⫺0.63* ⫺0.24 and pulmonary venous flow variDeceleration time of pulmonary venous diastolic ⫺0.74* ⫺0.37 velocity (ms) ables in patients with normal EF, its Pulmonary venous atrial reversal velocity duration– 0.56† 0.62* overall utility was limited by the mitral A velocity duration (ms) lower feasibility of satisfactory pulTissue Doppler late diastolic velocity (average cm/s) ⫺0.56* ⫺0.31† monary venous flow recordings E/flow propagation velocity 0.65* 0.5* (similar to previous studies2,11). UnE/Ea (lateral) 0.74* 0.7* E/Ea (septal) 0.65* 0.55* like patients with low EF, FPV had a E/Ea (anterior) 0.5* 0.56* minimal impact on the accuracy of E/Ea (inferior) 0.66* 0.52* mitral peak E velocity alone. This E/Ea (average Ea velocity) 0.71* 0.57* may be related to the significant ef*p ⬍0.01, †p ⬍0.05. fects of stroke volume on FPV that could reduce the influence of LV relaxation. In this and other studies,17 FPV was inversely related to endsystolic volume but directly to EF, stroke volume, and cardiac output. Accordingly, it is possible for the FPV to fall in the normal range in patients with normal EF despite the presence of impaired relaxation. Therefore, one should exercise caution when using the ratio of E/FPV to predict filling pressures in this population of patients. In patients with normal EF, the weaker relation between E/Ea and wedge pressure may be related to the lower correlation of peak E velocity FIGURE 4. Correlation of mean wedge pressure with E/FPV (left), lateral E/Ea (middle), and septal E/Ea (right) in group I patients with EF <50%. PCWP ⴝ mean wedge with filling pressures, as well as the pressure. inclusion of patients without cardiac disease whose preload has been shown to have an important effect on Ea.18 –20 Interestingly, the accuracy of E/Ea varied among the 4 TABLE 3 Prediction of Mean Wedge Pressure ⬎15 mm/Hg areas, with the lateral E/Ea ratio having the highest Using Flow Propagation Velocity (FPV) and Tissue Doppler correlation with mean wedge pressure. The better perVelocities formance using lateral Ea may be related to the fact that Cutoff Sensitivity Specificity in humans, preload has a reduced effect on it compared EF ⬍50% with septal Ea. In 1 study19 that examined normal subE/FPV 2.5 78 77 jects, preload-altering maneuvers had no significant efE/Ea (lateral) 11 85 82 fect on lateral Ea, whereas septal Ea was significantly E/Ea (septal) 20 59 88 affected. In another study, in which intravascular volume E/Ea (average of 4) 15 74 82 EF ⱖ50% was reduced by hemodialysis, Agmon et al20 noted a E/FPV 1.9 71 73 comparable decrease in mitral E and septal Ea, whereas E/Ea (lateral) 10 79 80 lateral Ea was much less reduced. Accordingly, E/Ea E/Ea (septal) 12 70 60 ratio at the septal corner was unchanged after dialysis E/Ea (average of 4) 10 82 72 despite a large weight loss, whereas lateral E/Ea ratio became significantly lower. TABLE 2 Correlation of Doppler Parameters With Mean Wedge Pressure Based on Left Ventricular Ejection Fraction (EF)
Doppler index of wedge pressure in patients with normal EF. Nevertheless, the accuracy of lateral E/Ea ratio was still lower in this group. Furthermore, for detecting wedge pressure ⬎15 mm Hg using septal Ea, a higher cutoff should be applied to patients with EF ⬍50% than to those with a normal EF in whom a
In summary, in patients with reduced EF, conventional and recent Doppler indexes can be used to predict to wedge pressure, but in those with an EF >50%, the E/Ea ratio using lateral Ea has the best correlation with wedge pressure. BRIEF REPORTS
783
TABLE 4 Correlation of Doppler Parameters With Mean Wedge Pressure Based on Regional Versus Global Dysfunction Segmental Dysfunction r (R2), SEE E/FPV E/Ea (lateral) E/Ea (septal) E/Ea (anterior) E/Ea (inferior) E/Ea (average of 2)† E/Ea (average of 3)‡ E/Ea (average of 4)
0.65* 0.73* 0.61* 0.3 0.61* 0.8* 0.8* 0.68*
(0.42) (0.53) (0.37) (0.09) (0.37) (0.64) (0.64) (0.46)
Global Dysfunction r (R2), SEE 0.61* 0.76* 0.71* 0.65* 0.71* 0.78* 0.79* 0.78*
(0.37) (0.56) (0.5) (0.42) (0.5) (0.61) (0.62) (0.61)
*p ⬍0.001; †average of only septal and lateral Ea; ‡average of only septal, lateral, and inferior Ea.
FIGURE 5. Correlation of mean wedge pressure with E/FPV (left), lateral E/Ea (middle), and septal E/Ea (right) in group II patients with EF >50%. Abbreviation as in Figure 4.
Acknowledgment: We thank Miguel A. Quinones, MD, for his review and helpful suggestions.
1. Mulvagh S, Quinones MA, Kleiman NS, Cheirif J, Zoghbi WA. Estimation of left ventricular end-diastolic pressure from Doppler transmitral flow velocity in cardiac patients independent of systolic performance. J Am Coll Cardiol 1992; 20:112–119. 2. Nagueh SF, Kopelen HA, Zoghbi WA. Feasibility and accuracy of Doppler echocardiographic estimation of pulmonary artery occlusive pressure in the intensive care unit. Am J Cardiol 1995;75:1256 –1262. 3. Kuecherer HF, Muhiudeen IA, Kusumoto FM, Lee E, Moulinier LE, Cahalan MK, Schiller NB. Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow. Circulation 1990; 82:1127–1139. 4. Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by trans-
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thoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol 1993;21:1687–1696. 5. Appleton CP, Galloway JM, Gonzalez MS, Gaballa M, Basnight MA. Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease. J Am Coll Cardiol 1993;22:1972–1982. 6. Yamamoto K, Nishimura RA, Chaliki HP, Appleton CP, Holmes DR Jr, Redfield MM. Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: critical role of left ventricular systolic function. J Am Coll Cardiol 1997;30:1527–1533. 7. Oki T, Tabata T, Yamada H, Wakatsuki T, Shinohara H, Nishikado A, Luchi A, Fukuda N, Susumo I. Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular relaxation. Am J Cardiol 1997;79:921–928. 8. Sohn D-W, Chai I-H, Lee D-J, Kim H-C, Kim H-S, OH B-H, Lee M-M, Park Y-B, Choi Y-S, Seo J-D, Lee Y-W. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997;30:474 –480. 9. Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997;30:1527–1533. 10. Sundereswaran L, Nagueh SF, Vardan S, Middleton KJ, Zoghbi WA, Quin˜ ones MA, Amione-Torre G. Estimation of left and right ventricular filling pressures after heart transplantation by tissue Doppler imaging. Am J Cardiol 1998;82:352–357. 11. Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation 2000;102:1788 –1794. 12. Brun P, Tribouilloy C, Duval AM, Iserin L, Meguira A, Pelle G, DuboisRande JL. Left ventricular flow propagation during early filling is related to wall relaxation: a color M-mode Doppler analysis. J Am Coll Cardiol 1992;20:420 – 432. 13. Takatsuji H, Mikami T, Urasawa K, Teranishi J, Onozuka H, Takagi C, Makita Y, Matsuo H, Kusuoka H, Kitabatake A. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol 1996;27:365–371. 14. Nagueh SF, Kopelen HA, Quinones MA. Doppler estimation of left ventricular filling pressure in patients with atrial fibrillation. Circulation 1996;94:2138 – 2145. 15. Garcia MJ, Ares MA, Asher C, Rodriguez L, Vandervoort P, Thomas JD. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure. J Am Coll Cardiol 1997;29:448 – 454. 16. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography: American Society of Echocardiography Committee on Standards, Subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr 1989;2: 358 –367. 17. Ohte N, Narita H, Akita S, Kurokawa K, Hayano J, Kimura G. Striking effect of left ventricular systolic performance on propagation velocity of left ventricular early diastolic filling flow. J Am Soc Echocardiogr 2001;14:1070 –1074. 18. Nagueh SF, Sun H, Kopelen HA, Middleton KJ, Khoury DS. Hemodynamic determinants of the mitral annulus diastolic velocities by tissue Doppler. J Am Coll Cardiol 2001;37:278 –285. 19. Firstenberg MS, Levine BD, Garcia MJ, Greenberg NL, Cardon L, Morehead AJ, Zuckerman J, Thomas JD. Relationship of echocardiographic indices to pulmonary capillary wedge pressures in healthy volunteers. J Am Coll Cardiol 2000;36:1664 –1669. 20. Agmon Y, Oh JK, McCarthy JT, Khandheria BK, Bailey KR, Seward JB. Effect of volume reduction on mitral annular diastolic velocities in hemodialysis patients. Am J Cardiol 2000;85:665–668.
MARCH 15, 2003
FIGURE 5. Aortic ratio at diagnosis (group 1, no aneurysm/dissection/death; group 2, aneurysm/dissection/death).
required during long-term follow-up. They concluded from their results that disappearance of the IMH suggested a good prognosis. Ide et al,6 in their series, found the descending aorta diameter (after resolution of the IMH) increased in 26% of patients. They also
1. Gore I. Pathogenesis of dissecting aneurysm of the aorta. Arch Pathol 1952; 53:142–153. 2. Wilson S, Hutchins G. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med 1982;106:175–180. 3. Hirst A, Johns V, Kime S. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217–219. 4. Ferguson JD, Moore N, Banning AP. Intramural aortic haematoma causing ischaemia of the spinal cord. Heart 1996;75:533. 5. Nishigami K, Tsuchiya T, Shono H, Horibata Y, Honda T. Disappearance of aortic intramural hematoma and its significance to the prognosis. Circulation 2000;102(suppl III):III-243–III-7. 6. Ide K, Uchida H, Otsuji H, Nishimine K, Tsushima J, Ohishi H, Kitamura S. Acute aortic dissection with intramural hematoma: possibility of transition to classic dissection or aneurysm. J Thorac Imaging 1996;11:46 –52. 7. Song JK, Kim HS, Kang DH, Lim TH, Song MG, Park SW, Park SJ. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol 2001;37:1604 –1610. 8. Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol 2000;86:664 –668.
Impact of Left Ventricular Ejection Fraction on Estimation of Left Ventricular Filling Pressures Using Tissue Doppler and Flow Propagation Velocity Carlos Rivas-Gotz,
MD,
Michael Manolios, MD, Vinay Thohan, Sherif F. Nagueh, MD
N
oninvasive estimation of left ventricular (LV) filling pressures is currently utilized in several laboratories using Doppler echocardiography. Previous studies have shown the accuracy of transmitral and pulmonary venous flow velocities1–5 in patients with a reduced ejection fraction (EF) and the limited From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas. Dr. Nagueh’s address is: Section of Cardiology, 6550 Fannin Street, SM-1246, Houston, Texas 77030-2717. E-mail: [email protected]. Manuscript received September 19, 2002; revised manuscript received and accepted November 11, 2002.
780
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 91 March 15, 2003
MD,
and
role they play in patients with normal EF.6 Recently, other ultrasound modalities have been described and include tissue Doppler (TD) imaging7–11 and color M-mode– derived flow propagation velocity (FPV).12–15 Because mitral peak E velocity is dependent on relaxation and preload, and FPV and mitral annular early diastolic velocity by TD (Ea) are related to LV relaxation, the ratio of E to FPV or Ea has been used to predict filling pressures. However, there is a paucity of data on the impact of LVEF on their accuracy. Furthermore, for Ea, the potential advantage—if any— of using the anterior, inferior, or average of all 0002-9149/03/$–see front matter doi:10.1016/S0002-9149(02)03433-1
FIGURE 1. Mitral inflow, FPV, and TD at the septal and lateral sides of the mitral annulus in a patient with EF of 20% and dilated cardiomyopathy. Notice that all Doppler indexes, i.e., mitral inflow, E/FPV, and E/Ea at either corner provide concordant information consistent with increased wedge pressure >15 mm Hg. Mean wedge pressure was 25 mm Hg.
velocities, especially in patients with segmental dysfunction, is unknown. This study was undertaken to prospectively evaluate the accuracy of TD imaging using all 4 areas of the mitral annulus, and FPV for predicting LV filling pressures in patients with and without normal EF, including those with segmental wall motion abnormalities. •••
The institutional review board of Baylor College of Medicine approved the protocol and all patients provided written informed consent. The study population comprised 2 parallel groups of consecutive patients (not included in previous studies): 54 patients with EF ⬍50% and 55 subjects with EF ⱖ50%. These patients were undergoing right-sided cardiac catheterization in the cardiac catheterization laboratory (n ⫽ 40) or the intensive care unit (n ⫽ 69). Inclusion criteria were sinus rhythm (60 to 100 beats/min), satisfactory Doppler and pressure recordings, and absence of mitral stenosis or prosthetic mitral valve. Patients had simultaneous echocardiographic and hemodynamic measurements. Patients were imaged in the supine position. After acquiring parasternal and apical views, pulsed-Doppler was used to record transmitral and pulmonary venous flow in the apical 4-chamber view as previously described.1,2 In the apical 4-chamber view, with the use of color Doppler, the M-mode cursor was aligned along the mitral inflow stream to record the early flow propagation velocity into the left ventricle as previously reported.12,14 Baseline shift was per-
FIGURE 2. Mitral inflow, FPV, and TD at the septal and lateral corners of the mitral annulus in a patient with EF of 20% and ischemic cardiomyopathy. Septal infarction was present and the basal segment of the lateral wall had normal function. Mean wedge pressure was 20 mm Hg. Notice that although septal E/Ea predicts a pressure >25 mm Hg, use of lateral Ea resulted in an estimated pressure of <15 mm Hg. An average of septal and lateral Ea (velocities 8.25, E/Ea ratio 14.5) provided the best estimate of the actual wedge pressure.
formed as needed to obtain a distinct border of the propagation velocity into the LV cavity. TD imaging (Figures 1 to 3) was applied in the pulsed-Doppler mode to record mitral annulus velocities at their septal, lateral, inferior, and anterior areas. Analysis was performed without knowledge of hemodynamic data. Two-dimensional measurements were obtained per the recommendations of the American Society of Echocardiography16 and included LV volumes, EF, and left atrial maximum volume. All Doppler values represent the average of 3 to 5 beats. Mitral inflow, pulmonary venous flow, and TD velocities were analyzed as previously described.1,2,9 –11 FPV was measured as the slope of the linear component of the color border produced by propagation of E velocity into the left ventricle past the mitral valve tips.12,14 The early diastolic (Ea) and late diastolic (Aa) TD velocities at the 4 areas of the mitral annulus were measured, and the dimensionless parameters— E/FPV14,15 and E/Ea9 –11—were computed. For patients in the intensive care unit, the chest x-ray was used to verify the position of the pulmonary artery catheter, whereas fluoroscopy was used in the cardiac catheterization laboratory. Medex transducers were balanced before the acquisition of hemodynamic data, with the zero level at the midaxillary line. Pressure measurements were acquired at end expiration and represent the average of 5 cycles. Cardiac output BRIEF REPORTS
781
dynamic variables were significantly related to FPV and Ea. Both velocities had an inverse, but weak, correlation with wedge pressure (r ⫽ ⫺0.25 to 0.37, p ⬍0.01), and both related positively to EF, stroke volume, and cardiac output (range for stroke volume of r ⫽ 0.33 with lateral Ea to r ⫽ 0.43 with FPV, both p ⬍0.01). In patients with EF⬍50%, several parameters derived from mitral inflow and pulmonary venous flow (recorded in 35 patients) were significantly related to wedge pressure (Table 2). A previous regression equation from our laboratory2 that uses isovolumetric relaxation time and E/A ratio well predicted mean wedge pressure (r ⫽ 0.79, p ⬍0.01). The correlation of E/FPV and E/Ea to wedge pressure are shown in Figure 4, and their most optimum values for the prediction of wedge pressure ⬎15 mm Hg are listed in Table 3. Patients with EF⬍50% were divided into 2 subgroups based on the presence or absence of regional dysfunction (Table 4). Patients with segmental dysfunction (n ⫽ 26) were older (66 ⫾ 3 vs 59 ⫾ 3 years, p ⫽ 0.07) and had a higher EF (37 ⫾ 1% vs 28 ⫾ 2%, FIGURE 3. Mitral inflow, FPV, and TD at the septal and lateral p ⫽ 0.012). Wedge pressure, FPV, and Ea (p ⬎0.1) corners of the mitral annulus in a patient with hypertension, LV were all similar in the 2 subgroups. In general, Ea hypertrophy, and EF of 55%. Notice that although mitral inflow showed a trend toward lower values in the wall inand E/Ea at either side provide concordant information consisvolved with infarction versus the contralateral sites tent with increased wedge pressure (24 mm Hg), the ratio of (septal: 4.1 ⫾ 0.3 vs 5.3 ⫾ 0.6 cm/s, p ⫽ 0.06; E/FPV is suggestive of filling pressures of <15 mm Hg. inferior: 5.1 ⫾ 0.6 vs 6.7 ⫾ 0.7 cm/s, p ⫽ 0.16, lateral: 4 ⫾ 1 vs 7.9 ⫾ 0.5 cm/s, p ⫽ 0.03; anterior: 4.4 ⫾ 0.4 TABLE 1 Demographic and Hemodynamic Characteristics of the Two Groups vs 6 ⫾ 0.6 cm/s, p ⫽ 0.1). The avEF ⬍50% EF ⱖ50% erage of septal and lateral Ea veloc(n ⫽ 54) (n ⫽ 55) ities resulted in a better relation to wedge pressure only in patients with Age (yrs) 62 ⫾ 2 64 ⫾ 2 Men/women 41/13 36/19 segmental dysfunction. In both subEjection fraction (%) 34 (22.5–40)* 65 (58–67) groups, the inclusion of Ea at other Heart rate (beats/min) 81 ⫾ 2 84 ⫾ 2 areas did not result in a better preSystolic blood pressure (mm Hg) 120 ⫾ 3 124 ⫾ 4 diction than that achieved by averagDiastolic blood pressure (mm Hg) 64 ⫾ 2 65 ⫾ 2 Pulmonary artery systolic pressure (mm/Hg) 44 ⫾ 2 44 ⫾ 3 ing Ea velocity at only the septal and Pulmonary artery diastolic pressure (mm/Hg) 23 ⫾ 1 21 ⫾ 1 lateral sites. Mean right atrial pressure (mm/Hg) 12 ⫾ 1 12 ⫾ 1 In patients with normal EF, mitral Stroke volume (ml) 48 ⫾ 2* 69 ⫾ 2 inflow and TD velocities were satisCardiac output (L/min) 4.4 ⫾ 0.2* 5.4 ⫾ 0.2 factorily recorded from all patients; Pulmonary capillary wedge pressure (mm/Hg) 20 (14–28)* 16 (11–20) End-diastolic volume (ml) 152 (110–191)* 112 (99–131) however, pulmonary venous flow End-systolic volume (ml) 89 (66–140)* 42 (33–57) was obtained in 32 and FPV in 46 patients. E/FPV had the weakest cor*p ⬍0.01 versus patients with EF ⱖ50%. Data are expressed as mean ⫾ SEM or median (25th to 75th percentile) where appropriate. relation with wedge pressure and lateral E/Ea had the best relation (although weaker than in patients with was derived by the thermodilution technique, averag- EF⬍50% [Figure 5]). ing 3 cardiac cycles with ⬍10% variation. ••• Data are presented as mean ⫾ SEM or median This study shows the impact of LVEF on the (25th to 75th percentile) where appropriate. Unpaired accuracy of wedge pressure prediction using the availStudent’s t and Mann-Whitney rank-sum tests were able Doppler parameters. Novel findings include the used to compare LV volumes, EF, and hemodynamics strong impact of EF on the accuracy of predicting between the 2 groups. Linear regression analysis was filling pressures using the ratio of E/FPV. When using applied to examine the relation between wedge pres- this ratio in patients with a reduced EF, a higher cutoff sure and Doppler parameters. A p value ⱕ0.05 was is needed to detect elevated filling pressures than considered significant. when using a lower ratio in patients with normal EF. Table 1 lists demographic and hemodynamic char- TD Ea was useful irrespective of LVEF. E/Ea ratio at acteristics of patients in both groups. Several hemo- the lateral side of the mitral annulus was the best 782 THE AMERICAN JOURNAL OF CARDIOLOGY姞
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lower ratio should be used. In the presence of regional dysfunction, the combination of septal and lateral Ea EF ⬍50% EF ⱖ50% appears to be most accurate. Although the pulmonary venous Left atrial maximal volume (ml) 0.5* 0.36† Peak E velocity (cm/s) 0.6* 0.5* atrial reversal velocity duration miE/A ratio 0.65* 0.41* nus the mitral A velocity duration Isovolumetric relaxation time (ms) ⫺0.72* ⫺0.41* had the strongest relation to mitral Pulmonary venous systolic filling fraction ⫺0.63* ⫺0.24 and pulmonary venous flow variDeceleration time of pulmonary venous diastolic ⫺0.74* ⫺0.37 velocity (ms) ables in patients with normal EF, its Pulmonary venous atrial reversal velocity duration– 0.56† 0.62* overall utility was limited by the mitral A velocity duration (ms) lower feasibility of satisfactory pulTissue Doppler late diastolic velocity (average cm/s) ⫺0.56* ⫺0.31† monary venous flow recordings E/flow propagation velocity 0.65* 0.5* (similar to previous studies2,11). UnE/Ea (lateral) 0.74* 0.7* E/Ea (septal) 0.65* 0.55* like patients with low EF, FPV had a E/Ea (anterior) 0.5* 0.56* minimal impact on the accuracy of E/Ea (inferior) 0.66* 0.52* mitral peak E velocity alone. This E/Ea (average Ea velocity) 0.71* 0.57* may be related to the significant ef*p ⬍0.01, †p ⬍0.05. fects of stroke volume on FPV that could reduce the influence of LV relaxation. In this and other studies,17 FPV was inversely related to endsystolic volume but directly to EF, stroke volume, and cardiac output. Accordingly, it is possible for the FPV to fall in the normal range in patients with normal EF despite the presence of impaired relaxation. Therefore, one should exercise caution when using the ratio of E/FPV to predict filling pressures in this population of patients. In patients with normal EF, the weaker relation between E/Ea and wedge pressure may be related to the lower correlation of peak E velocity FIGURE 4. Correlation of mean wedge pressure with E/FPV (left), lateral E/Ea (middle), and septal E/Ea (right) in group I patients with EF <50%. PCWP ⴝ mean wedge with filling pressures, as well as the pressure. inclusion of patients without cardiac disease whose preload has been shown to have an important effect on Ea.18 –20 Interestingly, the accuracy of E/Ea varied among the 4 TABLE 3 Prediction of Mean Wedge Pressure ⬎15 mm/Hg areas, with the lateral E/Ea ratio having the highest Using Flow Propagation Velocity (FPV) and Tissue Doppler correlation with mean wedge pressure. The better perVelocities formance using lateral Ea may be related to the fact that Cutoff Sensitivity Specificity in humans, preload has a reduced effect on it compared EF ⬍50% with septal Ea. In 1 study19 that examined normal subE/FPV 2.5 78 77 jects, preload-altering maneuvers had no significant efE/Ea (lateral) 11 85 82 fect on lateral Ea, whereas septal Ea was significantly E/Ea (septal) 20 59 88 affected. In another study, in which intravascular volume E/Ea (average of 4) 15 74 82 EF ⱖ50% was reduced by hemodialysis, Agmon et al20 noted a E/FPV 1.9 71 73 comparable decrease in mitral E and septal Ea, whereas E/Ea (lateral) 10 79 80 lateral Ea was much less reduced. Accordingly, E/Ea E/Ea (septal) 12 70 60 ratio at the septal corner was unchanged after dialysis E/Ea (average of 4) 10 82 72 despite a large weight loss, whereas lateral E/Ea ratio became significantly lower. TABLE 2 Correlation of Doppler Parameters With Mean Wedge Pressure Based on Left Ventricular Ejection Fraction (EF)
Doppler index of wedge pressure in patients with normal EF. Nevertheless, the accuracy of lateral E/Ea ratio was still lower in this group. Furthermore, for detecting wedge pressure ⬎15 mm Hg using septal Ea, a higher cutoff should be applied to patients with EF ⬍50% than to those with a normal EF in whom a
In summary, in patients with reduced EF, conventional and recent Doppler indexes can be used to predict to wedge pressure, but in those with an EF >50%, the E/Ea ratio using lateral Ea has the best correlation with wedge pressure. BRIEF REPORTS
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TABLE 4 Correlation of Doppler Parameters With Mean Wedge Pressure Based on Regional Versus Global Dysfunction Segmental Dysfunction r (R2), SEE E/FPV E/Ea (lateral) E/Ea (septal) E/Ea (anterior) E/Ea (inferior) E/Ea (average of 2)† E/Ea (average of 3)‡ E/Ea (average of 4)
0.65* 0.73* 0.61* 0.3 0.61* 0.8* 0.8* 0.68*
(0.42) (0.53) (0.37) (0.09) (0.37) (0.64) (0.64) (0.46)
Global Dysfunction r (R2), SEE 0.61* 0.76* 0.71* 0.65* 0.71* 0.78* 0.79* 0.78*
(0.37) (0.56) (0.5) (0.42) (0.5) (0.61) (0.62) (0.61)
*p ⬍0.001; †average of only septal and lateral Ea; ‡average of only septal, lateral, and inferior Ea.
FIGURE 5. Correlation of mean wedge pressure with E/FPV (left), lateral E/Ea (middle), and septal E/Ea (right) in group II patients with EF >50%. Abbreviation as in Figure 4.
Acknowledgment: We thank Miguel A. Quinones, MD, for his review and helpful suggestions.
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