Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure

JACC Vol. 24. No. 1 July 19wP32-9

132

IN R. , ANT

GONG-YUAN XIE, JOHN C. GURLEY, Lexington. Kentucky

ophysiologyand consequentclinicalimications of transmittalflow patterns by Dopplerechocardihave been well delineated, resulting in increased

edicine. University of Kentucky was presentedin part at the of the American Colle& of Cardiology, r 1. 1993; revised manuscript received

Kentucky 4W6-OW. 01994 by the American C&ge

Yuan Xie. Division of Cardiology. enter, 800 Rose Street, Lexington,

of Cardiology

C,

tern, referred to as “imis characterized by a long isovol ’ decelerationof early sling (E) and atrial filling (A) velocities, with a decreased E/A secondtype, termed a restrictive;:ottem, is cb~teti short isovolumicrelaxationtime, rapid fillingin early (shortdecelerationtime and highE velocity)and minimalfilling duringatrialsystole (reducedA velocity).Thus, in the restrictive pattern the decelerationof the and the WA ratio is normalpattern that ha tolic abnormalities are In this pattern, left present regardless of the degree of left ventricular systolic dysfunction. Preliminarydata io patients wit congestive &art Giltwe suggest that the restrictive transmitral flow pattern may be related to advanced New York Heart Association functional class (13),poor exercise capacity (14)and even mortality in 07351097/94/$7.00

spectively cate~urized a

ve fillingpattern. Gau ~ys~ciaa/c~rQ~er cert restrictive, and 5140 ms was nner using commercially available

tral valve leaflets. Pulsed valve annulus (I@ Ca

‘beam.Color Doppler was also performed in a assess the degree of mitral regurgitationwhen present. Data were recorded on professionalvideotapeand analyzedusing a computer-assistedoff-linesystem (Microsonics,Version4.2).

&i-square analysis was utilized to assess the relative preas mean dictive power. All descriptive data are expres and p 5 0.05 was considered sig ant.

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JACC Vol. 24, No. 1

XIE ET AL.

hlly I

MITRAL FLOW PAVERNS PREDICT CARDIAC MORTALITY

1. Doppler Variables in the Restrictive and Nonrestrictive Groups NonrestrictiveGroup

Restrictive Group E/A=lto2 DT5 MOms (n = 19)

WA22 (n = 39)

E (cmkl

71 +20

72 2 16

A (cm/s)

19 f 13

49 + 14

E/A=lto2 QT> lams (n = 17)

ElA s 1 (a = 25)

69 r 24 53 + 16

f I2 62 ” 14

55% and dilated cardiomyopathy in the remaining 45%. Meanleft ventricularejection fraction was 26 f 6%. At entry 31 patients were in functional class II, 45 in class I11anti 17 in class IV. Mean length of follow-up was 16 9 8 months (range 3 to 31). On the basis of Doppler transmittal flow patterns, there were 58 patients in the restrictive group and 42 in the nonrestrictive group (Table I). Table 2 lists the bas~l~~~ T&$e 2. Baseline Characteristics of Patients in the Restrictive and Nonrestrictive Groups

Atv (yr) Gender(F&Q EtiOlo$y

CAD DCM NYHA II III

Restrictive Group

Nonrestrictive Group

P Vdtle

60+ 13 13145

602 II 11131

NS

33 2s

22 20

I2 29

26 16 ._

IV

MR Mild-mod Severe HR (beatslmin) EF (%I LVEDV(ml) Na (mEQAiter) R (mEQIiter1 BUN (mgldl) CR 0n@l) Follow-up(mo)

NS

NS

0

39 8 89* 17 24 + I 198?: 68 137* 5 4.3 2 (a.7 28 r 21 1.7 2 2.0 16I 8

29 2 77 + 12 28 2 7 167c 57 139t 5 4.2 f 0.4 21 + I5 1.4 + t.3 17 f 8

NS 0.003 O&O4 NS 0.05 NS 0.06 NS NS

Datapresentedare meanvalues+ SDor numberof patients.CAD= coronaryarterydisease;CR = creaijnjne;DCM = d&d cardiomyopathy;EF = ejectionfraction;F = female;IiR ,=heartrate;LVEDV= lefi ventricularend-diastolic vohune;M = male;mod = moderate;MR= miti regurgitation;NYHA = New York HeartAssociationfUnctionalclass.

: 132-9

be able to strat

a

rest~ct~vetrans

relate 18 8

periodof 165 8 months,24in the only 2 in the nonrestrictivegroup (73%)diedof worseningof congestiveheartfailureandseven(27%) of suddendeath.

congestive be relation in congestive heart failure. A sfnnction (SOEVD)s~bst~dy (22) recently sbowe at women had higher rates of co rtdity (12% vs. 9%) and gestive heart failureheart failure (22%vs. 17%) rences were observed only in whites. In the multivariateanalysis of that study, female

All patients in tbis study

1

CHF Death

19/26(73%)

Suddea Death 7/26(27%)

previous studies (13,14) have shown that patients wit rt failure with restrictive trams ppler echocardiography exhibit m

IX

JACC Vo!. 24. No. 1 July 1994:132-9

XIE ET AL. MITRAL FLOW PATTERNS PREDICT CARDIAC MORTALITY

Sudden Death (I)

Nenresrricfirr

onal class and diminished exercise cawith a non~st~ctive pattern in the le reductions in left ventricular ejection fraction. These data support the cont~bution of ventricular diastolic dysfunction in the production of sy toms and reduction of exercise capacity in patients WI congestive heart failure. Recently, Klein et al. (1% monti et al. (16) and Shen et al. (17) have indicate Doppler-derived left ventricular diastolic filling va~~bles play an ~rn~~ant role in p~dicting cardiac mortality * ethos cardiac amyloidosis and dilated c~iomyo~athy, let? ventricular ejection fraction has been considered a predictor of cardiac death in patients with congestive heart tic~ts with congestive heart flow pattern by edly increased d with those with the non~st~ctlve In the restrictive group, an inc mav ncreased rapid early hlling or conn to diastolic filling of the left ventricle, or both (9). A short deceleration time of the E wave has been shown to correspond to the “dip-and-plateau” pattern of cardiac ~thete~~tion, which is indicative of restrictive physiology $423). Left ventricular diastolic volume (198 k 68 ml) is

mitral valve resulting from

driving pressure acre eased i~~ti~i left atlas

5. Effect of New York Heart Association (NYWA) functional on cumulative cardiac mortality. Cardiac mortality rate at 1 year in functional class IV (41%) was significantly higher than that in class III (7%) and class II (8%). res~ctively (p < 0.05 by log-rank analysis for both). Cardiac mortality rate at 2 years in functional classes IV, III and II was 66%. 2% and 25%, respectively. The t only between classes IV and 11(p < 0.05). = number of survivors at I2 and 24 months.

tars of Cardiac Deatb by Cox Proportional

TMF (restrictive vs. nonrestrictive) Patient Fnder (F vs. M) NYi?A functional class (IV vs. II) LVEF NYHA functional class (IV vs. III)

P

Chi-Square Value

Value

6.99 4.59 3.95 2.97 1.71

0.008 0.03 0.05 0.08 0.19

LVEF = left ventricular ejection fraction; TMF = transmitml flow pattern; other abbreviations as in bble 2.

6

12

18

24

Follow-up (mos)

30

i6

Abbrevialionsas in Tables 2 and 3.

nti et a!. (16), our results ppler ~easu~e~e~ts, either

.,.I! oh. j;.kii~:5 on cumulative cardiac My rite was 19% in the restrictive group ive group (p < 0.05). Note t divergence of two mortality rate cnrves after 1 year, res Zyear mortality rate of 51% in the the nonrestrictive group (p < 0. number of survivors at 12 and 24 months.

Nonrestrictive 0

6

12

18

24

Follow-up (mos)

30

36

with idiopathic dilated cardiom for these differences. e cornb~~at~o~ of E/A ra etter predictor of cardiac mortality than ppler measurements ir8 patients with Therefore, we used as a definition of

d into restrictive and deceleration time measurement. ler echocardiography

are partially

138

JACC Vol. 24, No. I July 1994:132-9

XIE ET AL. hUTRAL FLOW PATTERNS PREDICT CARDIAC MORTALITY

heart rate (27), loading conditions (28) and degree of mitral regurgitation (6,29). However, it is difficult to control those factors in a clinical study. Age may be unlikely to have significant impact on our results because age distribution was similar between the restrictive and nonrestrictive groups, and patient age in this study was relatively old (average 60 years). Normal subjects in this age group show a progression of increased A wave size, resulting in a pattern of impaired relaxation (nonrestrictive). However, oklr high risk patients with congestive heart failure showed a restrictive pattern. Heart rate was s&ificantly increased in the restrictive roup, and increased hea in a nonrestrictive rather F unlikely that heart rate

heart failure: clinical response and its relationship to ~~rno~y~arn~s measurements. Circulation 1981:63:269-78. , et al. Plasma aQre~inepbr~n~ as a guide 4. Cohn JN, Levine TB. Qlivari onic congestive heart failure. N Engl J Prognostic importance of serum sodium coucentrae i~b~b~l~oo in pdtients with ;73:251-67. severe chronic heart failure. Circulat e~ln~tion of parameters of left 6. Rokey R. Kuo LC, Zoghbi WA, et al. ventricular diastolic filling with pulsed Doppler echocardiography: comparison with cinean~og~p~y. Ci~c~lat~ou t~5;7t:543~~~.

5.

K. Dabestani A, Gardin JM. et al. Left ventricular filling in 7. Take&a ppler ecboca~dio&rap~ic hypertrophic car~iomyo~t~y: a pulsed study, J Am Colt Cardiol 19~?~12~~~7~. 8.

9.

restrictive ventrieCall Cardiol lY88:

IO.

iz patients with severe these patients have a larger E ive pattern. In the restrictive group of this study, e of mitral regurgitation was severe in only 8 (14%) ents, and Cox proportional hazards model analysis did not show any significant relation between mitral regurgitation and cardiac death. Although the loading conditions of patients were not the majority were t characterized, in our st 1, digitalis (74% vs. 6 uretic agents (100% vs. I angiotensin-convcrti~g e inhibitors (85% vs. 75%) in the restrictive and nonrestrictive groups, respectively. Therefore, loading conditions and medical treatment were unlikely to affect our results. Finally, the use of a single ppler ec~~ardio~r~p~ic study to assess prognosis has limitations because t~~srn~tr flow patterns may change during the tallow-up period. Seri ardiographic follow-up studies might provide into the complex diastolic filling dynamics in congestive heart failure (30). This study shows that left ventricular diastolic filling paitems by Doppler echocardiography, female gender and advanced functional class are important predictors Of cardiac mortality in patients with congestive heart failure. The restrictive transmitral flow pattern, defined as an EIA 2 2 or E/A = I to 2 with a deceleration time of E wave 1140 ms, is the single best predictor of cardiac death. Thus, nOninVaSiVe assessment of transmitral flow velocities by Doppler is useful in identifying a subgroup of high risk patients with congestive heart failure.

1. Packer M. Prolonging life m patients with congestive heart failure: the next frontier: introduction. Circulation 1987;75: Suppl IV:IV-l-3. 2. Gradman A, Deedwania P. Cody R. et al. Predictors of total mortality and sudden death in mild to moderate heart failure. J Am Coil C&o1 1989;14564-70. 3. Massie B, Ports T, Chatterjee K, et al. Long-term vasodilator therapy for

Doppler ech~ardiography. J Am Coil Cardiol Hatle LK. Appleton CP. Popp RL. ~iff~~~~tiatio~ of constrictive perippler ~ch~~rdio~ra~by. carditis and restrictive cardiomyopathy by Circulation 1~9;79:357-70. !ation of t~nsmit~l Bow velocity 12. Appleton CP, Hatle LK. Popp RL. patterns to left veot~cular diastolic function: new ~nsjRbts from a comppler ecb~ardiogra~bic study. J Am Cell bined hemodynarric and Cardiol t~$:l2:426-~. Xie GY. Cutshaw BA. Ed al. The role of impaired 13. II.

14.

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16. Pinamonti B, Lenarda AD. Sinagra C. et al. Restrictive ieft ventricular filling pattern in dilated cardiomyopathy assessed by Doppler echocardiographic and hemodynamic correlations and prognostic implications. J Am Coil Cardiol ~~3~22:808-~S. 17. Shen WF. Trihouilloy 6. Rey JL. et . Prognostic significance of Doppler-delived IeR ventricular diastolic lling variables in dilated cardiomyopathy. Am Heart J 1992:124:1524-33. 18. Gardin JM. Daoeslani A. Takenakr K. et al. Effect of imaging view and sample volume location on evaluation of mitral flow velocity by pulsed Doppler echocardiography. Am J Car&o! 1986;57:1335-9. 19. Srhiller NB. Shah PM. Crawford M. et al. Recommendations for quantitalion of the Iefl ventricle by two dimensioaal echocardiography: American Society of Echocardiography Subcommittee on Standards. J Am Sot Echocardiogr 1*2:358-67. 20. Helmcke F. Nanda NC, Hsiung MC. et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987;75:175-83. 21. Parmley WW. Pathophysiology of congestive heart failure. Clin Cardiol 1992;is: Suppl H:ll-s-12. 22. Bourassa MG. Gume 0. Bangdiwala Sl. et al. Natural history and patterns of current practice in heart failure. J Am Cdl Cardiol 1993:22 Suppl A:l4A-2lA. 23. Benotti JR, Grossman W. Cohn PF. Clinical profile of restrictive cardio. myopathy. Circulation 1980;61: 1206-12. 24. Xie GY, Berk MR. Smith MD, et al. The role of the left atrium in beart failure: assessment by transmitral and pulmonary vein Doppler [abstract]. J Am Sot Echocardiogr 1993$:S-34. 2.5. Hirota Y. A clinical study of left ventricular relaxation. Circulalion 1980.62:746-63. 26. Kuo LC, Quinones MA, Rokey R, et al. Quantification of atrial contribution to left ventricular filling by pulsed tippler echocardiography and the effect of ape in normal and diseased hearts. Am J Cardiol 198759: 1174-8. -

uction ofleft vehtricuktnr preload

2

oppler traasmitral tilhg pat-

terns.J AimCoil C

AL, Hatie EK, Taliercio CP, et al. Serial Doppler echocardiographicf&0w-up of left ventt-iculas diastolicfunc1ion incardiacamyloid-

30. Kkn

osis. J Am Cdl Cardiol 1940;16: BM-41.