Doppler Echocardiography Yields Dubious Estimates of Left Ventricular Diastolic Pressures

Abstract

For normal cardiac performance, the left ventricle (LV) must be able to eject an adequate stroke volume at arterial pressure (systolic function) and fill without requiring an elevated left atrial (LA) pressure (diastolic function). These systolic and diastolic functions must be adequate to meet the needs of the body both at rest and during stress. Response by Tschöpe and Paulus on p 809Systolic function is conveniently (although not always accurately) measured as the ejection fraction (EF), calculated as stroke volume divided by end-diastolic volume. 1 The LV EF is easily interpreted. The lower limit of normal is Ϸ50%. The lower the EF is, the greater the reduction in systolic function. Diastolic function has been more difficult to evaluate. 2 Traditionally, invasive measures of LV diastolic pressure-volume relations and the rate of LV pressure fall during isovolumetric relaxation have been used. However, these methods are not practical for routine clinical use and do not adequately evaluate all aspects of diastolic filling. 3 Comprehensive echocardiographic evaluation of the dynamics of LV filling using blood pool and tissue Doppler has now progressed so that it provides clinically important information that can be used to direct patient care. We present data that support the use of echocardiographic evaluation of diastolic function to recognize cardiac dysfunction in patients with heart failure, especially those with preserved EF; to guide the management of patients by identifying those with and without elevated left filling pressures regardless of underlying EF; and to determine prognosis in a wide variety of patient populations. LV FillingAlthough the LV end-diastolic pressure-volume relation describes the passive properties of the LV, LV filling is not a passive or slow process. 3 In fact, the peak flow rate across the mitral valve is equal to or greater than the peak flow rate across the aortic valve. Understanding the physiological basis of LV filling provides the basis for the interpretation of the information available from a comprehensive echocardiographic evaluation of LV filling dynamics.During LV ejection, energy is stored as the myocytes are compressed and the elastic elements in the myocardial wall are compressed and twisted. 4 Relaxation of myocardial contraction allows this energy to be released as the elastic elements recoil. This causes LV pressure to fall rapidly during isovolumetric relaxation. Furthermore, for the first 30 to 40 milliseconds after mitral valve opening, relaxation of LV wall tension is normally rapid enough to cause the LV pressure to continue to decline despite an increase in LV volume. 5 This fall in LV pressure produces an early diastolic pressure gradient from the LA that extends to the LV apex (Figure 1). 6 This accelerates blood out of the LA andThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

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“…At discharge, higher left ventricular filling pressures are an accurate predictor of repeat hospitalization and increased mortality [25, 26]. While the overall accuracy of E/e’ for prediction of diastolic filling pressure remains the subject of intense debate [27, 28], our results agree with findings from several recent studies examining the relation between elevated E/e’ at discharge and increased readmission rates [29, 30]. Thus, E/e’ also might provide a ready measure of response to treatment and a useful noninvasive marker for elevated filling pressures, especially in patients with HFNEF.…”