Noninvasive Assessment of Left Ventricular End-Diastolic Pressure with Tissue Doppler Imaging in Patients with Mitral Regurgitation

Abstract

Background: The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity (E/Ea) is a widely used noninvasive tool to estimate left ventricular end diastolic pressure (LVEDP). The aim of this study was to explore whether E/Ea ratio was a reliable index for the estimation of LVEDP in patients with mitral regurgitation (MR). Methods: Sixteen patients with nonischemic MR (primary MR group; 6 male, 58 ± 12 years) 51 patients with ischemic MR (secondary MR group; 29 male, 63 ± 9 years) and 29 patients without MR (control group; 19 male, 53 ± 10 years) were consecutively included. The peak transmitral flow and mitral annular velocities during early diastole were measured. LVEDP was determined invasively by left heart catheterization. Results: Primary and secondary MR groups had significantly higher E/Ea ratios and LVEDP than control group. LVEDP significantly correlated with E/Ea ratio in patients with primary MR, but not in patients with secondary MR. Multiple regression analysis revealed that E/Ea ratio was an independent predictor of LVEDP in patients with primary MR. Ten patients with primary MR had LVEDP ≥15 mmHg. ROC analysis demonstrated cutoff values for E/Ea ratios as >10.5 for lateral mitral annulus (sensitivity: 80%, specificity: 66%, PPV: 80%, NPV: 66%) and as >14 for medial mitral annulus (sensitivity: 90%, specificity: 83%, PPV: 90%, NPV: 83%) to predict primary MR patients with LVEDP ≥15 mmHg. Conclusion: E/Ea ratio is still reliable in estimation of LVEDP in primary MR patients while it is not predictive for LVEDP in secondary MR patients. (Echocardiography 2011;28:633-640) Key words: echocardiography, left heart catheterization, left ventricular end-diastolic pressure, mitral regurgitation, tissue Doppler imaging Because of the large compliance of the pulmonary circulation, pulmonary capillary wedge pressure (PCWP) provides an indirect measure of the left atrial (LA) pressure (LAP) and left ventricular (LV) filling pressure (LVFP). PCWP is measured by inserting a balloon-tipped, multilumen catheter (Swan-Ganz catheter) into a peripheral vein, then advancing the catheter into the right atrium, right ventricle, pulmonary artery, and then into a branch of the pulmonary artery.

Use and Limitations of E/e' to Assess Left Ventricular Filling Pressure by Echocardiography

“…Caution should be used when using E/e' in LV disorders such as hypertrophic cardiomyopathy27) and myocardial infarction,28) as the downward movement during diastole can be influenced by upward movement during systole 29)30). Conversely, the transmitral E measurement may be the source of misleading information in the setting of moderate to severe mitral regurgitation (MR)31) and severe LV dysfunction 25). In patients with constrictive pericarditis, LV diastolic properties are usually well preserved despite increased LV filling pressure, 32) and the positive correlation of e' with LV filling pressure leads to an inverse relationship between E/e' and LV filling pressure 33)…”

Noninvasive estimation of pulmonary capillary wedge pressure in patients with mitral regurgitation: A speckle tracking echocardiography study

“…In many previous studies about E/e 0 performed by Nagueh et al or Ommen et al, MR patients were excluded [4,17]. Some previous studies have reported on the estimation of PCWP by using mitral inflow in MR patients [1,5,18]. However, among several measurements using mitral inflow including E/A ratio, deceleration time, and isovolumic relaxation time to predict PCWP [19], the best correlations between Doppler measurements and PCWP were observed in patients without significant MR [17].…”

“…Moreover, Van de Veire et al showed that E/e 0 was independently predicted by ischemic (secondary) MR severity [20]. On the other hand, Yesildag et al did not show that E/e 0 had any association with LVEDP in patients with secondary MR [1]. Agricola et al showed that E/e 0 was an independent predictor of LVEDP in primary MR [21].…”

“…There was conflict in the use of E/e 0 to estimate LV end-diastolic pressure (LVEDP) in MR [1,5]. It was reported that the e 0 would be increased in patients with MR and preserved LV ejection fraction because of the increased LV stroke volume [1].…”

“…However, existing Doppler and two-dimensional methods including left atrial volume (LAV), mitral inflow pattern, pulmonary vein flow pattern, and E/e 0 have several limitations when they are applied to the estimation of LVFP in patients with MR [1,5]. There was conflict in the use of E/e 0 to estimate LV end-diastolic pressure (LVEDP) in MR [1,5]. It was reported that the e 0 would be increased in patients with MR and preserved LV ejection fraction because of the increased LV stroke volume [1].…”