Preload Dependence of New Doppler Techniques Limits Their Utility for Left Ventricular Diastolic Function Assessment in Hemodialysis Patients

Abstract

Abstract. Left ventricular (LV) hypertrophy leads to diastolic dysfunction. Standard Doppler transmitral and pulmonary vein (PV) flow velocity measurements are preload dependent. New techniques such as mitral annulus velocity by Doppler tissue imaging (DTI) and LV inflow propagation velocity measured from color M-mode have been proposed as relatively preloadindependent measurements of diastolic function. These parameters were studied before and after hemodialysis (HD) with ultrafiltration to test their potential advantage for LV diastolic function assessment in HD patients. Ten patients (seven with LV hypertrophy) underwent Doppler echocardiography 1 h before, 1 h after, and 1 d after HD. Early (E) and atrial (A) peak transmitral flow velocities, peak PV systolic (s) and diastolic (d) flow velocities, peak e and a mitral annulus velocities in DTI, and early diastolic LV flow propagation velocity (V p ) were measured. In all patients, the E/A ratio after HD (0.54; 0.37 to 1.02) was lower (P Ͻ 0.01) than before HD (0.77; 0.60 to 1.34). E decreased (P Ͻ 0.01), whereas A did not. PV s/d after HD (2.15; 1.08 to 3.90) was higher (P Ͻ 0.01) than before HD (1.80; 1.25 to 2.68). Tissue e/a after HD (0.40; 0.26 to 0.96) was lower (P Ͻ 0.01) than before HD (0.56; 0.40 to 1.05). Tissue e decreased (P Ͻ 0.02), whereas a did not. V p after HD (30 cm/s; 16 to 47 cm/s) was lower (P Ͻ 0.01) than before HD (45 cm/s; 32 to 60 cm/s). Twenty-four hours after the initial measurements values for E/A (0.59; 0.37 to 1.23), PV s/d (1.85; 1.07 to 3.38), e/a (0.41; 0.27 to 1.06), and V p (28 cm/s; 23 to 33 cm/s) were similar as those taken 1 h after HD. It is concluded that, even when using the newer Doppler techniques DTI and color M-mode, pseudonormalization, which was due to volume overload before HD, resulted in underestimation of the degree of diastolic dysfunction. Therefore, the advantage of these techniques over conventional parameters for the assessment of LV diastolic function in HD patients is limited. Assessment of LV diastolic function should not be performed shortly before HD, and its time relation to HD is essential.Intradialytic hypotension is an important complication of hemodialysis (HD), and its pathogenesis is not completely understood. It frequently requires intervention, which limits the efficacy of HD. The incidence is 25% with a range of 15 to 50% (1-3) and increases with age. Hypotension results from a decreased product of stroke volume (SV), heart rate, and systemic vascular resistance. Compensatory mechanisms, such as tachycardia and arterial vasoconstriction, require adequate venous return. Ultrafiltration (UF) withdraws volume from the hemodynamically active "central" circulation, whereas most of the volume overload resides in the interstitial and, to a lesser extent, in the intracellular compartment. The venous system contains an important buffer against hypovolemia (2,4 -6). However, if plasma-refilling rate lags behind UF rate, then intravascular volume depletion may exceed the limit of the buffer capacity, ...

Preload Dependency of the Time Interval Between the Onset of Mitral Inflow and the Early Diastolic Annular Motion A Hemodialysis-Related Preload Reduction Study

“…[20][21][22][23][24][25] In this study, the mitral inflow parameters were changed after HD, which is very consistent with previous studies. 26 Although the E' velocity was unchanged in some earlier studies that used sublingual nitroglycerin, the Valsalva maneuver or saline loading, 21,27 the E' velocity was suggested to be preload dependent by other studies.…”

Non Invasive Evaluation of Cardiac Hemodynamics in End Stage Renal Disease (ESRD)

“…Our data are confirmatory in detecting preload sensitiveness of not only transmitral flow Doppler [7,19] but of main tissue Doppler parameters as well [9,20]. Inferior vena cava diameters as expected were significantly modified by dehydration, accordingly to previous studies [17,20,21].…”

Predictors of Congestive Heart Failure in Patients on Maintenance Hemodialysis

“…31 However, several reports have revealed that, even with these techniques, the advantage over conventional parameters for the assessment of LV diastolic function is limited in patients on maintenance HD. [32][33][34][35] Thus, at present, it would have been very difficult to discern the presence of LV diastolic function in our study cohort.…”

“…[28][29][30] Evaluation of E/A in HD patients is complicated. The early diastolic mitral annulus velocity determined by Doppler tissue echocardiography (E') 31 and LV inflow propagation velocity measured from color M-mode 32,33 are purported to be less sensitive to alterations in loading conditions than the transmitral flow velocity pattern. 31 However, several reports have revealed that, even with these techniques, the advantage over conventional parameters for the assessment of LV diastolic function is limited in patients on maintenance HD.…”