PVF Velocity Pattern in Patients with Heart Failure: Transesophageal Echocardiographic Assessment

Abstract

In order to assess the role of the pulmonary venous flow (PVF) velocity pattern in the evaluation of patients with congestive heart failure (CHF), we studied 41 CHF patients by means of transthoracic echocardiography (TTE) and multiplane transesophageal echocardiography (TEE). The etiology of CHF was idiopathic or ischemic dilated cardiomyopathy in 19 patients and hypertensive heart disease in 22. Sixteen subjects without cardiovascular disease were selected as normal controls. PVF peak systolic and peak early diastolic (D) velocities were recorded by TEE and TTE and the systolic fraction (SF) was measured (i.e., the systolic velocity-time integral – VTI – expressed as a fraction of the sum of systolic and early diastolic VTI). TEE tracings were obtained in all patients and had more laminar-appearing spectral signals, thus were used for analysis. By TTE the mitral flow velocity patterns were also evaluated: peak early diastolic velocity (E), peak velocity at atrial contraction, E velocity normalized for VTI (E/VTI), deceleration time (DT), and left ventricular isovolumic relaxation time (LVIRT). The left ventricular ejection fraction (LVEF) was calculated by two-dimensional echocardiographic images using the modified Simpson method. The SF was lower in CHF patients as compared with normal controls (p < 0.0001). The E/VTI ratio was higher, and DT and LVIRT were shorter (p < 0.0001) in CHF patients. A significant correlation was observed between SF and LVEF in CHF patients (r = 0.76, p < 0.001). Two different PVF velocity patterns (type A: SF < 0 50%, D > 50 cm/s; type B: SF ∼ 50%, D > 50 cm/s) were recognized in patients with a low LVEF (type A) and a nearly normal or normal LVEF (type B). Patients with LVEF < 40% showed mean SF values significantly lower than patients with LVEF > 40% (33.26 ± 10.84 vs. 51.00 ± 4.00%, p < 0.0001). Mean DT and LVIRT values were not significantly different in patients with LVEF < 40% and > 40%. Thus in CHF patients TEE PVF velocity patterns help in distinguishing patients with systolic dysfunction (low LVEF and SF) from patients with predominant diastolic impairment (normal or nearly normal LVEF, high D velocities).

Impact of Left Ventricular Function on the Pulmonary Vein Doppler Spectrum:

“…Conflicting results were noted in previous studies that used load‐sensitive indices. Positive correlations of SF with CO 2 , 10 , 11 or LVEF 12 were observed in some studies, but no correlations with FS of LV inner dimensions 8,9 or LVEF 5 were noted in others. The conflicting results might be due partly to the fact that the pulmonary vein Doppler spectrum was highly load‐dependent, and load‐insensitive indices were not used in these studies to control the confounding of loading change.…”

“…On one hand, this nature is the basis for the estimation of LV filling pressure 6,7 . On the other hand, it complicates our understanding of the effect of LV systolic and diastolic function on the pulmonary vein Doppler spectrum because most of the previous clinical studies used load‐sensitive indices such as fractional shortening (FS) of LV inner dimensions, 8,9 cardiac output (CO), 2 , 10 , 1 or LV ejection fraction (EF) 5 , 12 . Specifically, we do not know for certain how LV systolic and diastolic function affect the various components of the pulmonary vein Doppler spectrum.…”

“…diastolic function on the pulmonary vein Doppler spectrum because most of the previous clinical studies used load-sensitive indices such as fractional shortening (FS) of LV inner dimensions, 8,9 cardiac output (CO), 2,10,1 or LV ejection fraction (EF). 5,12 Specifically, we do not know for certain how LV systolic and diastolic function affect the various components of the pulmonary vein Doppler spectrum. In this regard, our understanding of the hemodynamic determinants of pulmonary vein Doppler spectrum remains incomplete and may limit its potential clinical application.…”

Increased pulmonary blood volume variation in patients with heart failure compared to healthy controls: a noninvasive, quantitative measure of heart failure

“…LA pressure is usually elevated in patients with left-sided HF (10). An increased LA pressure in patients with HF has been shown to affect the pulmonary venous flow pattern, which in turn results in a decreased systolic pulmonary venous flow (30) that in theory should lead to an elevated PBVV. Increased LA pressure could therefore influence the PBVV to a higher degree than the mechanisms of increased serum levels of vasoconstrictors and potential remodeling of the pulmonary vessels.…”

Assessment of severity of mechanical prosthetic mitral regurgitation by transoesophageal echocardiography

“…This is not surprising given the multifactorial nature of pulmonary venous flow, which is also influenced by atrial and left ventricular function. 27 The correlation is improved if patients with atrial fibrillation are excluded; thus, this method has important limitations, since patients with mitral valve regurgitation often have atrial fibrillation either permanently or intermittently. The presence of blunted or reversed systolic flow in pulmonary veins has been reported to be suggestive of significant mitral regurgitation in both native and prosthetic valves.…”