Bedside evaluation of pulmonary capillary wedge

Transcription

1 Noninvasive Differentiation of Pseudonormal/ Restrictive from Normal Mitral Flow by Tei Index: A Simultaneous Echocardiography-Catheterization Study in Patients with Acute Anteroseptal Myocardial Infarction AlaaAldin Rabea Abd El Rahim, MSc, Yutaka Otsuji, MD, Toshinori Yuasa, MD, Hui Zhang, MD, Kunitsugu Takasaki, MD, Toshiro Kumanohoso, MD, Shiro Yoshifuku, MD, Eiji Kuwahara, MD, Kouichi Toyonaga, MD, Takashi Murayama, MD, Chihaya Koriyama, MD, Akira Kisanuki, MD, Aly Hegazy, MD, Shinichi Minagoe, MD, and Chuwa Tei, MD, Kagoshima, Japan, and El-Menya, Egypt Background: Differentiation of pseudonormal/restrictive from normal mitral flow is still clinically problematic. Pseudonormal/restrictive flow is usually associated with left ventricular dysfunction, which can be detected by Doppler Tei index, combining systolic and diastolic function. Therefore, the purpose of this study was to test the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow. Methods: In 26 patients with anteroseptal acute myocardial infarction and early diastolic mitral flow velocity (E) to late diastolic mitral flow velocity (A) ratio (E/A) > 1, left ventricular volumes; E and A; deceleration time of E; and the Tei index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated by Doppler echocardiography, and pulmonary capillary wedge pressure was measured by catheterization. Pseudonormal/restrictive mitral flow was defined as E/A > 1 associated with pulmonary capillary wedge pressure > 12 mm Hg. Results: There were 19 and 7 patients with pseudonormal/restrictive and normal mitral flow, respectively. Among the indices of left ventricular function, the Tei index achieved the best correlation with pulmonary capillary wedge pressure (r , P <.0001). By setting the Tei index > 0.55 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had the sensitivity, specificity, and accuracy of 84%, 100%, and 88%, respectively. Conclusion: The Tei index allows noninvasive differentiation of pseudonormal/restrictive from normal mitral flow. (J Am Soc Echocardiogr 2003;16: ) Bedside evaluation of pulmonary capillary wedge pressure (PCWP) is important in decision making for From the First Department of Internal Medicine and Department of Public Health (C.K.), Kagoshima University School of Medicine, Kagoshima, Japan; Division of Cardiology, National Kyushu Cardiovascular Center, Kagoshima, Japan (T.K., T.M.); Division of Cardiology, Kagoshima Municipal Hospital, Kagoshima, Japan (Dr Toyonaga); and Division of Cardiology, El-Menya University Hospital, El-Menya, Egypt (A.H.). Supported by the Ministry of Education, Egypt (Dr AbdElRahim) and the 22nd Sasagawa Medical Researcher Scholarship (Dr Zhang). Drs Abd El Rahim and Otsuji equally contributed to this manuscript. Reprint requests: Yutaka Otsuji, MD, First Department of Internal Medicine, Kagoshima University School of Medicine, Sakuragaoka, Kagoshima City , Japan ( yutaka@m.kufm.kagoshima-u.ac.jp). Copyright 2003 by the American Society of Echocardiography /2003/$ doi: /j.echo patients with potential congestive heart failure. Mitral flow velocity pattern evaluated by Doppler echocardiography enables prediction of PCWP. 1-5 However, patients with significantly elevated and normal PCWP can occasionally reveal a comparable mitral flow velocity pattern; pseudonormal/restrictive and normal mitral flow are both characterized with relatively large early diastolic mitral flow velocity (E) to late diastolic mitral flow velocity (A) ratio (E/A) and short E deceleration time. 5 These confusing comparable mitral flow velocity patterns with different PCWPs make bedside clinical decision difficult. Patients with pseudonormal/restrictive mitral flow or elevated PCWP usually have left ventricular (LV) dysfunction, which can be detected by the Tei index, combining systolic and diastolic ventricular function We, therefore, hypothesized that patients with pseudonormal/restrictive mitral flow 1231

2 1232 Abd El Rahim et al December 2003 Figure 1 Scheme for measurement of Doppler Tei index. a, cessation to onset of mitral inflow; b, duration of left ventricular (LV) ejection flow; ET, ejection time; ICT, isovolumetric contraction time; IRT, isovolumetric relaxation time; LVOT, LV outflow tract. have an abnormally increased Tei index. The purpose of this study was to test the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow. METHODS Patients We prospectively studied 26 consecutive patients (16 men and 10 women; mean age years) with first anteroseptal acute myocardial infarction (AMI) and E/A 1. Anteroseptal AMI was diagnosed when the patients had the following findings: (1) chest pain attack lasting for 30 minutes; (2) electrocardiographic evidence of S-T elevation 1 mm in the precordial leads; and (3) serum creatine kinase level 2 times upper value of the normal range. All patients underwent emergency Doppler echocardiographic studies in the catheterization laboratory, followed by subsequent and emergency catheterization with diagnostic and therapeutic purpose. All patients had in sinus rhythm and no patients in this study group had valvular regurgitation greater than mild. All patients gave their informed consent and the institutional committee on human research of Kagoshima University Hospital, Kagoshima, Japan, also approved the study protocol. Doppler Echocardiography A standard 2-dimensional and Doppler echocardiographic examination was performed immediately after admission in the cardiac catheterization laboratory with commercially available equipment (SSH 380A, Toshiba, Tokyo, Japan; and ATL HDI 3000, Advanced Technology Laboratory, Bothell, Wash). In all patients, mitral flow velocities were recorded in an apical 4-chamber view, placing the pulsed wave Doppler sample volume between the tips of the mitral leaflets. LV outflow tract velocities were recorded from the apical long-axis view, placing the sample volume in the center of the aortic annulus. All images were recorded on VHS videotapes for later play back and analysis. Echocardiographic measurements were performed on an offline analysis station by an independent observer who had no knowledge of the clinical and hemodynamic findings. LV end-diastolic and end-systolic volumes were measured using the apical biplane Simpson s method. 11 Peak E and A, and E/A, were measured by pulsed wave Doppler echocardiography. Deceleration time was also measured from the peak of the E wave to the time when the extrapolated descent of the E wave intercepted the baseline. The slope of deceleration was calculated as the peak E divided by the deceleration time. Doppler time intervals were measured from mitral inflow and LV outflow velocity time intervals as shown in Figure 1. The interval a, measured with mitral filling flow velocity profile from the cessation to the onset of mitral inflow, was equal to the sum of isovolumetric contraction time (ICT), ejection time (ET), and isovolumetric relaxation time (IRT). The interval b, measured with LV outflow velocity profile as the duration of the LV ejection flow, was equal to ET. The Doppler Tei index was calculated as (a b)/b, which means (ICT IRT)/ET (Figure 1). A total of 5 consecutive cardiac cycles were measured and averaged. Cardiac Catheterization Cardiac catheterization was performed from the right femoral approach. A balloon-tipped Swan-Ganz catheter was inserted from the right femoral vein to the pulmonary artery. The pressure was balanced and calibrated with the external pressure transducer at the midaxillary line. PCWP was recorded before the injection of the contrast agent. Definition of Pseudonormal/Restrictive and Normal Mitral Flow by Hemodynamic Measurements On the basis of the Doppler mitral flow and the directly measured PCWP, E/A 1 with abnormally elevated LV filling pressure or PCWP 12 mm Hg 12 was defined as pseudonormal/restrictive flow and E/A 1 with PCWP 12 mm Hg was defined as normal flow. Reproducibility Two independent observers repeated 10 measurements of the Tei index. The differences in the measurements by the

3 Volume 16 Number 12 Abd El Rahim et al 1233 Table 1 Differences between pseudonormal/restrictive and normal group 2 observers were obtained to express interobserver variability. The same observer repeated the 10 measurements, and intraobserver variability was also calculated. Statistical Analysis Continuous numerous variables are expressed as mean values SD. Differences in variables between 2 groups were assessed by unpaired Student t test. The relations between continuous variables were evaluated by simple linear regression analysis. Categoric variables were compared using the chi-square test. The diagnostic use of the functional variables by Doppler echocardiography was compared through receiver operating characteristic curves. Results are expressed in terms of the area under the curve. A P value.05 was considered statistically significant. RESULTS Pseudonormal/ restrictive flow n 19 Normal flow n 7 P value Age (y) N.S. HR (bpm) N.S. SBP (mm Hg) N.S. DBP (mm Hg) N.S. LVEDV (ml) N.S. LVESV (ml) N.S. LVEF (%) LAD (cm) N.S. E (cm/s) N.S. A (cm/s) N.S. E/A N.S. DT (msec) N.S. Slope N.S. Interval a (msec) N.S. Interval b (msec) Tei index PCWP (mmhg) A, Late diastolic mitral flow velocity; DBP, diastolic blood pressure; DT, early diastolic mitral flow velocity deceleration time; E, early diastolic mitral flow velocity; EDV/ESV, end-diastolic-systolic volume; EF, ejection fraction; HR, heart rate, LAD, left atrial dimension; LV, Left ventricle; N.S., not significant; PCWP, pulmonary capillary wedge pressure; SBP, systolic blood pressure. Hemodynamic and Echocardiographic Findings The clinical, hemodynamic, and echocardiographic findings are summarized in Table 1. There were 19 and 7 patients with pseudonormal/restrictive and normal flow, respectively. Patients with pseudonormal/restrictive flow had a significantly reduced LV ejection fraction, shorter ET, and larger Tei index compared with those with normal flow. PCWP was Figure 2 Correlation between Tei index and pulmonary capillary wedge pressure (PCWP) in patients with acute anteroseptal myocardial infarction and early to late diastolic mitral flow velocity ratio 1. also larger in those with pseudonormal/restrictive flow by definition. Differentiation of Pseudonormal/Restrictive from Normal Mitral Flow Correlation between the indices of LV function and PCWP were significant for LV end-diastolic volume (r ), LV end-systolic volume (r ), LV ejection fraction (r ), left atrial dimension (r ), E (r ), E/A (r ), E deceleration time (r ), E slope (r ), ET (r ), and Tei index (r ). Among the indices of LV function, the Tei index showed the best correlation with PCWP (Figure 2) and highest diagnostic accuracy to identify patients with pseudonormal/restrictive mitral flow (Table 2). Reproducibility of Measurement The interobserver and intraobserver variability for the measurement of the Tei index was or % and or % of the mean value, respectively. DISCUSSION Differentiation of Pseudonormal/Restrictive from Normal Mitral Flow by the Tei Index Although most of the LV functional indices showed a significant correlation with PCWP, the Tei index achieved the best correlation. The Tei index is a

4 1234 Abd El Rahim et al December 2003 Table 2 Differential diagnosis of pseudonormal/restrictive from normal mitral flow AUC area 95% CI Sensitivity % Specificity % Accuracy % LVEDV 81 ml LVESV 50 ml LAD 33 mm EF 51% E 90 cm/s E/A DT 159 msec Interval b 260 msec Tei index A, Late diastolic mitral flow velocity; AUC, area under the curve; CI, confidence interval; DT, early diastolic mitral flow velocity deceleration time; E, early diastolic mitral flow velocity; EDV/ESV, end-diastolic/systolic volume; EF, ejection fraction; LAD, left atrial dimension; LV, left ventricle. measure of combined systolic and diastolic LV function, 6-10 with a potential to show a better correlation with PCWP compared with other conventional indices of purely systolic or diastolic cardiac function, because both systolic and diastolic dysfunction contribute to elevation of LV filling pressure. 13 This better correlation results in relatively high accuracy of the Tei index to diagnose pseudonormal/restrictive mitral flow defined by elevated PCWP. Relation to Previous Studies Pseudonormal/restrictive mitral flow with greater E/A, higher E, and shortened E deceleration time has been reported as a good index to predict high PCWP or poorer prognosis. 5,14-17 Significant relations between mitral deceleration time and PCWP in this study confirmed these previous studies. In addition, multiple noninvasive approaches analyzing pulmonary venous flow, M-mode color mitral flow, 21,22 and tissue Doppler mitral annular velocity 12,23-25 have been shown to be useful to predict PCWP. Therefore, there have been several studies demonstrating the feasibility of noninvasive techniques to estimate PCWP or differentiation of pseudonormal/restrictive from normal mitral flow. This study demonstrated practical differentiation of pseudonormal/restrictive from normal mitral flow by the Tei index, which requires only transmitral and aortic flow velocity recording by routine pulsed Doppler echocardiography. IRT occasionally and paradoxically shortens or pseudonormalizes with marked elevation of LV filling pressure. 5 Therefore, Tei index may also pseudonormalize with elevation of PCWP. However, Tei index uses IRT/ET, which is more difficult to pseudonormalize because ET usually shortens with elevation of PCWP. In addition, Tei index is a sum of ICT/ET and IRT/ET. ICT or ET is not known to pseudonormalize with elevation of PCWP, therefore, Tei index can be expected to be much more resistant to pseudonormalization compared with IRT. In this series of consecutive 26 patients with anteroseptal AMI and mitral E/A 1, there were no patients with pseudonormalization of Tei index. There have been several studies reporting the clinical usefulness of the Tei index. Prognostic information can be obtained in patients with cardiac amyloidosis, 8 dilated cardiomyopathy, 26 primary pulmonary hypertension, 27 and AMI. 28,29 The Tei index is a useful tool to differentiate patients with and without congestive heart failure. 8 Poulsen et al 30 demonstrated the feasibility of the Tei index to detect impaired hemodynamics in patients with AMI by demonstrating a significant difference in the Tei index between patients with or without abnormal respiratory sounds. This study further demonstrated the clinical use of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow defined by direct measurement of PCWP. Limitations The IRT can be measured by subtracting the interval d, between the peak QRS and cessation of aortic ejection flow, from the interval c, between the peak QRS and the onset of mitral flow. In addition, ICT can also be calculated by subtracting the IRT from (a b). However, the ICT and IRT were not measured in this study to avoid measurement error with frequently noisy electrocardiography in the emergency situation. A significant but only fair correlation between the Tei index and LV filling pressure has previously been demonstrated (r ), 9 however, the same correlation was much better in this study (r ). It is expected that a correlation between the Tei index and PCWP can be significant but only fair, because the index is only modestly influenced by changes in loading. 9,31 It is suggested that the Tei index can potentially show better correlations with PCWP in patients with AMI compared with those with chronic cardiac dysfunction, because those with AMI have limited time for compensation and are usually not on intervention to reduce cardiac loading, such as vasodilators or diuretics, which can potentially cause discrepancy between PCWP and LV function. However, the reason for the better correlation between Tei index and PCWP compared with the previous report 9 remains unclear. Never-

5 Volume 16 Number 12 Abd El Rahim et al 1235 theless, the purpose of this study was achieved by demonstrating the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow in patients with anteroseptal AMI. REFERENCES 1. Kitabatake A, Inoue M, Asao M, Tanouchi J, Masuyama T, Abe H, et al. Transmitral blood flow reflecting diastolic behavior of the left ventricle in health and disease a study by pulsed Doppler technique. Jpn Circ J 1982;46: Thomas JD, Choong CYP, Flachskampf FA, Weyman AE. Analysis of the early transmitral Doppler velocity curve: effect of primary physiologic changes and compensatory preload adjustment. J Am Coll Cardiol 1990;16: Nishimura RA, Abel MD, Housmans PR, Warnes CA, Tajik AJ. Mitral flow velocity curves as a function of different loading conditions: evaluation by intraoperative transesophageal Doppler echocardiography. J Am Soc Echocardiogr 1989;2: Matsukida K, Otsuji Y, Hamasaki S, Yoshifuku S, Kumanohoso T, Fujiyama-Koriyama C, et al. Monophasic transmitral flow pattern with less increase in heart rate indicates left ventricular dysfunction. Jpn Circ J 2001;65: Appleton CP, Hatle LK, Popp RL. Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coll Cardiol 1988;12: Tei C. New non-invasive index for combined systolic and diastolic ventricular function. J Cardiol 1995;26: Tei C, Ling LH, Hodge DO, Bailey KR, Oh JK, Rodeheffer RJ, et al. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function a study in normals and dilated cardiomyopathy. J Cardiol 1995;26: Tei C, Dujardin KS, Hodge DO, Kyle RA, Tajik AJ, Seward JB. Doppler index combining systolic and diastolic myocardial performance: clinical value in cardiac amyloidosis. J Am Coll Cardiol 1996;28: Bruch C, Schmermund A, Marin D, Katz M, Bartel T, Schaar J, et al. Tei-index in patients with mild-to-moderate congestive heart failure. Eur Heart J 2000;22: Ishii M, Tsutsumi T, Himeno W, Eto G, Furui J, Hashino K, et al. Sequential evaluation of left ventricular myocardial performance in children after anthracycline therapy. Am J Cardiol 2000;86: Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr 1989;2: Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures. Circulation 2000;102: Paulus WJ, Grossman W, Serizawa T, Pourdillon PD, Pasipoulurides A, Mirsky I. Different effects of two types of ischemia on myocardial systolic and diastolic function. Am J Physiol 1985;248:H Giannuzzi P, Imparato A, Temporelli PL, de Vito F, Silva PL, Scapellato F, et al. Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction. J Am Coll Cardiol 1994;23: Pinamonti B, Di Lenarda A, Sinagra G, Camerini F, and the Heart Muscle Disease Study Group. Restrictive left ventricular filling pattern in dilated cardiomyopathy assessed by Doppler echocardiography: clinical, echocardiographic and hemodynamic correlations and prognostic implications. J Am Coll Cardiol 1993;22: Yamamoto K, Nishimura RA, Chaliki HP, Appleton CP, Holmes DR Jr, Redfield MM. Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: critical role of left ventricular systolic function. J Am Coll Cardiol 1997;30: Møller JE, Søndergaard E, Poulsen SH, Egstrup K. Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study. J Am Coll Cardiol 2000;36: Yamamuro A, Yoshida K, Hozumi T, Akasaka T, Takagi T, Kaji S, et al. Noninvasive evaluation of pulmonary capillary wedge pressure in patients with acute myocardial infarction by deceleration time of pulmonary venous flow velocity in diastole. J Am Coll Cardiol 1999;34: Kuecherer HF, Muhiudeen IA, Kusumoto FM, Lee E, Moulinier LE, Cahalan MK, et al. Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow. Circulation 1990;82: Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol 1993;21: Takatsuji H, Mikami T, Urasawa K, Teranishi J, Onozuka H, Takagi C, et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol 1996;27: Garcia MJ, Smedira NG, Greenberg NL, Main M, Firstenberg MS, Odabashian J, et al. Color M-mode Doppler flow propagation velocity is a preload insensitive index of left ventricular relaxation: animal and human validation. J Am Coll Cardiol 2000;35: Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997;30: Garcia MJ, Ares MA, Asher C, Rodriguez L, Vandervoort P, Thomas JD. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may predict capillary wedge pressure. J Am Coll Cardiol 1997;29: Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quiñones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997;30: Dujardin KS, Tei C, Yeo TC, Hodge DO, Rossi A, Seward JB. Prognostic value of a Doppler index combining systolic and diastolic performance in idiopathic-dilated cardiomyopathy. Am J Cardiol 1998;82: Yeo TC, Dujardin KS, Tei C, Mahoney DW, McGoon MD, Seward JB. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol 1998;81: Poulsen SH, Jensen SE, Nielsen JC, Møller JE, Egstrup K. Serial changes and prognostic implications of a Dopplerderived index of combined left ventricular systolic and diastolic myocardial performance in acute myocardial infarction. Am J Cardiol 2000;85:19-25.

6 1236 Abd El Rahim et al December Møller JE, Sondergaard E, Poulsen SH, Appleton CP, Egstrup K. Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction. J Am Soc Echocardiogr 2001;14: Poulsen SH, Jensen SE, Tei C, Seward JB, Egstrup K. Value of the Doppler index of myocardial performance in the early phase of acute myocardial infarction. J Am Soc Echocardiogr 2000;13: Møller JE, Poulsen SH, Egstrup K. Effect of preload alternations on a new Doppler echocardiographic index of combined systolic and diastolic performance. J Am Soc Echocardiogr 1999;12: Correction: In the article Improvement in echocardiographic evaluation of left ventricular wall motion using still-frame parametric imaging, by Caiani et al, in the September 2002 issue (J Am Soc Echocardiogr 2002;15:926-34), the last 3 paragraphs in the Methods section should have appeared as the last 3 paragraphs in the Parametric Imaging section. The last 3 paragraphs in the Parametric Imaging section should have appeared as the last 3 paragraphs in the Methods section.