Left ventricular diastolic function and filling pressure in patients with dilated cardiomyopathy

Transcription

1 Left ventricular diastolic function and filling pressure in patients with dilated cardiomyopathy Bogdan A. Popescu University of Medicine and Pharmacy Bucharest, Romania My conflicts of interest: I have nothing to declare

2 Why bother? ESC Guidelines for HF. Eur Heart J 2008;29:

3 Dilated cardiomyopathy LV diastolic dysfunction present / not LV filling pressures elevated / not reversibly elevated / not grading LV diastolic dysfunction

4 Left ventricular diastolic function by echo Relaxation Compliance E/A ratio, E deceleration time Isovolumic relaxation time Flow propagation velocity Myocardial Ve, Se, SRe Short duration A wave Increased PV reversed flow E/e ratio Left atrial volume Courtesy: A. Fraser

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6 Eur J Echocardiogr 2009;10:

7 Nagueh S, et al. Eur J Echocardiogr 2009;10:

8 LV filling by transmitral PW Doppler E/A ratio very good Relaxation Filling pressure very, very bad restrictive filling good pseudonormal bad impaired relaxation Disease severity

9 Mitral EDT The single most important variable of mitral inflow

10 Clinical applications of mitral inflow parameters in patients with DCM PW Doppler mitral inflow variables and filling pattern correlate better with LV filling pressure functional class E restrictive filling A prognosis than LV ejection fraction IVRT

11 Mitral EDT is a strong predictor of PCWP 140 postinfarct pts in SR LV ejection fraction < 35% EDT < 120 ms best predictor of PCWP > 20 mm Hg 35 pts with HF and A Fib Mean LVEF 22 ± 5% EDT < 120 ms best predictor of PCWP > 20 mm Hg Giannuzzi P, et al. J Am Coll Cardiol 1994 Temporelli PL, et al. Am J Cardiol 1999

12 EDT relation to filling pressures depends on LVEF LVEF 50% LVEF > 50% Yamamoto K, et al. J Am Coll Cardiol 1997;30:

13 Persistence of Restrictive Filling Pattern in DCM: an ominous prognostic sign Free of TX or Death Nonrestrictive FP Reversible RFP >115msec >115msec <115msec >115msec Persistent RFP <115msec <115msec Pinamonti B, et al. J Am Coll Cardiol 1997;29:

14 EDT and survival in patients with systolic HF 13 studies 2046 pts Thohan V. Curr Opinion Cardiol 2004;19:

15 Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis Rihal CS, et al. Circulation 1994;90:

16 Mitral inflow - limitations U-shaped relation with LV diastolic function (normal vs pseudonormal) Sinus tachycardia & first degree AV block (fusion of the E and A waves) Arrhythmias: atrial flutter (LV filling influenced by rapid atrial contractions) 1 st degree AV block Atrial flutter F F F

17 Unmasking of impaired relaxation in pseudonormalization by reducing transmitral filling pressure using the Valsalva maneuver baseline Valsalva or restrictive filling pattern pseudonormalization impaired relaxation pattern normal normal pattern

18 A wave velocity change during Valsalva as a predictor of increased LVEDP Schwammenthal E, et al. Am J Cardiol 2000;86:

19 Pulmonary vein flow PW-Doppler A systolic fraction <40% reliably predicts a PCWP >18 mm Hg (in pts with systolic dysfunction) Brunazzi MC, et al. Am Heart J 1994;128:293. Kuecherer H, et al. Am Heart J 1991;122:1683. Pozzoli M, et al. J Am Coll Cardiol 1996;27:883.

20 Pulmonary venous Flow Pattern and Filling Pressure S D S D A LA A R A R A R A R dur >A predicts a LVEDP > 15 mm Hg with a sensitivity of 85% and a specificity of 79% Independent of LV ejection fraction Rossvoll and Hatle, J Am Coll Cardiol 1993 Age-independent Klein et al, J Am Soc Echocardiogr 1997 Courtesy of E. Schwammenthal

21 Progression of diastolic indices Amplitude E E Time / severity of disease Courtesy: A. Fraser

22 Assessment of LV filling pressures by combined Tissue Doppler and PW echocardiography E p w /tau E 1/tau E/E p w Nagueh SF, et al. J Am Coll Cardiol 1997;30:

23 Impact of LVEF on estimation of LVFP by TDI Patients with EF < 50% Patients with EF 50% Rivas-Gotz C, et al. Am J Cardiol 2003;91:780-4.

24 Estimation of filling pressures in patients with preserved EF Nagueh S. et al. Eur J Echocardiogr 2009;10:

25 Assessing LVFP by E/E E/E <8 likely normal E/E >15 likely elevated E/E of 8-15 unclear Ommen SR, et al. Circulation 2000;102:

26 108 pts w CHF, follow-up: 351 ± 252 days 4 groups were defined Group I: EF >40% and E/E ratio <15 Group II: EF >40% and E/E ratio 15 Group III: EF 40% and E/E ratio <15 Group IV: EF 40% and E/E ratio 15 primary end point: combined risk of cardiac mortality or rehospitalization for HF Am J Cardiol 2009;103:

27 Hirata K, et al. Am J Cardiol 2009;103: In terms of cardiac death, group IV and age were independent prognostic predictors.

28 Problems with E/E in LVFP assessment Uses a regional parameter (E ) to assess LVFP With poor LV relaxation very low velocities of E are measured, and small variations in measurements will strikingly affect calculations of E/E (denominator) Cut-off values are different for different sites Relatively wide overlap in the middle range (E/E between 8-15)

29 106 pts with EF 30% NYHA class III-IV simultaneous echo and right heart cath

30 No correlation was found between E/E ratio and PCWP, especially in pts with larger LV volumes, more impaired CI, CRT PCWP > 18 mmhg PCWP > 15 mmhg Mullens W, et al. Circulation 2009;119:62-70

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32 Correspondence on Mullens study concerns regarding: technical aspects of echo and PCWP measurements the inclusion of pts with significant MR and of pts with CRT the cut-off used for average E/E the potentially greater utility of transmitral flow parameters (eg EDT) in this population

33 79 pts - decompensated systolic HF (DCM and CAD), including large LV vol and CRT simultaneous echo and right heart catheterization noninvasive measurements of pulmonary artery systolic and diastolic pressure, mean right atrial pressure and stroke volume had significant correlations with invasive measurements

34 Several Doppler indices had good accuracy in identifying pts with PCWP > 15 mm Hg Nagueh S, et al. Circ Cardiovasc Imag 2011;4:

35 Assessment of the ASE-EAE guidelines for diastolic function in pts with depressed EF retrospective study 62 pts, LVEF < 50% echo 20 of left heart cath correlations with LV pre-a pressure: E/e R=0.43 E/A R=0.52 EDT R=-0.51 LAVi R=0.50 (all significant) 54 of 62 pts accurately classified using the algorithm Dokainish H, et al. Eur J Echocardiogr 2011;12:

36 Conclusions Assessment of diastolic function and filling pressure has clinical and prognostic value in patients with DCM No single echo parameter is enough for all situations An integrated algorithm is more useful in identifying patients with normal and elevated LV filling pressures

37 Thank you!