Euroecho Kopenhagen Echo in Resynchronization in 2010 E/Ea is NOT an essential estimator of LV filling pressures Wilfried Mullens, MD, PhD December 10, 2010 Ziekenhuis Oost Limburg Genk University Hasselt Belgium - Europe
Background Invasively measured PCWP has been widely used as a surrogate for LVEDP, and is directly associated with functional capacity and prognosis in HF patients However, routine hemodynamic assessment via PAC has decreased substantially the last decade Although with limitations, transmitral flow velocity curves and other Doppler variables have been utilized as non-invasive estimates of intracardiac filling pressures In particular, the early transmitral velocity / tissue Doppler mitral annular early diastolic velocity (E/Ea) has shown to correlate with PCWP in a wide range of cardiac patients
Left Ventricular Pressure I: Filling Pressure: mean LA pressure needed to fill LV = Simplification of complex phenomenon Relaxation: how quickly LV reaches fully relaxed state Left Ventricular Volume Compliance: PV relationship of fully relaxed ventricle Carrol JD, Circ 1986;74:815-25
II. Resting Diastology Exercise Diastology DFT DFT A IVPG Despite shorter diastolic filling time, NO increase in LAP secondary to improved relaxation, improved compliance, greater atrial contraction Cheng, Circ Res 1992;70:9-19
III. Exercise Can Unmask Delayed Relaxation Relaxation Rate Diastolic Pressure Normal Diastolic dysfunction Normal Heart Rate (bpm) Heart Rate (bpm)
IV. Mitral Inflow: E/A velocity pitfalls - Beam Alignment: parallel to mitral inflow - Proper sample volume size (1-2 mm) Correct Sample Volume Placement Between MV Tips in the LV - Too close to annulus: higher velocities, shorter DT - Too far into LV: lower velocities, longer DT, spectral broadening
V. Mitral Inflow: E/A velocity pitfalls 300 Normal Delayed Relaxation Pseudonormal Restrictive
VI. Effect of LV relaxation on LV inflow = 28 LA = 8 = 31 LA = 8 = 43 LA = 8 With delayed relaxation (preload / LAP similar), acceleration is slowed and E peak is lower Choong. Circ.1987
VII. Effect of LA pressure (preload) on LV inflow = 29 LA = 5 = 31 LA = 9 = 31 LA = 13 With rising LA pressure (similar relaxation), acceleration is faster and E peak is higher. Choong. Circ.1987
Confouding effects of Preload vs Relaxation 2.0 E/A ratio 1.5 1.0 0.5 best Diastolic function worst Garcia. J Am Coll Card.1998
HOLY GRAIL. Preload INDEPENDENT parameter Blood: High velocity, low amplitude Tissue: Low velocity, high amplitude S TISSUE DOPPLER E A
Myocardial Flow Velocities do NOT Pseudonormalize Implication is that E/Ea can predict LAP E LAP/tau Ea 1/tau then LAP E/Ea Normal Delayed Relaxation Pseudonormal Restrictive Sohn. J Am Coll Card 1997; 30: 474-80
The Good News Show Implication is that E/Ea can predict LAP - Systolic heart failure - Diastolic heart failure - Sinus tachycardia - Mitral valve disease - Hypertrophic cardiomyopathy EF > 50% EF < 50% Ommen, Circulation 2000 Nagueh, J Am Coll Card 1997 Bruch, Am J Card 2005
The saga continues
Even adopted in important Guidelines Paulus W, Guidelines DHF Eur Heart J 2007
BUT some doubts even in isolated diastolic dysfunction
Serious doubts of value E/E in normal patients Firstenberg. J Am Coll Card 2000; 36: 1664-9
And poor correlation of E/E in patients with mitral valve disease Diwan, Nagueh. Circul 2005; 111: 3281-89
False low E/E in case of Constriction M-mode Doppler MV Flow Normal Restriction Constriction E 50cm/s 50cm/s E E 20cm/s TDE Ea 5cm/s Ea 5cm/s Ea Garcia. J Am Coll Card 1996; 27: 108-114
No correllation of E/E during exercise in normal / DHF Maeder T. J Am Coll Card 2010; 56: 855-63
But also doubts in systolic dysfunction What about the patient group for which we really wanna know the LAP in a fast, easy to obtain, reliable fashion in order to guide therapy??? Doikanish, Circulation 2004
Case 1 72 y/o female admitted to heart failure ICU Patient has a previous history of HF, PVD and cardiac defibrillator Height 157 cm Weight 53.3 kg BP 94/62
Hemodynamics Heart rate 88 bpm CVP 17 mmhg PA 33/18 mmhg PCWP 14 mmhg C.O. 2.35 l/min C.I. 1.55 l/min.m2 SVR 1634 dynes/cm5
LV function hypokinetic basal segments LEDV 170 ml LESV 130 ml EF 24 % LA biplane 58 ml Mild MR
E/Ea MV E wave = 135 Septal Ea wave = 2 Lateral Ea wave = 2 E/Ea = 67 (PCWP 14 mmhg)
Case 2 64 y/o male admitted to heart failure ICU Patient has a previous history of HF, diabetes, CAD, kidney disease and cardiac defibrillator Height 168 cm Weight 77.3 kg BP 134/62
Hemodynamics Heart rate 67 bpm CVP 23 mmhg PA 80/26 mmhg PCWP 25 mmhg C.O. 5.85 l/min C.I. 3.13 l/min.m2 SVR 1149 dynes/cm5
LV function LEDV 160 ml LESV 118 ml EF 27 % LA biplane 64 ml Mild - moderate MR
E/Ea MV E wave = 89 Septal Ea wave = 5.9 Lateral Ea wave = 6.7 E/Ea = 14 (PCWP 25 mmhg)
Case 3 73y/o female admitted to heart failure ICU Patient has a previous history of HF, HTN and Diabetes Height 177cm Weight 83kg BP 93/67
Baseline Hemodynamics Heart rate 70 bpm CVP 11 mmhg PA 34/18 mmhg PCWP 10 mmhg C.O. 4.67 l/min C.I. 2.33 l/min.m2 SVR 993 dynes/cm5
Baseline LV function LEDV 191 ml LESV 140 ml EF 26 % LA biplane 64 ml Mild moderate MR
Baseline E/Ea MV E wave = 95 Septal Ea wave = 3.2 Lateral Ea wave = 5.4 E/Ea = 22 (PCWP 10 mmhg)
24hr FU Hemodynamics Heart rate 90 bpm CVP 3 mmhg PA 37/20 mmhg PCWP 19 mmhg C.O. 4.83 l/min C.I. 2.42 l/min.m2 SVR 1358 dynes/cm5
24hr FU E/Ea MV E wave = 74 Septal Ea wave = 4.2 Lateral Ea wave = 6.6 E/Ea = 14 (PCWP 19 mmhg)
Objectives To examine the relationship between mitral E/Ea and PCWP in patients with ADHF To explore the potential clinical utility of serial mitral E/Ea assessment in estimating changes in PCWP in response to intensive medical therapy in the ADHF setting Inclusion criteria included: 1) LVEF 30% 2) NYHA class III-IV symptoms 3) Admitted to HF-ICU for PAC guided therapy
Methods Echocardiographic analysis was performed offline, blinded to hemodynamic data, three consecutive cycles and as recommended by the American Society of Echocardiography Mitral Ea Septal, lateral and average mitral annulus velocities PW-TDI (higher temporal resolution than c-tdi) Gain and filter settings were applied so the onset of mitral Ea could be reliably identified Scale: -15 to 20 to +15 to 20 cm/s Sweep speed: 100 mm/s to achieve the optimal spectral display of myocardial velocities Identical R-R intervals (<5 ms)
Results: Patient Characteristics All Patients (n = 106) Patients without CRT-D (n = 55) Patients with CRT-D (n = 51) Baseline Characteristics Age (y) 57 ±12 56 ±13 59 ±12 Men (%) 76 72 78 Weight (kg) 81 ±22 82 ±22 78 ±22 QRS width (msec) 141 ±34 123 ±29 160 ±29* Hypertension (%) 58 56 60 Hyperlipidemia (%) 59 59 63 Diabetes (%) 32 34 27 Ischemic etiology (%) 42 44 39 LV Ejection Fraction (%) 24 ±8 25 ±8 24 ±9 Hemoglobin (g/dl) 11.7 ±2 11.7 ±2 11.8 ±2 Creatinine (mg/dl) 1.8 ±1.1 1.7 ±0.7 1.9 ±1.3 BNP (pg/ml) 1710 ±1406 1628 ±1247 1734 ±1386 Mullens W et al. Circulation 2009;119:62-70.
Results: Patient Characteristics All Patients (n = 106) Medical Treatment During Admission (%) Patients without CRT-D (n = 55) Patients with CRT-D (n = 51) Beta Blockers 58 54 62 ACE inhibitors / ARB 54 56 52 Spironolactone 44 39 48 Loop Diuretic 85 84 78 Digoxin 22 17 24 Hydralazine 38 40 35 Isosorbide dinitrate 37 37 37 Inotropic Drugs 35 38 32 Nitroprusside 41 44 40 Mullens W et al. Circulation 2009;119:62-70.
Results: Hemodynamic Data All Patients (n = 106) Patients without CRT-D (n = 55) Patients with CRT-D (n = 51) Heart Rate (bpm) 75 ±29 84 ±24 67 ±32* MAP (mmhg) 75 ±11 76 ±13 74 ±9 CVP (mmhg) 12 ±7 13 ±6 11 ±8 MPA (mmhg) 34 ±11 34 ±11 36 ±10 PCWP (mmhg) 21 ±7 21 ±6 20 ±7 CI (l/min.m2) 2.1 ±0.7 2.0 ±0.7 2.1 ±0.8 LV mass (g) 376 ±134 367 ±130 395 ±145 Left atrial volume (ml) 92 ±38 89 ±39 96 ±38 LVEDV (ml) 252 ±114 210 ±85 294 ±124* Mullens W et al. Circulation 2009;119:62-70.
Relation Mitral E/Ea - PCWP Mullens W et al. Circulation 2009;119:62-70.
Correlation Mitral E/Ea - PCWP Mullens W et al. Circulation 2009;119:62-70.
ROC curves for elevated PCWP > 18 mmhg > 15 mmhg Mullens W et al. Circulation 2009;119:62-70.
Correlation Changes Mitral E/Ea - PCWP Mullens W et al. Circulation 2009;119:62-70.
Relation of mitral E/Ea and PCWP to LVEDV and CI Mullens W et al. Circulation 2009;119:62-70.
Conclusions Diastolic function is complex, dependent on preload, relaxation, compliance, exercise, heart rate therefore no single parameter can provide you with LVEDP The predictive value of baseline mitral E/Ea in estimating LVEDP in normals, DHF, SHF, MVD, constriction and especially advanced SHF is far less robust than previously reported No reliable direct correlation between changes in mitral E/Ea and PCWP and E/Ea should therefore not be used for serial mitral E/Ea assessment during titration of diuretic / hemodynamic therapy
Some doubts