194 Imaging and heart failure: atrial function and diastology

Imaging and heart failure: atrial function and diastology
Impact of inotropic drugs on the validity of left ventricular filling
pressure echocardiographic assessment in end-stage heart failure
J.E. Salem 1 , L. Paluszkiewicz 2 , J.S. Hulot 3 , L. Perdrix 1 , M. Morshuis 2 ,
P. Leprince 4 , J. Gummert 2 , B. Diebold 1 , N. Aissaoui 1 . 1 AP-HP - European
Hospital Georges Pompidou, Department of Cardiology, Paris, France; 2 Heart
and Diabetes Center NRW, Ruhr-University of Bochum, Dept of Thoracic
& Cardiovascular Surgery, Bad Oeynhausen, Germany; 3 AP-HP - Hospital
Pitie-Salpetriere, University Pierre & Marie Curie Paris VI, Dept of Cardiology,
Paris, France; 4 AP-HP - Hospital Pitie-Salpetriere, Department of Cardiovascular
Surgery, Paris, France
Purpose: Several studies found that the ratio of early diastolic transmitral flow
velocity to tissue Doppler mitral annular early diastolic velocity E/e
correlated well
with the mean pulmonary capillary wedge pressure (PCWP). Recently, the validity
of E/e’ ratio in predicting PCWP was challenged in patients with decompensated
end-stage systolic heart failure. In the latter study, influence of inotropic drugs
was not taken into consideration. We hypothesize that inotropes modify relaxation
properties and may have impaired the validity of E/e’ as a surrogate of filling
pressure in this setting.
Methods and results: Hemodynamic and echocardiographic data were gathered prospectively in 37 patients with decompensated end stage heart failure
(EF≤35%, NYHA≥III, LVTDD>31 mm/m2 ). Those patients (Mean age 56yo,
PCWP 22±8 mmHg, septal E/e’ 17±5) were admitted for ventricular assist device
implantation or heart transplantation. For 11 patients, we had at least two points of
evaluation, before and after introduction of inotropes. In the overall study (n=49),
E/e’ ratio (lateral,septal,mean) was not or poorly correlated to PCWP (r=0,35,
p<0,01 for septal E/e’). In examinations performed without inotropic drugs (n=17),
correlation between septal E/e’ and PCWP was good (r=0,66; p<0,01) while no
correlation was found in examinations during inotropes use (n=28). Lateral and
mean E/e’ were not or poorly correlated to PCWP in both cases.
Conclusions: In decompensated patients with advanced systolic heart failure,
the E/e’ ratio for assessing left ventricular filling pressure is accurate in the absence of inotropes but unreliable when inotropic drugs are used.
Interstudy reproducibility of echocardiographic parameters in the
serial assessment of left ventricular diastolic function
M. Asrar Ul Haq 1 , V. Mutha 1 , S. Stewart 2 , M. Carrington 2 , C. Wong 3 . 1 Northern
Health, Melbourne, 2 Baker IDI Heart and Diabetes Institute, Melbourne,
Western Hospital, Centre for Cardiovascular Therapeutics, Melbourne, Australia
Background: Serial monitoring of left ventricular (LV) diastolic function using
echocardiography remains a challenge and carries prognostic value. We examine the interstudy variations of echo parameters for myocardial function to assess
their test-retest reliability.
Methods: We studied 620 patients recruited for interventional trial in a tertiary
hospital who had common antecedents of Chronic Heart Failure (CHF) including pre-existing cardiovascular disease but no clinical diagnosis of CHF. Detailed
transthoracic echocardiogram studies were performed whilst in clinically stable
state at baseline and 18 months performed blinded of the earlier studies.
Results: 68% male with mean age 67±11 years and mean BMI 27±7. The BlandAltman graphs of interstudy differences (second minus first study measurements)
plotted against average values comparing baseline and 18 months showed a
good interstudy reproducibility of deceleration time (DT) and left atrial pressure
(E/e’) while tissue Doppler velocity (e’) was highly reproducible with least variability and a mean interstudy difference of 0.01±0.01 cm/s (CI 0.14-0.16). Inter-
Pulmonary capillary wedge pressure estimated by the combined
assessment of left atrial volume and emptying function using
speckle tracking echocardiography in patients with atrial
T. Kojima 1 , M. Kawasaki 2 , R. Tanaka 1 , K. Ono 1 , T. Watanabe 2 , T. Hirose 1 ,
M. Arai 1 , T. Noda 1 , S. Watanabe 1 , S. Minatoguchi 2 . 1 Gifu Prefectural General
Medical Center, Department of Cardiology, Gifu, Japan; 2 Gifu University
Graduate School of Medicine, Department of Cardiology, Gifu, Japan
Purpose: The evaluation of diastolic abnormalities in atrial fibrillation (AF) remains clinically challenging and noninvasive estimation of pulmonary capillary
wedge pressure (PCWP) in AF using echocardiography has not yet been elucidated. We have recently developed a novel index to estimate PCWP using
left atrial (LA) emptying function (EF) and volume (LAV) assessed by speckle
tracking echocardiography (STE) and named it kinetics-tracking (KT) index: log
(LAEF/LAV index). The estimated PCWP (ePCWP) was determined as 10.7 –
12.4 × KT index in sinus rhythm. However, usefulness of the KT index in AF
rhythm is unknown. Thus, we examined the feasibility and the accuracy of KT index in patients with AF by comparing ePCWP determined by KT index with PCWP
measured by cardiac catheterization.
Methods: We enrolled consecutive 36 patients with AF (age 65±8, 25 men)
who were going to undergo cardiac catheterization. Maximum (max) and minimum (min) LAV and LAEF were measured just before cardiac catheterization by
speckle tracking echocardiography that can provide the time-LA volume curve automatically. We estimated ePCWP using KT index: log (LAEF/min LAV index) and
compared it with PCWP obtained by cardiac catheterization just after echocardiography. LAEF was defined as (max LAV – min LAV)/max LAV x 100%. E/e’ and
E/A were measured as conventional parameters of a diastolic function. Average
of three cardiac cycles was analyzed.
Results: Max and min LAV measured by speckle tracking echocardiography was
directly associated with PCWP measured by cardiac catheterization (r=0.42 and
r=0.53, respectively, p<0.05). LAEF was inversely associated with PCWP (r=0.65, p<0.001). LAEF/max LAV and LAEF/min LAV were logarithmically associated with PCWP (r=-0.72, r=-0.73, p<0.001, respectively). E/e’ was also associated with PCWP (r=0.47, p<0.05). In multivariate analysis, only KT index
was independently associated with PCWP measured by catheterization. Using
13 of KT index as an optimal cutoff, the sensitivity and specificity for elevated
PCWP>15mmHg were 71% and 94% and area under curve was 0.90. ePCWP
could be estimated using the formula of KT index and had a good correlation with
PCWP by catheterization (r=0.73, p<0.001).
Conclusion: The ePCWP was easily estimated by the KT index that is the combined assessment of LAEF and LAV using speckle tracking echocardiography in
patients with AF. This pilot study demonstrated that the combined assessment of
LA volume and function is a novel and more powerful predictor for PCWP in AF
rhythm as well as sinus rhythm than any other echocardiographic parameters.
Severe obstructive sleep apnea increases left atrial volume
independent of left ventricular diastolic impairment
Y. Imai, Y. Takata, Y. Usui, S. Kurohane, Y. Takei, A. Yamashina. Tokyo Medical
University Hospital, Tokyo, Japan
Purpose: Previous studies have demonstrated that severe obstructive sleep apnea (OSA) itself impairs directly left ventricular (LV) diastolic function. Meanwhile,
left atrial (LA) volume index which is an independent predictor of future cardiovascular events is related to the OSA severity. Thus, the purpose of this study
was to investigate whether OSA is associated with increase of LA volume index
irrespective of LV diastolic function.
Methods: We enrolled 450 middle-aged OSA{apnea hypopnea index (AHI) ≥5/h}
patients without cardiac disease. All the patients underwent overnight fully attended polysomnograpy. They also underwent 2-dimensional echocardiography
in order to estimate LA volumes and LV diastolic function which was assessed by
the transmitral flow velocity (E/A ratio), deceleration time (DCT), systolic/diastolic
pulmonary vein velocity (S/D), and mitral annular velocity (Ea) was derived from
tissue Doppler imaging (TDI). Patients were divided into the mild to moderate
OSA (5 ≤AHI < 30/h) group and the severe OSA (AHI ≥30/h) group, and compared LA volume index and LV diastolic function between the groups. Multivariate
analysis performed whether OSA is the independent factor of LA volume index
irrespective of LV diastolic function.
Results: The LA volume index in the severe OSA group was significantly
larger than those in the mild to moderate OSA group (23.6±5.9 vs. 21.2±5.0,
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PCWP-E/e’ correlation-linear regression
class correlations of e’ (r=0.74; CI 0.67-0.8) and E/e’ (r=0.87; CI 0.83-0.9) were
very high. Interstudy reproducibility of left atrial volume (LA) and ejection fraction
(LVEF) was modest only with relatively large 95% CI; LA (-7.6 cm2 - 6.8 cm2 ) and
LVEF (-16.3% - 12.9%). There were no significant relations among interstudy differences of various echo measurements as well as with change in BMI and age
to suggest any true change to account for the variations.
Conclusion: Echocardiographic parameters DT (load dependent), and e’ and
E/e’ (less load dependent) have acceptable interstudy variance and may provide
a useful and reliable assessment of LV diastolic function in serial studies.