Document 380392

Eur J Echocardiography (2002) 3, 229–232
doi:10.1053/euje.2002.0155, available online at on
M. Pozzoli and G. S. de Ruiter
Case 3: A Patient with Atypical Chest Pain
A 73-year-old female patient with a history of hypertension complains of dyspnoea at exercise and atypical chest
pain. She is in sinus rhythm. A systolic ejection murmur, 3/6 of intensity is heard at the base of the heart. Right and
left heart catheterization and a simultaneous echocardiogram is performed. The echocardiogram shows a
hypertrophied LV with normal systolic function (Fig. 1) and moderate-to-severe aortic stenosis (peak pressure
gradient 69 mmHg).
What is the LV filling pressure?
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Figure 1
1525-2167/02/030229+04 $35.00/0
Teaching Corner
See Fig. 3.
Eur J Echocardiography, Vol. 3, issue 3, September 2002
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This patient has a hypertrophic LV with normal systolic function. Doppler of mitral flow shows an ‘abnormal
relaxation’ pattern, which is an unequivocal sign of low PCWP in patients with LV systolic dysfunction. In
patients with normal LV systolic function and severe diastolic dysfunction, however, it is less reliable to predict
low filling pressures. In fact, if relaxation is markedly abnormal, E wave can be relatively low (and its
deceleration prolonged) even when the left atrial pressure is high. Similarly, the S wave of the pulmonary venous
can be relatively high even when left atrial pressure is elevated if the LV produces vigorous downward
displacement of the mitral annulus. In this kind of patient the most reliable parameters to use in order to
estimate LV filling pressure are those that are independent from LV relaxation such as the difference in duration
between the retrograde pulmonary venous flow (dZ) and the forward mitral flow (dA) at atrial contraction and
the ratio E/E. In this patient dZ-dA is prologed (indicating an LVEDP >15 mmHg), while E/E is low
(indicating low left atrial pressure; Fig. 2). Indeed, LVEDP turned out to be moderately elevated, while mean
PCWP was normal at catheterization (Fig. 3). This example underlines the fact that, although LVEDP and
PCWP are correlated, significant discrepancies may exist in patients with normal left atrial pressure during
systole and early diastole and elevated pressure in late diastole after atrial contraction.
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Figure 2
Teaching Corner
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Figure 3
Eur J Echocardiography, Vol. 3, issue 3, September 2002