Evaluation of left ventricular filling pressure using doppler echocardiography in severe heart failure patients with reduced ejection fraction

Journal of military pharmaco-medicine n08-2018

EVALUATION OF LEFT VENTRICULAR FILLING PRESSURE
USING DOPPLER ECHOCARDIOGRAPHY IN SEVERE HEART
FAILURE PATIENTS WITH REDUCED EJECTION FRACTION
Le Thi Bich Van1; Pham Nguyen Vinh2
SUMMARY
Objectives: To estimate left ventricular filling pressure using Doppler echocardiography
according to American Society of Echocardiography guidelines in NYHA classes III - IV heart
failure patients with an ejection fraction ≤ 40%. Subjects and methods: A descriptive crosssectional study on 101 patients with NYHA class III - IV severe chronic heart failure with an
ejection fraction ≤ 40%, from April 2016 to June 2018 at Hochiminh City Heart Institute. Left
ventricular filling pressure was estimated using 5 Doppler echocardiographic parameters,
including peak E-wave velocity, mean E/A ratio, mean E/e’ ratio, mean peak tricuspid
regurgitation velocity and mean left atrial volume index. Results: We have identified 83 patients
(82.2%) with elevated left ventricular filling pressure and 18 patients with normal left ventricular
filling pressure (17.8%). Peak E-wave velocity = 86.7 ± 27.2 cm/s; mean E/A ratio = 1.99 ± 1.18;
mean E/e’ ratio = 14.2 ± 5.9; peak tricuspid regurgitation velocity > 2.8 m/s (62.4%) and mean
2
(left atrial) volume index > 34 mL/m (96%). We recognized that an E-wave deceleration time ≤
125 ms, which accounted for over 50% (52.4%) of patients in the ejection fraction ≤ 30% and
was statistically higher than 30% of patients having ejection fraction ≤ 40% (28.9%) (p = 0.02).
Only 41.6% of patients had mean E/e’ ratio > 14, while 82.2% of patients were shown to have
elevated left ventricular filling pressure after integrating 5 echocardiographic parameters.
Diastolic dysfunction grade I, II and III group each accounted for 17.8%, 37.6% and 44.6% of
patients, respectively. As for the left ventricular filling pressure group, more than half of them
(54.2%) had diastolic dysfunction grade III. Conclusion: By integrating these 5 parameters, the
chance of missing elevated left ventricular filling pressure patients will be lowered by half, which
would be otherwise undetectable if only E/e’ ratio was used.
* Key words: Heart failure; Left ventricular filling pressure; Diastolic dysfunction.

INTRODUCTION

Clinical assessment of left ventricular
filling pressure (LVFP) is not only essential
for effective medical management of heart
failure patients, especially in severe cases,
but also important in selecting treatment
methods and titrating individualized diuretic,

vasopressor and inotropic dosage to relieve
symptoms and avoid late complications
such as renal failure, hypotension, fluid
and electrolyte disturbances which can
increase mortality rate. Moreover, it can
prevent invasive and unnecessary procedures
such as central venous catheterization and
the use of pulmonary arterial wedge pressure.

1. Columbia Asia Hospital Binhduong
2. Tam Duc Heart Hospital, Pham Ngoc Thach University of Medicine
Corresponding author: Le Thi Bich Van ()
Date received: 02/08/2018
Date accepted: 20/09/2018

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Journal of military pharmaco-medicine n08-2018
However, when LVFP can’t be measured
reliably in 50% of cases on clinical
settings [1], Doppler echocardiography is
the most powerful tool in these cases.

Doppler echocardiography surpasses clinical
evaluation in accuracy and can determine
LVFP 1.5 times more accurate when both
are combined [2]. LVFP is considered
elevated when PAWP > 12 mmHg or left
ventricular end-diastolic pressure > 16 mmHg
[3], both of which can change the following
Doppler echocardiographic parameters
and in turn are used to determine LVFP:
peak E-wave velocity, E/A ratio, E/e’ ratio,
peak tricuspid regurgitation velocity (TRV),
left atrial (LA) volume index as per 2016
American Society of Echocardiography
(ASE) Guidelines [4]. Therefore we decided
to conduct this study: To investigate several
Doppler echocardiographic parameters
and its integration in estimating LVFP
including peak E-wave velocity, mean E/A
ratio, mean E/e’ ratio, mean peak TRV,
mean LA volume index in NYHA classes
III - IV heart failure patients with an EF ≤ 40%.

based on the New York Heart Association
(NYHA) Functional Classification.

SUBJECTS AND METHODS

Table 1: Characteristics of several
parameters used to estimate LVFP on
Doppler echocardiography.

1. Subjects.
We enrolled 101 inpatients with NYHA
classes III - IV with an EF ≤ 40% (EF =
27.2 ± 8.2%) at Hochiminh Heart Institute,
in which 65.3% and 34.7% of them were
males and females, respectively, having
an average age of 62 ± 15, from April
2016 to June 2018.
* Inclusion criteria: Heart failure with
reduced left-ventricular systolic function
based on 2016 European Society of
Cardiology’s (ESC) recommendations.
Heart failure classes III - IV were categorized
138

2. Methods.
Descriptive cross-sectional study.
Data collection: We’ve collected personal
information, NYHA classes III - IV heart
failure with EF ≤ 40% diagnoses, and 5
Doppler echocardiographic parameters
including E wave, E/A ratio, E/e’ ratio,
TRV, LA which are measured using
Philips HD XE ultrasound imaging system
and 3.5 MHz probe.
* Statistical analyses: Our data is entered
in Epi. Data version 3.1 and then analyzed
using Stata version 14.2.
RESULTS AND DISCUSSION

1. Characteristics of several Doppler
echocardiographic parameters used to
estimate LVFP.
Over the last few years, the clinical
and pathophysiological importance of the
mitral inflow pattern comprising the E-wave
and A-wave measured by echocardiography
has been studied thoroughly.

Characteristics

n = 101 (M ± SD)

E (cm/s)

86.7 ± 27.2

E/A

1.99 ± 1.18

EDT (ms)

143 ± 72

PAPs (mmHg)

36.0 ± 11.8

Mean E/e’

14.2 ± 5.9

Septal E/e'

18.1 ± 7.1

Lateral E/e'

12.5 ± 6.3

TRV (m/s)

2.96 ± 0.49


Journal of military pharmaco-medicine n08-2018
The onset of E-wave on Doppler
echocardiography reflects the end of
isovolumetric relaxation period and the
beginning of mitral valve opening, which
occurs when the LA pressure is greater
than that of LV and thereby increases the
mitral flow; when the opposite happens,
the mitral flow will decrease. Therefore
alterations in LV end-systolic and/or enddiastolic volume, elastic recoil and/or
diastolic pressure will all directly affect the
E-wave velocity.
The A-wave velocity indicates the LA-LV
pressure gradient during late diastole,

which is affected by the LV compliance and
LA contractile function.
Our study had an E/A ratio > 1.5,
which concured with many others such as
Dokainish (1.66 ± 0.82) [5] and Hansen’s
(1.9 ± 1.6) findings [6].
E-wave deceleration time (EDT) iwa
influenced by LV relaxation, LV diastolic
pressure after mitral valve opening, LV
compliance and therefore it demonstrated
the correlation between LV pressure and
volume. The shorter EDT was, the shorter
the LV filling time will be and a shortened
EDT ≤ 125 ms was strictly correlated with
increased mortality risk and need of heart
transplantation.
Table 2: EDT characteristics in patients
categorized according to EF.
EDT

EF > 30% EF ≤ 30% Overall
n (%)
n (%)
n (%)

> 125 ms

27
(71.1)

30
(47.6)

57
(56.4)

≤ 125 ms

11
(28.9)

33
(52.4)

44
(43.6)

EDT
(M ± SD)

160.2 ±
66.2

132.1 ±
73.0

142.7 ±
71.5

p

0.02

0.06

We recognized that an E-wave deceleration
time ≤ 125 ms, which accounted for over
50% (52.4%) of patients in the EF ≤ 30%
group and was statistically higher than 30%
of patients having EF ≤ 40% (p = 0.02).
The EDT in our study was 143 ± 72 (ms),
lower than that of Rihal’s (172 ± 66 ms)
[7] and higher than that of Pinamonti’s
(134.9 ± 18.9 ms) [8].
Table 3: Characteristics of E/e’ ratio,
TRV and LA.
Doppler

n = 101

Percentage %

Mean E/e’ > 14

42

41.6

Mean E/e’ ≤ 14

59

58.4

TRV > 2.8 m/s

63

62.4

TRV ≤ 2.8 m/s

38

37.6

2

97

96

2

4

4

LA > 34 mL/m
LA ≤ 34 mL/m

Mean E/e’ > 14 was one of the basic
and non-invasive parameters that indicated
the presence of an elevated LVFP. This
ratio was more significant in predicting a
patient’s prognosis and the existence of
an elevated LVFP than several single tissue
Doppler imaging parameters (e.g. e’ wave),
other conventional echocardiographic
parameters and pulmonary vein inflow.
Pulmonary arterial pressure (PAP) is
considered elevated when mean PAP
> 25 mmHg measured at rest by cardiac
catheterization. Based on pulmonary
artery systolic pressure (PAPs) calculations
from TR (PAPs = 4 x TR x TR) by means
of Doppler echocardiography, PAP was
considered elevated when PAPs
> 35 mmHg, which was equivalent to a
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Journal of military pharmaco-medicine n08-2018
TR > 2.8 m/s. In our study, we successfully
measured TR in 100% of our patients,
in which 62.4% had peak TRV > 2.8 m/s,
while none had TR > 2.8 m/s in the control
group; also mean PAPs in the diseased
group was 2.96 ± 0.49 m/s, which agreed
with the findings of the study by Dokainish

[5] and they also showed that TR and
PAPs were elevated in patients with heart
failure with reduced EF.
Left atrial hypertrophy (LAH) is associated
with poor cardiac prognosis. Several
etiologies of LAH include LV systolicdiastolic dysfunction as well as atrial
fibrillation. LA size seems to reflect LVFP
and may be caused by accumulation of
diastolic dysfunction over time. Of the
study population, 96% of the diseased
group had LA volume > 34 mL/m2, which
were also compatible with the findings of
a dilated left atrium in heart failure patients in
the study by Hansen [6].
2. Estimated LVFP and diastolic
function.
Treatment efficacy in severe heart
failure depends greatly on dose titration in
a way that preload, afterload, LV systolicdiastolic function must all be balanced to
maintain a suitable cardiac output. LVFP
is not only an important factor that helps
titrate dosage, but it also varies over time
and changes according to treatment
response.
Echocardiography is an imaging
modality of paramount importance in
assessing LVFP. Recently, guidelines for
LVFP evaluation by echocardiography
based on experts’ consensus, are published
140

together with ASE/EAE guidelines and
proven to be exact using invasive LVFP
measurement, which indicates the fact
that LVFP evaluation by echocardiography
is easily accessible, feasible and highly
accurate.
In this study, estimating LVFP was
done by integrating echocardiographic
parameters based on 2016 ASE clinical
practice guidelines in NYHA classes III - IV
heart failure patients with an EF ≤ 40%,
in which there were 83 patients (82.2%)
diagnosed with elevated LVFP and
18 patients (17.8%) with normal LVFP.
The following table illustrates the LVFP
and diastolic dysfunction group.
Table 4: Characteristics of LVFP and
diastolic dysfunction.
Left ventricular
filling pressure

n = 101

Percentage
%

Elevated LVFP

83

82.2

Non-elevated LVFP

18

17.8

Diastolic dysfunction
grade I

18

17.8

Diastolic dysfunction
grade II

38

37.6

Diastolic dysfunction
grade III

45

44.6

17.8%, 37.6% and 44.6% of the diseased
group had diastolic dysfunction grade I, II
and III, respectively.
* Percentage of patients with diastolic
dysfunction in the elevated LVFP group:
As for the elevated LVFP group, 45.8%
and 54.2% of patients had diastolic
dysfunction grade II and grade III,
respectively, no patient with diastolic
dysfunction grade I.


Journal of military pharmaco-medicine n08-2018
CONCLUSIONS
Of the study population, only 41.6% of
our patients had mean E/e’ ratio > 14,
while 82.2% of patients were shown to
have elevated LVFP after integrating 5
echocardiographic parameters. Therefore,
E/e’ ratio > 14 had limited usage in
predicting elevated LVFP and will miss
half of the cases.
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