CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 1, January/February 2014
34
AFRICA
Echocardiographic estimation of left ventricular filling
pressures in patients with mitral valve stenosis
Roya Sattarzadeh, Anahita Tavoosi, Parvin Tajik
Abstract
Background:
Estimation of left ventricular end-diastolic
pressure (LVEDP) among patients with mitral valve disease
may help to explain their symptoms. However, conven-
tional Doppler measurements have limitations in predicting
LVEDP in this group of patients. The aim of this study was
to construct a Doppler-derived LVEDP prediction model
based on the combined analysis of transmitral and pulmonary
venous flow velocity curves.
Methods:
Thirty-three patients with moderate to severe mitral
stenosis (MS) who had indications for left heart catheterisa-
tion enrolled. Two-dimensional, M-mode, colour Doppler
and tissue Doppler imaging indices, such as annular early
diastolic velocity (Ea), isovolumic relaxation time (IVRT),
pulmonary vein systolic and diastolic flow velocities, veloc-
ity propagation, left atrium area (LAA), interval between the
onset of mitral E and annular Ea (TE–Ea), and Tei index were
obtained. LVEDP was measured in all patients during left
cardiac catheterisation. Linear correlation and multiple linear
regressions were used for analysis.
Results:
The mean of LVEDP was 9.9
±
5.3 mmHg. In
univariate analysis, the only significant relationship was noted
with LAA (
p
=
0.05,
R
2
=
0.11). However, in multivariate
regression, LAA, Tei index and Ea remained in the model
to predict LVEDP (
p
=
0.02,
R
2
=
0.26). For prediction of
LVEDP
≥
15 mmHg, the best model consisted of LAA, IVRT
and Ea, and had a sensitivity of 85% and specificity of 85%.
Conclusion:
Our results provided evidence that, in patients
with moderate to severe MS, LVEDP can be estimated by
combining Doppler echocardiographic variables of mitral
flow. However, more studies are required to confirm these
results.
Keywords:
Doppler echocardiography, tissue Doppler imaging,
mitral stenosis, left ventricular end-diastolic pressure
Submitted 12/5/13, accepted 9/12/13
Cardiovasc J Afr
2014;
25
: 34–39
DOI: 10.5830/CVJA-2013-088
Mitral stenosis (MS) is prevalent in developing countries. By
improving healthcare systems, it could be expected that the
incidence of new cases would decrease and therefore the mean
age of mitral stenosis patients would increase. This increase in
age of MS patients is accompanied by the occurrence of other
diseases, such as coronary artery disease, hypertension, diabetes
mellitus and chronic obstructive pulmonary disease.
In a number of patients with MS, the question arises of
the impact of mitral valve disease (MVD) on the presenting
symptom. For example, in patients presenting with dyspnea, with
both significant MS and hypertension, increased left ventricular
(LV) filling pressure due to hypertension could influence
assessment of the severity of MS. In these patients, severity of
MS could be underestimated because the increased diastolic
pressure reduces the mitral valve gradient, and the increased LV
stiffness shortens pressure half-time (PHT).
Similarly, patients with both pulmonary disease and MS may
have dyspnoea because of pulmonary rather than cardiac cause.
It is therefore advantageous to assess LV filling pressure in
these cases in an attempt to prove or refute a cardiac cause for
dyspnoea.
Using Doppler measurements to estimate LV filling pressures
is desirable. However, conventional Doppler measurements have
limitations in the prediction of left ventricular end-diastolic
pressure (LVEDP) in this group of patients. For example, in
patients with MS, the left atrium (LA) is enlarged to compensate
for the increase in LA pressure. Similarly, mitral inflow peak
early diastolic velocity (E) is highly dependent on LA pressure
1
and also preload.
2
Pulmonary venous (PV) flow also has a
blunted pattern in most patients with MS.
3
Therefore, in MS
patients, LA size, mitral inflow pattern and pulmonary venous
pattern are all altered, making these measurements unreliable for
the estimation of LVEDP.
However, other Doppler and tissue Doppler echocardiographic
indices and time intervals, such as peak early diastolic velocity
of mitral annulus (Ea), E/Ea ratio, mitral inflow propagation
velocity (VP), E/VP, pulmonary vein velocities, Tei index and the
ratio of isovolumic relaxation time (IVRT) to interval between
the onset of mitral E and annular Ea (TE–Ea), which have shown
promising values in the prediction of LV filling pressure in a
variety of diseases,
4-11
have not been assessed in the setting of
mitral stenosis.
The aim of this study was to analyse the components of mitral
and pulmonary waves in patients with mitral stenosis and to
construct a Doppler-derived LVEDP prediction model based on
the combined analysis of transmitral and pulmonary venous flow
velocity curves.
Methods
The study population comprised 33 consecutive patients with
a mean age of 37
±
9 years, and 23 were women. Inclusion
Cardiology Department of Imam Khomeini Hospital,
Tehran University of Medical Sciences, Tehran, Iran
Roya Sattarzadeh, MD
Anahita Tavoosi, MD,
Department of Clinical Epidemiology, Biostatistics and
Bioinformatics, Academic Medical Centre, University of
Amsterdam, Amsterdam, the Netherlands
Parvin Tajik, MD, PhD
