title: Noninvasive estimation of left ventricular filling pressures in patients with heart failure after surgical ventricular restoration and restrictive mitral annuloplasty.
abstract: OBJECTIVE
  Doppler echocardiography, including tissue Doppler imaging, is widely applied to assess diastolic left ventricular function using early transmitral flow velocity combined with mitral annular velocity as a noninvasive estimate of left ventricular filling pressures. However, the accuracy of early transmitral flow velocity/mitral annular velocity in patients with heart failure, particularly after extensive cardiac surgery, is debated. Global diastolic strain rate during isovolumic relaxation obtained with 2-dimensional speckle-tracking analysis was recently proposed as an alternative approach to estimate left ventricular filling pressures.
  
  
  METHODS
  We analyzed diastolic function in patients with heart failure after surgical ventricular restoration and/or restrictive mitral annuloplasty. Echocardiography, including tissue Doppler imaging and speckle-tracking analysis, was performed to determine early transmitral flow velocity/atrial transmitral flow velocity, isovolumetric relaxation time, deceleration time, early transmitral flow velocity/mean mitral annular velocity, strain rate during isovolumic relaxation, and early transmitral flow velocity/strain rate during isovolumic relaxation. These noninvasive indices were correlated with relaxation time constant Tau, peak rate of pressure decline, and left ventricular end-diastolic pressure obtained in the catheterization room using high-fidelity pressure catheters.
  
  
  RESULTS
  Twenty-three patients were analyzed 6 months after restrictive mitral annuloplasty (n = 8), surgical ventricular restoration (n = 4), or a combined procedure (n = 11). The strongest correlation with invasive indices, in particular left ventricular end-diastolic pressure, was found for strain rate during isovolumic relaxation (r = -0.76, P < .001). Early transmitral flow velocity/mean mitral annular velocity did not correlate significantly with any of the invasive indices. Strain rate during isovolumic relaxation (cutoff value < 0.38 s(-1)) accurately predicted left ventricular end-diastolic pressure of 16 mm Hg or more with 100% sensitivity and 93% specificity.
  
  
  CONCLUSIONS
  In a group of patients with heart failure who were investigated 6 months after cardiac surgery, early transmitral flow velocity/mean mitral annular velocity correlated poorly with invasively obtained diastolic indexes. Global strain rate during isovolumic relaxation, however, correlated well with left ventricular end-diastolic pressure and peak rate of pressure decline. Our data suggest that global strain rate during isovolumic relaxation is a promising noninvasive index to assess left ventricular filling pressures in patients with heart failure after extensive cardiac surgery, including restrictive mitral annuloplasty and surgical ventricular restoration.
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Ellen A
authors.initials: EA
authors.lastname: ten Brinke
authors.forename: Matteo
authors.initials: M
authors.lastname: Bertini
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Klautz
authors.forename: M Louisa
authors.initials: ML
authors.lastname: Antoni
authors.forename: Eduard R
authors.initials: ER
authors.lastname: Holman
authors.forename: Nico R
authors.initials: NR
authors.lastname: van de Veire
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
authors.forename: Paul
authors.initials: P
authors.lastname: Steendijk
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures; D018618:Echocardiography, Doppler, Color; D018619:Echocardiography, Doppler, Pulsed; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D009426:Netherlands; D011237:Predictive Value of Tests; D020127:Recovery of Function; D012680:Sensitivity and Specificity; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D017725:Ventricular Pressure