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"Peak Summation" Left Ventricular Filling Pattern in Patients with Chronic Heart Failure: Frequency and Complementary
Soccorso Capomolla1, Oreste Febo, Giorgio Riccardi
1Department of Cardiology, Montescano Medical Center, Via per Montescano, 27040 Montescano, Pavia, Italy.
Insights
In chronic heart failure (CHF), a specific left ventricular pattern limits Doppler analysis. Pulmonary venous flow velocity patterns offer valuable noninvasive hemodynamic insights for these patients.
Area of Science:
- Cardiology
- Echocardiography
- Hemodynamics
Background:
- The "peak summation" left ventricular filling pattern in chronic heart failure (CHF) complicates Doppler assessment of mitral flow.
- Limited hemodynamic and prognostic information is available from mitral flow Doppler in these patients.
Purpose of the Study:
- To determine the frequency of the peak summation left ventricular filling pattern in CHF patients.
- To evaluate the incremental value of pulmonary venous flow velocity patterns for noninvasive hemodynamic profiling in CHF.
Main Methods:
- Prospective study of 263 consecutive CHF patients undergoing simultaneous right heart catheterization and echo-Doppler examination.
- Measurement of isovolumic relaxation time, mitral flow, and pulmonary venous flow velocities (peak systolic, diastolic forward, reverse, systolic fraction).
Main Results:
- 17% of CHF patients exhibited the peak summation pattern, associated with greater clinical deterioration and left atrial dysfunction.
- Pulmonary venous flow systolic fraction correlated well with pulmonary wedge pressure (r = -0.70) and cardiac index (r = -0.65) in specific subgroups.
- A pulmonary venous flow systolic fraction <40% accurately identified elevated pulmonary wedge pressure (>18 mmHg) with 100% sensitivity and 95% specificity.
Conclusions:
- The peak summation left ventricular filling pattern is prevalent in CHF patients.
- Pulmonary venous flow velocity analysis provides crucial, noninvasive hemodynamic information in CHF patients with this pattern, aiding in risk stratification and management.
Abstract:
In patients with chronic heart failure (CHF) and a "peak summation" left ventricular pattern, no hemodynamic and prognostic information can be drawn from Doppler examination of mitral flow. In 263 consecutive patients with CHF who were undergoing simultaneous right heart catheterization and echo-Doppler examination, we prospectively determined (1) the frequency of the peak summation left ventricular filling pattern and (2) the incremental information contributed by pulmonary venous flow velocity patterns in providing noninvasive hemodynamic profile estimation. Isovolumic relaxation time of mitral flow, peak systolic (X), diastolic forward (Y), reverse (Z) flow velocity, and systolic fraction (X/X + Y) of pulmonary venous flow were measured. Forty-six of 263 (17%) patients had a peak summation left ventricular filling pattern. This subgroup showed more clinical deterioration (New York Heart Association functional class III-IV, 57% vs 49%; P < 0.01) and left atrial dysfunction (left atrial ejection fraction, 31% vs 39%; P < 0.001). However, 40% of these patients had a pulmonary wedge pressure of <18 mmHg and a cardiac index of >2.2 L/min/m(2). The systolic fraction of peak velocities of pulmonary venous flow showed a good correlation with pulmonary wedge pressure (r = -0.70, P < 0.05). The correlation was stronger in patients without mitral regurgitation (r = -0.81, P < 0.05). A systolic fraction of <40% was accurate (sensitivity, 100%; specificity, 95%) in identifying patients with a pulmonary wedge pressure of >18 mmHg. In patients without mitral regurgitation, this variable was also correlated with cardiac index (r = -0.65, P < 0.05) and predicted a cardiac index of >2.2 L/min/m(2) (sensitivity, 91%; specificity, 71%). In conclusion, a peak summation left ventricular filling pattern is common in patients with CHF. Pulmonary venous flow provides useful information about the hemodynamic profile of these patients.
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