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Doppler Echocardiography for the Estimation of LV Filling Pressure in Patients With Mitral Annular Calcification
Muaz M Abudiab1, Lakshmi H Chebrolu1, Robert C Schutt1
1Cardiovascular Imaging Center, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
Insights
Doppler echocardiography can accurately assess left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC). A new algorithm using mitral E/A ratio and isovolumic relaxation time (IVRT) is effective for predicting LVFP in MAC patients.
Area of Science:
- Cardiology
- Echocardiography
- Medical Diagnostics
Background:
- Assessing left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC) presents significant challenges.
- Standard echocardiographic methods may be unreliable in the presence of MAC.
Purpose of the Study:
- To identify specific Doppler echocardiographic parameters for assessing LVFP in patients with MAC.
- To develop and validate a decision algorithm for accurate LVFP estimation in this population.
Main Methods:
- Prospective study involving 50 MAC patients undergoing Doppler echocardiography and cardiac catheterization.
- Correlation analysis of standard and nonstandard Doppler parameters with invasive LVFP measurements.
- Classification and regression tree analysis to create a predictive algorithm for LVFP.
Main Results:
- The mitral E/A ratio was the strongest predictor of LVFP (r=0.66, p<0.001) across all MAC severities.
- The E/e' ratio showed a weak correlation with LVFP (r=0.42, p=0.003).
- A decision algorithm using mitral E/A and isovolumic relaxation time (IVRT) demonstrated high specificity (100%) and positive predictive value (100%) for high LVFP, with 94% diagnostic accuracy upon validation.
Conclusions:
- The E/e' ratio is not recommended for LVFP estimation in patients with significant MAC.
- Mitral E/A ratio and IVRT are valuable Doppler parameters for predicting LVFP in MAC.
- The developed decision algorithm accurately estimates LVFP in patients with MAC.
Objectives:
This study sought to identify Doppler parameters useful for the assessment of left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC) and to develop and validate a decision algorithm for assessing LVFP in such patients.
Background:
Predicting LVFP in the presence of MAC is problematic.
Methods:
Prospectively, 50 patients with MAC (mean 72 ± 11 years of age) underwent a complete Doppler echocardiographic study and right or left heart catheterization. Standard and nonstandard parameters of ventricular filling and relaxation were correlated with LVFP. Classification and regression tree analysis was used to develop a decision tree for prediction of LVFP. Validation was performed prospectively using an additional cohort with MAC and invasive hemodynamics (n = 21).
Results:
In the initial study group, 26 patients had mild MAC, and 24 had moderate or severe MAC. Mean LVFP was 17.0 ± 8.1 mm Hg (range 4 to 50 mm Hg). Of the variables tested, the best predictor of LVFP was the ratio of early-to-late diastolic filling velocity (mitral E/A) (r = 0.66; p < 0.001). This finding was observed in subjects with mild as well as moderate-to-severe MAC. Importantly, the ratio of early diastolic filling velocity-to-mitral annulus velocity (E/e') demonstrated weak correlation (r = 0.42; p = 0.003). A clinical algorithm using mitral E/A and isovolumic relaxation time (IVRT) was associated with good specificity (100%) and positive predictive value (100%), and moderate sensitivity (81%) and negative predictive value (67%) for high LVFP. Validation of the clinical algorithm in a separate prospective cohort yielded a diagnostic accuracy of 94%.
Conclusions:
The E/e' ratio should not be used to estimate LVFP in subjects with significant MAC. However, mitral E/A ratio and IVRT are useful predictors of LVFP in this patient population. The proposed decision algorithm combining these Doppler parameters is accurate in estimating LVFP in patients with MAC.
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