Patients with high left ventricular filling pressure may be missed applying 2016 echo guidelines: a pilot study

Area of Science:

• Cardiology
• Echocardiography
• Cardiovascular Physiology

Background:

• Current 2016 guidelines for echocardiographic evaluation of left ventricular filling pressure (LVFP) utilize a limited algorithm.
• This algorithm primarily focuses on left atrial pressure indicators and excludes pulmonary venous flow analysis, which directly assesses left ventricular end-diastolic pressure (LVEDP).
• The exclusion of pulmonary venous flow may lead to underestimation of elevated LVEDP in certain patient populations.

Purpose of the Study:

• To determine the proportion of patients diagnosed with normal LVFP according to 2016 guidelines who actually have abnormal pulmonary venous flow profiles suggesting high LVEDP.
• To investigate the clinical implications of discrepancies between guideline-based LVFP assessment and pulmonary venous flow analysis.

Main Methods:

• Prospective study of 76 patients with stable ischemic cardiomyopathy and aortic stenosis prior to cardiac surgery.
• Comprehensive echocardiography was performed, including standard LVFP criteria and detailed pulmonary and mitral A wave duration analysis.
• Patients were categorized based on 2016 guideline recommendations for LVFP and pulmonary venous flow patterns (Apd-Amd duration).

Main Results:

• Of 58 patients classified as having normal LVFP by 2016 guidelines, 26 (45%) exhibited abnormal pulmonary venous flow (Apd-Amd duration > 30 ms), indicating high LVEDP.
• These 26 patients had significantly higher left ventricular (LV) mass and shorter mitral A wave durations compared to those with concordant normal LVFP and normal pulmonary venous flow.
• The findings highlight a significant discordance between the current guideline-based LVFP assessment and direct LVEDP evaluation via pulmonary venous flow.

Conclusions:

• The 2016 echocardiographic guidelines for LVFP may misclassify a substantial proportion of patients with elevated LVEDP.
• Pulmonary venous flow analysis, specifically Apd-Amd duration, should be reconsidered for inclusion in LVFP assessment algorithms.
• Incorporating pulmonary venous flow is particularly important in patients with unexplained symptoms, high LV mass, or truncated mitral A waves to ensure accurate LVEDP evaluation.