New Algorithm for Estimating Left Ventricular Filling Pressure by Echocardiography
Hossam Lababidi1, Wissam Rahi1, Otto A Smiseth2
1Methodist DeBakey Heart and Vascular Center, Houston, TX (H.L., W.R., S.F.N.).
Insights
A new algorithm significantly reduces indeterminate left ventricular filling pressure (LVFP) estimates, improving accuracy in cardiac diagnostics. This method enhances the feasibility of LVFP assessment, offering valuable insights when combined with natriuretic peptide data.
Area of Science:
- Cardiology
- Medical Diagnostics
- Echocardiography
Background:
- Accurate assessment of cardiac causes for dyspnea is crucial.
- 2016 guidelines for estimating left ventricular filling pressure (LVFP) resulted in a high rate of indeterminate results.
- A need exists for a more accurate and feasible method to determine LVFP.
Purpose of the Study:
- To validate a novel algorithm for estimating LVFP.
- To reduce the incidence of indeterminate LVFP measurements.
- To improve the accuracy of LVFP assessment compared to existing guidelines.
Main Methods:
- An observational, multicenter study involving 951 patients undergoing cardiac catheterization.
- Echocardiographic parameters including mitral inflow, pulmonary vein, and tissue Doppler velocities were analyzed.
- A stepwise algorithm utilizing multiple echocardiographic variables was developed to estimate LVFP.
Main Results:
- The new algorithm yielded only 2 indeterminate LVFP results, compared to 38 with 2016 guidelines (P<0.0001).
- Overall accuracy was 86% (sensitivity 86%, specificity 86%), outperforming 2016 guidelines.
- The algorithm showed significant net reclassification improvement over natriuretic peptides.
Conclusions:
- The novel algorithm substantially increases the feasibility of estimating LVFP.
- This new method demonstrates good accuracy and incremental value when used with natriuretic peptides.
- The algorithm offers a more reliable approach to diagnosing cardiac causes of dyspnea.
Background:
Evaluation of whether dyspnea has a cardiac cause is essential. Guidelines from 2016 were reported to result in a high incidence of indeterminate left ventricular (LV) filling pressure. We sought to validate a new algorithm for the estimation of LV filling pressure (LVFP) in a multicenter study, with the objective of decreasing the yield of indeterminate filling pressure and increasing accuracy.
Methods:
In an observational study, echocardiography was performed in 951 patients referred for cardiac catheterization. Echocardiographic measurements included mitral inflow, pulmonary vein and tissue Doppler mitral annulus velocities, tricuspid regurgitation velocity, assessment of mean right atrial pressure, biplane LV and left atrial volumes, and LV and left atrial strain. A stepwise approach was applied in a new algorithm for estimation of LVFP, whereby pressure >15 mm Hg was considered abnormally elevated. The first step included mitral annulus early diastolic velocity (e'), the ratio of mitral early flow velocity to e', and pulmonary artery systolic pressure. With concordant findings in all 3 variables, conclusions about LVFP could be reached. In case of discordant or incomplete variables, left atrial reservoir strain, left atrial maximum volume index, isovolumic relaxation time, and pulmonary vein flow were analyzed in a second step. In the presence of ≥1 abnormal measurement in the second step, the conclusion of elevated LVFP could be reached.
Results:
Only 2 patients had indeterminate LVFP as per the new algorithm versus 38 applying 2016 guidelines (P<0.0001). In 949 patients, sensitivity was 86% and specificity was 86%, with accuracy of 86%. Accuracy was higher than the 2016 algorithm in all patients (P<0.0001), and in patients with ejection fraction ≥50% (P<0.0001), whereas accuracy was similar in patients with ejection fraction <50%. In 663 patients with natriuretic peptides data, net reclassification improvement for echocardiography over natriuretic peptides was 1.1 (P<0.0001), and integrated discrimination improvement was 0.3 (P<0.0001).
Conclusions:
The new algorithm increases the feasibility of estimating LVFP and has good accuracy with incremental value when natriuretic peptides are considered.
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