Letter by Galderisi and Esposito Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure”
To the Editor:
We read with worry the article by Mullens et al1 with regard to the inaccuracy of tissue Doppler in estimating left ventricular (LV) filling pressure in advanced heart failure. Is the dream of noninvasive cardiologists truly disappearing? In our opinion, a critical analysis of this article is needed. The first criticism corresponds to the selected population, which included heterogeneous subsets of patients with advanced heart failure. In particular, cardiac resynchronization therapy represents an important confounding factor by influencing both LV filling and pulsed tissue Doppler in an unpredictable manner. The ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) has been reported to be unreliable for predicting LV diastolic pressures in patients with LV wall motion abnormalities related to left bundle-branch block and paced rhythm.2 A second concern is that, if the relation between pulmonary capillary wedge pressure (PCWP) and the E/Ea ratio is insignificant, even the similar relationship between PCWP and E velocity deceleration time, well established previously,3 is trivial. This finding can be at least partially explained by a trend toward the highest levels of PWCP occurring in the majority of patients with advanced heart failure: The narrower the PCWP dispersion, the lower the possibility of finding a significant relationship with both deceleration time and E/Ea ratio. However, the third and main concern is with regard to the choice of estimating the E/Ea ratio averaging Ea of septal and lateral mitral annulus. Some researchers prefer tissue Doppler sampling of the septal annulus because this moves parallel to the ultrasound beam and is less influenced by the translation movement of the heart. Others encourage the sampling at the junction between the LV lateral wall and the mitral annulus because septal velocities are conditioned by the right ventricular interaction. The rationale of averaging septal and lateral values is derived from the observation that a definite discrepancy in detecting LV myocardial diastolic dysfunction emerges by using a septal (overestimation) or a lateral (underestimation) annulus. Ea velocities are, in fact, significantly greater at the lateral location than at the septal placement of the annulus in the clinical setting. Mullens et al averaged Ea values of septal and lateral annulus but used E/Ea >15 as the cutoff point, which is accurate when using septal Ea.4 When using the average Ea, a more appropriate cutoff point would be fixed >10.5 In addition, the reproducibility of tissue Doppler of the lateral annulus can be questionable in patients with large and distorted ventricles as those participating in the Mullen et al study (see the second patient in Figure 5).
On the basis of these assumptions and personal experience, our viewpoint is that, in patients with advanced systolic heart failure and enlarged ventricles, a short deceleration time is enough (probably even more than the E/Ea ratio) to predict PCWP, as well as clinical symptoms and prognoses. Conversely, in patients with normal or near-normal ejection fraction, where deceleration time cannot be considered accurate, and a high E/Ea ratio (it is better if combined with left atrial dilation) provide the best way to noninvasively detect increasing LV filling pressure.
Mullens W, Borowski AG, Curtin RJ, Thomas JD, Tang WH. Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure. Circulation. 2009; 119: 62–70.
D'Souza KA, Mooney DJ, Russell AE, MacIsaac AI, Aylward PE, Prior DL. Abnormal septal motion affects early diastolic velocities at the septal and lateral mitral annulus, and impacts on estimation of the pulmonary capillary wedge pressure. J Am Soc Echocardiogr. 2005; 18: 445–453.
Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000; 102: 1788–1794.