Meta-analysis of echocardiographic quantification of left ventricular filling pressure

Abstract

Aims: The clinical reliability of echocardiographic surrogate markers of left ventricular filling pressures (LVFPs) across different cardiovascular pathologies remains unanswered. The main objective was to evaluate the evidence of how effectively different echocardiographic indices estimate true LVFP.

Methods and results: Design: this is a systematic review and meta-analysis.

Data source: Scopus, PubMed and Embase. Eligibility criteria for selecting studies were those that used echocardiography to predict or estimate pulmonary capillary wedge pressure or left ventricular end-diastolic pressures. Twenty-seven studies met criteria. Only eight studies (30%) reported both correlation coefficient and bias between non-invasive and invasively measured LVFPs. The majority of studies (74%) recorded invasive pulmonary capillary wedge pressure as a surrogate for left ventricular end-diastolic pressures. The pooled correlation coefficient overall was r = 0.69 [95% confidence interval (CI) 0.63-0.75, P < 0.01]. Evaluation by cohort demonstrated varying association: heart failure with preserved ejection fraction (11 studies, n = 575, r = 0.59, 95% CI 0.53-0.64) and heart failure with reduced ejection fraction (8 studies, n = 381, r = 0.67, 95% CI 0.61-0.72).

Conclusions: Echocardiographic indices show moderate pooled association to invasively measured LVFP; however, this varies widely with disease state. In heart failure with preserved ejection fraction, no single echocardiography-based metric offers a reliable estimate. In heart failure with reduced ejection fraction, mitral inflow-derived indices (E/e', E/A, E/Vp, and EDcT) have reasonable clinical applicability. While an integrated approach of several echocardiographic metrics provides the most promise for estimating LVFP reliably, such strategies need further validation in larger, patient-specific studies.

Keywords: Echocardiography; Invasive heart catheterization; Left ventricular end-diastolic pressure.

Figure 1

Case examples of Doppler‐based methods for left ventricular filling pressure (LVFP) assessment. The first case (green panel) is a healthy 20‐year‐old male; the second case (yellow panel) is a 60‐year‐old male patient admitted with heart failure (HF). In the healthy adult case, the E/e′ is <8 and suggests normal LVFP vs. in the patient, it is >12 and suggests raised LVFP.

Figure 2

Search strategy flow chart as per the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses 2009 guidance.

Figure 3

(A) Forest plot of all the 23 studies evaluated in meta‐analysis for non‐invasive assessment of left ventricular filling pressure. (B) Funnel plot of all the 23 studies.

Figure 4

Forest plots of all the methods applied by echocardiography for non‐invasive assessment of left ventricular filling pressure.

Figure 5

Forest plots of all the heart disease states in which echocardiography has been tested for non‐invasive estimation of left ventricular filling pressure. It is worth noting that the heterogeneous group represented the most patients in the total meta‐analysis (40.6%).