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. 2024 Jun 3;11(1):14.
doi: 10.1186/s44156-024-00048-x.

Evaluation of left ventricular filling pressure by echocardiography in patients with atrial fibrillation

Faraz H Khan #  1 , Debbie Zhao #  2 , Jong-Won Ha  3 , Sherif F Nagueh  4 , Jens-Uwe Voigt  5 , Allan L Klein  6 , Einar Gude  1 , Kaspar Broch  1 , Nicholas Chan  6 , Gina M Quill  2 , Robert N Doughty  7 , Alistair Young  2 , Ji-Won Seo  3 , Eusebio García-Izquierdo  8 , Vanessa Moñivas-Palomero  8 , Susana Mingo-Santos  8 , Tom Kai Ming Wang  6 , Stephanie Bezy  5 , Nobuyuki Ohte  9 , Helge Skulstad  1 , Carmen C Beladan  10 , Bogdan A Popescu  10 , Shohei Kikuchi  9 , Vasileios Panis  11 , Erwan Donal  11 , Espen W Remme  1   12 , Martyn P Nash  2 , Otto A Smiseth  13
Affiliations

Evaluation of left ventricular filling pressure by echocardiography in patients with atrial fibrillation

Faraz H Khan et al. Echo Res Pract. .

Abstract

Background: Echocardiography is widely used to evaluate left ventricular (LV) diastolic function in patients suspected of heart failure. For patients in sinus rhythm, a combination of several echocardiographic parameters can differentiate between normal and elevated LV filling pressure with good accuracy. However, there is no established echocardiographic approach for the evaluation of LV filling pressure in patients with atrial fibrillation. The objective of the present study was to determine if a combination of several echocardiographic and clinical parameters may be used to evaluate LV filling pressure in patients with atrial fibrillation.

Results: In a multicentre study of 148 atrial fibrillation patients, several echocardiographic parameters were tested against invasively measured LV filling pressure as the reference method. No single parameter had sufficiently strong association with LV filling pressure to be recommended for clinical use. Based on univariate regression analysis in the present study, and evidence from existing literature, we developed a two-step algorithm for differentiation between normal and elevated LV filling pressure, defining values ≥ 15 mmHg as elevated. The parameters in the first step included the ratio between mitral early flow velocity and septal mitral annular velocity (septal E/e'), mitral E velocity, deceleration time of E, and peak tricuspid regurgitation velocity. Patients who could not be classified in the first step were tested in a second step by applying supplementary parameters, which included left atrial reservoir strain, pulmonary venous systolic/diastolic velocity ratio, and body mass index. This two-step algorithm classified patients as having either normal or elevated LV filling pressure with 75% accuracy and with 85% feasibility. Accuracy in EF ≥ 50% and EF < 50% was similar (75% and 76%).

Conclusions: In patients with atrial fibrillation, no single echocardiographic parameter was sufficiently reliable to be used clinically to identify elevated LV filling pressure. An algorithm that combined several echocardiographic parameters and body mass index, however, was able to classify patients as having normal or elevated LV filling pressure with moderate accuracy and high feasibility.

Keywords: Atrial fibrillation; Diastolic function; Echocardiography; Filling pressure; Left atrium; Left ventricle.

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Conflict of interest statement

OA Smiseth is co-inventor of “Method for myocardial segment work analysis” and has patent on “Estimation of blood pressure in the heart”. He has received one speaker honorarium from GE Healthcare. The remaining authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Echocardiographic recordings in a patient with elevated left ventricular filling pressure: Mitral E velocity of 120 cm/s, deceleration time of mitral E of 120 ms, peak TR velocity of 4.2 m/s, septal e’ of 3 cm/s and septal E/e’ of 40; all consistent with elevated LV filling pressure. Pulmonary capillary wedge pressure was 25 mmHg
Fig. 2
Fig. 2
Regression plots showing association between echocardiographic parameters and LV filling pressure. BMI, Body mass index; E, early-diastolic mitral flow velocity; e’, mitral annular velocity; DT, deceleration time; LA, left atrial; LV, left ventricular; TR, Tricuspid regurgitation
Fig. 3
Fig. 3
Regression plot of left atrial volumes versus LV filling pressure. Left atrial minimum (left panel) and maximum (right panel) volume indices showed no correlation to LV filling pressure. LV, left ventricular; LAVI, left atrial volume index
Fig. 4
Fig. 4
Regression plot of body mass index (BMI) and NT-proBNP versus LV filling pressure. Logarithmic scale of NT-proBNP showing moderate correlation to LV filling pressure. LV, Left ventricular
Fig. 5
Fig. 5
Evaluation of left ventricular filling pressure in atrial fibrillation: The first step of the algorithm consists of 4 echocardiographic parameters applied to all patients, classifying them as having normal or elevated LV filling pressure. If a patient is unclassified by the first step in the algorithm, then 3 supplementary parameters in the second step of the algorithm are applied to further classify that patient. LV, Left ventricular; E, Early diastolic; Decel, Deceleration; TR, Tricuspid regurgitation; LA, Left atrial; BMI; Body mass index
Fig. 6
Fig. 6
Accuracy and feasibility of the proposed algorithm. Left panel shows the feasibility of the full algorithm; 85% of patients could be classified as normal or elevated LV filling pressure. Right panel shows that the accuracy of the full algorithm applied to the patients that could be classified was 75%. LV; Left ventricular
See this image and copyright information in PMC

References

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