Author + information
- Received March 20, 2014
- Revision received May 16, 2014
- Accepted June 3, 2014
- Published online September 23, 2014.
- Jerry D. Estep, MD∗∗ (, )
- Rey P. Vivo, MD∗,†,
- Selim R. Krim, MD‡,
- Andrea M. Cordero-Reyes, MD∗,
- Barbara Elias, RN∗,
- Matthias Loebe, MD, PhD∗,
- Brian A. Bruckner, MD∗,
- Arvind Bhimaraj, MD∗,
- Barry H. Trachtenberg, MD∗,
- Guha Ashrith, MD∗,
- Guillermo Torre-Amione, MD, PhD∗,§ and
- Sherif F. Nagueh, MD∗
- ∗Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
- †Mechanical Circulatory Support and Heart Transplantation Program, UCLA Ahmanson Cardiomyopathy Center, Los Angeles, California
- ‡John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
- §Catedra de Cardiologia y Medicina Vascular, Tecnológico de Monterrey, Nuevo León, Mexico
- ↵∗Reprint requests and correspondence:
Dr. Jerry D. Estep, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower Suite 1901, Houston, Texas 77030.
Background Hemodynamics assessment is important for detecting and treating post-implant residual heart failure, but its accuracy is unverified in patients with continuous-flow left ventricular assist devices (CF-LVADs).
Objectives We determined whether Doppler and 2-dimensional transthoracic echocardiography reliably assess hemodynamics in patients supported with CF-LVADs.
Methods Simultaneous echocardiography and right heart catheterization were prospectively performed in 50 consecutive patients supported by using the HeartMate II CF-LVAD at baseline pump speeds. The first 40 patients were assessed to determine the accuracy of Doppler and 2-dimensional echocardiography parameters to estimate hemodynamics and to derive a diagnostic algorithm for discrimination between mean pulmonary capillary wedge pressure ≤15 versus >15 mm Hg. Ten patients served as a validation cohort.
Results Doppler echocardiographic and invasive measures of mean right atrial pressure (RAP) (r = 0.863; p < 0.0001), systolic pulmonary artery pressure (sPAP) (r = 0.880; p < 0.0001), right ventricular outflow tract stroke volume (r = 0.660; p < 0.0001), and pulmonary vascular resistance (r = 0.643; p = 0.001) correlated significantly. Several parameters, including mitral ratio of the early to late ventricular filling velocities >2, RAP >10 mm Hg, sPAP >40 mm Hg, left atrial volume index >33 ml/m2, ratio of mitral inflow early diastolic filling peak velocity to early diastolic mitral annular velocity >14, and pulmonary vascular resistance >2.5 Wood units, accurately identified patients with pulmonary capillary wedge pressure >15 mm Hg (area under the curve: 0.73 to 0.98). An algorithm integrating mitral inflow velocities, RAP, sPAP, and left atrial volume index was 90% accurate in distinguishing normal from elevated left ventricular filling pressures.
Conclusions Doppler echocardiography accurately estimated intracardiac hemodynamics in these patients supported with CF-LVAD. Our algorithm reliably distinguished normal from elevated left ventricular filling pressures.
Over the last 6 years, ∼6,000 patients with advanced heart failure have received continuous-flow left ventricular assist devices (CF-LVADs), which constitute >95% of all long-term mechanical circulatory support implantations (1). With 1- and 2-year survival estimated at ∼82% and 74%, respectively, increasing use of these devices is expected (1,2). When evaluating patients with left ventricular assist devices (LVADs) for ventricular size and function, valvular function, and potential device complications, echocardiography remains the imaging modality of choice (3). Although echocardiography can reliably measure right ventricular (RV) and left ventricular (LV) hemodynamics in patients with decompensated heart failure (4), its utility and accuracy measured against invasively derived hemodynamics in the CF-LVAD population have not been fully examined.
Unplanned readmissions attributed to left-sided and/or right-sided heart failure after CF-LVAD accounts for significant patient morbidity (5,6). Current practice guidelines support the use of right heart catheterization in patients on CF-LVADs with persistent or recurrent heart failure (7). However, invasive testing is not always readily available and carries intrinsic risks in this patient group given their need for chronic anticoagulation. We therefore performed a prospective study to examine the application of Doppler echocardiography for the hemodynamic assessment of patients with CF-LVADs. In addition, we aimed to develop a practical echocardiographic algorithm to detect elevated LV filling pressures due to partial LV unloading in this patient population.
Between July 2009 and December 2013, a total of 55 consecutive patients supported with a CF-LVAD at the Houston Methodist Hospital and with a clinical indication for invasive hemodynamic assessment (e.g., persistent residual heart failure, pre–heart transplant pulmonary pressure assessment, or as part of a screening protocol to evaluate for myocardial recovery) were prospectively enrolled under an institutional review board–approved protocol. Patients with a mitral valve annuloplasty ring (n = 2), significant mitral annular calcification (n = 1), and those with suboptimal images due to poor acoustic windows (n = 2) were excluded.
All 50 patients received the HeartMate II CF-LVAD (Thoratec Corporation, Pleasanton, California). Simultaneous echocardiography and right heart catheterization were performed in the catheterization laboratory on all patients at baseline pump speed, typically 9,000 revolutions per minute (rpm). Clinical heart failure on CF-LVAD support was defined as the presence of shortness of breath (i.e., New York Heart Association [NYHA] functional class III or IV symptoms) with an elevated pulmonary capillary wedge pressure (PCWP) >15 mm Hg defined by using the right heart catheterization at baseline LVAD pump speed. Right-sided heart failure was attributed to residual left-sided heart failure while on CF-LVAD support; this assumption was made on the basis of right heart catheterization if the mean right atrial pressure (RAP) was >10 mm Hg in the presence of an elevated PCWP and pulmonary hypertension.
Echocardiographic imaging and analysis
Complete transthoracic echocardiographic studies were performed in standard fashion in accordance with current American Society of Echocardiography guidelines and were reviewed by an independent reader blinded to the invasive hemodynamic measurements. From the parasternal window, LV end-diastolic diameter, pulmonary annulus diameter, and right ventricular outflow tract (RVOT) velocity were measured per guidelines (8,9). RVOT stroke volume was derived as the RVOT cross-sectional area × RVOT time-velocity integral flow according to pulsed-wave Doppler (9). Right-sided cardiac output (the sum of LVAD flow and native LV outflow tract) was calculated as the product of RV stroke volume and heart rate, and indexed to body surface area to calculate cardiac index. In addition, 2-dimensional echocardiography and M-mode were used from the parasternal window to record aortic valve function per institutional guidelines in patients on CF-LVAD support with classification as follows: aortic valve opening after every cardiac cycle, intermittent aortic valve opening, or complete aortic valve closure (10).
From the apical window, left atrial volume was measured by using the biplane method of disks from the apical 4-chamber and apical 2-chamber views at ventricular end-systole, then indexed to body surface area to yield the left atrial volume index (LAVi) (8). Pulsed-wave Doppler was used to record mitral inflow for 3 to 5 cardiac cycles at the mitral valve leaflet tips. Doppler signals were analyzed for mitral valve peak early (E) and late (A) diastolic velocities, E/A ratio, and deceleration time of mitral E velocity (11). Tissue Doppler was applied to measure mitral annular early (e') velocities at the lateral and septal annulus. The resulting annular velocities according to pulsed-wave Doppler were recorded for 3 to 5 cardiac cycles at a sweep speed of 100 mm/s. E/e′ ratios were computed by using the average of the lateral and septal e′. Mitral deceleration index was derived as mitral deceleration time divided by peak E-wave velocity (12). Using at least 3 cardiac cycles, the estimated left atrial pressure (LAP) on the basis of diastolic interatrial septum position on either the apical 4-chamber or parasternal short-axis view was assessed as follows: if neutral atrial septal position, LAP = RAP; if atrial septal position was deviated to the right, LAP = RAP + 5; and if atrial septal position was deviated to the left, LAP = RAP − 5. At least 3 cardiac cycles were analyzed for this variable, and the effect of respiration on this variable was not a protocol mandate. Continuous-wave Doppler from multiple windows recorded tricuspid regurgitation signals. Inferior vena cava diameter and its collapse and hepatic venous flow were recorded in the subcostal view (13). RAP was estimated by using the inferior vena cava diameter and its change with respiration and hepatic venous flow recorded in the subcostal view. Systolic pulmonary artery pressure (sPAP) was derived by using the modified Bernoulli equation as sPAP = 4(v)2 of peak tricuspid regurgitation velocity in meters per second + RAP in millimeters of mercury. Pulmonary vascular resistance (PVR) in Wood units was calculated by using the ratio of peak tricuspid regurgitation velocity (meters per second) to the RVOT time-velocity integral (centimeters) × 10 + 0.16 (14). The pulmonic regurgitation jet was recorded per protocol; however, its feasibility was low and therefore not used to estimate pulmonary artery diastolic pressure.
Mean RAP, systolic and diastolic pulmonary artery pressure, mean pulmonary pressures, and mean PCWP were measured with a pulmonary artery catheter during right heart catheterization. Fluid-filled transducers were balanced before the study with the 0 level at the mid-axillary line. The wedge position was verified by fluoroscopy and changes in the waveform. Cardiac output was derived by thermodilution. Invasive measurements were averaged over at least 5 cycles and were acquired without knowledge of echocardiographic data. The transpulmonary gradient was computed as mean pulmonary artery pressure minus mean PCWP. PVR was calculated (Wood units) as the transpulmonary gradient divided by the calculated cardiac output.
Continuous variables are presented as mean ± SD and compared by using the Student t test; categorical variables are reported as number and percent and were compared by using the chi-square test. To determine the association between RV and LV hemodynamics between echocardiography and right heart catheterization, Pearson correlation analysis with linear regression and Bland-Altman plots were performed. To determine the optimal cutoff values that distinguished patients with normal and elevated PCWP, receiver-operating characteristic curves were constructed. Values of p < 0.05 were considered significant. Feasibility of the derived algorithm was calculated as the number of patients in whom the algorithm could be applied to determine normal versus elevated PCWP divided by the total number of patients evaluated. Accuracy of the algorithm was defined as the number of patients with correctly predicted PCWP (normal or elevated) divided by the total number of patients with a feasible algorithm assessment.
Among 40 patients comprising the initial derivation study population, the mean age was 57 ± 9 years, 32 were male (80%), and 24 had ischemic etiology of heart failure (60%). Table 1 summarizes a comparison of baseline characteristics of patients who had normal (n = 23) versus elevated (n = 17) PCWP at baseline pump speed support. There were no significant differences between groups, including variables that may affect clinical heart failure in patients on CF-LVADs, such as the degree of underlying LV unloading influenced by the baseline pump speed setting, duration of LVAD support, systemic hypertension, and medication utilization. Nine (53%) of 17 patients with resting PCWP >15 mm Hg were symptomatic (NYHA functional class III or IV), with 8 (89%) of these patients readmitted at least once after LVAD placement for clinical heart failure due to partial LV unloading while on CF-LVAD support. In addition, 9 (53%) of the 17 patients with PCWP >15 mm Hg had at least mild or greater mitral regurgitation severity compared with only 22% of the patients with PCWP ≤15 mm Hg, which is also reflective of partial LV unloading.
The invasive hemodynamic profile of those patients with PCWP >15 mm Hg consisted of moderately elevated left-sided filling pressure (mean PCWP 21.2 ± 5.4 mm Hg) with secondary pulmonary hypertension (mean pulmonary artery pressure 34.0 ± 6.8 mm Hg). On the basis of our catheter-derived parameters, an elevated RAP (mean RAP 14.8 ± 5.7 mm Hg) was noted at a baseline mean pump speed of 9,093 ± 471 rpm in 19 of 40 patients. Fourteen (74%) of these 19 patients with elevated RAPs had a concomitant elevated sPAP >40 mm Hg, and 16 (84%) of these 19 patients had an underlying PCWP >15 mm Hg. These results highlight that left-sided heart failure attributed to partial LV unloading while on a CF-LVAD is the main cause of right-sided heart failure in this patient population. The vast majority of patients (76%) with PCWP >15 mm Hg had normal or only mildly reduced qualitative RV systolic function and had normal RV outflow tract cardiac output. As noted in Table 2, the minority of these patients (18%) had tricuspid regurgitation of moderate or greater severity.
Feasibility of echocardiographic measurements
Of 40 patients, right-sided indices, including RAP and RV cardiac output and index, were calculable in 80.6% and 92.5% of the study population, respectively (Table 3). Distinct early and late mitral inflow velocities (E and A) were measurable in 30 (75%) of the patients, and 10 (25%) of the patients had fused or inadequate mitral inflow velocities due to tachycardia and/or suboptimal imaging, respectively. Assessment of tissue Doppler velocities was highly feasible for lateral (92.5%) and septal (87.5%) mitral annular velocities. Tricuspid regurgitation velocities were satisfactorily acquired in 32 patients (80%). Representative echocardiography measurements are shown in Figures 1 and 2⇓.
Estimation of right-sided hemodynamics
Noninvasive and invasive measurements of mean right atrial pressure and sPAP were strongly correlated (r = 0.863 and 0.880, respectively; p < 0.0001) (Figure 3). Echocardiographic estimates of RV outflow tract stroke volume and PVR also had a significant correlation (r = 0.660 and 0.643; p < 0.0001 and 0.001, respectively) (Figure 4). Excluding patients with moderate to severe mitral regurgitation and moderate to severe tricuspid regurgitation, echocardiographic estimates of right-sided or systemic cardiac output while on CF-LVAD support had a significant correlation (r = 0.516; p = 0.002).
Echocardiographic parameters and mean PCWP correlation
Several echocardiographic parameters differed significantly between patients with PCWP ≤15 mm Hg and those with PCWP >15 mm Hg, including: LAVi; mitral A velocity; E/A ratio; RAP; estimated LAP on the basis of the position of the interatrial septum; sPAP; and PVR (Table 2). As demonstrated in Table 3, several of the 18 examined Doppler and 2-dimensional echocardiographic parameters correlated significantly with mean PCWP: mean RAP (r = 0.825; p < 0.0001); sPAP (r = 0.795; p < 0.0001); LAVi (r = 0.488; p = 0.003); PVR (r = 0.451; p = 0.018); mitral A velocity (r = –0.414; p = 0.023); E/A ratio (r = 0.481; p = 0.007); and estimated LAP on the basis of the interatrial position and echocardiography-derived RAP (r = 0.657; p = 0.003). Similarly, several variables showed good accuracy in identifying patients with PCWP >15 mm Hg by using cutoff values established by receiver-operating characteristic curves (Table 4).
Echocardiographic algorithm to distinguish between normal and elevated PCWP
On the basis of good accuracy in identifying patients with PCWP >15 mm Hg, Doppler parameters that had feasibility of at least 75%, including E/A ratio, RAP or sPAP, LAVi, and E/e′, were selected with their respective cutoff values to create an algorithm for estimation of filling pressures. In keeping with an established algorithm to predict elevated left-sided filling pressures in heart failure patients with depressed LVEF, the mitral E/A ratio was selected as the focal point (Figure 5) (11), followed by 3 candidate Doppler parameters: RAP or sPAP, LAVi, and E/e′. Patients with E/A ≤1 and with any 1 other parameter (e.g., RAP ≤10 mm Hg or sPAP ≤40 mm Hg and/or LAVi ≤33 ml/m2 and/or E/e′ ≤14) were examined to detect PCWP ≤15 mm Hg. In contrast, patients with E/A >2 with any 1 parameter such as RAP >10 mm Hg or sPAP >40 mm Hg and/or LAVi >33 ml/m2 and/or E/e′ >14 were examined to detect elevated PCWP (>15 mm Hg). To distinguish between normal and elevated PCWP for patients with E/A ratios >1 to ≤2 (indeterminate group), 2 additional concordant findings from the 3 candidate categories were examined.
The algorithm was feasible in 29 (73%) of the 40 patients. Of the 11 patients for whom the algorithm could not be applied, 4 were in the indeterminate group (E/A ratio >1 to ≤2), and 7 had indistinct E and A waves. These patients either lacked echocardiographic parameters from the 3 candidate categories or had discordant candidate parameters to provide an assessment (normal or elevated PCWP). Overall, the accuracy of the algorithm to distinguish normal from elevated PCWP in the derivation cohort with available candidate echocardiographic parameters (RAP or SPAP, LAVi, and E/e′) was 90% (26 of the 29 patients were appropriately categorized as having normal or elevated PCWP) (Figure 6).
Characteristics of the validation cohort (n = 10) are shown in Table 5. As shown, this patient population was similar to the derivation cohort. The algorithm (Figure 5) could be applied to 9 of the 10 patients (90% feasibility) with an overall accuracy of 89% to correctly distinguish normal from underlying elevated PCWP. It was not possible to apply the algorithm to 1 patient in the validation. This patient had an E/A >1 and ≤2 (indeterminate group), an RAP and SPAP that were unavailable due to feasibility, and left atrial volume index and E/e′ that were discordant (48 ml/m2 with an E/e′ of 11.8, respectively).
The effect of continuous flow (LV to apical inflow cannula) on mitral inflow parameters and, in turn, the association between these echocardiographic parameters and LV filling pressure are incompletely understood. This is the first comprehensive study designed to validate the reliability of noninvasive estimation of intracardiac hemodynamics in patients on CF-LVAD support by using simultaneous echocardiography and right heart catheterization.
Very few studies have examined the correlation among echocardiographic parameters, invasively defined hemodynamics, and adverse outcomes (i.e., clinical heart failure) while on CF-LVAD support. Andersen et al. (15) demonstrated in 12 patients on HeartMate II support that, at rest, tissue Doppler–derived mitral annular peak systolic velocity positively correlated (r = 0.41) with cardiac output by using the thermodilution method. These investigators also showed a positive correlation between the E/e′ ratio with diastolic PAP at rest (r = 0.39). In contrast to the standard echocardiographic surrogates reflective of elevated left-sided filling in patients with heart failure, Topilsky et al. (12) reported that novel parameters, including mitral deceleration index and LAP estimated on the basis of diastolic interatrial septum position, correlated with PCWP among patients with CF-LVADs (n = 8; r = –0.72 and 0.74 for mitral deceleration index and estimated LAP, respectively). However, these studies were limited by sample size and the paucity of echocardiographic parameters examined (12,15). Two other reports demonstrated that in ambulatory patients on CF-LVADs (i.e., 1 to 3 months after implantation), parameters including significant prolongation of the mitral deceleration time, decrease in left atrial size, and decrease in E velocity and the E/e′ ratio were echocardiographic surrogates of decreased LV filling pressure (16,17). These studies did not, however, provide echocardiographic cutoff values that may be important for detecting elevated PCWP while on CF-LVAD support.
Our results, derived from the largest series of patients reported on to date, demonstrate that several echocardiographic parameters (including RAP, an established hemodynamic marker of elevated left-sided pressure in heart failure patients) strongly correlate with invasive hemodynamics. On the basis of our catheter-derived parameters, an elevated RAP in this patient population was predominantly secondary to left-sided heart failure attributed to partial LV unloading (persistently elevated PCWP) while on a CF-LVAD. LAP estimated on the basis of interatrial septum position determined by echocardiography and echocardiography-derived RAP (as originally proposed by Topilsky et al. ) was also among the parameters that correlated with PCWP.
More important than establishing these correlations, we provide potentially important cutoff values to detect elevated PCWP while on CF-LVAD support, including an RAP >10 mm Hg, sPAP >40 mm Hg, and LAVi >33 ml/m2, parameters associated with area under the curves of 0.95, 0.98, and 0.78, respectively. However, accuracy on the basis of sensitivity and specificity ranges for detecting partial unloading (PCWP >15 mm Hg) on CF-LVADs was only modest for individual parameters (38% to 81% and 44% to 100%, respectively). The strength of our proposed algorithm is 2-fold: 1) it is practical in that it includes several standard and readily available parameters that mirror proposed algorithms on the basis of mitral valve inflow indices used to evaluate left-sided filling pressures in heart failure (non-LVAD) patients; and 2) it has good potential accuracy (∼90%) in detecting residual left-sided heart failure. In an increasing destination therapy patient population on CF-LVAD support, in whom comorbidities such as chronic obstructive pulmonary disease and obesity are not uncommon and can contribute to heart failure–like symptoms, this finding has potentially significant clinical diagnostic and management implications. The physical examination is commonly challenging in these types of patients. In such a scenario, we find the provided echocardiography algorithm very useful for diagnosing complete (normal PCWP) or partial (elevated PCWP) LV unloading while on CF-LVAD support. For those patients with NYHA functional class III or greater dyspnea and echocardiographic surrogates of an underlying elevated PCWP, consideration is given to initiate or augment diuretic agents, more aggressively screen for occult hypertension, and to increase the level of pump speed support to decrease PCWP and minimize congestion. In our experience, persistent symptoms of shortness of breath (NYHA functional class III/IV) were associated with underlying elevated PCWP in the majority of these patients. Our derived echocardiography algorithm is most helpful clinically as a complement to the history and physical examination and to confirm underlying partial LV unloading to guide subsequent treatment (Central Illustration). Although the provided algorithm can be successfully applied in the majority of patients, for those with either an uninterpretable echocardiogram due to poor acoustic windows or with equivocal results, we still use invasive right heart catheterization to delineate if persistent dyspnea and/or fatigue are attributed to smoldering left- and/or right-sided heart failure.
To the best of our knowledge, the present study is the first to report the significant correlation between echocardiography and invasively derived PVR while on CF-LVAD support. Echocardiography-derived PVR had a modest correlation with mean PCWP (r = 0.45; p = 0.018) and was somewhat accurate in predicting PCWP >15 mm Hg (area under the curve: 0.73; p = 0.04). However, as with other echocardiographic parameters, echocardiography-derived PVR in isolation cannot reliably distinguish patients with a normal PCWP versus elevated PCWP. Our findings do support the observation that elevated PVR derived by using echocardiography is a marker of partial LV unloading and residual heart failure as reported by others and is a potential marker of worse clinical status while on CF-LVADs (17). Topilsky et al. (12) demonstrated that echocardiographic surrogates of elevated left-sided filling pressure, mitral deceleration index, and LAP estimated on the basis of the interatrial septum position were both associated with adverse 90-day outcomes, defined as persistent NYHA functional class III or IV symptoms, heart failure readmission, or death. In our study, LAP estimated on the basis of interatrial septum position correlated with mean PCWP and was significantly different between patients with PCWP ≤15 mm Hg versus >15 mm Hg. However, because this parameter was predominantly driven by echocardiography-derived RAP, and RAP was associated with greater significance in its correlation with mean PCWP compared with estimated LAP by using the interatrial septum position, it is not a parameter in our proposed algorithm. In addition, this parameter had lower feasibility versus other parameters. Also, in contrast to the study of Topilsky et al. (12), the calculated mitral deceleration index in our cohort of patients did not correlate with mean PCWP. In our patients, a mitral deceleration index cutoff value <2.5 was sensitive (81%); however, it lacked specificity (44%) to accurately predict PCWP compared with other standard echocardiographic parameters.
Our results demonstrate that Doppler and 2-dimensional echocardiography can be readily applied to the majority of patients implanted with a CF-LVAD. A comprehensive right-sided hemodynamic profile including RAP, RV stroke volume, PVR, and sPAP was feasible in the majority of our patients. In addition, we were able to apply the proposed algorithm to distinguish normal and elevated PCWP, which incorporates left atrial volume index and E/e′ with good feasibility and accuracy.
Our study limitations included the fact that this was a single-center experience, was of limited sample size for those with persistently elevated PCWP on CF-LVAD support, and was a relatively small validation cohort; this design resulted in larger confidence intervals despite optimal correlation coefficients and suggests that external validation of our results in larger cohorts is needed. Also, several key echocardiographic variables could not be measured in all patients. Our study examined only 1 type of CF-LVAD on the basis of axial flow physiology, and our findings may therefore not be applicable to patients on other types of CF-LVADs. Although our proposed echocardiographic algorithm to distinguish normal versus elevated PCWP was feasible in the majority of patients (76%), it may not be possible to apply in some patients.
Doppler echocardiographic estimation of left-sided and right-sided hemodynamics in patients supported with CF-LVADs remains accurate. Our proposed diagnostic algorithm integrating simple and standard echocardiographic parameters (i.e., mitral E/A ratio, RAP, sPAP, LAVi, E/e′) can reliably distinguish between normal and elevated LV filling pressures on baseline levels of LVAD support and can be used to detect partial LV unloading. Our findings merit validation in a larger, multicenter study. Future research should focus on whether these echocardiographic parameters or a combination of parameters are sensitive to filling pressure changes.
COMPETENCY IN MEDICAL KNOWLEDGE: Doppler velocity measurements provide accurate estimation of intracardiac pressures in patients supported with the HeartMate II CF-LVAD.
COMPETENCY IN PATIENT CARE: Doppler-echocardiography can provide an objective estimate of pulmonary capillary wedge pressure and right heart pressures to guide management of a patient with persistent heart failure symptoms despite CF-LVAD support.
TRANSLATIONAL OUTLOOK: Further studies are needed to understand the limitations of Doppler-echocardiography in patients with heart failure receiving CF-LVAD support and to define the specific therapeutic implications of these noninvasive hemodynamic assessments.
Dr. Estep has received consulting fees from Thoratec Corp. All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- mitral inflow late diastolic filling peak velocity
- continuous-flow left ventricular assist device
- mitral inflow early diastolic filling peak velocity
- early diastolic mitral annular velocity
- left atrial pressure
- left atrial volume index
- left ventricular
- left ventricular assist device
- New York Heart Association
- pulmonary capillary wedge pressure
- pulmonary vascular resistance
- right atrial pressure
- revolutions per minute
- right ventricular
- right ventricular outflow tract
- systolic pulmonary artery pressure
- Received March 20, 2014.
- Revision received May 16, 2014.
- Accepted June 3, 2014.
- American College of Cardiology Foundation
- Estep J.D.,
- Stainback R.F.,
- Little S.H.,
- et al.
- Nagueh S.F.,
- Bhatt R.,
- Vivo R.P.,
- et al.
- Hasin T.,
- Marmor Y.,
- Kremers W.,
- et al.
- Smedira N.G.,
- Hoercher K.J.,
- Lima B.,
- et al.
- Feldman D.,
- Pamboukian S.V.,
- Teuteberg J.J.,
- et al.,
- for the International Society for Heart and Lung Transplantation
- Lang R.M.,
- Bierig M.,
- Devereux R.B.,
- et al.,
- for the Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography
- Quinones M.A.,
- Otto C.M.,
- Stoddard M.,
- et al.,
- for the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography
- Estep J.D.,
- Chang S.M.,
- Bhimaraj A.,
- et al.
- Topilsky Y.,
- Hasin T.,
- Oh J.K.,
- et al.
- Rudski L.G.,
- Lai W.W.,
- Afilalo J.,
- et al.
- Abbas A.E.,
- Fortuin F.D.,
- Schiller N.B.,
- et al.
- Andersen M.,
- Gustafsson F.,
- Madsen P.L.,
- et al.