Author + information
- Anthony C. Pearson, MD∗ ()
- ↵∗Noninvasive Cardiac Imaging, St. Luke’s Hospital, 7331 Cornell Avenue, St. Louis, Missouri 63130
Andersen et al. (1) are to be congratulated for their work on testing recent guidelines (2) to estimate left ventricular (LV) filling pressure using echocardiography. I have several concerns about the utility of this approach.
First, E/e’ (the ratio between early mitral inflow velocity and mitral annular early diastolic velocity) is clearly the most useful predictor of LV filling pressure. In fact, if E/e’ is <14 even with tricuspid regurgitant velocity elevated and left atrial volume index high, only 11 of 19 patients had left ventricular elevated filling pressure (LVEFP). Thus, the algorithm in this case would have one reporting out “Grade II, diastolic dysfunction, high left atrial pressure” on a patient in whom 50% of the time the LVEFP is normal.
Second, the authors state that “the algorithm is based on the interpretation of 2D and Doppler signals in patients with cardiovascular diseases and not in patients without cardiac diseases who are explicitly excluded from the algorithm” (1). It is not clear from the paper what qualified patients as having cardiovascular disease. Indeed, deciding which patients qualify for this algorithm is quite problematic because most echocardiograms in clinical practice are read without complete knowledge of the patient’s clinical history. For instance, a patient with significant coronary artery disease could have normal appearing LV size and function by 2-dimensional echocardiography: a reader of the echocardiogram would call “normal diastolic function” if unaware of that history and call “abnormal diastolic function” if aware of the coronary artery disease. Similarly, presumably LV hypertrophy puts the patient in the category of “myocardial disease.” Most clinical echocardiography laboratories do not routinely or accurately measure LV mass index, the gold standard of LV hypertrophy.
Third, mitral annular calcification has a profound effect on mitral inflow independent of LVEFP. It would be instructive to know how many study patients had severe mitral annular calcification and whether this group skewed the overall results.
In an accompanying editorial (3), the authors note that the 2009 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines were widely criticized for being “awkward, ambiguous and frequently wrong.” It does not appear that the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines will be able to eliminate those criticisms.
Finally, I would agree that diastolic function assessment from noninvasive data is “an impossible mission” and question why guidelines and echocardiographers continue to refer to grades of “diastolic dysfunction” when LVEFP is dependent on factors other than diastolic dysfunction.
Please note: Dr. Pearson has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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