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Background:Early trans-mitral inflow velocity and mitral annular tissue Doppler imaging (E/Em ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However, E/Em ratio has a significant gray zone among patients with severely impaired ejection fraction. Speckle tracking echocardiography (STE) was recently proposed as an alternative surrogate to estimate LV filling pressures. This study aimed at assessing performance of tissue Doppler parameters and left atrial global longitudinal strain as noninvasive surrogates for LV filling pressures and comparing accuracy of these two parameters across different striae of LVEF. Methods: A total of 96 patients with sinus rhythm and different ejection fraction who divided into four groups of 24 patients each according to their EF(>55%, 45–54%, 30– 44%, and <30%), had an invasive measurement of the LV pressure. Both medial and lateral E/Em ratio were measured in all subjects by 2D Tissue Doppler, peak atrial longitudinal strain (PALS) and Peak atrial contraction strain (PACS) were obtained by averaging all segments measured in the 4-chamber. Results: Significant Correlation between global PALS and invasive LVEDP in all groups (r = 0.70 P < 0.000), While Lateral E/E’ shows significant correlation only in two groups; preserved and mildly impaired EF (r=0.42 P=0.023, r=0.439 p-0.032; respectively) Conclusion:In patients with preserved or mildly reduced LV ejection fraction, global PALS and Lateral E/E’ ratio presented good correlations with LVEDP. In patients with moderate or severe reduction of EF, E/E’ ratio correlated poorly with invasively measured LV filling pressures. Global PALS provided an overall better estimation of LV filling pressures. Background Heart failure is among the most common causes for hospitalization in patients older than 65 years of age in the developed world. In Egypt alone, approximately 3 million patients are hospitalized each year with a primary or secondary diagnosis of heart failure, and AHF contributes to more than 7 million hospital days annually. Elevated left ventricular filling pressure (LVFP) is a major determinant of cardiac symptoms and prognosis in patient with chronic heart failure independent from LV ejection fraction (EF). There is conversing evidence that left atrial enlargement determined by echocardiography strongly and independently predicts many cardiovascular outcomes as it reflects chronic exposure to increase LV filling pressure. Left cardiac catheterization allows an accurate and direct evaluation of some hemodynamic variables that estimate LVFP, although it’s a tool not completely free from complication. PDF created with pdfFactory Pro trial version www.pdffactory.com SOHAG MEDICAL JOURNAL Comparing the Performance of Tissue Doppler versus Left Atrial Strain Vol. 22 No.1 Jan 2018 Aliaa Tarek Mahfouz 214 Despite its wide use, the real utility of E/e’ ratio has been challenged in some studies which include patient with either very advanced heart failure or normal LV ejection fraction.Recently peak atrial longitudinal strain determined by speckle tracking has demonstrated to be more accurate than E/e’ ratio to estimate pulmonary capillary wedge pressure or left ventricular end diastolic pressure in patients with advanced heart failure. Methods: Study population: A total of 96 compensated heart failure patients indicated for left heart catheterization were enrolled. This population was selected in order to have four equal groups clustered according to LV ejection fraction (≥55% ; ≥45% to 54% ; ≥30% to 44%; and <30%). All patients were selected aged >18years, in normal sinus rhythmwho agreed to an informed written consent. All had clinical evaluation to ensure having symptoms and/or signs of heart failure. Patients were scheduled for cardiac catheterization after receiving optimal medical therapy and achieving euvolemic or near euvolemic status. All underwent a two-dimensional and Doppler echocardiographic examination within 24 hours from the catheterization. Patients with recent acute coronary syndrome <48 hours, prosthetic valves, more than grade two mitral regurgitation, any kind of implantable cardiac devices, pericardial diseases and insufficient imaging quality of the LA endocardial border were excluded. Cardiac catheterization: A 6F multipurpose catheter was balanced to atmospheric pressure and then inserted through a hemostasis valve into the lumen of the fluid-filled catheter to its distal end. It was advanced into the LV cavity through retrograde radial or femoral artery approach. The pressure measurements were obtained with high fidelity manometer-tipped catheter and were calibrated against the pressure measured simultaneously with the fluid filled catheter at end diastole. An elevated LVEDP was defined as >12 mmHg. Two-D Echocardiography: All patients were studied in the left lateral decubitus position using an ultrasound system (Philips IE 33, Philips,Andover, MA) using a Philips “S5” transducer. Standard two dimensional, M-mode and Tissue Doppler echocardiograms were obtained in the apical 4 and 2 chambers and left parasternal views according to the American society of echocardiography (ASE) guidelines.Measurements of left ventricular (LV),left atrial (LA) dimensions, LV ejection fraction using biplane Simpson’s method and diastolic LV filling velocities were obtained in accordance with ASE recommendations. The ratio between peak early (E) and late (A) diastolic LV filling velocities was used as standard index of LV diastolic function. LA volumes were measured using the area–length method, from the apical fourand two-chambers views, the time interval between the onset of QRS on the electrocardiogram and theaortic and mitral opening and closures were measured using pulsed wave Doppler.Early diastolic (E’), and late diastolic (A’) annular velocities were obtained by averaging respective values measured at the septal and lateral sides of the mitral annulus. Mean E’ and the derived E/E’ ratio were used as loadindependent markers of ventricular diastolic relaxation.

sohag medical journal

Comparing the Performance of Tissue Doppler versus Left Atrial Strain in Predicting Left Ventricular End Diastolic Pressure in Patients with Different Left Ventricular Ejection Fractions