Visualization of left atrial appendage and assessment of its function by transthoracic second harmonic imaging and contrast-enhanced pulsed Doppler.

BACKGROUND: Low flow velocity within the left atrial appendage, as assessed by transoesophageal echocardiography, is a predictor of thromboembolism and of a low success rate of cardioversion of atrial fibrillation. However, the semi-invasive nature does limit its serial application as a screening technique. METHODS AND RESULTS: We investigated the value of transthoracic second harmonic echocardiography and pulsed Doppler at baseline and after intravenous contrast injection to visualize the left atrial appendage and assess blood flow velocities within its cavity. We studied 51 consecutive patients undergoing transoesophageal echocardiography. After transoesophageal echocardiography, transthoracic second harmonic imaging was performed and the left atrial appendage was visualized in 46 patients. Interpretable pulsed Doppler tracings of left atrial appendage flow were obtained at baseline in 39 patients and in 45 patients during Levovist administration. The correlations between peak emptying velocity of left atrial appendage as measured by transoesophageal echocardiography and by transthoracic standard and contrast-enhanced Doppler were 0.81 and 0.91, respectively. The agreement between transoesophageal echocardiography and transthoracic contrast-enhanced pulsed Doppler echocardiography in classifying left atrial appendage flow velocity patterns was 93%. Left atrial appendage thrombus was detected by transthoracic second harmonic imaging in only one of the eight patients shown by transoesophageal echocardiography to have a thrombus. However, all but one of the patients with left atrial appendage thrombus and/or spontaneous echocardiographic contrast at transoesophageal echocardiography had <30cm/s left atrial appendage flow velocity by transthoracic Doppler. CONCLUSIONS: This study shows that left atrial appendage can be visualized by transthoracic second harmonic imaging and that the flow velocity within its cavity is reliably measured by pulsed Doppler in a substantial fraction of patients. Contrast enhancement improves the feasibility and the accuracy of transthoracic evaluation of left atrial appendage flow velocity. The practical value of these results in predicting thromboembolic risk and success of cardioversion of atrial fibrillation needs to be proved by prospective studies.

Doppler echocardiography reliably predicts pulmonary artery wedge pressure in patients with chronic heart failure even when atrial fibrillation is present.

BACKGROUND AND AIMS: In patients with chronic congestive heart failure a high pulmonary artery wedge pressure (PAWP) is associated with poor prognosis, severe symptoms and low exercise tolerance. When atrial fibrillation is present the non-invasive prediction of PAWP by Doppler echocardiography is generally considered to be not reliable. METHODS: In 51 consecutive patients with chronic heart failure, due to either ischemic and non-ischemic dilated cardiomyopathy, and atrial fibrillation simultaneous Doppler echocardiographic and hemodynamic studies were used to estimate PAWP. The power of the obtained multivariate equation was compared with that of previously developed equations and was then prospectively tested in a group of 15 patients. RESULTS: The deceleration rate (DR) of early diastolic mitral flow, the left ventricular iso-volumic relaxation time (IVRT) and the systolic fraction of pulmonary venous flow (SF) were independent predictors of PAWP and the following multivariable equation was derived: PAWP=24.04 + 1.23 x DR- 0.089 x IVRT - 0.175 x SF. The correlation between invasive PAWP and the PAWP non-invasively estimated by this equation in the testing group was 0.91 (standard error of estimate=3.2 mmHg). The mean difference was 0.93 and the standard error of differences was 2.7 mmHg. CONCLUSION: In patients with chronic heart failure due to dilated cardiomyopathy who are in atrial fibrillation a relatively accurate estimation of PAWP can be obtained by Doppler echocardiography of mitral and pulmonary venous flow.

[Non-invasive evaluation of the hemodynamic profile in patients with heart failure: estimation of left atrial pressure]. / Valutazione non invasiva del profilo emodinamico nel paziente con scompenso cardiaco: stima della pressione atriale sinistra.

The management of patients with heart failure requires an accurate and non-invasive estimation of left ventricular filling pressures. This is essential in order to optimize unloading treatment, interpret equivocal symptoms, assess disease severity (and prognosis), and follow up the hemodynamic effect of long-term treatments. Since Doppler technique was implemented, several non-invasive methods to estimate left ventricular filling pressures were developed. Among these, a method based on the calculation of the left ventricular-atrial pressure gradient and its subtraction from systolic arterial blood pressure can be used in patients with significant mitral regurgitation and well-defined continuous wave Doppler signal of the regurgitant flow. Mitral and pulmonary venous flow velocities, as assessed by pulsed Doppler, are closely related to left atrial pressures, and several derived indices can be used to qualitatively estimate left ventricular filling pressures in patients with heart failure due to left ventricular systolic dysfunction who are in sinus rhythm. Furthermore, the combination of these indices in multivariable equations can improve this relationship and allows for a quantitative estimation of filling pressures, even in patients with significant mitral regurgitation and atrial fibrillation. There are, however, several groups of patients with heart failure in whom pulsed Doppler of mitral and pulmonary venous flow provides limited hemodynamic information. These include those with a) sinus tachycardia and/or prolonged P-R interval; b) normal left ventricular systolic function (and "pure" diastolic heart failure); c) primarily abnormal left atrial dysfunction (such as patients who had undergone heart transplantation), and d) technically inadequate Doppler recordings of pulmonary venous flow. To assess left ventricular filling pressures in these patients, two new methods which combine pulsed Doppler mitral flow indices with load-independent indices of left ventricular relaxation (either early diastolic velocity of mitral annulus, as assessed by tissue Doppler, or propagation velocity of mitral inflow, as assessed by color M-mode) can be used.

Dobutamine stress echocardiography and thallium-201 SPECT for detecting ischaemic dilated cardiomyopathy in patients with heart failure.

AIMS: A diagnosis of ischaemic aetiology of a dilated cardiomyopathy has important therapeutic and prognostic implications. In such patients, abnormal ECG and atypical symptoms limit the usefulness of standard ECG-ergometry in detecting myocardial ischaemia. To assess the values of high-dose dobutamine stress echocardiography and of Thallium-201 SPECT (exercise-reinjection-rest protocol) in differentiating between ischaemic and non-ischaemic dilated cardiomyopathy, 37 patients with suspected myocardial ischemia, low ventricular ejection fraction (23 +/- 5%) and heart failure were studied. METHODS AND RESULTS: Coronary artery disease was defined as >50% coronary stenosis in at least one coronary artery. By dobutamine stress echocardiography, ischaemic dilated cardiomyopathy was considered present when either an ischaemic response (biphasic response or direct deterioration) or a scar (fixed dyssynergy) was documented in at least two segments. By Thallium-201 SPECT, severe perfusion defects, either reversible (ischaemia) or fixed (scar), in at least two segments were considered markers of ischaemic dilated cardiomyopathy. Twenty-three patients had ischaemic dilated cardiomyopathy, while 14 had normal coronary arteries. The presence of myocardial ischaemia and/or scar by dobutamine stress echocardiography identified patients with ischaemic dilated cardiomyopathy with a sensitivity of 100% and a specificity of 86%. The sensitivity of Thallium-201 SPECT was 92%, its specificity was 69%. Three of the four false positive results occurred in patients with left bundle branch block. Thirty-two patients were concordantly classified by the two techniques (agreement=86%, k=0.73). CONCLUSION: Both dobutamine stress echocardiography and Thallium-201 SPECT are sensitive techniques for detecting the ischaemic aetiology of dilated cardiomyopathy. The specificity is lower, particularly by SPECT, when left ventricular branch block is present.

The bicaval anastomosis technique for orthotopic heart transplantation yields better atrial function than the standard technique: an echocardiographic automatic boundary detection study.

BACKGROUND: Atrial function is an important determinant of cardiac performance. In patients who undergo operation by standard heart transplantation atrial enlargement, distortion of geometry and asynchronous contraction resulting from the donor/recipient atrial connections may affect atrial function. The bicaval anastomosis technique should be free from these limitations. METHODS: We used the echocardiographic automatic boundary detection technique to obtain on-line time/volume curves of right and left atria from patients who had undergone bicaval (n = 22) or standard (n = 27) heart transplantation and from 15 control subjects. Maximal, middiastolic, preatrial contraction, and minimal volumes of both atria were measured. Reservoir volume (defined as the difference between maximal and middiastolic atrial volumes); pump volume (defined as the difference between preatrial contraction and minimal atrial volumes); and conduit volume (defined as the difference between left ventricular stroke volume and the sum of reservoir and pump volumes) were derived for both atria. Atrial emptying fraction was calculated as the difference between maximal and minimal volumes divided by the maximal volume and expressed in percent and pump fraction as the pump volume divided by the sum of reservoir and pump volumes. Tricuspid and mitral regurgitation, evaluated by color-flow Doppler scanning, were considered significant when they were greater than grade 1. Atrial ejection force was calculated from mitral and tricuspid flow velocities at atrial contraction. RESULTS: In patients who had bicaval heart transplantation, both atria were smaller than in patients who underwent standard heart transplantation. With the bicaval technique right and left atrial emptying (right 45% +/- 9% vs 36% +/- 10%, p < .05; left 51% +/- 8% vs 39% +/- 8%, p < .001) and pump fractions (right 57% +/- 17% vs 19% +/- 13%, p < .001; left 45% +/- 28% vs 22% +/- 12%, p < .01) were greater than with the standard technique and similar to those in control subjects. Right atrial ejection force was significantly greater in bicaval (10.0 +/- 5.6 kdyne) than in standard heart transplantation (4.5 +/- 2.2 kdyne, p < .0001). Significant tricuspid or mitral regurgitation was rarely found in bicaval heart transplant recipients (3 and 1 of the 22 patients, respectively), although they were much more frequent after standard heart transplantation (13 and 8 of the 27 patients, respectively). CONCLUSIONS: Heart transplantation performed with the bicaval anastomosis technique determines smaller atrial volumes, yields better right and left atrial function and fewer atrioventricular valve regurgitation than the standard technique.

Predictors of primary atrial fibrillation and concomitant clinical and hemodynamic changes in patients with chronic heart failure: a prospective study in 344 patients with baseline sinus rhythm.

OBJECTIVES: This study investigated the incidence, predisposing factors and significance of the onset of atrial fibrillation (AF) in patients with chronic congestive heart failure (CHF). BACKGROUND: The association between CHF and AF is well documented, but the factors that predispose to the onset of the arrhythmia and its impact remain controversial. Methods. We prospectively followed up 344 patients with CHF and sinus rhythm (SR). Over a period of 19 +/- 12 months (mean +/- SD), 28 patients developed atrial fibrillation (AF), which became chronic in 18. RESULTS: At baseline, no differences were found in any clinical and hemodynamic variables between patients who developed chronic AF and those who did not. Reversible AF occurring during follow-up and lower mitral flow velocity at atrial contraction as detected at the last evaluation in SR were independent predictors of the subsequent development of chronic AF. When AF occurred, New York Heart Association functional class worsened (from 2.4 +/- 0.5 to 2.9 +/- 0.6, p = 0.0001), peak exercise oxygen consumption declined (from 16 +/- 5 to 11 +/- 5 ml/kg per min, p = 0.002), cardiac index decreased (from 2.2 +/- 0.4 to 1.8 +/- 0.4, p = 0.0008), and mitral and tricuspid regurgitation increased (from grade 1.8 +/- 1.1 to grade 2.4 +/- 1.4, p = 0.0001 and from grade 1.0 +/- 1.2 to grade 1.8 +/- 1.2, p = 0.001, respectively). Systemic thromboembolism occurred in 3 of the 18 patients with AF. Nine of 18 patients died after AF, and the occurrence of AF was a predictor of major cardiac events. CONCLUSIONS: In patients with CHF, reversible AF and reduction of left atrial contribution to left ventricular filling predict the subsequent development of chronic AF. The onset of AF is associated with clinical and hemodynamic deterioration and may predispose to systemic thromboembolism and poorer prognosis.

Arterial baroreflex modulation of heart rate in chronic heart failure: clinical and hemodynamic correlates and prognostic implications.

BACKGROUND: In chronic heart failure (CHF), arterial baroreflex regulation of cardiac function is impaired, leading to a reduction in the tonic restraining influence on the sympathetic nervous system. Because baroreflex sensitivity (BRS), as assessed by the phenylephrine technique, significantly contributes to postinfarction risk stratification, the aim of the present study was to evaluate whether in CHF patients a depressed BRS is associated with a worse clinical hemodynamic status and unfavorable outcome. METHODS AND RESULTS: BRS was assessed in 282 CHF patients in sinus rhythm receiving stable medical therapy (age, 52+/-9 years; New York Heart Association [NYHA] class, 2.4+/-0.6; left ventricular ejection fraction [LVEF], 23+/-6%). The BRS of the entire population averaged 3.9+/-4.0 ms/mm Hg (mean+/-SD) and was significantly related to LVEF and hemodynamic parameters (LVEF, P<.005; cardiac index and pulmonary wedge pressure, P<.001 by regression analysis). Patients in NYHA classes III or IV and those with severe mitral regurgitation had markedly depressed vagal reflexes. The association of BRS with survival was described after its categorization in three groups: below the lowest quartile (<1.3 ms/mm Hg), between the lowest quartile and the median (1.3 to 3 ms/mm Hg), and above the median (>3 ms/mm Hg). During a mean follow-up of 15+/-12 months, 78 primary events (cardiac death, nonfatal cardiac arrest, and status 1 priority transplantation) occurred (27.6%). BRS was significantly related to outcome (log rank, 9.1; P<.01), with a relative risk of 2.7 (95% confidence interval, 1.6 to 4.7) for patients with the major derangement in BRS (<1.3 ms/mm Hg). At multivariate analysis, BRS was an independent predictor of death after adjustment for noninvasive known risk factors but not when hemodynamic indexes were also considered. In CHF patients with severe mitral regurgitation, however, BRS remained a strong prognostic marker independent of hemodynamic function. CONCLUSIONS: In moderate to severe CHF, a depressed sensitivity of vagal reflexes parallels the deterioration of clinical and hemodynamic status and is significantly associated with poor survival. Particularly in patients with severe mitral regurgitation the baroreceptor modulation of heart rate provides prognostic information of incremental value to hemodynamic parameters.

Sleep disorders and breathing alterations in patients with chronic heart failure.

Cheyne-Stokes respiration can appear during sleep in patients with chronic heart failure and is generally attributed to a tendency to hyperventilate causing PCO2 to fall below the apnea threshold. We recorded sleep pattern and nocturnal arterial oxygen desaturation during Cheyne-Stokes respiration and correlated those with hemodynamic alterations, in order to investigate their possible role in the evolution of chronic heart failure. Sixty chronic heart failure patients, after optimization of therapy, underwent a polysomnographic study and hemodynamic and echocardiographic evaluations within a few days. The patients were then enrolled in the follow-up of our pre-transplantation program. Only slight alterations of sleep architecture were detected. During sleep, Cheyne-Stoke respiration was present in 50% and arterial oxygen desaturations in 54% of patients. An increased pulmonary wedge pressure (24.7 +/- 8.3 vs 16.7 +/- 8.9 mmHg, p < 0.000) was significantly correlated with the presence of nocturnal Cheyne-Stokes episodes, while cardiac index was not (1.9 +/- 0.6 vs 2.0 +/- 0.5 l m-2 min-1, p = 0.42). In a multivariate analysis of hemodynamic and polysomnographic data, mortality or heart transplantation in status 1 was predicted at the two year follow-up only by an increased pulmonary wedge pressure. In conclusion, in advanced chronic heart failure, with optimized therapy, nocturnal Cheyne-Stokes respiration is present in half of the cases, with concomitant falls in arterial oxygen desaturation. These events were not independently predictive of mortality. The strong correlation found between increased left ventricular filling pressure and presence of Cheyne Stokes respiration and the lack of correlation with cardiac index suggest that other hemodynamic mechanisms besides reduced cardiac output are responsible for this respiratory abnormality.

Loading manipulations improve the prognostic value of Doppler evaluation of mitral flow in patients with chronic heart failure.

BACKGROUND: Mitral flow velocity patterns (MFVPs) evaluated by Doppler echocardiography are strong predictors of survival in various cardiac diseases. However, MFVPs may change over time according to loading conditions. We performed this prospective study to assess whether changes in MFVP induced by loading manipulations provided additional prognostic information in 173 patients with chronic heart failure. METHODS AND RESULTS: Simultaneous Doppler echocardiographic and right-sided hemodynamic recordings were obtained at baseline in all patients, during nitroprusside infusion in the 98 patients who had a baseline restrictive (early-to-late flow velocity ratio > 1 and deceleration time < or = 130 ms) MFVP, and during passive leg lifting in the 75 patients who had a baseline nonrestrictive MFVP. Patients were categorized, according to changes in MFVP, into four groups: 61 patients with an irreversible restrictive, 37 with a reversible restrictive, 48 patients with a stable nonrestrictive, and 27 patients with an unstable nonrestrictive MFVP. Fifty patients experienced major cardiac events. Cox analysis revealed that MFVP was a strong predictor of events and that the response to loading manipulations improved its prognostic value. Patients with an irreversible restrictive MFVP had a higher event rate (51%) than patients with a reversible restrictive MFVP (19%). Among patients with a baseline nonrestrictive MFVP, those with a stable nonrestrictive MFVP had the lowest event rate (6%), whereas the event rate was 33% in patients with an unstable nonrestrictive MFVP. CONCLUSIONS: In patients with chronic heart failure, MFVPs provide independent prognostic information. Their prognostic value can be further increased by assessment of the changes induced in them by loading manipulations.

Dobutamine and nitroprusside infusion in patients with severe congestive heart failure: hemodynamic improvement by discordant effects on mitral regurgitation, left atrial function, and ventricular function.

OBJECTIVES: In patients with severe heart failure additional therapeutic support with intravenous inotropic or vasodilator drugs is frequently used in the attempt to obtain hemodynamic control. The nature and extent to which diastolic filling, atrial function, and mitral regurgitation are modified by these drugs have not been fully explored. The aim of this study was to compare the acute adaptations of the left ventricular performance, left atrial function, and mitral regurgitation that accompanied hemodynamic improvement during intravenous dobutamine and nitroprusside infusions in patients with severe chronic heart failure. METHODS: Forty consecutive patients with severe heart failure were evaluated by simultaneous echo-Doppler and hemodynamic investigations at baseline and during nitroprusside and dobutamine administration. Mitral flow velocity variables, left atrial and ventricular volumes, left atrial reservoir, conduit and pump volumes, and mitral regurgitation jet area were compared by analysis of variance for repeated measurements. RESULTS: Nitroprusside increased cardiac output (2.1 +/- .5 vs 2.6 +/- .5 L/min/m2, p < 0.004), reduced left ventricular filling pressure (25 +/- 6 vs 14 +/- 4 mm Hg, p < 0.0001), and improved left atrial pump volume (19 +/- 3 vs 26 +/- 12 ml, p < 0.02) without variations in left atrial reservoir and conduit volume. The restoration of preload reserve and improvement of the atrial contribution to left ventricular diastolic filling were demonstrated by the Doppler mitral flow pattern, which moved from a restrictive to a normal pattern. Furthermore mitral regurgitation decreased in all patients (9 +/- 4.6 vs 4.6 +/- 3.4 cm2, p < 0.0001). Dobutamine increased cardiac output (2.1 +/- .5 vs 2.8 +/- .6 L/min/m2), but the effects on pulmonary wedge pressure and mitral regurgitation were variable and unpredictable. Left atrial reservoir and conduit volumes increased, whereas left atrial pump volume did not change (19 +/- 13 vs 22 +/- 14 ml, p = NS). Furthermore Doppler mitral flow showed a persistent restrictive pattern. CONCLUSIONS: In patients with advanced congestive heart failure both nitroprusside and dobutamine improve cardiac output, with different adaptations of left ventricular performance and left atrial function. Nitroprusside seems to restore both atrial and ventricular pump function better. Careful echo-Doppler monitoring during drug infusion provides information relevant to the clinical treatment of individual patients.

Assessment of right ventricular function in patients with congestive heart failure by echocardiographic automated boundary detection.

In patients with chronic heart failure, echocardiographic automated boundary detection (ABD) can reliably assess right ventricular function. The measurements obtained by ABD were highly reproducible, strongly correlated with radionuclide right ventricular ejection fraction, and superior to those obtained by conventional manual echocardiographic methods.

Mitral flow velocity changes after 6 months of optimized therapy provide important hemodynamic and prognostic information in patients with chronic heart failure.

Transmitral flow velocity patterns evaluated by Doppler echocardiography provide important hemodynamic and prognostic information in various cardiac conditions. However, these patterns may change over time, and so far the hemodynamic and prognostic significance of these changes has not been established. Accordingly, we performed this study to determine the hemodynamic and prognostic value of changes in transmitral flow velocity patterns after 6 months of optimized medical treatment in patients with chronic heart failure due to ischemic or nonischemic dilated cardiomyopathy. Ninety-eight consecutive patients with chronic heart failure underwent a clinical examination, a cardiopulmonary exercise test, and simultaneous Doppler echocardiographic and hemodynamic studies at baseline and after 6 months, patients were followed up for 12 +/- 7 months. Cardiac death and heart transplantation while patients were in critical condition were considered events. A restrictive pattern was defined by an early-to-late peak diastolic velocity ratio > 1 and an early diastolic deceleration time < or = 130 msec. Patients were grouped according to their mitral flow pattern at baseline and its changes after chronic optimized therapy. No significant changes in clinical, ergometric, and hemodynamic variables were found after 6 months in the 49 patients who had a persistent restrictive transmitral flow pattern or the 24 patients who had a persistent nonrestrictive transmitral flow pattern. In the 19 patients who had a restrictive pattern at baseline that reverted into a nonrestrictive pattern, this change was accompanied by a highly significant reduction in pulmonary wedge pressure (from 25 +/- 7 mm Hg to 11 +/- 3 mm Hg) and by an increase in exercise capacity, whereas in the 6 patients who had a nonrestrictive pattern that became restrictive, hemodynamic features markedly deteriorated. Seventeen of the 21 events occurred in the 49 patients (event rate 35%) with a persistent restrictive pattern, whereas the event rate was much lower in the 19 patients with a reversible restrictive pattern (5%) and in the 24 patients with a persistent nonrestrictive pattern (4%). Two (33%) of the 6 patients in whom a restrictive pattern developed had events. Cox analysis revealed that a restrictive transmitral flow pattern (p = 0.0068) and peak rate of oxygen consumption (p = 0.0056) detected at the late examination were significantly related to cardiac events. These results show that in patients with chronic heart failure, changes in transmitral flow patterns after chronic optimized therapy are correlated with changes in pulmonary wedge pressure, are accompanied by changes in functional capacity, and provide relevant independent prognostic information.

[Pulmonary venous flow in patients with chronic heart failure: feasibility and additional value compared to transmitral flow for non-invasive estimation of pulmonary wedge pressure]. / Flusso venoso polmonare in pazienti con scompenso cardiaco cronico: fattibilità e valore incrementale rispetto al flusso transmitralico per la stima non invasiva della pressione capillare polmonare.

BACKGROUND: In many cardiac conditions, Doppler of transmitral flow has been showed to be related to left ventricular filling pressure, but several factors may limit its practical value in estimating pulmonary wedge pressure in patients with chronic heart failure. Pulmonary venous velocities directly depend on the oscillations of left atrial pressure. Recent studies suggest that transthoracic Doppler of pulmonary venous flow provides a more accurate estimation of pulmonary wedge pressure. However the relative values of transmitral and pulmonary venous flow for assessing pulmonary wedge pressure in patients with chronic heart failure have not been fully classified until now. Accordingly, we performed this study to assess the feasibility of transthoracic Doppler of pulmonary venous flow in patients with chronic heart failure and to evaluate whether it provides additional information regarding pulmonary wedge pressure when compared with Doppler indices of transmitral flow. METHODS: Simultaneous Doppler echocardiographic examinations and right heart catheterizations were performed prospectively in 300 consecutive patients with chronic heart failure due to dilated cardiomyopathy. The correlations of mitral and pulmonary venous flow velocity variables, left atrial volumes, mitral regurgitation jet area and left ventricular ejection fraction with pulmonary artery wedge pressure were evaluated. RESULTS: A complete recording of transthoracic pulmonary venous flow including all components was obtained in 66% of patients, while only systolic and diastolic forward flow were recorded in 88% of patients. Several indices, derived from pulmonary venous flow, were correlated with pulmonary wedge pressure; the strongest correlation was between systolic fraction of peak velocities and pulmonary wedge pressure (r = -0.76). This value was similar to that obtained between deceleration rate (r = 0.78) and deceleration time (r = -0.67) of transmitral flow and pulmonary wedge pressure. A systolic fraction > 40% showed a greater positive predictive value than restrictive pattern of transmitral flow for identifying patients with pulmonary wedge pressure > 18 mmHg (95% vs 86% p < 0.05). This accuracy is confirmed also in patients who had a single peak of transmitral flow. CONCLUSIONS: Doppler of pulmonary venous flow can be performed in a high percentage of patients with chronic heart failure due to dilated cardiomyopathy. The indices derived from transthoracic pulmonary venous flow are strongly correlated with pulmonary wedge pressure and improve the noninvasive identification of patients with high pulmonary wedge pressure, even when transmitral flow pattern is difficult to be interpreted.

Comparison of Doppler echocardiography with thermodilution for assessing cardiac output in advanced congestive heart failure.

Noninvasive cardiac output estimation by Doppler echocardiography was compared with thermodilution and Fick oxygen methods in 73 patients with advanced chronic congestive heart failure due to dilated cardiomyopathy. In these patients, Doppler echocardiographic measurements showed a closer agreement with Fick measurements than that of thermodilution.

Systemic thromboembolism in chronic heart failure. A prospective study in 406 patients.

In patients with heart failure the risk of systemic thrombo-embolism and the benefit of anticoagulation are uncertain. To assess the incidence of systemic thromboembolism and the factors associated with an increased risk, 406 consecutive patients with chronic heart failure were prospectively investigated. Their left ventricular ejection fraction was 23 +/- 8%, pulmonary wedge pressure 19 +/- 10 mmHg and cardiac index 2.3 +/- 1.41. min-1.m-2 of body surface area. Two hundred patients were in NYHA functional class III-IV. Two hundred and thirty-two patients were receiving oral anticoagulants. Over a follow-up period of 16 +/- 11 months, thromboembolism occurred in 11 patients (2.7%), seven of whom were on anticoagulants. Among clinical, echocardiographic and haemodynamic variables, atrial fibrillation, more severe haemodynamic impairment and low exercise capacity were associated with increased thromboembolic risk. No echocardiographic findings, including the presence of intracavitary thrombi, either at baseline or during follow-up, were related to subsequent thromboembolic events. The rate of embolism did not differ in patients receiving anticoagulants (4%) compared with those who did not receive anticoagulants (1%). No major bleeding occurred during follow-up. Thus, in patients with chronic heart failure and sinus rhythm the incidence of systemic thromboembolism is low regardless of anticoagulant treatment. Atrial fibrillation, particularly when associated with low cardiac index, identifies a subgroup of patients at high risk of events. In this subgroup, a moderate-intensity anticoagulant regimen provides unsatisfactory protection against thromboembolism.

Concomitant factors of decompensation in chronic heart failure.

The concomitant factors implicated in 328 nonfatal decompensations of 304 patients with congestive heart failure were: arrhythmias in 24%, infections in 23%, poor compliance in 15%, angina in 14%, iatrogenic factors in 10%, and other causes in 5% of cases. New York Heart Association class and right atrial pressure significantly related to the occurrence of decompensation. Poor compliance and angina were unpredictable, infection was related to pulmonary wedge pressure, iatrogenic factors were predicted by the more advanced functional classes, whereas arrhythmias were more frequent in patients with renal failure.

Doppler echocardiography reliably predicts pulmonary artery wedge pressure in patients with chronic heart failure with and without mitral regurgitation.

OBJECTIVES: This study was performed to assess whether the combination of multiple echocardiographic and Doppler variables can provide a reliable estimation of pulmonary artery wedge pressure in patients with chronic heart failure. BACKGROUND: In patients with chronic heart failure a high pulmonary artery wedge pressure is associated with poor prognosis, more severe symptoms and low exercise tolerance. Several Doppler echocardiographic indexes have been shown to be related to pulmonary artery wedge pressure, but the dispersion of data has generally not allowed a quantitative assessment of this important variable. METHODS: Simultaneous Doppler echocardiographic examinations and right heart catheterizations were performed in 231 patients with chronic heart failure due to dilated cardiomyopathy. Mitral and pulmonary venous flow velocity variables, left atrial volumes, mitral regurgitation jet area and left ventricular ejection fraction were correlated with pulmonary artery wedge pressure by both single and multilinear regression analysis. The reliability of the obtained multilinear equations was then tested in a separate group of 60 patients. RESULTS: By univariate analysis, the deceleration rate of early diastolic mitral flow and the systolic fraction of pulmonary venous flow showed the strongest correlations (r=0.78 and =-0.76, respectively). Stepwise regression analysis led to two multilinear equations for predicting pulmonary artery wedge pressure in the whole population: the first included only two-dimensional echocardiographic and mitral flow velocity variables (r=0.84) and the second also included pulmonary venous flow variables (r=0.87). The highest correlation was obtained (r=0.89) by a third equation in the 73 patients without significant mitral regurgitation. Correlation coefficients between estimated and measured pulmonary artery wedge pressure were 0.91 (SEE=2.7 mm Hg) and 0.97 (SEE=1.8 mm Hg) when the first and the second equation, respectively, were applied to the testing group. CONCLUSIONS: These results indicate that, in patients with chronic heart failure due to dilated cardiomyopathy, pulmonary artery wedge pressure can be reliably estimated even when mitral regurgitation is present by combining Doppler echocardiographic variables of mitral and pulmonary venous flow.