Invasive Validation of the Echocardiographic Assessment of Left Ventricular Filling Pressures Using the 2016 Diastolic Guidelines: Head-to-Head Comparison with the 2009 Guidelines

Abstract

Background Recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines for echocardiographic evaluation of left ventricular (LV) diastolic function provide a practical, simplified diagnostic algorithm for estimating LV filling pressure. The aim of this study was to test the accuracy of this algorithm against invasively measured pressures and compare it with the accuracy of the previous 2009 guidelines in the same patient cohort. Methods Ninety patients underwent transthoracic echocardiography immediately before left heart catheterization. Mitral inflow E/A ratio, E/e′, tricuspid regurgitation velocity, and left atrial volume index were used to estimate LV filling pressure as normal or elevated using the ASE/EACVI algorithm. Invasive LV pre-A pressure was used as a reference, with >12 mm Hg defined as elevated. Results Invasive LV pre-A pressure was elevated in 40 (44%) and normal in 50 (56%) patients. The 2016 algorithm resulted in classification of 9 of 90 patients (10%) as indeterminate but estimated LV filling pressures in agreement with the invasive reference in 61 of 81 patients (75%), with sensitivity of 0.69 and specificity of 0.81. The 2009 algorithm could not definitively classify 4 of 90 patients (4.4%), but estimated LV filling pressures in agreement with the invasive reference in 64 of 86 patients (74%), with sensitivity of 0.79 and specificity of 0.70. Conclusions The 2016 ASE/EACVI guidelines for estimation of filling pressures are more user friendly and efficient than the 2009 guidelines and provide accurate estimates of LV filling pressure in the majority of patients when compared with invasive measurements. The simplicity of the new algorithm did not compromise its accuracy and is likely to encourage its incorporation into clinical decision making.

A comparative analysis of British and American Society of Echocardiography recommendations for the assessment of left ventricular diastolic function

“…This is significantly lower than in our population where 21% of patients had indeterminate results with the ASE/EACVI algorithm. The discrepancy between our findings and those obtained by Balaney and colleagues (9) may be attributed to their sample selection as they only included patients undergoing left heart catheterisation whereas our study involved unselected patients attending for transthoracic echocardiography. In addition our study did not set out to evaluate the accuracy of the ASE/EACVI guidelines for assessing LV filling pressure, rather our aim was simply to determine the outcome of the application of the guideline in the clinical setting.…”

“…In addition our study did not set out to evaluate the accuracy of the ASE/EACVI guidelines for assessing LV filling pressure, rather our aim was simply to determine the outcome of the application of the guideline in the clinical setting. Balaney and colleagues (9) concluded that the main cause of an indeterminate grading within their study was attributed to insufficient TR to allow assessment of TR Vmax. This finding was also observed in our analysis as 68.2% of patients labelled with an indeterminate grading had no measurable TR.…”

“…This phenomenon has also been highlighted by Mitter and colleagues (8) as there are numerous combinations which result in indeterminate outcomes when applying the ASE/EACVI guidelines. In spite of this a recent investigation by Balaney and colleagues validating the 2016 ASE/EACVI guidelines when compared to invasive catheterisation laboratory data concluded that only 10% of patients were classified as indeterminate using the ASE/EACVI algorithm estimating left ventricular filling pressures in the remaining 90% of the sample population (9). This is significantly lower than in our population where 21% of patients had indeterminate results with the ASE/EACVI algorithm.…”

Biatrial and right ventricular deformation imaging: Implications of the recent EACVI consensus document in the clinics and beyond

“…Based on the LVEF, a combination of variables (at least 50% to 100% of these) may aid in the diagnosis of LV diastolic dysfunction with or without elevated LA pressure. However, invasive validation of diastolic measures has shown to have only a modest correlation with the 2009 as well as the 2016 ASE recommendations for LV diastolic function evaluation in preserved as well as reduced LVEF . The same group has shown that LA strain may be a superior marker that could not only discriminate all grades of LV diastolic dysfunction vs. normal with excellent areas under the curves but also demonstrate that LA strain is useful for “accurate characterization” of LV diastolic dysfunction .…”

Diastolic function recommendations: Are we too relaxed when reporting myocardial relaxation?

“…Even though the framework of the 2009DF recommendations was built on the seminal study by Appleton et al 13 and the Mayo Clinic model, 14 the variables and cutoffs were not derived from these studies, and the classification system was validated post hoc. (c) The 2016DF classification has by now been validated against invasive measures 15–18 and showed good inter‐observer agreement irrespective of experience 4 …”