Simple Two-Dimensional Echocardiographic Scoring System for the Estimation of Left Ventricular Filling Pressure

Abstract

Background: When left ventricular filling pressure (LVFP) increases, the mitral valve opens early and precedes tricuspid valve opening in early diastole. The authors hypothesized that a visually assessed time sequence of atrioventricular valve opening could become a new marker of elevated LVFP. The aim of this study was to test the diagnostic ability of a novel echocardiographic scoring system, the visually assessed time difference between mitral valve and tricuspid valve opening (VMT) score, in patients with heart failure.Methods: One hundred nineteen consecutive patients who underwent cardiac catheterization within 24 hours of echocardiographic examination were retrospectively analyzed as a derivation cohort. In addition, a prospective study was conducted to validate the diagnostic ability of the VMT score in 50 patients. Elevated LVFP was defined as mean pulmonary artery wedge pressure (PAWP) $ 15 mm Hg. The time sequence of atrioventricular valve opening was visually assessed and scored (0 = tricuspid valve first, 1 = simultaneous, 2 = mitral valve first). When the inferior vena cava was dilated, 1 point was added, and VMT score was ultimately graded as 0 to 3. Cardiac events were recorded for 1 year after echocardiography.Results: In the derivation cohort, PAWP was elevated with higher VMT scores (score 0, 10 6 5; score 1, 12 6 4; score 2, 22 6 8; score 3, 28 6 4 mm Hg; P < .001, analysis of variance). VMT score $ 2 predicted elevated PAWP with accuracy of 86% and showed incremental predictive value over clinical variables and guidelinerecommended diastolic function grading. These observations were confirmed in the prospective validation cohort. Importantly, VMT score $ 2 discriminated elevated PAWP with accuracy of 82% in 33 patients with monophasic left ventricular inflow in the derivation cohort. Kaplan-Meier analysis demonstrated that patients with VMT scores $ 2 were at higher risk for cardiac events than those with VMT scores # 1 (P < .001).Conclusions: VMT scoring could be a novel additive marker of elevated LVFP and might also be associated with adverse outcomes in patients with heart failure.

Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction

“…In line with our recent study, 11 the VMT score was assessed as a marker of LVFP elevation. Based on earlier opening of the MV than TV in the presence of a higher LVFP compared to RA pressure, 11 this scoring system consists of (i) visual assessment of the time sequence of atrioventricular valve openings and (ii) estimated RA pressure based on inferior vena cava (IVC) findings.…”

“…In line with our recent study, 11 the VMT score was assessed as a marker of LVFP elevation. Based on earlier opening of the MV than TV in the presence of a higher LVFP compared to RA pressure, 11 this scoring system consists of (i) visual assessment of the time sequence of atrioventricular valve openings and (ii) estimated RA pressure based on inferior vena cava (IVC) findings. Briefly, from the cine loops (6–9 beats) of the apical four-chamber view, the time sequence of the MV and TV openings was visually assessed by slow playback, if necessary, and scored into three grades: 0 = TV opening first, 1 = simultaneous, and 2 = MV opening first.…”

“…Some participant data from this study have been recently published; 12 however, they were not regarding VMT scoring. Any patients included in the former invasive-echocardiographic study 11 were not included in the present investigation. A total of 27 633 subjects who were referred to the echocardiographic laboratories of the Gunma University Hospital ( n = 17 507) or Hokkaido University Hospital ( n = 10 126) between January 2014 and December 2018 were screened.…”

“… 13 In patients with AF, the peak systolic TR velocity >2.8 m/s and E/e′ ratio ≥11 were used to determine LVFP elevation according to the previous reports. 8 , 11 …”

“… 5 , 6 , 10 A recent study highlighted that a two-dimensional echocardiographic scoring system, the visually assessed time difference between mitral valve (MV) and tricuspid valve (TV) opening (VMT) score, was associated with elevation of LVFP in HF patients. 11 We thus hypothesized that the VMT score could be a useful indicator of HFpEF prognosis and aimed to evaluate the association between the VMT scoring and clinical outcomes in patients with HFpEF.…”