Author + information
- Received August 8, 2016
- Revision received October 18, 2016
- Accepted October 20, 2016
- Published online December 4, 2017.
- Muaz M. Abudiab, MD,
- Lakshmi H. Chebrolu, MD,
- Robert C. Schutt, MD,
- Sherif F. Nagueh, MD and
- William A. Zoghbi, MD∗ ()
- ↵∗Address for correspondence:
Dr. William A. Zoghbi, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, SM-677, Houston, Texas 77030.
Objectives This study sought to identify Doppler parameters useful for the assessment of left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC) and to develop and validate a decision algorithm for assessing LVFP in such patients.
Background Predicting LVFP in the presence of MAC is problematic.
Methods Prospectively, 50 patients with MAC (mean 72 ± 11 years of age) underwent a complete Doppler echocardiographic study and right or left heart catheterization. Standard and nonstandard parameters of ventricular filling and relaxation were correlated with LVFP. Classification and regression tree analysis was used to develop a decision tree for prediction of LVFP. Validation was performed prospectively using an additional cohort with MAC and invasive hemodynamics (n = 21).
Results In the initial study group, 26 patients had mild MAC, and 24 had moderate or severe MAC. Mean LVFP was 17.0 ± 8.1 mm Hg (range 4 to 50 mm Hg). Of the variables tested, the best predictor of LVFP was the ratio of early-to-late diastolic filling velocity (mitral E/A) (r = 0.66; p < 0.001). This finding was observed in subjects with mild as well as moderate-to-severe MAC. Importantly, the ratio of early diastolic filling velocity-to-mitral annulus velocity (E/e′) demonstrated weak correlation (r = 0.42; p = 0.003). A clinical algorithm using mitral E/A and isovolumic relaxation time (IVRT) was associated with good specificity (100%) and positive predictive value (100%), and moderate sensitivity (81%) and negative predictive value (67%) for high LVFP. Validation of the clinical algorithm in a separate prospective cohort yielded a diagnostic accuracy of 94%.
Conclusions The E/e′ ratio should not be used to estimate LVFP in subjects with significant MAC. However, mitral E/A ratio and IVRT are useful predictors of LVFP in this patient population. The proposed decision algorithm combining these Doppler parameters is accurate in estimating LVFP in patients with MAC.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Abudiab and Chebrolu contributed equally to this work. A. Jamil Tajik, MD, served as the Guest Editor for this article.
- Received August 8, 2016.
- Revision received October 18, 2016.
- Accepted October 20, 2016.
- 2017 American College of Cardiology Foundation