Search

Background: The aim of this study was to test the hypothesis that a restrictive left ventricular diastolic filling pattern, as an index of elevated pulmonary wedge pressure, would predict a depressed baroreflex sensitivity (BRS) in patients with chronic heart failure., Methods: A total of 189 consecutive patients with an ejection fraction < or = 40% at echocardiography, in sinus rhythm and clinically stable for at least 1 month in oral therapy, underwent clinical examination, echo-Doppler study and the phenylephrine test., Results: The correlations between the NYHA functional class, echo-Doppler variables and BRS were weak, although significant (r ranging from -0.15 to 0.40). However, patients with a deceleration time < 140 ms as an expression of restrictive filling, compared to those with a deceleration time > or = 140 ms, had a lower BRS (3 +/- 4 vs 6 +/- 4 ms/mmHg, p < 0.00001), a lower ejection fraction (20 +/- 6 vs 28 +/- 7%, p < 0.00001), greater left ventricular (end-diastolic volume index 137 +/- 43 vs 113 +/- 45 ml/m2, p < 0.00001) and left atrial dimensions (25 +/- 6 vs 20 +/- 5 cm2, p < 0.00001), more severe mitral regurgitation (3 +/- 1 vs 2.3 +/- 1, p < 0.00001) and were in a higher NYHA class (2.3 +/- 0.6 vs 1.8 +/- 0.5, p < 0.00001). Medications at the time of the study were similar in the two groups. At stepwise regression analysis, the deceleration time emerged as the most powerful independent predictor of a depressed BRS (< 3 ms/mmHg), followed by mitral regurgitation, age, and NYHA class (all data p = 0.0001)., Conclusions: In patients with chronic heart failure, the presence of a restrictive left ventricular filling pattern is highly predictive of autonomic derangement as expressed by low values of BRS.

The estimation of right atrial pressure is often needed for the diagnosis, management and monitoring of various pathologic hemodynamic conditions and plays a significant role in patients with chronic heart failure. In the past decade several attempts have been made to non-invasively estimate right atrial pressure, and echocardiography has always been considered the most reliable tool. Morphologic parameters such as respiratory motion of the inferior vena cava, its respiratory diameters and percent collapse (caval index), left hepatic vein diameter or right atrial dimension (areas, volumes) were initially studied. More recently, functional data such as left hepatic or tricuspid flow variables have been considered. Some of these indexes, however, offer only semiquantitative measures of right atrial pressure, and have failed to demonstrate any prognostic value. Others, although highly sensitive and specific, are useful only in selected groups of patients because of technical or clinical limitations. In recent years, attention has focused on Doppler diastolic tricuspid flow as a means of predicting mean right atrial pressure. Analyzing the Doppler tricuspid velocity profile and mean right atrial pressure (Swan-Ganz catheter) simultaneously recorded in patients with severe left ventricular systolic dysfunction and chronic heart failure, acceleration rate of early filling emerged as the strongest independent predictor of right atrial pressure both in patients in sinus rhythm and in those with atrial fibrillation (r = 0.98), irrespective of whether the recordings are at baseline or after acute loading manipulations.

Background: We investigated whether Doppler-derived variables of tricuspid flow could estimate mean right atrial pressure and monitor its changes after loading manipulations in patients with chronic heart failure., Methods: Simultaneous mean right atrial pressure (Swan-Ganz catheterization) and tricuspid Doppler recordings were initially evaluated in 136 patients (23 with atrial fibrillation) with chronic heart failure and severe left ventricular systolic dysfunction, and then were repeated in 18 patients after unloading (sodium nitroprusside infusion) and in 13 patients after overloading (active leg elevation) manipulations., Results: A significant correlation was observed between mean right atrial pressure and peak E velocity (r = 0.70), early deceleration time (r = -0.72) and acceleration time (r = -0.75). However, the best correlation found was between the acceleration rate of early flow and mean right atrial pressure, and it was identical in patients in sinus rhythm or with atrial fibrillation (r = 0.98). Moreover, after acute effective unloading or overloading manipulations, although all Doppler tricuspid variables changed significantly, the acceleration rate of early flow still emerged as the strongest independent predictor of mean right atrial pressure (r = 0.95 and 0.99, respectively)., Conclusions: Doppler-derived acceleration rate of early diastolic tricuspid flow is a powerful tool to predict mean right atrial pressure and to monitor its changes after loading manipulations.