How to assess left ventricular filling pressures

Left ventricular diastolic dysfunction (LVDD) plays a key role in the pathophysiology of heart failure (HF). It is caused by impaired left ventricular (LV) relaxation with or without reduced restoring forces and increased LV chamber stiffness leading to the inability of the ventricle to fill adequately and to provide a normal stroke volume at normal filling pressure (LVFP), at rest and/or during exercise.

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In patients with HF, there is typically elevated LVFP at rest, and in some cases only during exercise. Elevated LVFP is a hallmark of HF and therefore has great importance in HF diagnostics.

During left heart catheterization, LVFP is measured as LV end-diastolic pressure (LVEDP). Alternatively, LVFP is measured as LV pressure prior to onset of left atrial (LA) contraction (LV pre-A pressure), which approximates LA mean pressure. During right heart catheterization, LVFP is assessed as pulmonary capillary wedge pressure (PCWP), which is an indirect measure of LA mean pressure. During sinus rhythm, LVEDP is higher than PCWP and LV Pre-A pressure.

A combination of transmitral flow velocities, mitral annular velocities, LA volume and strain, and estimated systolic pulmonary pressures is recommended to assess LVFP in clinical practice. Importantly, none of these parameters is accurate enough to be used as a single diagnostic marker.

Importantly, the recommendations advocate careful consideration of all available clinical, 2D, and Doppler data to conclude about diastolic function. Thus, the evaluation of LV diastolic function should always start by assessing the presence of clinical risk factors associated with LVDD (e.g. hyperten­sion, coronary artery disease, diabetes), by looking for structural cardiac abnormalities (e.g. pathological LV hypertrophy, LA dilation), or by detecting LV systolic dysfunction (e.g. reduced EF, mitral annulus systolic velocities, and LV global longitudinal strain).

Read more in:

How to assess left ventricular filling pressures by echocardiography in clinical practice 
European Heart Journal - Cardiovascular Imaging, Volume 23, Issue 9, September 2022, Pages 1127–1129, https://doi.org/10.1093/ehjci/jeac123
28 June 2022