From the Guidelines
Left ventricular (LV) filling pressure refers to the pressure within the left ventricle during the diastolic phase of the cardiac cycle when the ventricle is filling with blood, and it is a critical hemodynamic parameter that reflects the pressure required to fill the left ventricle adequately before contraction. Normal LV filling pressure ranges from 8-12 mmHg at rest. Elevated LV filling pressure (>12 mmHg) is an important indicator of left ventricular dysfunction and heart failure. This pressure can be measured directly through cardiac catheterization using the pulmonary capillary wedge pressure (PCWP) or left ventricular end-diastolic pressure (LVEDP) as surrogate markers. Elevated LV filling pressure occurs when the left ventricle becomes stiff (diastolic dysfunction) or fails to contract properly (systolic dysfunction), causing blood to back up into the lungs and potentially leading to pulmonary edema and symptoms like shortness of breath. Some of the key echocardiographic parameters used to estimate LV filling pressures include:
- Mitral peak E-wave velocity
- E/A ratio
- E velocity deceleration time (DT)
- E/e′ ratio
- Pulmonary vein systolic-to-diastolic velocity ratio
- Peak velocity of tricuspid regurgitation (TR) by continuous-wave (CW) Doppler
- Left atrial (LA) maximum volume index
- Pulsed-wave TDI-derived mitral annular early diastolic velocity: e′
- Mitral E/e′ ratio
- T E2e′ time interval
- LA maximum volume index
- Pulmonary veins: systolic (S) velocity, diastolic (D) velocity, and S/D ratio
- Ar-A duration
- CW Doppler TR systolic jet velocity
- CW Doppler PR end-diastolic velocity According to the study by 1, the term LV filling pressures can refer to mean pulmonary capillary wedge pressure (PCWP), mean left atrial (LA) pressure (LAP), LV pre-A pressure, mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP). The different LV and LA indices should always be interpreted in a wider context that includes clinical status and the other 2D and other Doppler measurements. In patients with heart failure with preserved ejection fraction (HFpEF), E/e′ showed the best, albeit modest correlation with invasive measurements of elevated left ventricular filling pressure 1. E/e′ ratio is a useful parameter for estimating LV filling pressures, with values < 8 indicating normal LV filling pressures and values > 14 indicating elevated LV filling pressures 1. However, the accuracy of E/e′ ratio is reduced in patients with coronary artery disease and regional dysfunction at the sampled segments 1. LA maximum volume index is also a useful parameter for estimating LV filling pressures, with increased LA volume index indicating elevated LV filling pressures 1. Pulmonary vein systolic-to-diastolic velocity ratio is another useful parameter for estimating LV filling pressures, with reduced S velocity and S/D ratio indicating increased mean LAP 1. In summary, LV filling pressure is a critical hemodynamic parameter that reflects the pressure required to fill the left ventricle adequately before contraction, and it can be estimated using various echocardiographic parameters, including E/e′ ratio, LA maximum volume index, and pulmonary vein systolic-to-diastolic velocity ratio.
From the Research
Definition of Left Ventricular Filling Pressure
- Left ventricular (LV) filling pressure refers to the pressure within the left ventricle during diastole, which is the period of relaxation and filling of the heart [(2,3,4,5,6)].
- It is an important measure of ventricular performance and can be used to assess diastolic function [(2,3,4,5,6)].
Assessment of Left Ventricular Filling Pressure
- The gold standard for assessing LV filling pressure is right heart catheterization (RHC) 2.
- However, non-invasive methods such as echocardiography can also be used to estimate LV filling pressure [(2,3,5,6)].
- Echocardiographic parameters such as diastolic longitudinal force (DLF), peak filling rate/end-diastolic volume (PFR/EDV), and left atrial strain (LAS) have been shown to be associated with LV filling pressure [(2,3,5)].
Clinical Significance of Left Ventricular Filling Pressure
- Elevated LV filling pressure is commonly reported in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with impaired relaxation in diastole 3.
- Increased LV filling pressure is also a predictor of subsequent heart failure in patients following an acute myocardial infarction 4.
- Accurate assessment of LV filling pressure is important for diagnosis and management of heart failure [(2,3,4,5,6)].
Challenges in Assessing Left Ventricular Filling Pressure
- Assessing LV filling pressure can be challenging in patients with atrial fibrillation, as there is no established echocardiographic approach 6.
- A combination of several echocardiographic and clinical parameters may be used to evaluate LV filling pressure in patients with atrial fibrillation 6.
- The choice of parameter used to represent LV filling pressure can lead to different cutoffs for predicting high pressures 5.