Doppler Velocimetry in Superior Vena Cava Provides Useful Information on the Right Circulatory Function in Patients with Congestive Heart Failure - PDF

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Reprinted with permission from ECHOCARDIOGRAPHY, Volume 18, No. 6, August 2001 Copyright 2001 by Futura Publishing Company, Inc., Armonk, NY Doppler Velocimetry in Superior Vena Cava Provides
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Reprinted with permission from ECHOCARDIOGRAPHY, Volume 18, No. 6, August 2001 Copyright 2001 by Futura Publishing Company, Inc., Armonk, NY Doppler Velocimetry in Superior Vena Cava Provides Useful Information on the Right Circulatory Function in Patients with Congestive Heart Failure Stefano Ghio, M.D. Franco Recusani, M.D., Roberta Sebastiani, M.D., Catherine Klersy, M.D.,* Claudia Raineri, M.D., Carlo Campana, M.D., Luca Lanzarini, M.D., Antonello Gavazzi, M.D., and Luigi Tavazzi, M.D. From the Dipartimento di Cardiologia and *Direzione Scientiéca, Policlinico S Matteo, Pavia, Italy Background: Although èow velocities curves recorded with pulsed-wave Doppler in systemic vein are known to provide functional data on the right circulatory function, little information is available on the relationship between right heart élling dynamics and right ventricular function. Methods: Consecutive patients with chronic heart failure due to severe systolic left ventricular dysfunction and in sinus rhythm underwent echocardiography and right heart catheterization. In the initial part of the study, the hemodynamic correlates of different èow velocity patterns recorded into the superior vena cava were evaluated in 120 patients. The accuracy of the prediction of different right heart hemodynamic proéles by means of the different venous èow patterns was then prospectively tested in a subsequent series of 86 patients. Results: The venous èow pattern was closely related to right heart hemodynamics. A normal Doppler pattern identiéed patients with normal right heart hemodynamics (sensitivity 86%, speciécity 78%); a predominant systolic wave pattern identiéed patients with a reduced thermodilution-derived right ventricular ejection fraction (,30%) and normal or slightly elevated right atrial pressure (#8 mmhg) (sensitivity 69%, speciécity 81%); a predominant diastolic wave pattern identiéed patients with a reduced right ventricular ejection fraction (,30%) and elevated right atrial pressure (.8 mmhg) (sensitivity 52%, speciécity 95%). The observed and the predicted hemodynamic proéles turned out to be concordant in 80% of patients. Conclusions: The analysis of the èow velocity pattern into the superior vena cava is a useful tool to estimate the extent of the right circulatory impairment in patients with congestive heart failure. (ECHOCARDIOGRAPHY, Volume 18, August 2001) heart failure, Doppler velocimetry, systemic veins Central venous èow velocity curves recorded with pulsed-wave Doppler echocardiography into the hepatic veins or the superior vena cava provide functional data on the right heart and are commonly used to estimate the degree of tricuspid regurgitation to differentiate cardiac tamponade from pericardial effusion and constrictive pericarditis from restrictive cardiomyopathy. 1-4 However, no information is available This study was supported in part by grant 080RFM92/02 from the Italian Health Ministry to IRCCS Policlinico S Matteo, Pavia. Address for correspondence and reprint requests: Stefano Ghio, M.D., Dipartimento di Cardiologia, Policlinico S Matteo, Pavia, Italy. Fax: ; on the relationship between right heart élling dynamics and right ventricular function, even though it has been demonstrated in the left side of the heart that the élling of the atrial cavity through the pulmonary veins is strongly inèuenced by the function of the left ventricle. 5 The usefulness of this approach in the right circulation is emphasized by the diféculty encountered when measuring the volume and ejection fraction of the right ventricle by noninvasive techniques, due to the complex geometry of this cardiac chamber. These data could be of greatest clinical relevance in patients with congestive heart failure (CHF), in whom right ventricular function is an important determinant of symptoms and an independent predictor of prognosis GHIO ET AL. Accordingly, we designed an echocardiographic study to test the hypothesis that different èow velocity patterns in systemic vein discriminate among different degrees of right heart hemodynamic impairment in patients with moderate to severe CHF. Study Design Methods The study was developed in two phases. The initial part of the study was aimed at determining the hemodynamic correlates of the systemic venous èow velocity patterns in patients with CHF. In the second part of the study we tested the predictive accuracy of Doppler-derived venous èow velocity patterns versus different right heart hemodynamic proéles in a subsequent series of CHF patients. Patients In the érst part of the study we enrolled 120 consecutive patients in sinus rhythm with chronic congestive heart failure due to severe systolic left ventricular dysfunction (ejection fraction, 35%). This series included patients with primary dilated cardiomyopathy, ischemic heart disease, or end-stage valvular heart disease who were referred to our center for heart failure management and/or heart transplantation evaluation. Patients with (a) restrictive cardiomyopathy, (b) hypertrophic cardiomyopathy, (c) need for infusional therapy at the initial clinical evaluation, (d) atrial ébrillation or permanent pacing in VVI mode, or (e) severe tricuspid regurgitation were excluded from the study. In the second part of the study we enrolled 86 patients with identical inclusion and exclusion criteria. The clinical characteristics of the patients are shown in Table I. Echocardiographic and Doppler Study The echocardiographic examination was performed using either a Toshiba SSA 270A (Toshiba Corp., Tokyo, Japan) or an Esaote SIM 7000 Challenge (Esaote, Firenze, Italy) ultrasound equipment. A complete M-mode, two-dimensional, and Doppler study was performed using standard parasternal, apical, and subcostal approaches. Left ventricular end-diastolic and end-systolic volumes and left ventricular ejection fraction were calculated using the area-length method. End-diastolic and endsystolic right ventricular areas were measured in the apical view and the fractional area shrinkage was calculated as end-diastolic area minus end-systolic area, divided by end-diastolic area, The systolic displacement of the lateral portion of the tricuspid annular plane was measured on the M-mode tracing under the two-dimensional (2-D) echo guidance. Echocardiographic data were averaged over three beats. Categorical evaluation of mitral insuféciency was made by measuring the radius of the aliased portion of the èow acceleration proximal to the leaking oriéce using the color Doppler format. 9 Tricuspid regurgitation was graded using the jet area method. 10 The hepatic vein èow velocity curve was recorded by pulsed-wave Doppler using the subcostal approach. The superior vena cava èow velocity curve was recorded from the right supraclavicular approach by placing the sample volume in the middle of the stream visualized by the color Doppler format. Peak velocities of the systolic and diastolic centripetal waves in the superior vena cava and hepatic veins were measured and the ratio calculated. The venous èow velocity pattern was considered normal when the systolic/diastolic ratio was $1 and #2, the èow pattern was categorized as predominant systolic wave when the ratio was.2, and as predominant diastolic wave when the ratio was,1 (Figs. 1A-C). 4 All Doppler measurements were evaluated in éve consecutive beats obtained during quiet respiration. Reproducibility TABLE I Clinical Characteristics of the Patients Initial Population (120 patients) Prospective Population (86 patients) P Age (years) 51 (10) 49 (11) NS Sex (male/female) 89/31 64/22 NS NYHA classiécation: class II 35% 32% NS class III 59% 55% NS class IV 6% 13% NS Etiology Primary dilated CM 62% 70% NS Ischemic 35% 27% NS Valvular 3% 3% NS CM 5 cardiomyopathy. Intraobserver and interobserver variability of the Doppler parameters were calculated in 15 random patients. Measurements were per- 470 DOPPLER VELOCIMETRY IN SYSTEMIC VEIN IN PATIENTS WITH CHF formed by two independent observers and repeated by the érst observer after a 1-day interval. The variability of the assignment of the venous èow velocity pattern to one of the three categories was evaluated using the Cohen kappa statistics. Right Heart Catheterization Right heart catheterization was performed within 1 hour of the echo and Doppler examination. A modiéed Swan-Ganz thermodilution catheter with a rapid response thermistor (93A-431H-7F, American Edwards Laboratories, Irvine, CA, USA) was inserted transcutaneously via the right internal jugular vein. The thermistor was connected to a dedicated computer (REF-1 Ejection Fraction/Cardiac Output Computer, American Edwards Laboratories) to display online the cardiac output and the right ventricular ejection fraction. The distal and proximal lumina of the catheter were connected to a calibrated and balanced transducer for pulmonary artery and right atrial pressure monitoring. Pressure calibration was performed before and immediately after measurements; all readings were referenced to the midaxillary line with the patient supine. Thermodilution measurements were obtained in triplicate. The correct positioning of the catheter was established èuoroscopically and conérmed by recording pressures from the injectate port. 11,12 The following hemodynamic parameters were measured or calculated: systemic blood pressure (arm-cuff sphygmomanometer); right atrial, pulmonary artery (systolic, diastolic, and mean), and pulmonary wedge pressures; right ventricular ejection fraction; cardiac output; cardiac index; and systemic vascular and pulmonary vascular resistance. Statistical Analysis Data are shown as mean 6 SD for continuous variables and absolute or relative frequencies for categoric variables. Concordance be- Figure 1. Representative superior vena cava èow velocity curves. A. normal. The atrial contraction generates a short retrograde èow -a- (above the zero velocity line). During ventricular systole and ventricular diastole two centripetal waves are observed, called X and Y according to the classic venous pulse recording. The systolic component has larger peak velocity than the diastolic component. B. Predominant systolic wave. The atrial component (a) is followed, below the zero line, by an X wave with absent Y wave. C. Predominant diastolic wave. The atrial component (a) is followed, below the zero line, by a diminutive X wave and then a predominant Y wave. 471 GHIO ET AL. tween superior vena cava and hepatic veins èow patterns was assessed by means of Kendall tau coefécient of concordance. In the érst part of the study the hemodynamic and echocardiographic parameters were compared in the three groups of patients with different venous èow patterns by means of oneway analysis of variance (ANOVA); Scheffé test was used for post-hoc comparisons when the F-test was signiécant at P, On the basis of the initial results, each systemic venous èow velocity pattern was associated to a speciéc right heart hemodynamic proéle. We used the receiver operating characteristics (ROC) curves of a series of logistic models to identify the cutoffs of the hemodynamic variables that best discriminated among the three èow cathegories. In the second part of the study, the predictive accuracy of each èow pattern to identify a different hemodynamic proéle was prospectively tested in a subsequent series of patients. The percentage of cases that were correctly identiéed was computed together with the Kendall tau statistics to assess the accuracy of the prediction. Sensitivity and speciécity of each èow velocity pattern in the identiécation of patients with different right heart hemodynamic proéles were calculated. The statistical package Stata 6.0 (Stata Corp., College Station, TX, USA) was used for computations. 13 A P value, 0.05 was retained as statistically signiécant. Results Feasibility of Doppler Recordings into the Superior Vena Cava and the Hepatic Veins TABLE II Agreement Between Flow Velocity Patterns in Hepatic Veins and Superior Vena Cava SVC- Pattern 1 SVC- Pattern 2 SVC- Pattern 3 HV-pattern HV-pattern HV-pattern HV 5 hepatic veins; SVC 5 superior vena cava. Agreement /91 (90%); Kendall tau , P In the érst study group, analyzable superior vena cava èow velocity tracings were recorded in all patients while the hepatic veins èow velocity tracings could be recorded in only 91 patients (76%): 29 patients had an unacceptable intercept angle between the direction of exploration and the direction of èow or small size venous vessels. In the 91 patients in whom both hepatic veins and superior vena cava èow velocity tracings could be recorded, the èow patterns were concordant in 90% of cases (Kendall tau , P, 0.000) (Table II). The categoric evaluation of the superior vena cava èow pattern was optimally reproducible: Cohen kappa statistic was equal to 0.79 for intraobserver and interobserver agreement. The evaluation of hepatic vein èow patterns was less reproducible: the Cohen kappa statistic was 0.75 for intraobserver and interobserver agreement. Clinical, Echocardiographic, and Hemodynamic Parameters Associated with Different Venous Flow Velocity Curves A normal SVC èow pattern was found in 61 patients (group 1), a predominant systolic wave pattern in 48 patients (group 2), and a predominant diastolic wave pattern in 11 patients (group 3). Age, sex, and etiology of congestive heart failure were similar in the three groups; patients assigned to group 3 tended to have a greater functional impairment than patients in groups 1 and 2 (Table III). According to the inclusion criteria, systolic left ventricular function was severely impaired in all groups, although patients in group 3 tended to have smaller volumes. The mitral inèow pattern was substantially normal in group 1 and restrictive in group 2 and group 3 patients; importantly, the overlapping of the peaks of the biphasic inèow precluded measurement in 19 patients. Right ventricular area shrinkage was normal in group 1 and reduced in group 2 and group 3 patients; however, the systolic excursion of the tricuspid annular plane was exclusively reduced in patients with a predominant diastolic wave èow pattern. A minor degree of mitral insuféciency was evenly distributed in the three groups. Tricuspid insuféciency was usually absent or graded as mild in the patients of groups 1 and 2, whereas it was graded as mild-to-moderate in 6 of the 11 patients in group 3 (Table IV). Group 1 patients had a substantially normal right heart hemodynamic proéle. The cardiac index was low in groups 2 and 3. High pulmonary artery and wedge pressures were found in group 2 and group 3 patients. Right ventricular ejection fraction was reduced in group 2 and 472 DOPPLER VELOCIMETRY IN SYSTEMIC VEIN IN PATIENTS WITH CHF TABLE III Clinical Characteristics of the Three Groups with Differing Superior Vena Cava Flow Velocity Curves Group 1 (n 5 61) Normal Pattern Group 2 (n 5 48) Predominant Systolic Group 3 (n 5 11) Predominant Diastolic Age (years) 50 (10) 51 (10) 51 (6) Male sex NYHA classiécation Class II Class III Class IV Etiology Primary dilated CM Ischemic CM Valvular CM 3 1 CM 5 cardiomyopathy. group 3 patients. Right atrial pressure was much greater in group 3 than in group 2 patients (Table V). Prediction of Right Heart Hemodynamic Proéle by Means of Superior Vena Cava Flow Velocity Pattern The hypothesis that each of the three èow velocity patterns identiées a different right heart hemodynamic proéle was prospectively tested in the second population. Overall, the predicted and the observed hemodynamic proéle turned out to be concordant in 80% of patients. The agreement between a normal èow velocity pattern and a normal hemodynamic proéle was 79% (Kendall tau , P, 0.000); the agreement between a predominant systolic wave èow velocity pattern and a hemodynamic proéle characterized by right ventricular systolic dysfunction associated with normal or slightly elevated right atrial pressure was 70% (Kendall tau , P, 0.000); TABLE IV Echocardiographic Parameters Associated with Different Superior Vena Cava Flow Velocity Curves Group 1 (n 5 61) Normal Pattern Group 2 (n 5 48) Predominant Systolic Group 3 (n 5 11) Predominant Diastolic P (ANOVA) LVEDD (mm) 75 (10) 76 (7) 70 (7) LVESD (mm) 65 (10) 66 (8) 62 (8) LVEDV (ml) 351 (125) 358 (95) 249 (87)* LVESV (ml) 272 (111) 281 (86) 199 (71)* LVEF (%) 23 (8) 22 (6) 20 (4) DT (msec) 124 (41)* 94 (24) 77 (30) E/A 1.4 (1.5)* 3.0 (2.7) 4.5 (2.9) TAPSE (mm) 20 (5)* 17 (5)* 12 (4)* RVFAS (%) 48 (18)* 29 (14) 22 (17) RVTAC (%) 34 (13)* 20 (11) 15 (16) RVEDD (mm) 23 (6) 28 (7) 31 (6) HV diameter (mm) 6.2 (2.2)* 8.3 (2.5) 10.1 (2.5) Mitral regurgitation 1/11/111 43/8/1 27/18/0 5/6/0 Tricuspid regurgitation 1/11 26/0 36/2 3/7 * 5 P, 0.05 vs other groups (Scheffé test); 5 P, 0.05 gr 1 vs gr 3 (Scheffé test). LVEDV 5 LV end-diastolic volume; LVESV 5 LV end-systolic volume; LVEF 5 LV ejection fraction; E/A 5 ratio of early to late transmitral peak èow velocity; DT 5 deceleration time of the early mitral élling wave; TAPSE 5 tricuspid annular plane systolic excursion; RVFAS 5 RV fractional area shrinkage; RVTAC 5 RV transverse axis change; RVEDD 5 RV end-diastolic diameter; HV 5 hepatic veins. 473 GHIO ET AL. TABLE V Hemodynamic Parameters Associated with Different Superior Vena Cava Flow Velocity Curves Group 1 (n 5 61) Normal Pattern Group 2 (n 5 48) Predominant Systolic Group 3 (n 5 11) Predominant Diastolic P (ANOVA) HR (beats/min) 74 (13) 80 (14) 80 (17) SAP mmhg 96 (20) 102 (21) 90 (8) SVR (dyne sec cm 25 ) 1521 (422)* 1785 (554)* 2304 (733)* CI (l/min/m 2 ) 2.5 (0.6)* 2.1 (0.6)* 1.5 (0.9)* PWP (mmhg) 13 (8)* 24 (8) 28 (6) PAPm (mmhg) 18 (8)* 35 (11) 39 (9) PVR (dyne sec cm 25 ) 115 (74)* 264 (139)* 378 (240)* RVEF (%) 36 (10)* 21 (9) 14 (13) RAP (mmhg) 1 (4)* 4 (4)* 12 (4)* * 5 P, 0.05 vs other groups (Scheffé test). HR 5 heart rate; SAP 5 systolic arterial pressure; SVR 5 systemic vascular resistance; CI 5 cardiac index; PWP 5 pulmonary wedge pressure; PAPm 5 mean pulmonary artery pressure; PVR 5 pulmonary vascular resistance; RVEF 5 right ventricular ejection fraction; RAP 5 mean right atrial pressure. the agreement between a predominant diastolic wave èow velocity pattern and a hemodynamic proéle characterized by right ventricular systolic dysfunction plus raised right atrial pressure was 91% (Kendall tau , P, 0.000). The sensitivity and speciécity of each èow velocity pattern in the identiécation of patients with a different hemodynamic proéle are shown in Table VI. A normal èow pattern identiéed with a high sensitivity and a good speciécity patients with a normal right heart hemodynamic proéle. A predominant systolic wave èow pattern that identiéed patients with a diastolic wave èow pattern was extremely speciéc, but not that sensitive, in identifying patients with right ventricular dysfunction plus raised right atrial pressure. Discussion The study shows that in patients with moderate-to-severe congestive heart failure, Doppler interrogation of èow velocities into the superior vena cava is easy to obtain and provides a useful estimate of the overall impairment of the right circulation. It differentiates, with high sensitivity and speciécity, patients with normal right heart hemodynamics, patients with compensated right ventricular dysfunction, and patients with right ventricular dysfunction associated with raised right atrial pressure. Right Heart Hemodynamic Correlates of Doppler Velocimetry in the Systemic Vein The feasibility of noninvasive recording of the èow velocity curve in the jugular gulf by means of an ultrasonic Doppler èowmeter was érst described by Benchimol et al. in A few years later Sivaciyan and Ranganathan found that èow velocity curves characterized by a diastolic nadir equal to or larger than the systolic nadir were always associated with abnormal right hear
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