Cardiovascular Imaging Center, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
Cardiovascular Imaging Center, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
JACC Cardiovasc Imaging. 2017 Dec;10(12):1411-1420. doi: 10.1016/j.jcmg.2016.10.017. Epub 2017 Mar 15.
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.
Predicting LVFP in the presence of MAC is problematic.
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).
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%.
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.
本研究旨在确定用于评估二尖瓣环钙化（MAC）患者左心室充盈压（LVFP）的多普勒参数，并开发和验证一种用于评估此类患者 LVFP 的决策算法。
在存在 MAC 的情况下预测 LVFP 存在问题。
前瞻性地，50 例 MAC 患者（平均年龄 72±11 岁）接受了完整的多普勒超声心动图研究和右心或左心导管检查。心室充盈和松弛的标准和非标准参数与 LVFP 相关。使用分类和回归树分析来开发用于预测 LVFP 的决策树。使用具有 MAC 和侵入性血液动力学的另外一组患者（n=21）进行前瞻性验证。
在初始研究组中，26 例患者有轻度 MAC，24 例患者有中度或重度 MAC。平均 LVFP 为 17.0±8.1mmHg（范围 4 至 50mmHg）。在测试的变量中，LVFP 的最佳预测因子是舒张早期至晚期充盈速度比（二尖瓣 E/A）（r=0.66；p<0.001）。这一发现见于轻度和中度至重度 MAC 患者。重要的是，舒张早期充盈速度与二尖瓣环速度比（E/e'）的相关性较弱（r=0.42；p=0.003）。使用二尖瓣 E/A 和等容舒张时间（IVRT）的临床算法与良好的特异性（100%）和阳性预测值（100%）相关，对高 LVFP 的敏感性（81%）和阴性预测值（67%）适中。在单独的前瞻性队列中验证临床算法得出诊断准确性为 94%。
在有明显 MAC 的患者中，不应使用 E/e'比值来估计 LVFP。然而，二尖瓣 E/A 比值和 IVRT 是该患者人群中 LVFP 的有用预测因子。结合这些多普勒参数的建议决策算法可准确估计 MAC 患者的 LVFP。
