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Tissue Doppler Imaging Measures Correlate Poorly with Left Ventricular Filling Pressures in Pediatric Cardiomyopathy David S. Ezon, MD, Shiraz A. Maskatia, MD, Kristen Sexson-Tejtel, MD, William J. Dreyer, MD, Aamir Jeewa, MD, and Susan W. Denfield, MD Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Tex, USA ABSTRACT
Setting. In adults with cardiomyopathy, tissue Doppler imaging (TDI) has been shown to correlate with left ventricular filling pressures (LVFPs) and has been advocated as a surrogate to catheterization. However, this has not been validated in children. Design. This is a retrospective review of children ≤18 years old with dilated, hypertrophic, restrictive, and left ventricular noncompaction cardiomyopathy who underwent cardiac catheterization within 3 months of an echocardiogram. Spearman’s correlation coefficients were calculated to assess a correlation between LVFP and mitral inflow E/A ratio, lateral mitral E/E′, and septal E/E′. Results. Thirty-eight patients were included in the study; median age was 8.6 years old. The median LVFP was 19 mm Hg, median mean pulmonary artery pressure was 25 mm Hg, and median pulmonary vascular resistance index (PVRi) was 2.4 Wu. There was no significant correlation between LVFP or PVRi with lateral mitral E/E′ or septal E/E′. There was a positive correlation between LVFP and mitral inflow E/A ratio (rs = 0.59, P < .01). In a subgroup analysis of patients with hypertrophic or restrictive cardiomyopathy, there was a negative correlation (rs = 0.56, P = .02) between the mean pulmonary artery pressure and septal A′. Conclusions. TDI measures of diastolic function are not reliable surrogates for LVFP, mean pulmonary artery pressures, and PVRi at catheterization in children. Key Words. Tissue Doppler Imaging; Pediatric Cardiomyopathy; Diastolic Function; Pulmonary Hypertension
Introduction
T
he annual incidence of pediatric cardiomyopathy is 1 in 100 000 children.1 In most pediatric age groups, it is the most common indication for heart transplantation.2 Cardiac catheterization may be necessary to assess for pulmonary hypertension that is often associated with severe diastolic dysfunction, as it may alter operative and perioperative strategies. However, catheterization in this patient population is not without risk. Reliable noninvasive methods of assessing diastolic dysfunction would be useful, as severe diastolic dysfunction may be a precursor of pulmonary hypertension. Several adult studies have shown a correlation between tissue Doppler imaging (TDI) parameters and left ventricular filling pressures,3–6 advocating the use of TDI as an alternative, nonC 2015 Wiley Periodicals, Inc. V © 2015
invasive method to assess diastolic function. However, these have not been validated in children with cardiomyopathy. The aim of this study was to determine if TDI measurements obtained on echocardiography correlate with left ventricular filling pressures and measures of pulmonary hypertension obtained at cardiac catheterization in children with cardiomyopathy. Methods
After obtaining approval of our institutional review board, a retrospective chart review was performed on all patients with a known diagnosis of dilated, hypertrophic, restrictive, or left ventricular noncompaction cardiomyopathy who underwent an echocardiogram that included TDI performed within 3 months of a diagnostic cardiac Congenit Heart Heart Dis. 2015;10:E203–E209 Congenit Dis. 2015;••:••–••
E204 2 catheterization, who were ≤18 years old at the time of the catheterization, and without an intervening change in their clinical status. An intervening change was defined as escalation or de-escalation of care (e.g., admission, transfer into or out of an intensive care unit), new onset of symptoms, or new medication use. Patients that met these criteria were included in the study. If the patient had two catheterizations with concurrent echocardiograms, the most recent catheterization and the echocardiogram closest to the catheterization were used. Patients were excluded if they had structural heart disease, heart block requiring a pacemaker, or prior surgical intervention (ventricular assist device placement, pericardiocentesis, myomectomy). A subgroup analysis of patients with restrictive and/or hypertrophic cardiomyopathy was performed, as these are classically diseases of diastolic dysfunction. TDI measurements were obtained from the apical four-chamber view with an angle of insonation of 25 mm Hg (range, 12–34), though the PVRi was
Tissue Doppler Imaging Measures Correlate Poorly with Left Ventricular Filling Pressures in Pediatric Cardiomyopathy David S. Ezon, MD, Shiraz A. Maskatia, MD, Kristen Sexson-Tejtel, MD, William J. Dreyer, MD, Aamir Jeewa, MD, and Susan W. Denfield, MD Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Tex, USA ABSTRACT
Setting. In adults with cardiomyopathy, tissue Doppler imaging (TDI) has been shown to correlate with left ventricular filling pressures (LVFPs) and has been advocated as a surrogate to catheterization. However, this has not been validated in children. Design. This is a retrospective review of children ≤18 years old with dilated, hypertrophic, restrictive, and left ventricular noncompaction cardiomyopathy who underwent cardiac catheterization within 3 months of an echocardiogram. Spearman’s correlation coefficients were calculated to assess a correlation between LVFP and mitral inflow E/A ratio, lateral mitral E/E′, and septal E/E′. Results. Thirty-eight patients were included in the study; median age was 8.6 years old. The median LVFP was 19 mm Hg, median mean pulmonary artery pressure was 25 mm Hg, and median pulmonary vascular resistance index (PVRi) was 2.4 Wu. There was no significant correlation between LVFP or PVRi with lateral mitral E/E′ or septal E/E′. There was a positive correlation between LVFP and mitral inflow E/A ratio (rs = 0.59, P < .01). In a subgroup analysis of patients with hypertrophic or restrictive cardiomyopathy, there was a negative correlation (rs = 0.56, P = .02) between the mean pulmonary artery pressure and septal A′. Conclusions. TDI measures of diastolic function are not reliable surrogates for LVFP, mean pulmonary artery pressures, and PVRi at catheterization in children. Key Words. Tissue Doppler Imaging; Pediatric Cardiomyopathy; Diastolic Function; Pulmonary Hypertension
Introduction
T
he annual incidence of pediatric cardiomyopathy is 1 in 100 000 children.1 In most pediatric age groups, it is the most common indication for heart transplantation.2 Cardiac catheterization may be necessary to assess for pulmonary hypertension that is often associated with severe diastolic dysfunction, as it may alter operative and perioperative strategies. However, catheterization in this patient population is not without risk. Reliable noninvasive methods of assessing diastolic dysfunction would be useful, as severe diastolic dysfunction may be a precursor of pulmonary hypertension. Several adult studies have shown a correlation between tissue Doppler imaging (TDI) parameters and left ventricular filling pressures,3–6 advocating the use of TDI as an alternative, nonC 2015 Wiley Periodicals, Inc. V © 2015
invasive method to assess diastolic function. However, these have not been validated in children with cardiomyopathy. The aim of this study was to determine if TDI measurements obtained on echocardiography correlate with left ventricular filling pressures and measures of pulmonary hypertension obtained at cardiac catheterization in children with cardiomyopathy. Methods
After obtaining approval of our institutional review board, a retrospective chart review was performed on all patients with a known diagnosis of dilated, hypertrophic, restrictive, or left ventricular noncompaction cardiomyopathy who underwent an echocardiogram that included TDI performed within 3 months of a diagnostic cardiac Congenit Heart Heart Dis. 2015;10:E203–E209 Congenit Dis. 2015;••:••–••
E204 2 catheterization, who were ≤18 years old at the time of the catheterization, and without an intervening change in their clinical status. An intervening change was defined as escalation or de-escalation of care (e.g., admission, transfer into or out of an intensive care unit), new onset of symptoms, or new medication use. Patients that met these criteria were included in the study. If the patient had two catheterizations with concurrent echocardiograms, the most recent catheterization and the echocardiogram closest to the catheterization were used. Patients were excluded if they had structural heart disease, heart block requiring a pacemaker, or prior surgical intervention (ventricular assist device placement, pericardiocentesis, myomectomy). A subgroup analysis of patients with restrictive and/or hypertrophic cardiomyopathy was performed, as these are classically diseases of diastolic dysfunction. TDI measurements were obtained from the apical four-chamber view with an angle of insonation of 25 mm Hg (range, 12–34), though the PVRi was
