IL CALCOLO DEL RAPPORTO E/e’ VA ROUTINARIAMENTE INSERITO IN OGNI REPORT IN QUANTO METODO AFFIDABILE

PER IL RILIEVO DELLA PRESSIONE TELEDIASTOLICA E LA GESTIONE CLINICA DEL PAZIENTE?

Alessandro SalustriCardiology Consultant

Head Noninvasive LaboratorySheikh Khalifa Medical City – Abu Dhabi, U.A.E.

•What is E/e’?

•Determination of LV filling pressure

•Evaluation of pts (with HF)

E/e’ and LV filling pressure l April 21, 2023 l 2

TO THE POINT

LV relaxation kinetics

LA pressure

MITRAL INFLOW VELOCITY

E wave

E/e’ and LV filling pressure l April 21, 2023 l 3

PHYSIOLOGY OF LV FILLING

Little and Oh. Circulation 2009;120:802-809.

E/e’ and LV filling pressure l April 21, 2023 l 4

Presentation Title l April 21, 2023 l 5

RESTRICTIVE LV FILLING

Masutani et al. Circulation 2008;117:1550-1554.

E/e’ and LV filling pressure l April 21, 2023 l 6

DOPPLER FLOW PARAMETERS AND LVDP

E/A 0.59

DT 0.48

PVs/PVd 0.31

Pva-Mva 0.29

∆ E/A 0.43

Variable

Ommen et al. Circulation 2000;102:1788-1794.

r

E/e’ and LV filling pressure l April 21, 2023 l 7

E/A 0.59 0.25 0.46

DT 0.48 0.17 0.60

PVs/PVd 0.31 0.03 0.23

Pva-Mva 0.29 0.39 0.12

∆ E/A 0.43 0.36 0.30

Variable EF >50% EF <50%

Ommen et al. Circulation 2000;102:1788-1794.

DOPPLER FLOW PARAMETERS AND LVDP

r

Presentation Title l April 21, 2023 l 8

∆ E/A Pva-MVa PVs/PVd

0

20

40

60

80

100

Ommen et al. Circulation 2000;102:1788-1794.

DOPPLER FLOW PARAMETERS AND LVDP

Co

rre

ctly

cla

ssifi

ed

, %

E/A DT

Presentation Title l April 21, 2023 l 9

E/A DT ∆ E/A Pva-MVa PVs/PVd

0

20

40

60

80

100

Co

rre

ctly

cla

ssifi

ed

, %

Ommen et al. Circulation 2000;102:1788-1794.

DOPPLER FLOW PARAMETERS AND LVDP

Mitral flow Doppler Mitral flow Doppler alone is not enough!alone is not enough!

LV DIASTOLIC FUNCTION

E/e’ and LV filling pressure l April 21, 2023 l 10

MITRAL ANNULAR VELOCITY

LV relaxation kinetics

e’ wave

E/e’ and LV filling pressure l April 21, 2023 l 11

WHAT IS e’?

•It behaves as an index of LV relaxation

•Significant inverse correlation with tau

•No change with preload alterations

E/e’ and LV filling pressure l April 21, 2023 l 12

LV relaxation kinetics

LA pressure

LV relaxation kinetics

E

e’

WHY E/e’?

E/e’ and LV filling pressure l April 21, 2023 l 14

LV relaxation kinetics

LA pressure

LV relaxation kinetics

WHY E/e’?

E

e’

E/e’ and LV filling pressure l April 21, 2023 l 15

Presentation Title l April 21, 2023 l 16

Masutani et al. Circulation 2008;117:1550-1554.

RESTRICTIVE LV FILLING

DIASTOLIC MITRAL ANNULAR VELOCITY

Hasegawa et al. J Am Coll Cardiol 2003;41;1590-7.

E/e’ and LV filling pressure l April 21, 2023 l 18

NormalNormal

HF

HF

DIASTOLIC PARAMETERS AND TAU ()

Hasegawa et al. J Am Coll Cardiol 2003;41;1590-7.

E/e’ and LV filling pressure l April 21, 2023 l 19

E (

ml/s

ec)

Pea

k e’

(m

m/s

ec)

•What is E/e’

•Determination of LV filling pressure

•Evaluation of pts with HF

E/e’ and LV filling pressure l April 21, 2023 l 20

TO THE POINT

ASSESSMENT OF LV FILLING PRESSURE

Ommen et al. Circulation 2000;102:1788-1794.

E/e’ and LV filling pressure l April 21, 2023 l 21

LV FILLING PRESSURE DEFINED BY E/e’

Ommen et al. Circulation 2000;102:1788-1794.

E/e’ and LV filling pressure l April 21, 2023 l 22

EF <50%

EF >50%

E/e’ <8 E/e’ >15

LV

DP

(m

mH

g)

LV FILLING PRESSURE DEFINED BY E/e’

Ommen et al. Circulation 2000;102:1788-1794.

E/e’ and LV filling pressure l April 21, 2023 l 23

LV

DP

(m

mH

g)

E/e’ 8÷15

EF <50%

EF >50%

E/e’ and LV filling pressure l April 21, 2023 l 24

Ommen et al. Circulation 2000;102:1788-1794.

LV FILLING PRESSURE DEFINED BY E/e’

X XX X

PVa-Mva >30 ms

Valsalva +ve

Flow Doppler -ve

>1 variable +ve X

E/e’ 8÷15

LV

DP

(m

mH

g)

E/e’ and LV filling pressure l April 21, 2023 l 25

Ommen et al. Circulation 2000;102:1788-1794.

LV FILLING PRESSURE DEFINED BY E/e’

X XX X

PVa-Mva >30 ms

Valsalva +ve

>1 variable +ve X

E/e’ 8÷15

LV

DP

(m

mH

g)

E/e’ and LV filling pressure l April 21, 2023 l 26

Ommen et al. Circulation 2000;102:1788-1794.

LV FILLING PRESSURE DEFINED BY E/e’

X X

Flow Doppler -ve

E/e’ 8÷15

LV

DP

(m

mH

g)

ONE SIZE FITS ALL!

E/e’ and LV filling pressure l April 21, 2023 l 27

CONSTRICTIVE PERICARDITIS

Ha et al. Circulation 2001;104:976-978.

PCWP 31 mmHgE/e’ 5

PCWP 18 mmHgE/e’ 17

E/e’ and LV filling pressure l April 21, 2023 l 29

•What is E/e’

•Determination of LV filling pressure

•Evaluation of pts with HF

E/e’ and LV filling pressure l April 21, 2023 l 30

TO THE POINT

E/e’ and LV filling pressure l April 21, 2023 l 33

E/e’

E/e’ ≤8(sept, lat, or average)

Sept E/e’ ≥15or

Lat E/e’ ≥12or

Aver E/e’ ≥13

Estimation of filling pressures in patients with normal EF

LAP

E/e’ 9-14

LAV <34 ml/m2

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

LAV ≥34 ml/m2

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

LAP

E/e’ and LV filling pressure l April 21, 2023 l 34

Normal LAP

Normal LAP

Estimation of filling pressures in patients with normal EF

E/e’ and LV filling pressure l April 21, 2023 l 35

E/e’ and LV filling pressure l April 21, 2023 l 36

E vel = 82 cm/sec e’ vel = 4 cm/sec

E/e’ = 82/4 = 20.5

E/e’

E/e’ ≤8(sept, lat, or average)

Sept E/e’ ≥15or

Lat E/e’ ≥12or

Aver E/e’ ≥13

Estimation of filling pressures in patients with normal EF

LAP

E/e’ 9-14

LAV <34 ml/m2

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

LAV ≥34 ml/m2

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

LAP

E/e’ and LV filling pressure l April 21, 2023 l 37

Normal LAP

Normal LAP

E/e’

E/e’ ≤8(sept, lat, or average)

Sept E/e’ ≥15or

Lat E/e’ ≥12or

Aver E/e’ ≥13

Estimation of filling pressures in patients with normal EF

LAP

E/e’ 9-14

LAV <34 ml/m2

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

LAV ≥34 ml/m2

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

LAP

E/e’ and LV filling pressure l April 21, 2023 l 38

Normal LAP

Normal LAP

E/e’

E/e’ ≤8(sept, lat, or average)

Sept E/e’ ≥15or

Lat E/e’ ≥12or

Aver E/e’ ≥13

Estimation of filling pressures in patients with normal EF

LAP

E/e’ 9-14

LAV <34 ml/m2

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

LAV ≥34 ml/m2

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

LAP

E/e’ and LV filling pressure l April 21, 2023 l 39

Normal LAP

Normal LAP

E/e’

E/e’ ≤8(sept, lat, or average)

Sept E/e’ ≥15or

Lat E/e’ ≥12or

Aver E/e’ ≥13

Estimation of filling pressures in patients with normal EF

LAP

E/e’ 9-14

LAV <34 ml/m2

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

LAV ≥34 ml/m2

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

LAP

E/e’ and LV filling pressure l April 21, 2023 l 40

Normal LAP

Normal LAP

Mitral E/A

E/A <1 and

E ≤50 cm/secE/A ’ ≥2,

DT <150 ms

Estimation of filling pressures in patients with depressed EF

E/A 1÷2, or E/A <1 and E >50 cm/sec

E/e’ (average e’) <8

E/Vp <1.4

S/D >1

Ar-A <0 ms

Valsalva Δ E/A <0.5

PAS <30 mmHg

IVRT/TE-e’ >2

E/e’ (average e’) >15

E/Vp ≥2.5

S/D <1

Ar-A ≥30 ms

Valsalva Δ E/A ≥0.5

PAS >35 mmHg

IVRT/TE-e’ <2

E/e’ and LV filling pressure l April 21, 2023 l 41

Normal LAP

Normal LAP

LAP LAP

E/e’

E/e’ and LV filling pressure l April 21, 2023 l 42

E/e’ and LV filling pressure l April 21, 2023 l 43

VIZI PRIVATI, PUBBLICHE VIRTU’

E/e’ and LV filling pressure l April 21, 2023 l 44

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E/e’ and LV filling pressure l April 21, 2023 l 47

SI FA, MA NON SI DICE …

Dini FL et al. Eur J Echocardiogr 2010;11;703-710.

E/e’ and LV filling pressure l April 21, 2023 l 48

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Presentation Title l April 21, 2023 l 50

IL CALCOLO DEL RAPPORTO E/e’ VA ROUTINARIAMENTE INSERITO IN OGNI REPORT IN QUANTO METODO AFFIDABILE

PER IL RILIEVO DELLA PRESSIONE TELEDIASTOLICA E LA GESTIONE CLINICA DEL PAZIENTE?

Pro: Alessandro SalustriContro: Maurizio Galderisi

Moderatori:

Alfredo Zuppiroli

Maurizio Galderisi

E/e’ and LV filling pressure l April 21, 2023 l 51

E/e’ and LV filling pressure l April 21, 2023 l 52

Presentation Title l April 21, 2023 l 53