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Estimation of filling pressure by E/e' in left bundle branch block: why is it so difficult?

Session Poster Session 3

Speaker Kasumi Masuda

Event : ESC Congress 2018

  • Topic : imaging
  • Sub-topic : Systolic and Diastolic Function
  • Session type : Poster Session

Authors : K Masuda (Suita, Osaka,JP), J Aalen (Oslo,NO), OS Andersen (Oslo,NO), M Krogh (Oslo,NO), HH Odland (Oslo,NO), M Stugaard (Suita, Osaka,JP), EW Remme (Oslo,NO), S Nakatani (Suita, Osaka,JP), OA Smiseth (Oslo,NO)

K. Masuda1 , J. Aalen2 , O.S. Andersen2 , M. Krogh2 , H.H. Odland2 , M. Stugaard1 , E.W. Remme2 , S. Nakatani1 , O.A. Smiseth2 , 1Osaka University Graduate School of Medicine Division of Functional Diagnostics - Suita, Osaka - Japan , 2Oslo University Hospital - Oslo - Norway ,

Echocardiography: Systolic and Diastolic Function

European Heart Journal ( 2018 ) 39 ( Supplement ), 562

Introduction: Current guidelines recommend the ratio between early-diastolic mitral flow velocity and mitral annular velocity (E/e') as a key parameter for noninvasive estimation of left ventricular (LV) filling pressure. It is debated, however, if E/e' should be used in patients with left bundle branch block (LBBB).

Purpose: To determine how LBBB modifies the relationship between E/e' and LV filling pressure.

Methods: Heart failure patients with wide QRS due to LBBB or right ventricular (RV) pacing (n=13) were compared to heart failure patients with narrow QRS (n=82). Mitral annular velocities were measured at septal (e'septal) and lateral (e'lateral) locations, and average (e'average) was calculated. LV filling pressure was measured as pulmonary capillary wedge pressure (PCWP). In 6 anaesthetized dogs we induced LBBB activation pattern by RF ablation and by RV pacing, measured pressures by micromanometers and E and e' by echocardiography.

Results: In heart failure patients with narrow QRS there was good correlation between E/e' and PCWP with r values 0.54 and 0.46, for e'average and e'septal, respectively (p<0.0001.) In heart failure patients with LBBB, however, neither e'average nor e'septal correlated with PCWP (r=0.32 and 0.28 respectively, NS).

In the dog model, induction of LBBB and RV pacing caused QRS widening and septal motion similar to patients with LBBB. Septal e' decreased from 6±2 to 3±2 cm/s (mean±SD) (P<0.05), but e'lateral was unchanged at 6±1 cm/s. Septal E/e' increased from 8±2 to 15±6 (p<0.05), whereas E/e'average showed no significant change (8±2 and 9±2, respectively). There was no significant change in mean left atrial pressure (7.4±3.2 vs. 9.0±2.8 mmHg, respectively).

Conclusions: Induction of LBBB markedly increased septal E/e' due to reduction in septal e', but this did not reflect elevation of LV filling pressure. As suggested by the clinical data and strongly supported by the experimental study, septal E/e' should not be used for estimation of LV filling pressure in patients with LBBB. Whether the average of septal and lateral E/e' is useful, should be explored further in larger patient populations with LBBB.

Figure 1

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