The deceleration time of pulmonary venous diastolic flow is more accurate than the pulmonary artery occlusion pressure in predicting left atrial pressure

OBJECTIVES This study compared a prediction of mean left atrial pressure (PLA) ascertained by Doppler echocardiography of pulmonary venous flow (PVF), with predicted PLA using the pulmonary artery occlusion pressure (PPAO). BACKGROUND In select patient groups, PVF variables correlate with PPAO, an indirect measure of PLA. METHODS In 93 patients undergoing cardiac surgery, we recorded with transesophageal echocardiography mitral valve early (E) and late (A) wave velocities, deceleration time (DT) of E (DTE), and pulmonary vein systolic (S) and diastolic (D) wave velocities, DT of D (DTD) and systolic fraction. The PPAO was measured using a pulmonary artery catheter zeroed to midaxillary level. A further catheter was held at midatrial level to zero a transducer and was then inserted into the left atrium. A prediction rule for PLA from DTD was developed in 50 patients and applied prospectively to estimate PLA in 43 patients. RESULTS A close correlation (r 52 0.92) was found between PLA and DTD. Systolic fraction (r 5 20.63), DTE (r 52 0.61), D wave (r 5 0.57), E wave (r 5 0.52), and E/A ratio (r 5 0.13) correlated less closely with PLA. The mean difference between predicted and measured PLA was 0.58 mm Hg for DTD method and 1.72 mm Hg for PPAO, with limits of agreement (mean 6 2 SE) of 22.94 to 4.10 mm Hg and 22.48 to 5.92 mm Hg, respectively. A DTD of ,175 ms had 100% sensitivity and 94% specificity for a PLA of .17 mm Hg. CONCLUSIONS Deceleration time of pulmonary vein diastolic wave is more accurate than PPAO in estimating left atrial pressure in cardiac surgical patients. (J Am Coll Cardiol 2001;37:2025‐30) © 2001 by the American College of Cardiology Pulmonary artery occlusion pressure (PPAO) is considered the clinical gold standard for estimation of mean left atrial pressure (PLA), an indirect indicator of left ventricular intracavity filling pressures (1,2). However, insertion of a pulmonary artery catheter is not a risk-free procedure, and a reliable, less-invasive alternative has been sought (3). Both pulsed-wave Doppler echocardiography of mitral inflow and, subsequently, pulmonary vein flow (PVF) have been extensively studied, and a clear relationship between selected variables and PPAO was found (4 ‐12). However, mitral inflow and PVF patterns are influenced by multiple factors including left atrial pressure, left ventricular relaxation (4,13), compliance and afterload (14,15), ventricular interaction (16,17), heart rate (18,19), cardiac output (20) and age (21). These confounding factors preclude routine clinical use of mitral inflow or PVF patterns to predict PLA. Two recent studies have found a close relationship between the deceleration time of the diastolic wave (DTD) of PVF and PPAO in selected patient groups (22,23). Therefore, this study set out to investigate the relationship between the DTD and directly measured PLA in a more general group of cardiac surgical patients. We then attempted to predict PLA in a test group using a regression equation developed from the correlation between DTD and PLA in the study group. Finally, we compared the accuracy of this method of estimating PLA with PPAO estimation of PLA.