Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Hence, in the absence of a clear evidence for the superiority of averaged values and for the sake of ease and feasibility particularly in daily routine echocardiography, the recommendation to take averaged E' values should be modified.”
This author reply defends the ESC consensus recommendation of using averaged lateral and septal tissue Doppler velocities (E/E'ave > 15) to diagnose diastolic LV dysfunction in patients with heart failure and normal ejection fraction.
The authors appreciated Dr Kindermann's interest in our consensus document on ‘How to diagnose diastolic heart failure ?’1 and understand his concern on the use of averaged tissue Doppler (TD) lateral and septal mitral annular lengthening velocities to calculate the E/E' ratio (E/E'ave). The consensus document considers an E/E'ave > 15, derived from real-time pulsed TD, diagnostic evidence for diastolic LV dysfunction and requires additional noninvasive investigations for the diagnosis of diastolic LV dysfunction if the E/E'ave is encompassed in between 8 and 15. These cut-off values were indeed first proposed by Ommen et al.,2 who preferred the septal mitral annular lengthening velocity for the calculation of the E/E' ratio (E/E'sept). In patients with LV ejection fraction (EF) < 50% and elevated mean LV filling pressures (16.9 ± 6.4 mmHg), this study however observed equally strong correlations between mean LV filling pressures and E/E'sept (r = 0.60) or E/E'ave (r = 0.60). Only in patients with LVEF > 50% was the correlation between mean LV filling pressures and E/E'sept (r = 0.47) slightly better than E/E'ave (r = 0.45). These patients however had normal mean LV filling pressures (11.4 ± 5.6 mmHg). The better correlation observed in this group can therefore not be extrapolated to patients with heart failure and normal LV ejection fraction (HFNEF). A similar study3 correlating mean pulmonary capillary wedge pressure (PCWP) with E/E'ave also revealed E/E'ave > 15 to be the optimal cut-off value to predict elevated PCWP. These investigators preferred the use of E/E'ave following a prior study,4 in which they had compared E/E' ratios using lateral, septal, anterior, inferior, average of two, average of three, and average of four mitral annular lengthening velocities. In this study, the use of averaged lateral and septal mitral annular lengthening velocities yielded the best correlation with PCWP even in the presence of segmental LV dysfunction. Recently, the E/E' ratio using the lateral mitral annular lengthening velocity (E/E'lat) and E/E'sept was correlated in HFNEF patients with a conductance catheter derived LV stiffness modulus.5 In this study, only E/E'lat correlated with the LV stiffness modulus (r = 0.53; P < 0.001). Moreover, only E/E'lat discriminated HFNEF patients from age-matched controls possibly because of aspecific ageing-induced elevation of E/E'sept.6
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Paulus et al. (2007) conducted a letter in Heart failure with normal left ventricular ejection fraction (diastolic heart failure). Averaged tissue Doppler lateral and septal mitral annular lengthening velocities (E/E'ave) vs. Septal (E/E'sept) or lateral (E/E'lat) mitral annular lengthening velocity alone was evaluated on Correlation with mean LV filling pressures, PCWP, and LV stiffness modulus for diagnosing diastolic LV dysfunction (p=<0.001). Averaged tissue Doppler E/E' > 15 provides diagnostic evidence for diastolic LV dysfunction, while lateral E/E' correlates with LV stiffness modulus in HFNEF (r = 0.53; P < 0.001).
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