Evaluation Of Ventricular Diastolic Function By Doppler Echocardiography Correlation With Simultaneous Cardiac Catheterization In Patients With Congenital Heart Disease

BackgroundCongenital heart disease(CHD) patients are likely to presented with growth retardation, recurrent respiratory tract infections, severe pulmonary hypertension and heart failure.thus left ventricular systolic function is almost normal, heart failure is seriously in some patients at clinical observation, may consider diastolic heart failure, especially the left to right shunt type, the left ventricular volume is easily overload and enlargement, left ventricular end-diastolic pressure (LVEDP) rise, lead to pulmonary congestion and respiratory failure. Cardiac catheterization is the invasive examination to evaluate diastolic function, and the left ventricular end-diastolic pressure is easily measured. The major methods of heart Doppler ultrasound to evaluate ventricular diastolic function is tissue Doppler imaging(TDI), mitral valve flow spectrum(MVF), Pulmonary vein flow spectrum(PVF). The ratio of transmitral diastolic early peak inflow velocity (E) to late peak inflow velocity(A)has been widely used to evaluate left ventricular end-diastolic pressure (LVEDP) clinically, but is easily influenced by ventricular diastolic velocity and degree, ventricular compliance, left atrial pressure and other factors and limit its clinical application.Recent years some new and useful Echo parameters has been find, especially the ratio of transmitral diastolic early peak inflow velocity (E) to early diastolic velocities of mitral annulus(E’), the ratio is considered to be the exactly invasive examination to evaluate the left ventricular end-diastolic pressure(LVEDP). In some research in adult, Doppler E/E’is closely related to LVEDP. Some expert consensus documents has incorporate Doppler E/E’into the diastolic heart failure diagnostic criteria. In congenital heart disease field, it is difficult to diagnose diastolic dysfunction, and easily neglected, Doppler ultrasound studies about ventricular diastolic function is large. However, most lack of cardiac catheterization data for comparison. Therefore, it is significantly to do the comparative study between Doppler ultrasonography and cardiac catheterization.ObjectiveBy Comparing cardiac catheterization, to study the value of Doppler tissue imaging in measuring left ventricular end-diastolic pressure with congenital heart disease, and to select non-invasive valuable Doppler parameters for estimating of LVEDP or VEDP, and try to explore their evaluation of diastolic dysfunction.MethodWe enrolled 208 patients with congenital heart disease (CHD) who were admitted to Guangdong General Hospital and underwent cardiac catheterization or interventional therapy. The patients carry on echocardiography and Doppler tissue imaging inspection underwent within 24 hours before cardiac catheterization, to complete morphological diagnosis, measure tissue Doppler imaging (TDI), mitral valve flow spectrum (MVF), Pulmonary vein flow spectrum (PVF). Invasive measurements of LVEDP were obtained with 5F pig-tailed catheters. And the surrogate marker such as pulmonary capillary wedge pressue (PCWP), pulmonary pressure and left atrial pressue were obtained with 6F multifunction catheter. Patients were divided into two groups, the biventricular group (n=172) and univentricular group (n=36), and biventricular group were divided into three groups, the ventricular septal defect (VSD) group (n=81), the atrial septal defect (ASD) group (n=58), and the mixed group with different kinds of CHD (n=33). ASD group and VSD group have undergone transcatheter closure successfully, and follwed up for 6 months by echocardiography. Pearson correlations was performed between echocardiographic parameters and the invasive variables.Results1、the all patients mean age was 5.6±2.2 years,mean weight was 16.3±5.1Kg, 110(52.8%) were males and 98(47.2%) were females. Among the biventricular group, mean age was 3.5±1.2 years,mean weight was 13.6±5.6Kg,90(52.8%) were males and 82(47.2%) were females. The mean VEDP was 12.9±4.3mmHg (rang,5-39mmHg). Among the univentricular group, mean age was 8.2±2.9 years,mean weight was 18.6±7.9Kg,20(55%) were males and 16(45%) were females. The mean VEDP was 11.6±　4.4mmHg (rang,5-22mmHg).2、Among the biventricular group, a significant correlation was found between septal E/E’and EDP (r=0.65,p<0.001), lateral E/E’ and EDP(r=0.52,P<0.001), EDP correlated rather weakly with combined measurements E/A (r=0.19,p=0.087). Septal E/E’>10.85 had 77% sensitivity and 80% specificity for EDP>10 mmHg. Lateral E/E’>11.8 had 77% sensitivity and 80% specificity for EDP>10 mmHg. Among VSD group, septal E/E’>11.05 had 73% sensitivity and 86% specificity for EDP>10 mmHg. Among ASD group, septal E/E’>11.00 had 66% sensitivity and 74% specificity for EDP>10 mmHg. For the mixed group, septal E/E’>11.7 had 93% sensitivity and 75% specificity for EDP>10 mmHg. septal E/E’>14.6 had 78% sensitivity and 67% specificity for EDP>15mmHg.3、among ASD group, the left atrial diameter、left ventricular end-diastolic and end-systolic diameter were larger compared with pre-operation. the right atrial diameter was shorten after closure, which is statistically significant(p<0.05). septal E/E’ has been decreased 24 hours after transcatheter closure, which is statistically significant (p<0.05). Compared with pre-operation, the LVEDD were enlarger 1 days, 1 month,3 months,6 months after closure. Among VSD group, the left atrial diameter left ventricular end-diastolic and end-systolic diameter were shorten compared with pre-operation, the difference is statistically significant(p<0.05). The left ventricular ejection fraction has no statistically difference after transcatheter closure and the follow up. septal E/E’was decreased 24 hours after closure, the difference is statistically significant (p<0.05).4、Among the univentricular group, a significant positive correlation was found between ventricular free wall E/E’ and EDP (r=0.45,p<0.01), pulmonary vein atrial reversal duration (r=0.66,p< 0.01), and E’(r= 0.48,p<0.01).but have no correlation with pulmonary vein flow spectrum s/d(r=-2.1,p=0.25). Receiver operating characteristic curve analysis using an ventricular free wall E/E’ cutoff of 12 showed sensitivity of 83% and specificity of 78.0%(95%CI,49%-99%) for VEDP>10 mmHg. Receiver operating characteristic curve analysis using an E/E’ cutoff of 12 showed sensitivity of 89% and specificity of 61% (95%CI,51%-99%) for VEDP>15mmHg. However, parameters measured from ventricular septal did not show a relationship to VEDP.Conclusion1、For patients with biventricular heart, Doppler and tissue Doppler-derived E/E’ ratio is related to LVEDP in a heterogeneous group of patients with Congenital heart disease, an E/E’ ratio>11 predicted elevated left ventricular filling pressures, and a ratio>15 may predicted severe elevated left ventricular filling pressures. E/E’ ratio provides better estimates of LV filling pressures than other methods, it is promised to be an additional surrogate non-invasive estimation of ventricular diastolic performance in the routine follow-up of these patients.2、For patients with left to right congenital heart disease, left ventricular diastolic dysfunction occur earlier than the systolic dysfunction, when ventricular systolic function is normal, diastolic function is likely to be varying degree damage. For VSD group and ASD group, E/E’ ratios was decreased after transcatheter closure.3、For the single ventricles heart group, the ventricular free wall E/E’、TDI and pulmonary vein Doppler echocardiographic parameters correlated modestly with VEDP. An E/E’ ratio>12 predicted elevated left ventricular filling pressure. Tei index in single left ventricles group is lower than single right ventricles group. Combine the TDI parameters, single right ventricles patients’ diastolic function are poor relatively compared with single left ventricles patients.