"Peak Summation" Left Ventricular Filling Pattern in Patients with Chronic Heart Failure

In patients with chronic heart failure (CHF) and a “peak summation” left ventricular pattern, no hemodynamic and prognostic information can be drawn from Doppler examination of mitral flow. In 263 consecutive patients with CHF who were undergoing simultaneous right heart catheterization and echo-Doppler examination, we prospectively determined (1) the frequency of the peak summation left ventricular filling pattern and (2) the incremental information contributed by pulmonary venous flow velocity patterns in providing noninvasive hemodynamic profile estimation. Isovolumic relaxation time of mitral flow, peak systolic (X), diastolic forward (Y), reverse (Z) flow velocity, and systolic fraction (X/X + Y) of pulmonary venous flow were measured. Forty-six of 263 (17%) patients had a peak summation left ventricular filling pattern. This subgroup showed more clinical deterioration (New York Heart Association functional class III-IV, 57% vs 49%; P < 0.01) and left atrial dysfunction (left atrial ejection fraction, 31% vs 39%; P < 0.001). However, 40% of these patients had a pulmonary wedge pressure of> 18 mmHg and a cardiac index of < 2.2 L/min/m². The systolic fraction of peak velocities of pulmonary venous flow showed a good correlation with pulmonary wedge pressure (r = -0.70, P < 0.05). The correlation was stronger in patients without mitral regurgitation (r = -0.81, P < 0.05). A systolic fraction of < 40% was accurate (sensitivity, 100%; specificity, 95%) in identifying patients with a pulmonary wedge pressure of < 18 mmHg. In patients without mitral regurgitation, this variable was also correlated with cardiac index (r = -0.65, P < 0.05) and predicted a cardiac index of < 2.2 L/min/m² (sensitivity, 91% specificity, 71%). In conclusion, a peak summation left ventricular filling pattern is common in patients with CHF. Pulmonary venous flow provides useful information about the hemodynamic profile of these patients.