"Peak summation" left ventricular filling pattern in patients with chronicheart failure: Frequency and complementary value of pulmonary venous flow in its hemodynamic interpretation

In patients with chronic heart failure (CHF) and a "peak summation" left ve ntricular pattern, no hemodynamic and prognostic information can be drawn f rom Doppler examination of mitral flow. In 263 consecutive patients with CH F who were undergoing simultaneous right heart catheterization and echo-Dop pler examination, we prospectively determined (1) the frequency of the peak summation left ventricular filling pattern and (2) the incremental informa tion contributed by pulmonary venous flow velocity patterns in providing no ninvasive hemodynamic profile estimation. Isovolumic relaxation time of mit ral flow, peak systolic (X), diastolic forward (Y), reverse (Z) flow veloci ty, and systolic fraction (X/X + Y) of pulmonary venous flow were measured. Forty-six of 263 (17%) patients had a peak summation left ventricular fill ing pattern. This subgroup showed more clinical deterioration (New York Hea rt Association functional class III-IV, 57% vs 49%; P < 0.01) and left atri al dysfunction (left atrial ejection fraction, 31% vs 39%; P < 0.001). Howe ver, 40% of these patients had a pulmonary wedge pressure of < 18 mmHg and a cardiac index of > 2.2 L/min/m(2). The systolic fraction of peak velociti es of pulmonary venous flow skewed a good correlation with pulmonary wedge pressure (r = -0.70, P < 0.05). The correlation was stronger in patients wi thout mitral regurgitation (r = -0.81, P < 0.05). A systolic fraction of < 40% was accurate (sensitivity, 100%; specificity, 95%) in identifying patie nts with a pulmonary wedge pressure of > 18 mmHg. In patients without mitra l 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/m(2) (sensiti vity, 91%; specificity, 71%). In conclusion, a peak summation left ventricu lar filling pattern is common in patients with CHF. Pulmonary venous flow p rovides useful information about the hemodynamic profile of these patients.