Prognostic value of Doppler echocardiographic mitral inflow patterns: implications for risk stratification in patients with chronic congestive heart failure

OBJECTIVES This prospective study tested whether transmitral flow patterns add incremental value to peak oxygen consumption (V ;-4u 2) in determining the prognosis of patients with chronic congestive heart failure (CHF) and systolic dysfunction. BACKGROUND Peak V ;-4u 2 is an objective marker of functional capacity and is routinely used as a criterion to identify heart transplant candidates. Diastolic dysfunction limits functional capacity, but its prognostic importance relative to that of peak V ;-4u 2 is unknown. METHODS Peak V ;-4u 2 and mitral inflow velocities were prospectively measured in 311 consecutive patients (mean age 54 years, 84% male) with impaired left ventricular function (ejection fraction <40%; 88 patients with ischemic and 223 with dilated cardiomyopathy) who were evaluated for heart transplant candidacy. RESULTS During a mean follow-up period of 512 ± 314 days, 65 patients died and 43 patients underwent heart transplantation. Diastolic filling patterns, peak V ;-4u 2 and left ventricular end-diastolic diameters were independent predictors of cardiac mortality. In patients with peak V ;-4u 2 ≤14 ml/min per kg body weight, the outcome was markedly poorer in the presence of restrictive filling patterns as compared with their absence (two-year survival rate 52% vs. 80%). Similarly, despite peak V ;-4u 2 levels >14 ml/min per kg, the outcome was less favorable in the presence of restrictive filling patterns (two-year survival rate 80% vs. 94%). A risk-stratification model based on the identified independent noninvasive predictors separated groups into those with high (93%), intermediate (65%) and low (39%) two-year survival rates. CONCLUSIONS Transmitral flow patterns add incremental value to peak V;-4u 2 in determining the prognosis of patients with CHF and impaired systolic function