Echocardiographic Assessment of Diastolic Dysfunction in Severe Aortic Stenosis Undergoing Invasive Hemodynamics: The Value of Left Atrial Function and Pulmonary Vein Doppler Flow

Diastolic dysfunction (DD) and left ventricular filling pressure (LVFP), particularly mean pulmonary capillary wedge pressure (mPCWP), are key prognostic factors in severe aortic stenosis (AS). Echocardiographic parameters can help identify elevated LVFP, enabling timely aortic valve intervention. However, evidence on echocardiographic LVFP estimation in severe AS is limited and discordant. This study investigated 138 patients with severe AS in sinus rhythm who underwent both echocardiography and right heart catheterization (RHC) within five days between January 2020 and November 2024. We evaluated the correlation of clinical and echocardiographic parameters, including left atrial (LA) function and pulmonary vein (PV) Doppler indices, with mPCWP ≥ 15 mmHg. Echocardiographic parameters significantly correlated with mPCWP included the E/A ratio, S/D ratio, peak D wave velocity, and left atrioventricular coupling index (LACI) (p < 0.001). A cutoff S/D ratio ≥ 0.66 and peak D wave velocity ≥ 77 cm/s predicted mPCWP ≥ 15 mmHg with areas under the curve (AUCs) of 0.888 and 0.862, respectively. The 2016 ASE/EACVI algorithm for LVFP estimation showed modest accuracy (44%) with an AUC of 0.614. However, adding LACI improved accuracy (sensitivity 72%, specificity 70%, accuracy 67%, AUC 0.710). A second novel approach combining the S/D ratio and peak D wave velocity yielded the highest accuracy (sensitivity 64%, specificity 98%, accuracy 88%, AUC 0.810). These findings demonstrate that LA function and PV Doppler variables provide valuable insights into DD assessment in severe AS. Incorporating these parameters can improve early recognition of heart failure, refine diagnostic accuracy and guide clinical decisions in patients with severe AS.