Transthoracic echocardiography (TTE) is currently the gold standard in the routine evaluation of Left Ventricular Filling Pressure (LVFP) in patients with dyspnea and/or heart failure, which is guided by the 2016 American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines. Although, at least of 5 to 6 different parameters were necessary to conclude, each of them with their own intra- and interobserver variability. The present report examined the reproducibility of each parameter of the algorithm and its influence on the final decision of the clinician.

We selected 12 adults admitted for dyspnea with a complete TTE. Each exam was analysed by two readers (one junior and one senior) in 5 French cardiologic tertiary centres. The methodology was always the same and replicated blinded. We focused on the reproducibility of the dichotomial choice for each value because of it's the only information needed for using the algorithm. As demonstrated in Fig. 1, only E/A ratio and LVEF status (preserved or not) had a substantial – but not perfect – agreement, LAVi had the poorest reproducibility. The final decision on left ventricular filling pressure pattern had a moderate agreement. Of note, the conclusion was identical for 5 patients for all readers. For the others, there was some discrepancy between readers, which was similar for seniors and juniors. Main discordance exists in considering mitral calcifications significant or not and for value which are around the cut-off.

Without considering performance, this multicentric French study puts forward limits of actual algorithm recommended for left ventricular filling pressure pattern assessment. Agreement is excellent in caricatural (easy) cases (LV pressure clearly normal or clearly elevated), but a great discordance exists in grey zone. Improvement in the algorithm and in method for LVFP determination would be proposed.