Elevated E/e' and intraoperative fluids
58-year-old female, colonic resection. LVEF 65% — systolic function preserved — but E/e' 17 and LAVI 38 mL/m² raise the possibility of elevated filling pressure.
Clinical scenario
58-year-old female, scheduled for colonic resection for rectal adenocarcinoma. History of hypertension and obesity (BMI 31). Mild exertional dyspnea on flat ground. Preoperative TTE obtained.
Key TTE findings
LVEF 65% (preserved), E/e' 17 (elevated, reference ≤ 14), LAVI 38 mL/m² (elevated, reference ≤ 34), TR velocity 2.5 m/s (within normal range), TAPSE 2.1 cm (normal).
How the tool reads this
Filling pressure: Possible (E/e' > 14 and LAVI > 34). LV systolic reserve: Normal. Right heart: Normal.
What the E/e' and LAVI combination is telling you
E/e' is a surrogate marker for LV filling pressure. A ratio of 17 suggests impaired LV relaxation or elevated filling pressure — though it does not confirm it on its own. When combined with LAVI 38 mL/m², which reflects left atrial remodeling from chronic pressure load, the picture becomes more consistent. The ASE/EACVI 2016 algorithm treats this combination as 'possible' elevated filling pressure.
For intraoperative fluid strategy in colonic resection, E/e' alone does not make the call. Liberal fluids in a patient with elevated filling pressure can worsen congestion; over-restriction can leave a preload-responsive patient volume-depleted. Integrating SpO₂ trends, lung sounds, blood pressure response, and urine output is the practical approach.
- E/e' accuracy decreases in atrial fibrillation and significant MR — this case is sinus rhythm with no MR
- LAVI elevation reflects chronic filling pressure load, making it more reliable than an acute E/e' change
- TR velocity 2.5 m/s is within the normal range here — pulmonary hypertension is not suggested
Teaching points
- Combining E/e' and LAVI improves confidence in identifying elevated filling pressure
- Do not use E/e' alone to confirm filling pressure — integration with other markers is required
- Fluid management decisions should incorporate SpO₂, blood pressure, and clinical findings alongside echo data
What to watch in the OR
- Aggressive fluid loading in a patient with elevated filling pressure carries a real risk of acute pulmonary edema
- Consider goal-directed fluid therapy or pulse pressure variation to guide intraoperative volume administration
- Watch for postoperative hypoxemia — do not delay chest X-ray or reassessment if oxygen requirements increase