«Καρδιακή ανεπάρκεια»...heart failure (hf) is a global public health problem...
TRANSCRIPT
«Καρδιακή
ανεπάρκεια»
Απρίλιος 2017
Ξ. Δ. ΑποστολίδουΒ΄Καρδιολογική Κλινική Α.Π.Θ.
«Υπερηχογραφική
εκτίμηση της
καρδιακής
ανεπάρκειας»
Απρίλιος 2017
Ξ. Δ. ΑποστολίδουΒ΄Καρδιολογική Κλινική Α.Π.Θ. Απρίλιος 2017
Καμιά
σύγκρουση
συμφερόντων
«Υπερηχογραφική
εκτίμηση της
καρδιακής
ανεπάρκειας»
Heart failure (HF) is a global public health
problem affecting millions of people worldwide
The number of patients with HF in Europe has been estimated at 15 million. The overall medical and economic burden of HF-related care also results from the fact that the annual number of admissions due to HF is more than one million in both the United States and Europe.
More older Americans and Europeans are hospitalized for HF than for any other medical condition. Among people > 65 years of age presenting to primary care with breathlessness on exertion, one in six will have unrecognized HF (mainly HFpEF).
Despite advances in medical and device therapy for HF over the past few decades, mortality from HF remains high, with approximately 50% mortality within 5 years of HF diagnosis.
Additionally, the total costs of HF in the United States are projected to increase to $70 billion by 2030.
The Role of Echocardiography
in the Evaluation of Heart Failure
Echocardiography is a diagnostic test that provides information about structural and functional
abnormalities and can assess the underlying cause so that an optimal management strategy can be implemented
However,
• the prevalence of epicardial coronary artery disease, • the incidence of sudden cardiac death, and • the response to neurohumoral antagonists in patients
with a midrange ejection fraction
may be more similar to the values in patients with heart failure with reduced ejection fraction than in those with heart failure with preserved ejection fraction.
(Margaret M. Redfield, M.D. Mayo Clinic).
Many clinical characteristics are similar in patients with heart failure with midrange EF and in those with heart failure with preserved EF.
Assessment of Left Ventricular Systolic and
Diastolic Function by Echocardiography
Echocardiography may evaluate
• the percentage change in LV dimension (e.g. LV fractional shortening, LVFS; or LV ejection fraction, LVEF),
• parameters related to the LV output (e.g. stroke volume, cardiac output),
• the rate of change in intracavitary pressure (i.e. LV dp/dt), or• parameters of LV myocardial deformation (e.g. LV strain and strain
rate).
Current Approach to Heart Failure
Assessment of Left Ventricular Systolic
Function
Echocardiography offers several methods for assessment of systolic function, most of them being indirect estimates of LV systolic performance.
It reflects the volume shift (%LVEDV) during the cardiac cycle
Current Approach to Heart Failure
underestimation
biplane Simpson's methodimage quality, foreshortening of the LV
endocardial border definition, (contrast), ventricular geometry, assumptions and
representative orthogonal imaging plane
Left Ventricular Ejection Fraction3D Echocardiography
Current Approach to Heart Failure
Volumetric method SV can be measured by subtracting LV end-systolic volume from LV end-diastolic volume, obtained by the Simpson method or by 3D echocardiography, as previously described. The difference should be equal to the SV across the LVOT if there is no valvular regurgitation.
Doppler method SV can be measured by multiplying the velocity time integral (VTI) in the LV outflow tract (LVOT) by the LVOT area. The VTI in the LVOT can be measured by PW Doppler from the apical five-chamber/long-axis view, while LVOT diameter (DLVOT) is usually measured in the parasternal long-axis view and it is used to calculate the LVOT area assuming it has a circular shape. The formula used is: SV = π × (DLVOT2/4) × LVOT VTI (ml).
Stroke volume can be determined through volumetric or Dopplermethods.
Stroke Volume and Cardiac Output
Cardiac output can be calculated multiplying the SV by the heart rate, while the cardiac index dividing the cardiac output by the body surface area.
Current Approach to Heart Failure
Doppler method Stroke Volume
Current Approach to Heart Failure
The wall motion score index (WMSI) is the average value of all analyzed segments. Therefore, a normokinetic LV has a WMSI score of 1.0, and the index increases as wall motion abnormalities become more severe. This score also has prognosticvalue and a higher score is an independent predictor of morbidity and mortality.
LV Regional Function
Currently, regional wall motion is assessed qualitatively using a scoring system based on a 17-segment model.In this system, each segment is scored
as • normal or hyperkinetic (1 point), • hypokinetic (2 points),• akinetic (3 points), or • dyskinetic (4 points)
Current Approach to Heart Failure
Rate of LV Pressure Increase during isovolumic contraction
parameter of myocardial contractility
reflects force development
Doppler Methods of LV Systolic Function
Evaluation - Rate of LV Pressure Increase
values less than 1000 mm Hg/s indicate LV systolic dysfunction, and values less than 600 mm Hg/simply severely impaired LV
systolic function and are associated with poor outcome
Current Approach to Heart Failure
& Valvular Function
Strength and pitfalls of EF
Circulation. 2017;135:717–719
EF change may not reflect contractilityas much as it
reflects ventricular remodeling
It is a misconception that reduced EF equates with systolic dysfunction and
preserved EF with diastolic dysfunction.
It was not recognized that the nature of remodelling,
with or without LV dilation, was the primary driver toward reduced versus preserved EF.
Prediction of cardiovascular outcomes by non-invasive
techniques remains a priority in patients with
cardiovascular disease
Eur Heart J (2016) 37 (21): 1642-1650
Eur Heart J (2016) 37 (21): 1642-1650
JACC: Heart Failure, Volume 4, Issue 6, June 2016, Pages 502-510
It has proved useful in
• diagnosis and • risk stratification
does not describe intrinsic myocardial function
LVEF decreases only late in the course of many diseases
Thus, it has to be combined with more sensitive measures of LV dysfunction
Although LVEF carries important prognostic information and
is the basis for many therapeutic decisions,
it is not an index of contractility
Left Ventricular Ejection Fraction
Current Approach to Heart Failure
Modified, with permission from Smiseth et al
Diastole actually begins in systole,
as energy stored in titin within the myocyte and
as torsion in the interstitial fibers of the myocardium
Temporal Sequences of LV Twist
During a Cardiac Cycle
TWIST AND UNTWIST
MECHANICS
Assessment of left ventricle systolic function with the
mitral angular plane systolic excursion
MAPSE
sampling of myocardial motion which has lower velocities and larger amplitudes
Tissue Doppler imaging (TDI)
The peak systolic myocardial velocity S recorded at the LV base, reflects
longitudinal myocardial fiber shortening
While S values are uniformly reduced in HFrEF, reduced S-wave values have been reported in 50% of patients with HFpEF.
These findings suggest that TDI may detect impairment of longitudinal function as an early marker of LV dysfunction, that precedes the drop in LVEF
European Journal of Heart Failure , 2014
Systolic velocities in assessment of longitudinal systolic function in patients with heart failure and normal ejection fraction
Eur Heart J Cardiovasc Imaging 2016;17:722-731
Advantages of deformation indices over systolic velocities in assessment of longitudinal systolic function in patients with heart
failure and normal ejection fraction
Volume 13, Issue 3, pages 292-302, 18 FEB 2014 DOI: 10.1093/eurjhf/hfq203http://onlinelibrary.wiley.com/doi/10.1093/eurjhf/hfq203/full#ejhfhfq203-fig-0003 European Journal of Heart Failure
Volume 19, Issue 3, pages 307-313, 27 NOV 2016 DOI: 10.1002/ejhf.694http://onlinelibrary.wiley.com/doi/10.1002/ejhf.694/full#ejhf694-fig-0001 European Journal of Heart Failure
Myocardial strain to detect subtle left ventricular
systolic dysfunction
around -20%
HFpEF -15.8 cut-off HFrEF -10.3
Volume 19, Issue 3, pages 307-313, 27 NOV 2016 DOI: 10.1002/ejhf.694http://onlinelibrary.wiley.com/doi/10.1002/ejhf.694/full#ejhf694-fig-0003 European Journal of Heart Failure
Myocardial strain to detect subtle left ventricular
systolic dysfunction
cardiac amyloidosis
Myocardial strain to detect subtle left ventricular
systolic dysfunction
Volume 19, Issue 3, pages 307-313, 27 NOV 2016 DOI: 10.1002/ejhf.694http://onlinelibrary.wiley.com/doi/10.1002/ejhf.694/full#ejhf694-fig-0006 European Journal of Heart Failure
chemotherapy
Myocardial strain to detect subtle left ventricular
systolic dysfunction
Volume 19, Issue 3, pages 307-313, 27 NOV 2016 DOI: 10.1002/ejhf.694http://onlinelibrary.wiley.com/doi/10.1002/ejhf.694/full#ejhf694-fig-0007 European Journal of Heart Failure
Current Approach to Heart Failure
The most robust parameter of LV systolic function assessed by STE is
LV global longitudinal strain (GLS), calculated by
averaging the different segmental values measured
Eur Heart J (2016) 37 (21): 1642-1650
Screening for heart failure
Eur Heart J (2016) 37 (21): 1642-1650
Date of download: 3/29/2017Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For
permissions please email: [email protected]
From: Beyond ejection fraction: an integrative approach for assessment of cardiac structure and
function in heart failure
Eur Heart J. 2015;37(21):1642-1650. doi:10.1093/eurheartj/ehv510
Eur J Heart Fail 2016;18:1331–1339
Screening of asymptomatic subjects with ≥1 risk factor for HF and with normal left ventricular (LV) ejection fraction.
an event rate of 104 per 1000 person-years
Echocardiographic screening for non-ischaemic
stage B heart failure in the community
12.4%, 14 ± 4 months
the relaxation time constant, tau [τ]
Increased LV Filling
Pressures
Components of Healthy
Diastole and Disorders
That May Affect Them
J Am Coll Cardiol 2017;69:1451–64
The next step comprises an advanced workup in case of initial evidence of HFpEF/HFmrEF and consists of objective demonstration of structural and/or
functional alterations of the heart as the underlying cause for the clinical presentation.
Key structural alterations are a left atrial volume index (LAVI) >34 mL/m2 or a left
ventricular mass index (LVMI) ≥115 g/m2 for males and ≥95 g/m2 for females.
Echocardiography as a noninvasive Swan-Ganz catheter
The non-invasive estimation of LVFPs represents a main goal in the clinical setting
Date of download: 3/16/2017Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For
permissions please email: [email protected]
From: European multicentre validation study of the accuracy of E/e′ ratio in estimating invasive left
ventricular filling pressure: EURO-FILLING study
Eur Heart J Cardiovasc Imaging. 2014;15(7):810-816. doi:10.1093/ehjci/jeu022
NORRE study
Algorithm for diagnosis of
LV diastolic dysfunction in
subjects with normal LVEF
• atrial fibrillation, • left bundle branch block, • ventricular paced rhythm, • mitral annular calcification, • more than moderate MR/MS • mitral valve repair or
prosthetic mitral valve, • LV assist devices.
Algorithm not validated. It may be used in the absence of:
Algorithm for estimation of LV filling pressures and grading LV diastolic function in patients
with depressed LVEFs and patients with myocardial disease and normal LVEF after
consideration of clinical and other 2D data.
Mitter, S.S. et al. J Am Coll Cardiol. 2017;69(11):1451–64
Algorithm for Diagnosing Diastolic Dysfunction With Doppler Echocardiography
Whereas the E/A ratio of the mitral inflow exhibits a U-shaped relationship with progressive LVDD, the e’ velocity decreases in a continuous manner
Am J Cardiol 2000;86:169–174
When LV compliance ΔV/ΔP is reduced,a small change in volume results in
a large change in pressure.
Valsalva improves effective chamber
compliance
Am J Cardiol 2000;86:169–174
Load Manipulation
ventricular interdependence becomes dominant
Am J Cardiol 2000;86:169–174
The increased LV compliance (reduced stiffness) allows maintenance of the LV volume despite the reduction in atrial
driving pressure.
Because LV chamber stiffness (or LVEDP) essentially determines atrial afterload, the A wave will increase during the Valsalva
maneuver in patients with severely elevated filling pressures, in proportion to
the level of LVEDP.
Low amplitude and short duration of the transmitral A velocity in combination with a high amplitude and long duration of the reverse pulmonary venous velocity are typical for a ventricle with reduced chamber compliance and elevated LVEDP.
and instead blood regurgitates into the more compliant pulmonary veins, Ar
In the early phase of diastolic dysfunction and with a well-functioning LA, there may be a relatively normal LV pre–A-wave Pressure and a marked rise in LV pressure during vigorous atrial contraction.
Little blood moves forward across the mitral valve,
antegrade mitral flow is interrupted prematurely,
Circ Cardiovasc Imaging. 2011;4:671-677
Failure to Unmask Pseudonormal Diastolic Functionby a Valsalva Maneuver
Tricuspid Insufficiency Is a Major Factor
The Middiastolic L Wave
J Am Soc Echocardiogr 2004;17:428-31
Reduced S velocity, S/D ratio < 1, and systolic filling fraction (systolic VTI/total forward flow VTI) < 40% indicate increased mean LAP in patients with reduced LVEFs.
Ar - A duration > 30 msecindicates an increased LVEDP
J Am Soc Echocardiogr 1997;10:41–51
Ratio of IVRT to T E-e′ can be used to estimate LV filling pressures in normal subjects and patients with mitral valve disease
MR
Curr Cardiol Rep (2015) 17:561
T E-e′ = 38ms
T E-e′ = 20ms
IVRT/TE-e’ ratio < 3
Proposed Clinical Algorithm for Estimation of Left
Ventricular Filling Pressure in Subjects With Mitral
Annular Calcification
J Am Coll Cardiol Img 2017Abudiab et al.
Abudiab et al. Doppler LVFP in Mitral Annular Calcification J Am Coll Cardiol Img 2017
LA volume is the barometer of LV filing pressure
and reflects the burden of diastolic dysfunction
The LA size is measured at the LV end-systole when the LA chamber is at its greatest
dimension.It is imperative to avoid foreshortening of the LA
European Heart Journal – Cardiovascular Imaging (2016), 355
The left atrium modulates left ventricular filling through
three components:
• a phase of reservoir during systole,
• a conduit phase during diastole,
• an active contractile component
(when sinus rhythm ispresent) during late diastole
‘booster pump’
The relative contribution of LA phasic function to LV filling is dependent uponthe diastolic properties of LV
the relative contribution of LA reservoir and contractile function increases while conduit function decreases.
As LV relaxation gradually worsens
But with advanced diastolic dysfunction the LA serves
predominantly as a conduit
A LA volume index > 33 mL/m2, a cut-off already shown associated with increased risk of developing symptomatic HF, predicted abnormal exercise LV filling pressures with a high sensitivity (91%) and a good specificity (78%), while a LA volume index <26 ml/m2 was a marker of normal exerciseechocardiogram.
Hammoudi et al. showed that the patients with increased LV filling pressures at exercise echocardiography (E/e′ >13 in 12% of the population) were those with larger LA volumes at rest.
After Cardioversion
Heart failure in the setting of AF – How to assess?
Curr Cardiol Rep (2015) 17:561
Arrhythmia-induced heart failure
Predictors of Functional Recovery in Tachyarrhythmia
Clinical Utility of Longitudinal Strain to
Predict Functional Recovery in Patients
With Tachyarrhythmia and Reduced LVEF
J Am Coll Cardiol Img 2017;10:118–26
apical LSbasal + mid-LS values
Relative apical LS ratio
Date of download: 3/16/2017Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For
permissions please email: [email protected]
From: European multicentre validation study of the accuracy of E/e′ ratio in estimating invasive left
ventricular filling pressure: EURO-FILLING study
Speckle tracking echocardiography-derived left atrial systolic strain during cardiac cycle in two apical chamber views.
Determination of 12 regions, six in apical four-chamber view and six in apical two-chamber view by the use of ECG-derived
QRS complex as a reference point and measurement of the positive peak left atrial longitudinal strain.
Figure Legend:
Eur Heart J Cardiovasc Imaging. 2014;15(7):810-816. doi:10.1093/ehjci/jeu022
Correlation between global peak atrial
longitudinal strain (PALS) and
pulmonary capillary wedge pressure
Cardiovascular Ultrasound 2010 8:14
S’ velocity < 9,5 cm/s
TAPSE < 16 mm
< 35
European Heart Journal – Cardiovascular Imaging (2016) 17, 355–383
18
Eur Heart J Cardiovasc Imaging (2016) 17 (1): 106-113
following an acute HF episode with NT-pro-BNP >300 pg/mL (BNP > 100 pg/mL) and LVEF > 45% and reassessed by exercise echo-Doppler after 4–8 weeks of dedicated treatment
Ultrasound of extravascular lung water
Eur Heart J Cardiovasc Imaging (2016) 17 (1): 106-113
Date of download: 3/30/2017Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For
permissions please email: [email protected].
From: Clinical characteristics and determinants of exercise-induced pulmonary hypertension in patients
with preserved left ventricular ejection fraction
Incremental value of clinical data in addition to age, resting PASP, and resting E/e′ ratio as determinants of EIPH. PASP,
pulmonary artery systolic pressure; EIPH, exercise-induced pulmonary hypertension.
Figure Legend:
Eur Heart J Cardiovasc Imaging. 2016;18(3):276-283. doi:10.1093/ehjci/jew199
1 / 3
J Am Soc Echocardiogr 2015;28:95-105
Multimodality imaging for lead
placement for cardiacresynchronization therapy
Speckle-tracking
echocardiography (STE)
identifies the area with the
greatest dissynchrony.
Up to 30–45% of implanted patients are non-responders to CRT.Variability in the response to CRT and how to maximize its benefits remain a major issue.
Lead positioning is one of the most important variables.
Multimodality imaging for lead placement for
cardiac resynchronization therapy
Cardiac resynchronization therapy guided by multimodality cardiac imaging
European Journal of Heart Failure Volume 18, Issue 11, pages 1375-1382, 13 JUL 2016
Imaging markers of SCD in heart failure
Left ventricular ejection fraction has shown an association with
increased risk of ventricular arrhythmias and is included in the
recommendations for ICD as primary prevention.
A number of studies have demonstrated that appropriate therapy occurs in less than a third of ICD recipients with LVEF ≤35%
. Intraobserverstandard error
of measurement for Simpson's
method is 3.3%
The Uncertainties of Certainty
Zoran B. Popović JACC Cardiovasc. Imaging
speckle-tracking
echocardiography (LV) global longitudinal
strain
mechanical dispersion
Prediction of Sudden Cardiac Death and Life-
Threatening Arrhythmias After Myocardial Infarction
JACC Cardiovasc. Imaging 6 (2013) 851–860
LGS of the peri-infarct zone (22% increased risk of SCD per each 1% absolute worsening in LGS)
a surrogate of fibrosis a surrogate of slow and
heterogeneous electrical conduction
The cutoff value for mechanical dispersion of 76 ms provided 67 % specificity and 83 % sensitivity. Measurements of mechanical dispersion and global strain in ischemic patients add important information about the risk of sudden cardiac death apart from information provided by the EF. In patients with a preserved or slightly reduced EF, mechanical dispersion above 76 ms identified ischemic patients with an increased risk of sudden cardiac death.
Herz 2016 · 41:599–604
Circ Cardiovasc Imaging. 2017;10:e005096
Left ventricular dysfunction is a known predictor of ventricular arrhythmias
Cardiovascular Ultrasound 2017 15:3
Left Ventricular Contractile ReserveB-lines in heart failure
E/e’
Cardiac Resynchronization Therapy forecast
Wall Motion Score Index
SE in diastolic heart failure