echocardiography in heart failure€¦ · echocardiography in heart failure anthony demaria....
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Echocardiography in Heart Failure
Anthony DeMaria
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Dyspnea: Clinical Questions
• Is heart failure present?
• What is the etiology?
– Structural, systolic or diastolic dysfunction
• What is the state of systolic function
• What is the optimal treatment?
• How is the pt responding to therapy?
• What is the prognosis?
• Is the pt compensated or decompensating
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Dyspnea: Clinical Questions
• Is heart failure present?
• What is the etiology?
– Structural, systolic or diastolic dysfunction
• What is the state of systolic function
• What is the optimal treatment?
• How is the pt responding to therapy?
• What is the prognosis?
• Is the pt compensated or decompensating
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BNP vs Echocardiography
• Echocardiography provides data regarding cardiac structure and performance
• BNP provides information regarding LV/LA wall stress and pressure
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BNP vs Echocardiography
• BNP provides information regarding LV/LA wall
stress and pressure
– Distinguishes heart failure from other SOBs
– Tracks efficacy of therapy
– Assessment of prognosis, compensation and
decompensation currently underway
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BNP vs Echocardiography
• Echocardiography provides data regarding cardiac structure and performance
• Identify etiology
– Mechanical (structural) vs Functional
– Systolic vs Diastolic
– Ischemic vs Nonischemic
• Quantify abnormality
• Select therapy
• Define prognosis
• Follow course
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Etiology of Heart Failure by Echo
• Valve Disease Stenosis/Regurgitation
• Coronary Disease Segmental dysfunction
• Congenital Disease – Abnormal anatomy
• Pericardial Disease – Effusion/constriction
• Hypertension LVH
• Cardiomyopathy Composite (cavity size,
wall thickness, contraction)
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DCM HCM RCM
LV volume ↑↑↑↑ ↓↓ ↔
Wall thickness ↕ ↑↑↑ (IVS) ↑↑↑
Contractility ↓↓↓↓ ↑(↓) ↔
Echo Distinction of Cardiomyopathy
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Diagnostic Features of Nonischemic Cardiomyopathy
• Generalized myocardial dysfunction
– Absence of regional contractile abnormality
• Dobutamine or rest
– Absence of localized scar
– Absence of aneurysm
• Right ventricular dysfunction
• Diastolic dysfunction
• Increased LV sphericity
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Ischemic Heart Disease
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Assess LV Structure/Function
• Volumes and mass
• Ejection fraction
• Endocardial motion Velocity
• Wall thickening Extent
• Susceptible to in-plane motion and tethering
• Transition from motion to deformation (strain)
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Published Trials in Which EF was
Part of the Entry Criteria (Partial List)
• SOLVD Treatment Trial
• SOLVD Prevention Trial
• SAVE
• US Cravedilol Trials
• MERIT-HF
• CIBIS 1 & 2
• COPERNICUS
• CAPRICORN
• RALES
• ELITE 1 & 2
• Val-HEFT
• PRAISE 1 & 2
• OVERTURE
• ICD• Bi-ventricular pacing
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Quantitation of LV Function by Echocardiography
Lang et al; JASE, 18: 2005
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L0 L
Deformation (Strain) vs Movement
Thickening
Passive Movement
Strain = Change in Length / Original Length
Courtesy Toshiba Corp.
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Calculation of Strain From
Speckle Tracking
Frame 1 Frame 1 + n
Strain =Change in Length
Original Length
% Thickening
% Thinning
Modified from Freedman Z. and Lysysanksyv P
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CHF with Normal LVEF
• Wrong Diagnosis
• Volume Overload
• High Output Failure
• LV Underloading
– Mechanical lesions
– Pericardial disease
• Diastolic dysfunction
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Diastolic Dysfunction
• Multiple determinants
• Difficult to measure
• Diagnosis by exclusion
• Nonspecific treatment
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Determinants of Diastolic Function
• Myocardial Relaxation
• Chamber stiffness
• Compliance
• Atrial function
• Pericardial restraint
• Ventricular interaction
• Coronary blood volume
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Echo Assessment of Diastole
• Transmitral filling velocities (E, A, integrated)
• Decleration time
• Isovolumic Relaxation Time (IVRT)
• Pulmonary Vein Flow
• Tissue Doppler Velocities
• Color Doppler flow propagation
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Patterns of Diastolic Function
Mitral Inflow
PV flow
Tissue Doppler
Color M-mode
E
A
SD
Sm
Em
Am
vp
Nl (young)Delayed
relaxationPseudonormal
RestrictiveNl
(adult)
Mitral inflow
PV flow
TDE
CMM - Vp
NL (Young) NL (Adult)Delayed
Relaxation
Pseudo
normalRestrictive
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Aproaches to Estimate LV/LA Diastolic
Pressure
• MV systolic gradient with MR
• Transmitral filling dynamics
– E/A, DcT, IVRT,etc (with Valsalva)
• Pulmonary vein systolic filling fraction
• Ratio of pulmonary vein Ar/mitral A
• E/Ea (E/E’) ratio
• E/Vpm (color Doppler flow propagation)
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BP = 115/75Peak grad = 100LVSP = 15
LA Systolic Pressure from MR Jet Velocity
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Deceleration time
Deceleration Time
EA
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Gianuzzi,JACC
Deceleration Time Predicts Mortality and Events
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Nagueh et al; JACC, 1997
E/Ea Estimates LV Filling Pressure
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Limitations of E/E’ for Diastolic Function
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Limitations of E/E’ for Diastolic Function
Bhella et al; Circ CV Image, 2011
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E/E’ Ratio May Not Apply
• Normal heart
• Constrictive pericarditis
• Mitral stenosis or insufficiency
• Mitral or aortic valve replacement
• Mitral annular calcification
• Hypertrophic cardiomyopathy
• Acute decompensated heart failure (CRT)
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Diastolic Dysfunction and Mortality in
CHARM
• Subgroup of CHARM Preserved
• 66% had evidence of diastolic dysfunction
– 44% moderate to severe
• Adverse prognosis in those with
dysfunction
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Diastolic Dysfunction and Mortality in
CHARM
Persson et al; JACC, 2007
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Step Approach to Diastole (E/E’)
• Consider only E/E’> 15
– 12 if lateral included
• Evaluate corroborating findings
– Particularly LA size
• Combine all findings and include clinical
picture
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PROGNOSTIC FACTORS IN CHF
• Clinical class
• Age
• Diabetes
• Etiology
• LV size and function
• Cardiac pressures
• Ventricular arrhythmias
• Electrolyte and neurohormonal abnormalities
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XIE ET AL.MITRAL FLOW PATTERNS PREDICT CARDIAC MORTALITY
JACC Vol. 24, No. I July 1994:132-9
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XIE ET AL.MITRAL FLOW PATTERNS PREDICT CARDIAC MORTALITY
JACC Vol. 24, No. I July 1994:132-9
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Marwick; JNM: 2015Thavendiranathan et al; JACC: 2013Jenkins et al; JACC: 2004
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Biphasic Response to Dobutamine for Viability
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