imaging in heart failure: a multimodality approach - noninvasive... · imaging in heart failure: a...

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Imaging in Heart Failure:A Multimodality Approach

Thomas Ryan, MD

Heart Failure

HFrEF HFpEF

EF<40% EF>50%

Lifetime risk – 20%Prevalence ≈ 6M AmericansSocietal costs - $30B50% 5-year survival

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Systolic Heart Failure

Risk Factors

Myocardial Injury

RemodelingReduced

EF

Pump Failure

Arrhythmias

Chronic Heart

Failure

Symptoms

HypertensionDiabetesCADValve disease

Diastolic Heart Failure

Risk Factors

LVHFibrosis

Diastolic dysfunction

Preserved EF

Inc LVEDP

Arrhythmias

Chronic Heart

Failure

Symptoms

HypertensionDiabetesCAD

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Heart Failure Stages

End-Stage HF

End-Stage HF

Symptomatic HF

Symptomatic HF

Asymptomatic LV dysfunction

Asymptomatic LV dysfunction

High risk for developing HFHigh risk for developing HFA

B

C

D

Hunt et al, ACC/AHA Heart Failure Guidelines, 2001

Wang et al, Circ ‘03

Effect of LV Dysfunction on Survival

Normal subjects

ASx, mild LV dysfcn

ASx, mod/sev LV dysfcn

Pts w/ CHF

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LV Pressure-Volume LoopsLV Pressure-Volume Loops

Pre

ssu

re

Volume

Normal

Stroke Volume

Stage B Stage C Stage D

Inc LVEDP

Key Questions in Heart Failure

• Are the Sx due to heart failure?

• Can I exclude heart failure as a Dx?

• If it is heart failure, how bad is it?

• Can the imaging results help with therapy?

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Noninvasive Diagnostic Testing

Class I Recommendations:1. Laboratory studies, including BNP2. ECG3. CXR4. 2D Echo

Class IIa Recommendations:1. Viability/ischemia assessment, in selected pts2. MUGA or MRI, when echo is inadequate3. MRI to assess infiltrative process or scar

Class III Recommendations:1. Routine repeat assessment of LV function

Yancy et al, ACC/AHA Heart Failure Guidelines, 2013

Differential Dx of heart failure Sx• Pulmonary Causes:

• COPD• Pulmonary hypertension• Pulmonary embolus

• Non-cardiopulmonary Causes:• Anemia, anxiety, etc

• Cardiac Causes:• Valve disease• Pericardial disease, including

constriction• Diastolic heart failure – restrictive CM• Systolic heart failure• Hypertensive heart disease

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Goals of Initial Evaluation

1. Determine the etiology of HF

2. Assess prognosis

3. Determine functional status

4. Measure ventricular function

5. Assess volume status

Echo in Heart Failure• Systolic function

‒ EF‒ Wall motion‒ LV volume‒ Remodeling‒ New approaches – strain, torsion

• Diastolic function – filling pressure‒ Restrictive CM

• Valve disease

• Pericardial disease - constriction

• Viability

• Resynchronization therapy

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Ischemic vs Nonischemic?

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MRI in Heart Failure• Systolic function

‒ Precise quantitation (gold standard)‒ LV mass

• Diastolic function ‒ Scar burden

• Etiology‒ Ischemia, infarction‒ Htn‒ Myocarditis‒ Infiltrative – Iron, amyloid, sarcoid,

etc‒ Genetic – ARVC, HCM

• Viability

Shah, Judd, Kim, Clinical MRI, ‘06

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Late Gadolinium Enhancement ImagingDiffuse hyperenhancement of both ventricles

Dark signal within cardiac chambers due to T1 shortening of amyloid protein in blood

Where CMR Adds the Most Value: Myocardial Characterization

• T1 T2 T2*

• Magnetic resonance parameters that reflect intrinsic tissue properties‒ Coronary artery disease, hypertension‒ Myocarditis‒ Infiltrative (iron overload, amyloidosis,

sarcoidosis)‒ Genetic (HCM, ARVC, Anderson-Fabry, lamin

A/C, dystrophin, etc.)

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Imaging Approach to HF

Measure global LV systolic function

r/o valve disease

Assess the pericardium

Evaluate diastolic function

Estimate filling pressures

Assess the right heart

Differential Dx of heart failure Sx• Pulmonary Causes:

• COPD• Pulmonary hypertension• Pulmonary embolus

• Non-cardiopulmonary Causes:• Anemia, anxiety, etc

• Cardiac Causes:• Systolic heart failure• Pericardial disease, including

constriction• Diastolic heart failure – restrictive CM• Hypertensive heart disease• Valve disease

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Can heart failure be “ruled out” with echo?

• Measure LV function

• LA size, LVH

• E/A, Decel time, E/e’

• Septal motion, atria, IVC, hepatic veins

Yes, with a few simple

steps



• LA size, LVH



If EF >50%, systolicdysfunction hasbeen ruled out

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LV Systolic Function

How to Measure LV Ejection Fraction

2D single plane

2D biplane

Real-time 3D

D

A = r2

L

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Corsi et al, Circ ‘05

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MRI for LV Function

Precise Quantitation of Function

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Echo vs MRI?

T2 Increases with Myocardial Water Content…

Scholz TD et al. 1992. also – Higgins CB et al. 1983, Karolle BL et al. 1991.

3 – 30% in T2

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Is It Heart Failure???

Is the LVEFnormal?

No, <50% Yes, >50%

Measure EFAssess FPTherapy?

Rule outother causes Septal

motion

LVH/IVC

Atrial size

E/A, E/e’

Valves

Con Per

RCM

Htn

ValveDisease


If normal, Htn and diastolic dysfunctionare unlikely


• LA size, LVH



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LA Volume and Diastolic Dysfunction

Tsang et al, AJC ‘02

IndexedLA Volume

M-modeLA Dimension


If normal,diastolic fcn andfilling pressureare probably Nl


• LA size, LVH



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Diastolic Heart Failure

Normal Impaired Relaxation Pseudonormal Restrictive

E

A

E’A’

IVRT

MitralInflow

Mitral annularvelocity

Mitral Annulus TDI

E’ A’

E A

Increasing mean LV dias pressure

E/E’ = 5 to 15Normal

E/E’ = 20 to 40High LVDP

10 cm/s

80 cm/s

Mitral Annulus

Mitral Inflow

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Mitral Annulus TDI

84 cm/s

10 cm/s

E/E’ = 8.4

E/E’ = 100/4 = 25

Range of SeverityRange of Severity

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Mitral Annulus TDI

Nagueh et al, JACC ‘97

‘

Mitral Annulus TDI

Nagueh et al, JACC ‘97

E/E’ < 10: Normal

E/E’ > 15: High PCWP

‘

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LG

E S

core

= 0

LG

E S

core

= 4

LG

E S

core

= 8

LG

E S

core

= 1

2

Moreo A et al. Circ: Imaging 2009.

Normal Grade IIIGrade II Grade I

Increasing Fibrosis Progressive Diastolic Dysfunction

TAGGED CINE CMR DENSE CMR

Advanced Measures of LV Function: Strain, Rotation, Torsion

Refined Measures esp. for HFpEF

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This excludesconstriction and

restriction ascauses


• LA size, LVH



• Rigid, noncompliant pericardium

• Equalization of pressures

• Intrathoracic and intrapericardial pressures are dissociated

• Increased ventricular interdependence

Constrictive Pericarditis

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Healing hearts

Changing lives

>25% respiratory variation in mitral E velocity

Reciprocal respiratory relationship between LV and RV

TricuspidValve

MitralValve


Healing hearts

Changing lives

High E’ indicates preserved myocardial function

Mitral Annulus DTIMitral Annulus DTI

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• Diastolic dysfunction – “restrictive filling”‒ High E wave, increased E/A‒ Short deceleration time‒ Little or no respiratory variation

• Normal or slightly decreased LV systolic function

• Dilated LA and RA

• Normal or slightly increased LV mass

Restrictive Cardiomyopathy


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Very Low e’

Restrictive MV filling


Constriction

Increased E wave

High E/A

Short decel time

Marked resp variation

High E’ = Low E/E’

Constriction vs Restriction

Restrictive CM

Increased E wave

High E/A

Short decel time

No resp variation

Low E’ = High E/E’

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Myocardial Amyloidosis

Sig

nal

in

ten

sity

SI eTE/T2*

Echo time (TE)

Myocardium T2* = 32 ms

Liver T2* = 3.5 ms

TE: 2.0 8.3 15.7 20.0 ms

T2* - Measure of Tissue Iron Content

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Summary• Heart failure is a clinical diagnosis

• Imaging provides diagnostic support,

information on etiology, severity and

prognosis

• Echo is the backbone of HF assessment

• MRI is becoming increasingly important

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Heart Failure Present?

Low EF Normal EF

Measure EFE/e’ – filling press.

MR severity?CRT candidate

Assess valvesLVH, atrial sizeE/A, decel time

E/e’Septal motion, IVC

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Cases

imaging in heart failure: a multimodality approach - noninvasive... · imaging in heart failure: a...

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