«Καρδιακή ανεπάρκεια»...Heart failure (HF) is a global public health problem...

«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


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


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.


Doppler method Stroke Volume


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)


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


& 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

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


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

http://onlinelibrary.wiley.com/doi/10.1002/ejhf.2011.13.issue-3/issuetoc

http://onlinelibrary.wiley.com/doi/10.1093/eurjhf/hfq203/full#ejhfhfq203-fig-0003

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


http://onlinelibrary.wiley.com/doi/10.1002/ejhf.694/full#ejhf694-fig-0001




cardiac amyloidosis






chemotherapy




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



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



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


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

«Καρδιακή ανεπάρκεια»...Heart failure (HF) is a global public health problem...

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