Η ηχωκαρδιολογία στην διάγνωση κα πρόγνωση της καρδιακής ανεπάρκειας µε

µειωµένο και φυσιολογικό κλάσµα εξώθησης

Βασίλειος Σαχπεκίδης Επιµελητής Β΄ Καρδιολογίας Γ.Ν. Παπαγεωργίου Θεσσαλονίκη

ESC Guidelines

McMurray J et al. Eur Heart J 2012;33:1787-1847

McMurray J et al. Eur Heart J 2012;33:1787-1847

EF LVEF, DD, RV, Valves…

Information from echo

Echocardiography in HF

•  Assessment of LV size, geometry, mass and systolic function •  Assessment of LV diastolic function •  Hemodynamics •  Assessment of RV size and function •  Valvular heart disease •  Dyssynchrony •  Stress echocardiography •  Prognostic information

LV size and geometry

Much better validated for TTE than TOE (use analogous views)

Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63

M-mode vs 2D measurements of LV dimensions and wall thickness

Simpson’s Biplane Method

Calculation of LV mass

Linear method 2D method

Reference values of LV geometry

Most measurements presented are derived from fundamental imaging Harmonic imaging → increased values In clinical practice wall thickness > 1.1 cm is considered abnormal

Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63

Reference values of LV size

Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63

Prognostic importance of LV mass

Quinones MA et al. J Am Coll Cardiol 2000;35:1237-44.

LV geometric pattern is also important

2xPWTd/LVIDd

Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63

Pts with concentric hypertrophy have the worse prognosis

Muiesan M et al. Hypertension 2004;43:731-8

Concentric remodeling adversely impairs prognosis even if LV mass is normal

Verdecchia P et al. J Am Coll Cardiol 1995;25:871-8

Assessment of LV systolic function

•  Fractional shortening (FS) •  Ejection fraction (EF) by 2D or 3D imaging •  Stroke volume •  Systolic Doppler tissue velocity •  LV dP/dt •  Strain rate imaging •  Myocardial performance index (MPI)

Methods for assessing LVEF

•  Visual estimation (eyeball method)

•  From linear measurements of LV dimensions (M-mode or 2D)

•  From volumetric 2D measurements

EF calculation by Simpson�s Biplane Method

Moderately reduced EF

Problems with 2D EF and volumes

•  Poor acoustic windows

•  Underestimation compared to MRI

•  Load dependent index

Use of contrast

Malm S et al. J Am Coll Cardiol 2004;44:1030-5

3D echocardiography

Jacobs LD et al. Eur Heart J 2006;27:460-8

Deformation imaging – TDI

Wang M et al. J Am Coll Cardiol 2003;41:820-6

Deformation imaging

•  Strain imaging

•  Speckle tracking

Validation? – Incremental value?

Prognostic significance of EF

Vasan RS et al. J Am Coll Cardiol 1999;33:1948-55

Prognostic significance of LV EDD and EF

Wong M et al. J Am Coll Cardiol 2004;43:2022-7.

Prognostic significance of LV dimensions and EF after MI

Burns RJ et al. J Am Coll Cardiol 2002;39:30-6.

However…

•  LV dimensions and EF do not correlate well with HF symptoms, exercise capacity or myocardial oxygen consumption

Stroke volume ≠ Ejection Fraction

Hachicha Z et al. Circulation 2007;115:2856-64

Diastolic dysfunction: why is it important?

•  Half of pts with newly diagnosed HF have normal or near normal EF

•  Distinguish HF from other causes of dyspnoea

•  Filling pressures

•  Prognosis

Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133

In practice…

•  Assessment of LV and LA

•  Measurements not always suggestive of the same degree of DD

•  Presence of ≥ 2 abnormal measurements increases likelihood of diagnosis

E/e’

E/e’

Ommen SR et al. Circulation 2000;102:1788-1794

Diagnosis of HFPEF

Paulus W et al. Eur Heart J 2007;28:2539–2550

Prognosis of pts with HFPEF

Owan T et al. N Engl J Med 2006;355:251-9 Bhatia RS et al. N Engl J Med 2006;355:260-9

Persistence of restrictive filling pattern impairs survival

Pinamonti B et al. J Am Coll Cardiol 1997;29:604-12

Restrictive filling pattern in patients with preserved EF

Klein AL et al. Circulation 1991;83:808-16

Diastolic dysfunction and prognosis

Redfield MM et al. JAMA 2003;289:194-202.

LA volume

Abhayaratna WP et al. J Am Coll Cardiol 2006;47:2357-63

Hemodynamics

RA pressure

≤2.1 cm and >50% collapse

0 – 5 mmHg

Intermediate values

5 – 10 mmHg

>2.1 cm and <50% collapse

10 – 20 mmHg

Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713

PAP

E/e’ performs better than BNP in pts with cardiac disease

Dokainish H et al. Circulation 2004;109:2432-2439

Prognostic importance of E/e’

Hillis G et al. J Am Coll Cardiol 2004;43:360–7

Kirkpatrick J et al. J Am Coll Cardiol 2007;50:381–96

Prognostic importance of E/e’

Dokainish H et al. J Am Coll Cardiol 2005;45:1223– 6

Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133

Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133

RV size

RVD1>42 mm RVD2>35 mm

Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713

RV function

<35% <16 mm

S<10 cm/s >0.40

Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713

RV dysfunction and prognosis

Zornoff LA et al. J Am Coll Cardiol 2002;39:1450-5

Valvular Heart Disease – Assessment of severity

Vahanian A et al. Eur Heart J 2012;33:2451-96

Valvular Heart Disease – Assessment of severity

Vahanian A et al. Eur Heart J 2012;33:2451-96

Valvular Heart Disease – Treatment

Vahanian A et al. Eur Heart J 2012;33:2451-96

Valvular Heart Disease – Prognosis

Enriquez-Sarano M et al. N Engl J Med 2005;352:875-83

Grigioni F et al. Circulation 2001;103:1759-64

Dyssynchrony assessment •  1/3 of pts do not respond

•  EF<35% major criterion

•  Best echo method is elusive

•  PROSPECT disappointing results

Chung ES et al. Circulation 2008;117:2608-16

Dyssynchrony assessment

Stress echocardiography

•  Ischaemia – viability

•  Assessment of valvular disease

•  Diastolic stress test

CAD assessment

Viability assessment

Allman K et al. J Am Coll Cardiol 2002;39:1151-8 Underwood SR et al. Eur Heart J 2004;25:815-36

Assessment of valvular disease

Lancellotti P et al. Circulation 2003;108:1713-7 Pibarot P et al. J Am Coll Cardiol 2012;60:1845-53

Diastolic stress test

Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133

Therapeutic guidance

•  Medication

•  ICD/CRT

•  Valve surgery

•  Ventricular reconstruction surgery/Ventricular assist devices

Take home messages

•  LVEF (reduced vs preserved HF) – many treatment options rely on this (medication, ICD/CRT) – prognosis

•  LV diastolic dysfunction and filling pressures (diagnosis of HFPEF and prognosis)

•  RV function – prognosis

•  Assessment of valvular heart disease (severity, treatment and prognosis)

Take home messages

•  Dyssynchrony? – EF is a major criterion but other methods still of unproved efficacy

•  Stress echocardiography (ischaemia/viability, valvular heart disease, diastolic stress test)