the echocardiographic evaluation of the heart failure patient prof. patrizio lancellotti, md, phd,...

THE ECHOCARDIOGRAPHIC

EVALUATION OF THE HEART

FAILURE PATIENT

Prof. Patrizio Lancellotti, MD, PhD,

University hospital, CHU Sart Tilman, Liège

• Bedside non-invasive imaging tool

• Low cost and no radiation exposure

• Goals

• To highlight the underlying cardiac disease

• To quantify systolic-diastolic dysfunction and hemodynamics

• To match symptoms and cardiac involvement

• To stratify the prognosis

• To guide the therapy

• Potential benefit : “ The importance of being earlier ”

Potential Role of Echo in Heart failure

HEART FAILURE THERAPY

CongestiveHF

Congestive HF+

Appropriate therapy

Treated but no Congestive HF

EchoEcho

No-echoNo-echo

Time (months)Time (months)

00 1212 2424 3636 4848 6060 7272

Event-free survival (%) Event-free survival (%)

p<0.01p<0.01

00

1010

2020

3030

6060

100100

8080

4040

5050

7070

9090

Senni et al., J Am Coll Cardiol 1999,33:164

Diagnosis of HF1. Symptoms : dyspneoa or fatigue (rest or exer)2. Objective evidence of cardiac dysfunction

(echo)Guidelines of the ESC 2005

Use of Echocardiography

0

20

40

60

80

100%

Back to reality ¡¡¡ Euro Heart Failure

Cleland et al Lancet 2002

Establishing the diagnosis of HF

1. Is LV ejection fraction preserved or reduced ?

2. Is the LV structure normal or abnormal ?

3. Other structural abnormalities ?

Establishing the diagnosis of HFSystolic vs diastolic dysfunction

Diagnosis of diastolic HF (up to 40%)

Abnormal LV EF < 50%

Modified Simpson’s Method of

discs

• Endocardial Border ?

• Load dependent

• Geometric assumptions

• Foreshortening in 90%

• Accuracy ?

Establishing the diagnosis of HFSystolic vs diastolic dysfunction

4C 2C

Diagnosis: LVEF + Remodeling

Establishing the diagnosis of HF

Diastolic Heart failure

1. Symptoms or signs of HF

2. Normal or midly abnormal LV EF (≥ 50%)

(LV EDVI < 97 ml/m², LVESV < 49 ml/m²)

3. Evidence of abnormal LV relaxation/distensibility

Does “pure” diastolic dysfunction exists ?SvSv

Longitudinal function

“Natural”evolution of heart failure

LV velocities (Sv)

SHF

Radial function

EF < 45 %

DHF

Sv < 6.5 cm/s

E’E’

Diastolic function + LV filling pressure

EEAA VpVp

Nle > 8 cm/s

Nl > 55 cm/s

Evidence of diastolic dysfunction ?

Paulus W et al, Eur Heart J 2007; epub

E/E’ > 15

Heart failure with normal ejection fraction

EF > 50%+ EDVI < 97 ml/m²

NTproBNP > 220

Or BNP > 200

15 > E/E’ > 8 Echo-DopplerEcho-Doppler

Ap-Am > 30 msAp-Am > 30 msoror

LAVI > 40 ml/m²LAVI > 40 ml/m²oror

LVMI > 122 (149) g/m²LVMI > 122 (149) g/m²oror

Atrial fibrillationAtrial fibrillation

(E/A ? related to age)

E/E’ > 15

Heart failure with normal ejection fraction

Paulus W et al, Eur Heart J 2007; epub

EF > 50%+ EDVI < 97 ml/m²

Evidence of diastolic dysfunction ?

NTproBNP > 220 or BNP > 200

E/E’ > 8

Echo-DopplerEcho-Doppler

Ap-Am > 30 msAp-Am > 30 msoror

LAVI > 40 ml/m²LAVI > 40 ml/m²oror

LVMI > 122 (149) g/m²LVMI > 122 (149) g/m²oror

Atrial fibrillationAtrial fibrillation

Burgess MI et al, J Am Coll Cardiol 2006; 47: 1891-900

Supine bicycle ergometry during cardiac catheterisation in 37 patients, mean EF 58%

Septal annulus

E/E’ increased 12.1 to 17.1

E/E’ > 13 at exer

90% specificity of reduced exercise capacity

Mean 13.2

Mean 18.0

Diastolic stress echocardiography

LVEDP elevated only during exercise in 24%

REST EXER

E/E’ 8 E/E’ 16

REST EXER

ULC are a simple echographic sign of increased

extravascular lung water due to thickening of

interlobular septa

Ultrasound lung comets

Lichtenstein D et al. Intensive Care Med 1998;24:1331-1334

Jambrik Z, Picano E et al. Am J Cardiol 2004;93:1265-1270

The variation between postexercise and baseline ULC score

correlated significantly with:

•the variation between peak stress and rest PCWP (r = 0.62, p =.0001)

•systolic pulmonary artery pressure (r = 0.44, P = .0001)

•wall-motion score index (r = 0.30, P = .01)

•peak stress E/Em (r = 0.71, P = .0001)

Stress comet

Agricola E, Picano E et al. J Am Soc Echocardiogr 2006

ULC is a sensitive and accurate marker able to detect pulmonary interstitial edema even before it becomes apparent clinically

PULMONARY PRESSURE

D exp – D insp

D exp

RAPPASP

PASP = 4 V² max + RAP

• Underestimation of pressure if inadequate envelopeUnderestimation of pressure if inadequate envelope

• Enhanced signal by injecting agitated saline solutionEnhanced signal by injecting agitated saline solution

Simplified Bernoulli equation : not applicableSimplified Bernoulli equation : not applicable

Nl 2 – 2.5 cm/s

VC diameter IVC changes RAP

< 1.5 cm collapsus 0-5

1.5-2.5 cm > 50% 5-10

> 2.5 cm < 50% 10-15

> 2.5+HV dilation No change > 20

RV FUNCTIONTAPSE

TASv

IVA

RV FUNCTION

• EF Load dependency

• TAPSE : (Nl > 24 mm)

* if < 8.5 mm, RV EF < 25%

* < 14 mm bad prognosis

• TDI Tricuspid systolic annulus vel :

* if < 11.5 cm/s, RV EF < 45%

• IVA < 2.52 m/s², RV dP/dt, ….

Meluzin JASE 2005;18:435

* Less accurate in severe TR

Hsiao S JASE 2006;19:902

1. ESTABLISH HEART FAILURE

2. DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION

3. DETERMINE AETIOLOGY

4. IDENTIFY POTENTIALLY CORRIGIBLE LESIONS

5. ASSESS PROGNOSIS

6. CHOOSE APPROPRIATE MANAGEMENT

MANAGEMENT OUTLINE

15%

10%

10% 5%

60%

CAD

NIDC

HYPERTENSIVE HD

VALVULAR HD

OTHER

Heart failure Reviews,2003

ACC/AHA 2005 Guidelines for CHF

CAUSES OF HF

DEGENERATIVEMyxomatous : flail leaflet

Failure of valve tip coaptation

Lancellotti et al Eur Heart J 2007

1. ESTABLISH HEART FAILURE

2. DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION

3. DETERMINE AETIOLOGY

4. IDENTIFY POTENTIALLY CORRIGIBLE LESIONS

5. ASSESS PROGNOSIS

6. CHOOSE APPROPRIATE MANAGEMENT

MANAGEMENT OUTLINE

Prognostic indicators Abnormality

Mild Moderate SevereLV ESV (ml/m²) <30 30-60 >60LV EF (%) 45-54 44-30 <30Peak Sv (cm/s) < 6 4-6 ≤ 3E/A Gr I Gr II-III Gr IVMitral DT -- -- <130E/Ea <8 8-15 >15Ea (cm/s) -- -- <3Lung comets 5-15 16-36 >30MR (ERO:mm²) <10 10-20 >20LV dP/dt (mmHg/s) 550 450-450 <450 LA volume (ml/m²) -- -- >68WMSI 1-1.5 1.5-1.8 >1.8RV dysfunction -- -- +

LV EF + WSCI

Bader et al. J Am Coll Cardiol 2004;43:248Bader et al. J Am Coll Cardiol 2004;43:248

DaysDays00 5050 100100 150150 200200 250250 300300 350350

Event-free survival (%) Event-free survival (%)

Patients with Patients with intra-LV asynchronyintra-LV asynchrony

Patients with outPatients with outintra-LV asynchronyintra-LV asynchrony

p<0.001p<0.001

00101020203030

6060

100100

8080

40405050

7070

9090

New Prognostic indicators : Dyssynchrony

Care HF. Eur H J 2007Care HF. Eur H J 2007

Interventricular asycnhrony

86 ms 132 ms

Pulm Ao

« No single measure of mechanical dyssynchrony may be « No single measure of mechanical dyssynchrony may be

recommended to improve pt selection for CRT » recommended to improve pt selection for CRT »

High Echo lab variability High Echo lab variability Need for standardization Need for standardization

Criteria for the selection

Major ? Intraventricular asynchrony

- LV dispersion 65 ms

- TPS SD 12 31 ms

Others ? Inter + Intra V delay > 102 ms

Septal-to-posterior delay > 130 ms

Interventricular delay > 40 ms

Aortic pre-ejection time > 140 ms

LV filling time < 40 % of cardiac cycle

Diastolic mitral regurgitation

SD 16s 3D > 8.3%

Grigioni et al Circulation 2001, 103; 1759 Lancellotti et al Circulation 2003, 108:1713

MI > 16 daysNYHA Class IV

MI > 6 monthsNo NYHA IV

Prognostic indicators : ischemic MR

Grigioni et al Circulation 2001, 103; 1759 Lancellotti et al Circulation 2003, 108:1713

MI > 16 daysNYHA Class IV

MI > 6 monthsNo NYHA IV

Prognostic indicators : ischemic MR

STRESS ECHO dynamic MR

Lancellotti et al Circulation 2003, 108:1713

Lancellotti et al, Eur Heart J 2005, 26:1528

Peteiro et al, Eur J Echo 2007

Piérard et Lancellotti. N Engl J Med 2004,351:1627

Low-gradient AS

mean gradient < 25 - 30 mm Hg

calculated AVA < 1.0 cm²

Dobutamine-responsiveness : (class IIa)

Contractile reserve SV ≥ 20%

STRESS ECHO in Aortic Stenosis with low gradient

Operative mortality

5% ( 3 of 64 pts) if CR +

32% (10 of 35 pts) if CR-

Monin et al , Circ 2003

0 2 4 6 8 10 12

months

70

76

82

88

94

100

surv

ival

(%)

I - / V +

I + / V +I - / V -

I + / V -

00

55

1010

1515

2020

2525

3030

Mor

talit

y (%

)M

orta

lity

(%)

RVSRVS(n=728)(n=728)

3.23.2

RVSRVS(n=366)(n=366)

7.77.7

MEDMED(n=483)(n=483)

1616

MEDMED(n=579)(n=579)

6.26.2

-79.6%-79.6%χχ22=147=147

p<0.0001p<0.0001

23%23%χχ22=1.43=1.43p<0.23p<0.23

Sustained improvement

Ischemic

Picano Circulation 1998

Pratali L et al,Am J Cardiol 2001Allman et al. JACC 2002;39:1151

STRESS ECHO : Viability and Ischemia

VIABLEVIABLE NO VIABLENO VIABLE

1. ESTABLISH HEART FAILURE

2. DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION

3. DETERMINE AETIOLOGY

4. IDENTIFY POTENTIALLY CORRIGIBLE LESIONS

5. ASSESS PROGNOSIS

6. CHOOSE APPROPRIATE MANAGEMENT

MANAGEMENT OUTLINE

TREATMENT OF HEART FAILURE

Medications (Acute; Chronic: LV remodeling; Hypotension)

Heart transplantation

Revascularisation of hibernating myocardium

Mitral valve repair

Resynchronisation therapy (CRT)

Adaptation of Loop DiureticsReversibility under treatment and prognosis

Pinamonti B et al, JACC 1997;29(3):604

Group 1A: n=24

Irreversible restrictive profile

Group 1B: n=29

Reversible restrictive profile

Group 2: n=57

Non restrictive profile

Survival free of transplantation

Adaptation of Beta Blockers

Capomolla et al. JACC 2001;38:1675-84

Clinical trials: 12% Beta-blockers are not tolerated

Criteria of reverse LV remodeling (EDD, FS et LV mass)

Survival Cv events

Kawai et al, Am J Cardiol. 1999 Sep 15;84(6):671-6

LV REVERSE REMODELINGEffects of treatment

ESV 10-15%

Stress echo : LV Viability/Ischemia

EF < 35%

No or limitedViability

Viability> 4 segments

Medical therapyRevascularizationResynchronization

Bad responder

Goodresponder

Transplantation Allman et al. JACC 2002;39:1151

Braun EJCS 2005; Shiota AJC 2006,98; Calafiore ATS 2004, 77; Magne Circ 2007,115;782-791

TTE pre-op

- Coaptation height ≥ 1 cm- Tenting > 2.5-3 cm²- PLA > 45 °, lateral WMA- Central jet or Complex jets- EDD > 65 mm, ESD > 51 mm

HOW TO CORRECT FUNCTIONAL MR ?

PLL

CDPLA 1sin

CRT OFF CRT ON

Echo in Heart Failure

LV function Structural abnormalities

Treatment

Lung cometsEF, Volumes,

TDI Sv, E/EaMR

Stress echo

Evaluation of risk No one single echo parameter represents a magic number

Choose clinical strategy only after obtaining confirmation from several matching parameters