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  • Value of echocardiography in chronic dyspnea Jahrestagung Schweizerische Gesellschaft für Kardiologie/Schweizerische Gesellschaft für Pneumologie

    B. Kaufmann

    16.06.2016

    Kardiologie

  • Chronic dyspnea

    Kardiologie

    •Shortness of breath lasting longer than 1 month1

    •Cardiac and pulmonary etiologies predominate

    •Multifactorial in up to one third of patients1

    1 Wahls SA et al. Am Fam Physician. 2012

  • Chronic dyspnea – value of history, physical exam and chest x-ray

    Kardiologie

    Correct Incorrect

    Overall Less common

    diseases

    Cardiomyopathy

    Asthma

    COPD

    Interstitial lung disease

    %

    Pratter MR et al. Arch Intern Med. 1989;149:2277-2282

  • Differential diagnosis of chronic dyspnea

    Kardiologie

    Cardiac Myocardial disease

    Cardiac arrhythmias

    Pericardial disease

    Valvular heart disease

    Pulmonary Chronic obstructive pulmonary disease

    Asthma

    Interstitial lung disease

    Pleural effusion

    Malignancy

    Bronchiectasis

  • Differential diagnosis of chronic dyspnea (II)

    Kardiologie

    Noncardiac/ Thromboembolic disease

    Nonpulmonary Pulmonary hypertension

    Deconditioning

    Obesity

    Severe anemia

    Gastroesophageal reflux disease

    Metabolic conditions

    Liver cirrhosis

    Thyroid disease

    Neuromuscular disorders

    Chest wall deformities

    Upper airway obstruction

    Psychogenic causes

  • Differential diagnosis of chronic dyspnea

    Kardiologie

    Cardiac Myocardial disease

    Cardiac arrhythmias

    Pericardial disease

    Valvular heart disease

    Pulmonary Chronic obstructive pulmonary disease

    Asthma

    Interstitial lung disease

    Pleural effusion

    Malignancy

    Bronchiectasis

    Heart Failure

  • Differential diagnosis of chronic dyspnea (II)

    Kardiologie

    Noncardiac/ Thromboembolic disease

    Nonpulmonary Pulmonary hypertension

    Deconditioning

    Obesity

    Severe anemia

    Gastroesophageal reflux disease

    Metabolic conditions

    Liver cirrhosis

    Thyroid disease

    Neuromuscular disorders

    Chest wall deformities

    Upper airway obstruction

    Psychogenic causes

  • Chronic dyspnea – initial diagnostic testing

    Kardiologie

    •Complete blood count

    •Metabolic profile

    •Chest x-ray

    •Electrocardiogram

    •Spirometry

    •Pulse oximetry

    1 Wahls SA et al. Am Fam Physician. 2012

  • Echocardiography for the assessment of heart failure

    Kardiologie

    Patient with suspected HF

    Assessment of HF probability

    -Clinical history

    -Physical examination

    -ECG

    Natriuretic peptides

    -NT-proBNP≥125pg/ml

    -BNP≥35pg/ml

    HF unlikely:

    consider other diagnosis

    ECHOCARDIOGRAPHY

    If HF confirmed:

    determine etiology

    all absent

    normal

    no

    ≥1present

    yes

    Ponikowski P et al. Eur Heart J 2016

  • How to assess left ventricular ejection fraction?

    Kardiologie

    1. Eye-balling

    • Subjective

    • Experience dependent

    • Lack of standardisation

    • Large inter- and intraobserver

    variability

    2. Biplane Simpson‘s method

    • Time consuming

    • Geometric assumptions

    • Apical foreshortening

    • Image quality

    3. Left ventricular opacification 4. 3D echocardiography

    • iv line

    • Geometric

    assumptions

    • Image quality

    • Frame rate

  • Left ventricular ejection fraction

    Kardiologie

  • Kardiologie

    LV ejection fraction: reliability in a heart failure population

    -

    Kaufmann BA et al. Int J Cardiovasc Imaging. 2012

    413 patients participating in the TIME-CHF trial

    LVEF analyzed at the recruiting center and at the core lab

    Image quality optimal in 191 and suboptimal in 222

    0 10 20 30 40 50 60 70 80

    0

    10

    20

    30

    40

    50

    60

    70

    80

    E F

    r e c ru

    it in

    g c

    e n

    tr e [

    % ]

    EF biplane [%]

    y = 0.71x + 10.4

    R2 = 0.62

    p

  • LV ejection fraction vs. Systolic function

    Kardiologie

    Preload

    Afterload

    Contractility

    Heart rate

    Ejection fraction

  • LV ejection fraction vs. systolic function: Strain imaging

    Kardiologie

    60 patients with normal ejection fraction ≥50%

    LVEDP

  • Diastolic dysfunction – heart failure with preserved ejection fraction

    Kardiologie

    • Symptoms ± Signs

    • LVEF ≥ 50%

    • Elevated levels of natriuretic peptides (BNP

    ≥35pg/ml, NT-proBNP ≥125pg/ml)

    • At least one additional criterion

    • relevant structural heart disease (left ventricular

    hypertrophy, dilated LA)

    • diastolic dysfunction

    Ponikowski P et al. Eur Heart J 2016

  • LV Mass

    Kardiologie

    Cubed formula

    LV mass = 0.8x1.04x[(IVS+LVID+PWT)3- LVID3] +0.6g

    2D based formulas

    Area length

    Truncated ellipsoid

    • Cube formula has a 20% correction factor that is historical

    • Cube formula overestimates mass in basal septal hypertrophy

    • 2D based formulas underestimate mass in basal septal hypertrophy

    • Correction for BSA may mask hypertrophy in obese patients

    Lang RM et al. J Am Soc Echocardiogr 2015;28:1-39

  • LV hypertrophy

    Kardiologie

    LV mass 141 g/m2

  • Measurement of LA Volume

    Kardiologie

    Lester SJ et al. J Am Coll Cardiol. 2008;51(7):679-689

    Buechel R et al. J Am Soc Echocardiogr 2013;26:428-35

    Normal LA volume

  • Diastolic dysfunction

    Kardiologie

    Left atrial size Mitral inflow Mitral anular motion

    Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

  • Diastolic dysfunction – E/e’

    Kardiologie

    • 43 patients with normal ejection fraction with diastolic dysfunction confirmed

    by pressure-volume loop analysis

    • 12 control subjects

    Diastolic dysfunction Control

    Kasner M et al. Circulation. 2007;116:637-647

  • Diastolic dysfunction in normal ejection fraction

    Kardiologie

    1. Average E/e‘ > 14

    2. Septal e‘ velocity < 7cm/s or lateral e‘ velocity 2.8 m/s

    4. LA volume index >34ml/m2

    2 positive

    Normal diastolic

    function Indeterminate Diastolic dysfunction

    Nagueh SF et al. J Am Soc Echocardiogr 2016;29:277-314

  • Myocardial disease - etiology

  • Myocardial disease - etiology Coronary artery disease Hypertrophic obstructive cardiomyopathy

    Left ventricular non-compaction Amyloidosis

  • Valvular heart disease – aortic stenosis

    Kardiologie

    Mean PG 23mmHg

  • Valvular heart disease – aortic stenosis

    Kardiologie

    Mean PG 44mmHg

  • Valvular heart disease – aortic stenosis be prepared for the rare case!

    Kardiologie

  • Valvular heart disease – mitral regurgitation

    Kardiologie

  • Pericardial constriction

    Kardiologie

  • Pericardial constriction

    Kardiologie

    • 130 patients with surgically confirmed pericardial constriction, 30

    control patients

    • blinded analysis of echocardiographic data

    Welch TD et al. Circ Cardiovasc Imaging. 2014;7:526-534

    Sensitivity % Specificity %

    Change in mitral E velocity ≥14.6% 84 73

    Hepatic vein flow reversal ratio ≥0.79 76 88

  • Chronic thromboembolic disease

    Kardiologie

  • Pulmonary artery hypertension

    Kardiologie

  • Value of echocardiography in chronic dyspnea

    Kardiologie

    • First line diagnostic imaging test for

    • Myocardial disease

    • Valvular heart disease

    • Pericardial disease

    • May aid in the diagnosis of

    • Thromboembolic disease

    • Pulmonary artery hypertension

    • Importance of the clinical context

  • Thank you for your attention!

    Beat Kaufmann beat.kaufmann@usb.ch

    Kardiologie

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