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