Echo assessment of the failing heart

Mark K. Friedberg, MD

The Labatt Family Heart Center The Hospital for Sick Children

Toronto, Ontario, Canada

Cardiac function- definitions

Cardiovascular function: delivery of blood (oxygen) to tissues at a rate commensurate with oxygen consumption Cardiac & ventricular function: pump activity resulting in adequate amount of cardiac output at low filling pressures Myocardial function: phasic shortening and force generation followed by lengthening and force decay

Quantifying function

• No measurable quantity corresponds to integrated functional assessment

• Surrogates approximate individual aspects of cardiac function.

• It depends on what question you ask.

One of the biggest challenges is deciding how best to quantify cardiac function!

LV contractile function

Bijnens, European Journal of Echocardiography (2009) 10, 216–226

Determinants of Function

AFTERLOAD

PRELOAD

CONTRACTILITY

Also need to consider…

• Acute versus chronic changes

• Adaptation (hypertrophy)

• Heart rate

• Interactions (ventricular-vascular; ventricular-ventricular)

A routine echo report (partial list)….

Is this enough?

‘Eyeball’ assessment still a prevalent method

Experienced operator Quick and easy Subjective Subtle findings overlooked

‘Eyeball’ assessment: Newborn with cyanosis-this echo diagnosed critical PS (near atresia) intact septum

What is the LV function?

Sometimes the abnormality can be seen

Remodeling: Same SV with less contractility

McMahon, Heart 2004;90:908

Measurement of LV dimensions

Lopez, J Am Soc Echocardiogr 2010;23:465-95.

Molina, Circ: HF 2013;6:1214 Friedberg, In progress

The shape of the ventricle is important!

Friedberg, In progress

Mitral regurgitation

Fernandes, Am J Cardiol. 2011 15;107(1517-21

Ejection phase indices – Fractional shortening

– Ejection fraction % = EDV - ESV/ EDV x 100

• M-mode

• 2-D

• 3-D

Ejection fraction by 3-D

Courtesy Manni Vannan, MD

JASE 2016

Ejection fraction limitations

– Technique limitations

• Visualization of endocardial borders (contrast)

• LV is 3-dimensional; most models for calculation based on 2 dimensions (3D echo)

–Physiologic limitations

• Preload dependency

• Afterload dependency

• Heart rate

Why do we still use EF?

Any name, any study, any year Friedberg, In progress

Time intervals

Systolic time intervals

The myocardial performance index

The systolic to diastolic duration ratio

Friedberg, AJC 2006;97:101

McCrindle, Luc Mertens and Mark K. FriedbergTapas Mondal, Cameron Slorach, Cedric Manlhiot, Wei Hui, Paul F. Kantor, Brian W.

Idiopathic or Familial Dilated CardiomyopathyPrognostic Implications of the Systolic to Diastolic Duration Ratio in Children With

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Dallas, TX 75231is published by the American Heart Association, 7272 Greenville Avenue,Circulation: Cardiovascular Imaging

doi: 10.1161/CIRCIMAGING.114.0021202014;7:773-780; originally published online August 19, 2014;Circ Cardiovasc Imaging.

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Myocardial performance

Tissue Doppler Imaging

Molina, Circ: HF 2013;6:1214

shortens thickens twists along long axis

LV myocardial contraction

Longitudinal strain

Radial strain

Circumferential strain

Global strain

Courtesy B. Bijnens

Cikes M, Eur Heart J 2015; Shah AM, Eur Heart J 2012

Progressive LV dysfunction

Contractile Reserve

• Systolic dysfunction more likely under stress.

• Regional dysfunction during stress can identify ischemic and nonischemic cardiomyopathy.

• In HF, contractile reserve, (dP/dt, EF%, cardiac output response) is related to outcome.

Diastolic function

• Filling at low pressures

• Better filling at high heart rates despite shorter filling times

• During exercise increase in filling at persistently low filling pressures

Mitral inflow

Delayed relaxation in HCM

e’ and E/e’ have prognostic significance

–Decreased e’

–Increased E/e’ ratio

•Predicted SCD or VT in children

• Inversely related to peak VO2

McMahon, Circulation, 2004

HCM with restrictive physiology

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Avenue, Dallas, TX 72514Circulation: Cardiovascular Imaging is published by the American Heart Association. 7272 Greenville

DOI: 10.1161/CIRCIMAGING.112.000175 2013;6;254-261; originally published online January 23, 2013;Circ Cardiovasc Imaging

Andreea Dragulescu, Luc Mertens and Mark K. FriedbergCardiomyopathy by Echocardiography : Problems and Limitations

Interpretation of Left Ventricular Diastolic Dysfunction in Children With

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Systolic- diastolic coupling

Figure 4

Friedberg, J Appl Physiol. 2016;120,1301-18.

Figure 2B

0 2 4 6 8 10 12 14 16

2 4

6 8

10

12

14

16

0

1

2

3

4

Peak early diastolic velocity, cm/sec

Vis

it

Pe

ak s

ysto

lic v

elo

city, cm

/se

c

Within subject: r = 0.62, p<.001Between subject: r = 0.80, p<.001

Friedberg, J Appl Physiol. 2016;120,1301-18.

Figure 3A

Systolic-diastolic coupling in children with DCM

5y, DORV, progressive LV enlargement, AI dysfunction and exercise intolerance

QRS 130 msec

Summary • Assessment of cardiac function is central to clinical

management

• Echo is the mainstay of functional imaging

• Qualitative &quantitative measures should be used

• Well tested conventional measures should be combined with more recent modalities

• Often simple measures are very informative

• Systolic and diastolic function are tightly coupled and both should be assessed

• The reader’s role is to integrate multiple parameters into a comprehensive picture of function

THANK YOU