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
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• 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
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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
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Use of Echocardiography
0
20
40
60
80
100%
Back to reality ¡¡¡ Euro Heart Failure
Cleland et al Lancet 2002
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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 ?
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Establishing the diagnosis of HFSystolic vs diastolic dysfunction
Diagnosis of diastolic HF (up to 40%)
Abnormal LV EF < 50%
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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
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Diagnosis: LVEF + Remodeling
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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
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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
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E’E’
Diastolic function + LV filling pressure
EEAA VpVp
Nle > 8 cm/s
Nl > 55 cm/s
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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DEGENERATIVEMyxomatous : flail leaflet
Failure of valve tip coaptation
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Lancellotti et al Eur Heart J 2007
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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
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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 -- -- +
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LV EF + WSCI
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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
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« 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
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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%
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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
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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
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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
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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
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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
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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
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TREATMENT OF HEART FAILURE
Medications (Acute; Chronic: LV remodeling; Hypotension)
Heart transplantation
Revascularisation of hibernating myocardium
Mitral valve repair
Resynchronisation therapy (CRT)
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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
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Adaptation of Beta Blockers
Capomolla et al. JACC 2001;38:1675-84
Clinical trials: 12% Beta-blockers are not tolerated
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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%
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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
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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
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CRT OFF CRT ON
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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
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