Imaging in heart failure: role of echocardiography
Bogdan A. Popescu FESC, FACCUniversity of Medicine and Pharmacy “Carol Davila”
Euroecolab, Institute of Cardiovascular DiseasesBucharest, Romania
IMIC 2016Vienna, Oct 11, 2016
Echo in heart failure – clinical use
• Diagnosis• Prognosis• Therapy
Class I recommendation, LoE C
ESC Guidelines on HF. Eur Heart J 2016.
Applications of various imaging techniques in the diagnosis of HF
ESC Guidelines on HF. Eur Heart J 2012.
Local expertise!
ESC Guidelines on HF. Eur Heart J 2016
Algorithm forthe diagnosis
of HF ofnon-acute onset
TTE is the method of choice for assessment of myocardial systolic and diastolic function
of both left and right ventricles.
Diagnosis
ESC Guidelines on HF. Eur Heart J 2016.
HF with reduced EF• Symptoms ± Signs of HF• LVEF <40%
HF with mid-range and preserved EF• Symptoms ± Signs of HF• LVEF 40-49% OR LVEF ≥ 50%• Elevated levels of natriuretic peptides• At least one additional criterion
• relevant structural heart disease (LVH / LA dilation) • LV diastolic dysfunction
Diagnosis of heart failure
with reduced EF
Issues with LV ejection fraction
• Method used (eg Simpson’s biplane, 3D)
• Technical (eg endocardial border detection)
• Conceptual (eg load dependence)
Need to measure EF properly and to always interpret it in clinical context
Measuring LV ejection fraction by echocardiography
• The Teichholz method or the eye-balling of LVEF are not recommended
• The apical biplane method of discs is recommended
ESC Guidelines on HF. Eur Heart J 2016.
The use of a contrast agent is recommended when <80% of the endocardial border is adequately visualized
LVEF = accurate tracing of the endocardial border
ESC Guidelines on HF. Eur Heart J 2012.Lang R, et al. Eur J Echocardiogr 2006.
3D Echo for LV volumes and EF• Better accuracy than 2D• Lower variability• Validated against CMR
Jenkins C, et al. J Am Coll Cardiol 2004Caiani EG, et al. J Am Soc Echocardiogr 2005
normal EF =normal LV function?
Supranormal LVEF yet reduced
antegrade flow
VTILVOT=9.3 cm
EF overestimatesLV systolic function
in severe MR
Diagnosis of HFmrEF and HFpEF
ESC Guidelines on HF. Eur Heart J 2016.
• Symptoms ± Signs of HF• LVEF 40-49% OR LVEF ≥ 50%• Elevated levels of natriuretic peptides• At least one additional criterion
• relevant structural heart disease (LVH/LA dilation) • LV diastolic dysfunction
Relevant structural heart disease
Echocardiography• LV hypertrophy
LV mass index >115 g/m2 men; >95 g/m2 women
• LA dilation
LA volume index >34 ml/m2
LAVi = 73 ml/m2
LV mass index=130 g/m2
E/A ratio
Disease severity
very good
good
bad
very, very badFilling pressureRelaxation
restrictive filling
pseudonormal
impaired relaxation
Mitral inflow velocities by Doppler
Left ventricular diastolic dysfunction
S
e'
Myocardial velocities (PW-TDI) are sensitive parameters of global LV function
Courtesy: F. Flachskampf
a’
Tissue Doppler Imaging
Sohn DW, et al. J Am Coll Cardiol 1997;30:474-480.
p = 0.01
• 38 pts, simultaneous Doppler-catheterization
a
e’ as an index of LV relaxation
’
Echocardiographic parameters of LV diastolic dysfunction
• e’sep <7 cm/s, e’ lat <10 cm/s• average E/e’ratio >14• LA volume index >34 ml/mp• peak TR vel >2.8 m/s
ASE/EACVI guidelines and standards 2016
Echocardiographic reference ranges for normalcardiac Doppler data: results from the NORREStudy
• 449 healthy volunteers (198 M, 251 F)• 45.8 ± 13.7 y/o• Network of EACVI accredited echo labs enrolled in NORRE
Eur Heart J Cardiovasc Img 2015;16:1031-41.
Assessment of filling pressures and LVDD grade
Nagueh, Smiseth, et al. ASE/EACVI guidelines and standards 2016
European mult icentre validat ion study of theaccuracy of E/e′ rat io in est imat ing invasive leftventr icular fi lling pressure: EURO-FILLING studyMaur izio Galder isi1*†, Pat r izio Lancellot t i 2†, Erwan Donal3, Nuno Cardim 4,Thor Edvardsen5, Gilber t Habib6, Julien Magne2, Gerald Maurer 7, andBogdan A. Popescu8
Eur Heart J Cardiovasc Img 2014;15:810-6.
Still a matter of active research The EACVI is conducting the largest multicenter international
validation study of E/e’ against the invasive LV filling pressures
Beladan C / Popescu BA.Acta cardiologica 2016.
Integrative approach• Structural changes LA size LVH
• Functional parameters Mitral flow PV flow TDI pattern PA pressure
Vmax Ao = 4,9 m/s Gmediu = 63 mm Hg VTI Ao = 123 cmVTI TEVS = 25 cm
AVA = VTI LVOT x A LVOT/VTI Ao AVA = 0.6 cm2
Heart failure: aetiology
VTI Ao=123 cm VTI LVOT=25.9 cm
LVOT=1.9 cm
Heart failure: aetiologyMitral stenosis Mitral regurgitation
MVA=0.5 cm2
Recommendations for cardiac imaging in patients with suspected or established heart failure
ESC Guidelines on HF. Eur Heart J 2016
Echocardiography
A critical feature of echocardiography….
Bedside technique…
• Can be performed everywhere• Ideally suited for acute/severe pts
Patients with suspected acute heart failure
Management of patients with cardiogenic shock
ESC Guidelines on HF. Eur Heart J 2016
Beyond current guidelines:let us look at the myocardium
Heart 2014;100:731-40. B. Bijnens, J. d’Hooge
LONG
RADIAL
CIRCUMF
Normal longitudinal strain
GLS: -20.5%
Bull’s eye representation
GLS -4.2%
• 2D strain allows evaluation of global and regional myocardial deformation
• The regional pattern of myocardial dysfunction may suggest the etiology of heart failure
GLS -12.9%
DCM CAD
LVEF 59% LVEF 58%LVEF 61%
2D Global longitudinal strain = ‐7% 2D Global longitudinal strain = ‐22% 2D Global longitudinal strain = ‐19%
Normal Apical HCM Amyloidosis
Cardiomyopathies with normal LVEFHeterogeneity in LV myocardial function
Other techniques, incl. systolic TDI velocities and deformation indices, strain and strain rate, shouldbe considered in a TTE protocol in subjects at riskof developing HF in order to identify myocardialdysfunction at the preclinical stage
Class of recommendation II a, LoE C
ESC Guidelines on HF. Eur Heart J 2016.
Other echo techniques:recommendations in HF
Prognosis
ESC Guidelines on HF. Eur Heart J 2012.
n=1049p<0.001
Pulmonary pressures and death in heart failure
• Pulmonary hypertension is a strong and independent predictor of mortality among patients with HF and provides incremental and clinically relevant prognostic information independently of known predictors of outcomes.
• 1049 pts with HF• 75.6 ± 13.3 y/o• 49.3% men• 61.7% NYHA II-III• 32.3% NYHA IV• LVEF: 47.6 ± 16.5%• mean FU: 2.7 ± 1.9 yrs
Bursi F, et al. J Am Coll Cardiol 2012;59:222-231.
• 817 pts with CHF, NYHA class II-IV• follow-up: median 4.1 years
Eur J Heart Fail 2007;9:610-6.
• TAPSE cut-off 14 mm
• HF outpatients• Dg of HF: relevant symptoms and signs + objective evidence:
LVEF <45% or LA ≥4 cm + NT-proBNP ≥400 pg/ml• FU: 567 days (IQR: 413-736)• Endpoint: CV death and HF hospitalization• 568 pts with HF: 372 w LVEF ≤45% and 196 with LVEF >45%
JACC Imaging 2013
• The IVC is easy to measure and provides similar prognostic information as plasma NT-proBNP in outpts with chronic HF
JACC Imaging 2013
Echo measures aspredictors of outcome
IVC and NT-proBNP aspredictors of outcome
Therapy
• Medical treatment• Devices (eg CRT, ICD)• Surgery (eg VHD)
Pharmacological treatments indicated in potentially all patients with symptomatic (NYHA II–IV) systolic HF
• An ACE inhibitor is recommended for all patients with an EF≤40%
• A beta-blocker is recommended for all patients with an EF ≤40%
• A MRA is recommended for all patients with persisting symptoms and an EF ≤35%, despite treatment with an ACE inhibitor and a beta-blocker.
• All are Class I recommendations, LoE A, to reduce the risk of HF hospitalization and the risk of premature death.
ESC Guidelines on HF.
Time
Surv
ival
DiureticsACEI
Nitrates
Changes in mitral flow pattern after 6 months of optimized therapy provide important hemodynamic and prognostic information in pts with chronic HF
Traversi E, et al. Am Heart J 1996;132:809-19.Courtesy: E. Schwammenthal
CRT in sinus rhythm and a persistently reduced LVEF
ESC Guidelines on HF. Eur Heart J 2016.
Cardiac resynchronization therapy
LV ejection fraction <35%
Severe aortic stenosis
with low LVEF= surgery
Mean gradient: 77 mm Hg
Conclusions• Echocardiography plays a key role in patients with heart
failure for diagnosis (including aetiology), prognostic stratification and treatment planning and monitoring• Assessing cardiac structure and function allows a comprehensive evaluation of the patient’s status, for better decision making• Newer methods (e.g. strain imaging-based) may further add to the echo armamentarium providing incremental information to the conventional ones• The different imaging modalities should be used in a complementary way as needed to solve the clinical question
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Congresses
Danilo Neglia
The EACVI Team Thanks
Mitral EDT
EDT<130 ms in pts with HF-REF predicts
high LV filling pressure
J Am Soc Echocardiogr 2016Eur Heart J Cardiovasc Imag 2016
ESC Guidelines on HF.
Eur Heart J 2012
Algorithm forthe diagnosis
of HF
Echocardiographic parameters of LV diastolic dysfunction
• e’ septal <8 cm/s• e’ lateral <10 cm/s• e’ average <9 cm/s• E/e’ >15
LA dilationLV hypertrophy
The presence of at least two abnormal measurements and/or atrial fibrillation increases the likelihood of the diagnosis.
ESC Guidelines on HF. Eur Heart J 2012.
Sengelov M, et al. JACC Img 2015;8:1351-9.
• 1065 HFrEF patients• median FU: 40 mo (IQR: 22-57)• 177 pts (16.7%) died
• GLS is a strong prognosticator of mortality in HFrEF, superior to EF and other echo parameters. The optimal echo risk stratification tree in HFrEF includes LVEF, GLS, E, TAPSE
Sengelov M, et al. JACC Img 2015;8:1351-9.
A1-A4: Apical sparing in cardiac amyloidosisB1-B2: Isolated septal impairment in septal HCMC1-C2: Patchy reduction in long strain in LVH d/t AS
Phelan D, et al. Heart 2012
Patterns of LS suggestive of underlying etiology
Kraigher-Krainer, et al. J Am Coll Cardiol 2014;63:447-56.
• 219 HFPEF patients; myocardial deformation by 2D STE
• Systolic impairment in LV long and circumferential strain is prevalent in HFPEF
• Abnormalities of LV systolic function measured by strain imaging may contribute to the HFPEF syndrome
Kraigher-Krainer, et al. J Am Coll Cardiol 2014;63:447-56.
Diagnosis of HF-PEF
Signs typical of heart failure* Clinical examination
LVEF ≥50% and left ventricle not dilated Echocardiography (CMR)
a) relevant structural heart disease
(LV hypertrophy/LA enlargement) OR
b) LV diastolic dysfunction
Echocardiography (CMR)
Invasive measurements
Natriuretic peptides
Symptoms typical of heart failure History
ESC Guidelines on HF. Eur Heart J 2012.
* Signs may not be present in the early stages of HF and in patients treated with diuretics
Recommendations for cardiac imaging in patients with suspected or confirmed heart failure
ESC Guidelines on HF. Eur Heart J 2016
Eur Heart J 2016.
• 106 pts with EF ≤ 30%• NYHA class III-IV• simultaneous echo and right heart cath
No correlation was found between E/e’ ratio and PCWP, especially in ptswith larger LV volumes, more impaired CI, CRT.
• 79 pts - decompensated systolic HF, including large LV vol and CRT• simultaneous echo and RHC • E/e’, mitral inflow parameters, and estimated PA pressures had significant correlations with invasively measured PCWP
Diagnosis of LV diastolic dysfunction in subjects with normal LVEF
Nagueh, Smiseth, et al. ASE/EACVI guidelines and standards 2016
Echocardiographic reference ranges for normalcardiac Doppler data: results from the NORREStudy
• 449 healthy volunteers (198 M, 251 F)• 45.8 ± 13.7 y/o• Network of EACVI accredited echo labs enrolled in NORRE
Eur Heart J Cardiovasc Img 2015;16:1031-41.
European mult icentre validat ion study of theaccuracy of E/e′ rat io in est imat ing invasive leftventr icular fi lling pressure: EURO-FILLING studyMaur izio Galder isi1*†, Pat r izio Lancellot t i 2†, Erwan Donal3, Nuno Cardim 4,Thor Edvardsen5, Gilber t Habib6, Julien Magne2, Gerald Maurer 7, andBogdan A. Popescu8
Eur Heart J Cardiovasc Img 2014;15:810-6.
TheEURO-FILLING study isalarge, prospective observational study inwhich simultaneousassessment of invasive andnon-invasivemeasurementsofLVFPwill beacquired ineight referenceEuropeancentres.Centralized readingof thecol-lected parameterswill beperformed in acore laboratory.Not onlystandardized echo Doppler measurementsbut alsonovelechoparameterssuchasLVglobal longitudinal strainandglobal atrial strain(obtainablebytwo-dimensional speckletrackingechocardiography) will be tested for predicting invasivemeasurementsof LVFP.
The main reason for evaluating diastolic function in patients with reduced EF is to estimate LV filling pressure.The approach starts with mitral inflow velocities and is applied in the absence ofo atrial fibrillationo significant mitral valve disease (at least moderate mitral annular
calcification)o mitral valve repair / prosthetic mitral valveo LV assist deviceso left bundle branch block o ventricular paced rhythm
Nagueh, Smiseth, et al. ASE/EACVI guidelines and standards 2016
Mitral EDT
EDT<150 ms in pts with HF-REF predicts
high LV filling pressure
• Twisting helps to distribute LV fiber stress and fiber shortening uniformly across the wall, thus increasing the efficiency of LV contraction - role in ejection
• Fiber twisting and shearing deform the matrix and result in storage of potential energy, which is subsequently utilized for diastolic recoil - role in filling
Importance of cardiac twist & untwist
Arts T et al. Am J Physiol 1982Sengupta PP et al. J Am Coll Cardiol Imaging 2008
LV untwisting precedes both long-axis lengthening and short-axis expansion.
LV untwisting in normals
During exercise, the LV untwisting velocity was markedly enhanced, keeping the temporal sequence in early diastole.
Notomi Y et al. Circulation 2006.
• LV untwisting appears to be linked temporally with early diastolic base-to-apex pressure gradients, enhanced by exercise, which may assist efficient LV filling (ie suction)
• LV torsion and subsequent rapid untwisting appear to be manifestations of elastic recoil, critically linking systolic contraction to diastolic filling
Notomi Y et al. Circulation 2006.
J Am Coll Cardiol 2012;59:1509–18
220 pts scheduled for CRT STE 2D radial strain randomized 1:1 in 2 groups Gr. 1: LV lead positioned at the latest site of peak contraction with an amplitude of >10% to signify freedom from scar
Gr. 2: standard unguided CRT
Courtesy: E. Donal
J Am Coll Cardiol 2012;59:1509–18
• Use of STE to target LV lead placement yields significantly improved response and clinical status and lower rates of adverse events
