Imaging in heart failure: role of echocardiography · Imaging in heart failure: role of...

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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

GET READY FOR THE WORLD’S LARGEST CARDIOVASCULAR IMAGING CONGRESS

7‐10 December 2016Leipzig, GERMANY

Congresses

7-9 May 2017, Vienna

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