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THE ECHOCARDIOGRAPHIC EVALUATION OF THE HEART FAILURE PATIENT

THE ECHOCARDIOGRAPHIC EVALUATION OF THE HEART FAILURE PATIENT. Prof. Patrizio Lancellotti, MD, PhD, University hospital, CHU Sart Tilman, Liège. Potential Role of Echo in Heart failure . Bedside non-invasive imaging tool Low cost and no radiation exposure Goals

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THE ECHOCARDIOGRAPHIC EVALUATION OF THE HEART FAILURE PATIENT

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  1. THE ECHOCARDIOGRAPHIC EVALUATION OF THE HEART FAILURE PATIENT Prof. Patrizio Lancellotti, MD, PhD, University hospital, CHU Sart Tilman, Liège

  2. Potential Role of Echo in Heart failure • 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 ”

  3. 100 90 80 Congestive HF 70 60 Treated but no Congestive HF Echo 50 Event-free survival (%) 40 p<0.01 Congestive HF + Appropriate therapy No-echo 30 20 10 0 0 12 24 36 48 60 72 Time (months) HEART FAILURE THERAPY • Diagnosis of HF • Symptoms : dyspneoa or fatigue (rest or exer) • Objective evidence of cardiac dysfunction (echo) Senni et al., J Am Coll Cardiol 1999,33:164 Guidelines of the ESC 2005

  4. Back to reality ¡¡¡ Euro Heart Failure Use of Echocardiography % Cleland et al Lancet 2002

  5. Establishing the diagnosis of HF • Is LV ejection fraction preserved or reduced ? • Is the LV structure normal or abnormal ? • Other structural abnormalities ?

  6. Establishing the diagnosis of HFSystolic vs diastolic dysfunction Diagnosis of diastolic HF (up to 40%) Abnormal LV EF < 50%

  7. Establishing the diagnosis of HFSystolic vs diastolic dysfunction • Modified Simpson’s Method of discs • Endocardial Border ? • Load dependent • Geometric assumptions • Foreshortening in 90% • Accuracy ? 4C 2C

  8. Diagnosis: LVEF + Remodeling

  9. Establishing the diagnosis of HFDiastolic Heart failure • Symptoms or signs of HF • Normal or midly abnormal LV EF (≥ 50%) (LV EDVI < 97 ml/m², LVESV < 49 ml/m²) • Evidence of abnormal LV relaxation/distensibility

  10. Does “pure” diastolic dysfunction exists ? Sv LV velocities (Sv) Radial function DHF Sv < 6.5 cm/s Longitudinal function EF < 45 % SHF “Natural”evolution of heart failure

  11. Diastolic function + LV filling pressure E Vp A Nl > 55 cm/s E’ Nle > 8 cm/s

  12. E/E’ > 15 EF > 50%+ EDVI < 97 ml/m² 15 > E/E’ > 8 NTproBNP > 220 Or BNP > 200 Echo-Doppler Ap-Am > 30 ms or LAVI > 40 ml/m² or LVMI > 122 (149) g/m² or Atrial fibrillation Heart failure with normal ejection fraction Evidence of diastolic dysfunction ? (E/A ? related to age) Paulus W et al, Eur Heart J 2007; epub

  13. Evidence of diastolic dysfunction ? E/E’ > 15 EF > 50%+ EDVI < 97 ml/m² NTproBNP > 220 or BNP > 200 Echo-Doppler Ap-Am > 30 ms or LAVI > 40 ml/m² or LVMI > 122 (149) g/m² or Atrial fibrillation E/E’ > 8 Heart failure with normal ejection fraction Paulus W et al, Eur Heart J 2007; epub

  14. Diastolic stress echocardiography LVEDP elevated only during exercise in 24% REST EXER 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 18.0 Mean 13.2 REST EXER E/E’ 8 E/E’ 16 Burgess MI et al, J Am Coll Cardiol 2006; 47: 1891-900

  15. Ultrasound lung comets ULC are a simple echographic sign of increased extravascular lung water due to thickening of interlobular septa Lichtenstein D et al. Intensive Care Med 1998;24:1331-1334 Jambrik Z, Picano E et al. Am J Cardiol 2004;93:1265-1270

  16. Stress comet 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) ULC is a sensitive and accurate marker able to detect pulmonary interstitial edema even before it becomes apparent clinically Agricola E, Picano E et al. J Am Soc Echocardiogr 2006

  17. PULMONARY PRESSURE PASP RAP PASP = 4 V² max + RAP Nl 2 – 2.5 cm/s • Underestimation of pressure if inadequate envelope • Enhanced signal by injecting agitated saline solution D exp – D insp D exp 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 Simplified Bernoulli equation : not applicable

  18. RV FUNCTION RV FUNCTION TAPSE • 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 TASv IVA * Less accurate in severe TR Hsiao S JASE 2006;19:902

  19. MANAGEMENT OUTLINE • ESTABLISH HEART FAILURE • DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION • DETERMINE AETIOLOGY • IDENTIFY POTENTIALLY CORRIGIBLE LESIONS • ASSESS PROGNOSIS • CHOOSE APPROPRIATE MANAGEMENT

  20. CAUSES OF HF ACC/AHA 2005 Guidelines for CHF Heart failure Reviews,2003

  21. DEGENERATIVEMyxomatous : flail leaflet Failure of valve tip coaptation

  22. Lancellotti et al Eur Heart J 2007

  23. MANAGEMENT OUTLINE • ESTABLISH HEART FAILURE • DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION • DETERMINE AETIOLOGY • IDENTIFY POTENTIALLY CORRIGIBLE LESIONS • ASSESS PROGNOSIS • CHOOSE APPROPRIATE MANAGEMENT

  24. Prognostic indicators Abnormality Mild Moderate Severe LV ESV (ml/m²) <30 30-60 >60 LV EF (%) 45-54 44-30 <30 Peak Sv (cm/s) < 6 4-6 ≤ 3 E/A Gr I Gr II-III Gr IV Mitral DT -- -- <130 E/Ea <8 8-15 >15 Ea (cm/s) -- -- <3 Lung comets 5-15 16-36 >30 MR (ERO:mm²) <10 10-20 >20 LV dP/dt (mmHg/s) 550 450-450 <450 LA volume (ml/m²) -- -- >68 WMSI 1-1.5 1.5-1.8 >1.8 RV dysfunction -- -- +

  25. LV EF + WSCI

  26. 100 Patients with out intra-LV asynchrony 90 80 70 60 Event-free survival (%) 50 40 p<0.001 Patients with intra-LV asynchrony 30 20 10 0 0 50 100 150 200 250 300 350 Days New Prognostic indicators : Dyssynchrony 86 ms 132 ms Ao Pulm Interventricular asycnhrony Care HF. Eur H J 2007 Bader et al. J Am Coll Cardiol 2004;43:248

  27. « No single measure of mechanical dyssynchrony may be recommended to improve pt selection for CRT » High Echo lab variability  Need for standardization

  28. 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%

  29. Prognostic indicators : ischemic MR MI > 6 months No NYHA IV MI > 16 days NYHA Class IV Grigioni et al Circulation 2001, 103; 1759 Lancellotti et al Circulation 2003, 108:1713

  30. Prognostic indicators : ischemic MR MI > 6 months No NYHA IV MI > 16 days NYHA Class IV Grigioni et al Circulation 2001, 103; 1759 Lancellotti et al Circulation 2003, 108:1713

  31. 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

  32. STRESS ECHO in Aortic Stenosis with low gradient Operative mortality 5% ( 3 of 64 pts) if CR + 32% (10 of 35 pts) if CR- Low-gradient AS mean gradient < 25 - 30 mm Hg calculated AVA < 1.0 cm² Dobutamine-responsiveness : (class IIa) Contractile reserve   SV ≥ 20% Monin et al , Circ 2003

  33. 30 25 20 15 10 5 0 STRESS ECHO : Viability and Ischemia Sustained improvement -79.6% χ2=147 p<0.0001 23% χ2=1.43 p<0.23 Ischemic 16 Mortality (%) 7.7 6.2 3.2 RVS (n=728) MED (n=483) RVS (n=366) MED (n=579) VIABLE NO VIABLE Picano Circulation 1998 Allman et al. JACC 2002;39:1151 Pratali L et al,Am J Cardiol 2001

  34. MANAGEMENT OUTLINE • ESTABLISH HEART FAILURE • DISTINGUISH SYSTOLIC VS DIASTOLIC DYSFUNCTION • DETERMINE AETIOLOGY • IDENTIFY POTENTIALLY CORRIGIBLE LESIONS • ASSESS PROGNOSIS • CHOOSE APPROPRIATE MANAGEMENT

  35. TREATMENT OF HEART FAILURE Medications (Acute; Chronic: LV remodeling; Hypotension) Heart transplantation Revascularisation of hibernating myocardium Mitral valve repair Resynchronisation therapy (CRT)

  36. Adaptation of Loop DiureticsReversibility under treatment and prognosis Survival free of transplantation • Group 1A: n=24 • Irreversible restrictive profile • Group 1B: n=29 • Reversible restrictive profile • Group 2: n=57 • Non restrictive profile Pinamonti B et al, JACC 1997;29(3):604

  37. Adaptation of Beta Blockers Clinical trials: 12% Beta-blockers are not tolerated Capomolla et al. JACC 2001;38:1675-84

  38. LV REVERSE REMODELING Effects of treatment Criteria of reverse LV remodeling (EDD, FS et LV mass) ESV  10-15% Survival Cv events Kawai et al, Am J Cardiol. 1999 Sep 15;84(6):671-6

  39. Stress echo : LV Viability/Ischemia EF < 35% No or limited Viability Viability > 4 segments Medical therapy Revascularization Resynchronization Good responder Bad responder Transplantation Allman et al. JACC 2002;39:1151

  40. HOW TO CORRECT FUNCTIONAL MR ? 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 Braun EJCS 2005; Shiota AJC 2006,98; Calafiore ATS 2004, 77; Magne Circ 2007,115;782-791

  41. CRT OFF CRT ON

  42. Echo in Heart Failure Structural abnormalities LV function Lung comets EF, Volumes, TDI Sv, E/Ea MR Stress echo Evaluation of risk Treatment No one single echo parameter represents a magic number Choose clinical strategy only after obtaining confirmation from several matching parameters

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