View
3
Download
0
Category
Preview:
Citation preview
Η ηχωκαρδιολογία στην διάγνωση κα πρόγνωση της καρδιακής ανεπάρκειας µε
µειωµένο και φυσιολογικό κλάσµα εξώθησης
Βασίλειος Σαχπεκίδης Επιµελητής Β΄ Καρδιολογίας Γ.Ν. Παπαγεωργίου Θεσσαλονίκη
ESC Guidelines
McMurray J et al. Eur Heart J 2012;33:1787-1847
McMurray J et al. Eur Heart J 2012;33:1787-1847
EF LVEF, DD, RV, Valves…
Information from echo
Echocardiography in HF
• Assessment of LV size, geometry, mass and systolic function • Assessment of LV diastolic function • Hemodynamics • Assessment of RV size and function • Valvular heart disease • Dyssynchrony • Stress echocardiography • Prognostic information
LV size and geometry
Much better validated for TTE than TOE (use analogous views)
Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63
M-mode vs 2D measurements of LV dimensions and wall thickness
Simpson’s Biplane Method
Calculation of LV mass
Linear method 2D method
Reference values of LV geometry
Most measurements presented are derived from fundamental imaging Harmonic imaging → increased values In clinical practice wall thickness > 1.1 cm is considered abnormal
Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63
Reference values of LV size
Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63
Prognostic importance of LV mass
Quinones MA et al. J Am Coll Cardiol 2000;35:1237-44.
LV geometric pattern is also important
2xPWTd/LVIDd
Lang RM et al. J Am Soc Echocardiogr 2005;18:1440-63
Pts with concentric hypertrophy have the worse prognosis
Muiesan M et al. Hypertension 2004;43:731-8
Concentric remodeling adversely impairs prognosis even if LV mass is normal
Verdecchia P et al. J Am Coll Cardiol 1995;25:871-8
Assessment of LV systolic function
• Fractional shortening (FS) • Ejection fraction (EF) by 2D or 3D imaging • Stroke volume • Systolic Doppler tissue velocity • LV dP/dt • Strain rate imaging • Myocardial performance index (MPI)
Methods for assessing LVEF
• Visual estimation (eyeball method)
• From linear measurements of LV dimensions (M-mode or 2D)
• From volumetric 2D measurements
EF calculation by Simpson�s Biplane Method
Moderately reduced EF
Problems with 2D EF and volumes
• Poor acoustic windows
• Underestimation compared to MRI
• Load dependent index
Use of contrast
Malm S et al. J Am Coll Cardiol 2004;44:1030-5
3D echocardiography
Jacobs LD et al. Eur Heart J 2006;27:460-8
Deformation imaging – TDI
Wang M et al. J Am Coll Cardiol 2003;41:820-6
Deformation imaging
• Strain imaging
• Speckle tracking
Validation? – Incremental value?
Prognostic significance of EF
Vasan RS et al. J Am Coll Cardiol 1999;33:1948-55
Prognostic significance of LV EDD and EF
Wong M et al. J Am Coll Cardiol 2004;43:2022-7.
Prognostic significance of LV dimensions and EF after MI
Burns RJ et al. J Am Coll Cardiol 2002;39:30-6.
However…
• LV dimensions and EF do not correlate well with HF symptoms, exercise capacity or myocardial oxygen consumption
Stroke volume ≠ Ejection Fraction
Hachicha Z et al. Circulation 2007;115:2856-64
Diastolic dysfunction: why is it important?
• Half of pts with newly diagnosed HF have normal or near normal EF
• Distinguish HF from other causes of dyspnoea
• Filling pressures
• Prognosis
Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133
In practice…
• Assessment of LV and LA
• Measurements not always suggestive of the same degree of DD
• Presence of ≥ 2 abnormal measurements increases likelihood of diagnosis
E/e’
E/e’
Ommen SR et al. Circulation 2000;102:1788-1794
Diagnosis of HFPEF
Paulus W et al. Eur Heart J 2007;28:2539–2550
Prognosis of pts with HFPEF
Owan T et al. N Engl J Med 2006;355:251-9 Bhatia RS et al. N Engl J Med 2006;355:260-9
Persistence of restrictive filling pattern impairs survival
Pinamonti B et al. J Am Coll Cardiol 1997;29:604-12
Restrictive filling pattern in patients with preserved EF
Klein AL et al. Circulation 1991;83:808-16
Diastolic dysfunction and prognosis
Redfield MM et al. JAMA 2003;289:194-202.
LA volume
Abhayaratna WP et al. J Am Coll Cardiol 2006;47:2357-63
Hemodynamics
RA pressure
≤2.1 cm and >50% collapse
0 – 5 mmHg
Intermediate values
5 – 10 mmHg
>2.1 cm and <50% collapse
10 – 20 mmHg
Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713
PAP
E/e’ performs better than BNP in pts with cardiac disease
Dokainish H et al. Circulation 2004;109:2432-2439
Prognostic importance of E/e’
Hillis G et al. J Am Coll Cardiol 2004;43:360–7
Kirkpatrick J et al. J Am Coll Cardiol 2007;50:381–96
Prognostic importance of E/e’
Dokainish H et al. J Am Coll Cardiol 2005;45:1223– 6
Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133
Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133
RV size
RVD1>42 mm RVD2>35 mm
Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713
RV function
<35% <16 mm
S<10 cm/s >0.40
Rudski L et al.J Am Soc Echocardiogr 2010;23:685-713
RV dysfunction and prognosis
Zornoff LA et al. J Am Coll Cardiol 2002;39:1450-5
Valvular Heart Disease – Assessment of severity
Vahanian A et al. Eur Heart J 2012;33:2451-96
Valvular Heart Disease – Assessment of severity
Vahanian A et al. Eur Heart J 2012;33:2451-96
Valvular Heart Disease – Treatment
Vahanian A et al. Eur Heart J 2012;33:2451-96
Valvular Heart Disease – Prognosis
Enriquez-Sarano M et al. N Engl J Med 2005;352:875-83
Grigioni F et al. Circulation 2001;103:1759-64
Dyssynchrony assessment • 1/3 of pts do not respond
• EF<35% major criterion
• Best echo method is elusive
• PROSPECT disappointing results
Chung ES et al. Circulation 2008;117:2608-16
Dyssynchrony assessment
Stress echocardiography
• Ischaemia – viability
• Assessment of valvular disease
• Diastolic stress test
CAD assessment
Viability assessment
Allman K et al. J Am Coll Cardiol 2002;39:1151-8 Underwood SR et al. Eur Heart J 2004;25:815-36
Assessment of valvular disease
Lancellotti P et al. Circulation 2003;108:1713-7 Pibarot P et al. J Am Coll Cardiol 2012;60:1845-53
Diastolic stress test
Nagueh S et al. J Am Soc Echocardiogr 2009;22:107–133
Therapeutic guidance
• Medication
• ICD/CRT
• Valve surgery
• Ventricular reconstruction surgery/Ventricular assist devices
Take home messages
• LVEF (reduced vs preserved HF) – many treatment options rely on this (medication, ICD/CRT) – prognosis
• LV diastolic dysfunction and filling pressures (diagnosis of HFPEF and prognosis)
• RV function – prognosis
• Assessment of valvular heart disease (severity, treatment and prognosis)
Take home messages
• Dyssynchrony? – EF is a major criterion but other methods still of unproved efficacy
• Stress echocardiography (ischaemia/viability, valvular heart disease, diastolic stress test)
Recommended