Echocardiography findings in HFNEF

Évaluation échographique de l
insuffisant cardiaque
Serge Lepage
CHU Sherbrooke
Evaluation echographique complète
•
•
•
•
•
M-mode,
Two-dimensional,
Doppler,
Color M-mode
Myocardial (tissue Doppler) imaging.
Evaluation of LV Systolic Function
Insuffisance cardiaque

Est le résultat de toute anomalie
structurelle ou fonctionnelle qui
porte atteinte à la capacité du
ventricule pour éjecter le sang
(insuffisance cardiaque systolique)
ou se remplir de sang (insuffisance
cardiaque diastolique).
Relation pression volume
Forces
 Peut évaluer la morphologie et de la fonction
 peu cher
 Pas de rayonnement
 portable
 facilement disponible
Limitations
 Trouver une fenêtre acoustique
 - Espaces intercostaux étroits
 - Toutes les régions du VG non visualisés chez tous les
patients
 - l'obésité
 - Intervenir dans le tissu pulmonaire pt chez les MPOC
 - Malformations musculo-squelettiques par exemple
kyposis, déformité thoracique
Owan T
nejm
2006
Figure 11.1. Diagnostic Criteria:
HF with Reduced vs. HF with Preserved EF
Clinical evidence of HF:
Clear clinical presentation of HF
or Framingham or Boston criteria
If uncertain:
Plasma BNP
or chest x-ray
or cardiopulmonary exercise testing
LVEF < 50%
LVEF ≥ 50%
Supportive evidence:
Supportive evidence:
Concentric LVH or remodeling
Eccentric LVH or remodeling
Left atrial enlargement in absence of AF
Exclusions: Non-myocardial disease
Adapted from Yturralde FR. Prog
Cardiovasc Dis 2005;47:314-19
Echo Doppler or catheter evidence of
diastolic dysfunction
Exclusions: Non-myocardial disease
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Causes

dysfonction systolique


MCAS
Cardiomyopathie dilatée (ICM)






50% idiopathique (au moins 25% familiale)
9% mycoarditis (viral)
Cardiopathie ischémique, perpartum, l'hypertension, le VIH, les
maladies du tissu conjonctif, de la toxicomanie, de la doxorubicine
Hypertension
Cardiopathie valvulaire
dysfonction diastolique




Hypertension
Mcas
Cardiomyopathie obstructive hypertrophique (CMH)
Cardiomyopathie restrictive
Implantable Cardioverter-Defibrillators
for HF



Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
About one-third of mortality in
HF is due to sudden cardiac
death.
Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF ≤ 35% have a significant
survival benefit from an
implantable cardioverterdefibrillator (ICD) for the
primary prevention of SCD.
Fraction d éjection
 Dépend de la contractilité, de la précharge et la postcharge,
la fréquence cardiaque, la synchronicité des contractions
 Paramètre global
 les différences régionales dans la contractilité sont moyenné
17 Cardiac Segments
17 Cardiac Segments
Regional function indices
 WMS




Normal =1
Hypo=2
Akinetic=3
Dyskinetic=4
 WMSI
S WMS/N
Evaluation de la fonction VG
En présence d'une anomalie de mouvement
régional de la paroi toutes les méthodes d analyse
seront moins précis, car si la région de mouvement
de la paroi anormale est inclus dans les dimensions
ou la région de mesures, les volumes seront sur/sous
estimés.
Evaluation
L’ ASE (American Society of Echocardiography)
recommande l'utilisation de vues apicales biplan
avec une approche de la règle de Simpson
modifiée..
Simpson’s Rule – the biplane
method of disks
LV-ED

Volume left ventricle
- manual tracings in systole and
A4C
diastole
- area divided into series of disks
A2C
- volume of each disk ( πr2 * h )
summed = ventricular volume
LV-ES
Ejection fraction
3. Modified Simpson’s biplane
method [2D-Echo]
20
 Vol= p/4 S ai bi L
i=1
20
[Difference b/w ai & bi should be less
than 20%]
 Most reliable method in case of
regional difference in function
 EF calculated comparable to those
measured hemodynamically
Limitations
 Operator dependence
- inter/intra observer variability is 10-30%
 Limited utility
- MR high EF but little forward flow
- AS low EF but possibly reversible
Normal contraction of LV
J Am Coll Cardiol Img 2008;1:366 –76
Regional Indices of Left
Ventricular Function
 WMS [wall motion score]
 Center line chordal shortening
 Radian change, regional area change
 Strain rate imaging
 Torsion imaging
Ejection fraction
Drawbacks
 Depends on preload and afterload, as well as HR and synchronicity of
contraction.
Preload increases [AR,MR,
Anemia]
EF increases
Afterload increases [AS]
EF decreases
 Global parameter, major regional differences in contractility are
presented as an average
 Given EF may have different prognostic importance according to
clinical situation eg severe MR
Other parameters
 Myocardial Performance index
[TEI index]
ICT + IRT
ET
 Measure of both sys &
diastolic function
 Normal <0.4
 Strong inverse relationship
with EF
 Independent of ventricular
geometry
Hellenic J Cardiol 2009; 50: 60-6
Npuvelles méthodes




Echo 3d
Autimated border detection
Strain strain rate
Etc


Domaines de la recherche
Pas encore un standard de soins

Thank god
Deformation analysis
 Newer methods of TDI & speckle
tracking
 Analysis of strain, strain rate or torsion
 Strain- change in distance over time
 Strain rate- velocity of change over time
Deformation analysis
Drawbacks

Strain not uniform from base to apex & in circumferential plane [anterior & lateral wall higher]

Angle dependency

Preload dependent

Heterogenicity within the same myocardium

Patient to patient variability

Inter & Intra observer variability
APE
X
2-D Echo evaluation of LV
Function
 Most common method used is Simpson’s rule
 Most accurate when LV geometry is normal
 Correlation coefficients ~ 0.75 compared to RNA, cine angiography & autopsy
studies Circulation 1979, 60:760-766; Circulation 1980, 61:1119-112
 Limited by reproducibility b/w individual studies
 Improved by tissue harmonic imaging & contrast use.
3D Echocardiography
 Direct evaluation of cardiac chamber volumes without the need for
geometric modelling and without the detrimental effects of
foreshortened views
 Direct 3D assessment of regional LV wall motion
 Quantification of systolic asynchrony to guide CRT
 3D color Doppler imaging with volumetric quantification of
regurgitant lesions , shunts , and cardiac output
J Am Coll Cardiol 2006; 48:2053– 69
3D Echocardiography
Am J Cardiol 2005;95:809–813
Insuffisance cardiaque diastolique
• FE normale avec echo Bi-Di et evidence
clinique d une insuffisance cardiaque
• Le diagnostic peut être confirmé si
l'échocardiographie et l'imagerie par doppler
tissulaire du myocarde est anormale.
Figure 11.3. Diagnostic Algorithm
for HF with Preserved LVEF
HF with
Preserved LVEF
Dilated LV
Valvular disease
AR, MR
Non-dilated LV
No valvular dis.
High output HF
Increased
thickness
Normal or
increased QRS
Hypertrophic dis.
No aortic
valve disease
No hypertensive
history of PE
HCM, Fabry dis.
Normal
Thickness
Low QRS voltage
Infiltrative
myopathy
Aortic valve dis.
Aortic stenosis
Hypertensive
history of PE
Hypertensive-HCM
Some patients with RV
dysfunction have LV
dysfunction due to
ventricular interaction.
Right vent.
dysfunction
No mitral
obstruction
Pulmonary
hypertension
Pericardial dis.
Tamponade
Constriction
Isolated predominant RVMI
No pericardial
disease
Inducible ischemia
Intermittent/active
ischemia
Mitral obstruction
MS, atrial myxoma
No inducible ischemia, fibrotic, collagenVascular, RCM, cardinoid, diabetes,
Radiation or chemotherapy induced
heart disease, infiltrative disease, comorbid conditions, reconsider diagnosis
of HF
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Fonction diastolique vs pression diastolique?
• Présentement l insuffisance cardiaque avec fonction
systolique préservée représente plus de 50% des
patients hospitalisés pour ADHF
• L évaluation de la fonction diastolique est donc
primordiale
• Il faut faire une distinction entre fonction et pression
– Analogie entre un pt avec FE 30% ambulatoire et un autre
a 35% en OAP
– Fonction vs pression (LV/LA EDP)
• Présentement l echo est le meilleur outil non invasif
pour l évalaluation de la FD
Two-dimensional echocardiography
•
•
•
•
LA size
LV thickness
LVEF
Other structural heart diseases
Normal diastolic filling pattern
 Most LV filling occur in early diastole
 Longitudinal mitral annular velocity mirrors normal mitral inflow
 Normal E/e’ in rest and exercise
 Parameters
 E/A 0.9-1.5
 DT 160-240 ms
 IVRT 70-90 ms
 septal e’>10 cm/s
 E/e’<8
 Vp>50 cm/s
 LAVI-16 to 28 ml/m2
Doppler parameters in different
age groups
Grade 1 diastolic
dysfunction(mild)
 LV relaxation impaired



Slower LV pressure decay
Pressure crossover b/w LA and LV occurs late
IVRT,DT prolonged
Early transmitral gradient is reduced-reduced E vel
 Adequate diastolic filling period is critical to maintain LV
filling without increase in LA pressures
 Reduced LA emptying in early diastole increases atrial preload-A
velocity increases
 Pulmonary vein diastolic flow velocity parallels mitral E velocitydecreased.Compensatory increase in systolic velocity
 Pul vein atrial flow reversal usually normal,can increase if atrial
compliance decreases or LVEDP higher
 Septal e’ < 7 cm/s
 Vp< 50 cm /s
 Grade 1a diastolic dysfunction
 Filling pressure is increased (E/e’> 15) with grade 1 mitral inflow
pattern
Grade 2 –moderate diastolic
dysfunction
 LA pressures are elevated
 LA-LV pressure gradient restored
 Pseudonormalised mitral inflow pattern
 E/A returns to normal,DT normal
 Differentiation from true normal




Septal e’<7 cm/s
Valsalva decreases E/A by more than 0.5
Pulmonary vein atrial flow reversal exceeds mitral A duration
Vp<45 cm/s
Grade 3&4 LV diastolic
dysfunction(severe)
 Restrictive filling
 Valsalva may reverse restrictive pattern to grade 1 or 2reversible restrictive (grade 3)
 Even if no change with valsalva reversibility cannot be
excluded-filling pressure may be too high to be altered
by valsalva
 Grade 4 dysfunction not used in ASE rec.
 Early rapid diastolic filling into a less compliant LV
cause a rapid increase in early diastolic LV pressure
 Rapid equalisation produces a shortened DT
 A velocity and duration shortened as atrial contraction
produces rapid rise in LV pressure
 Systolic forward flow in pulmonary vein reduced due to
increased LA pressure
 E/e’ > 15
Types of Heart Failure

Low-Output Heart Failure

Systolic Heart Failure:



Diastolic Heart Failure:



Elevated Left and Right ventricular end-diastolic
pressures
May have normal LVEF
High-Output Heart Failure



decreased cardiac output
Decreased Left ventricular ejection fraction
Seen with peripheral shunting, low-systemic vascular
resistance, hyperthryoidism, beri-beri, carcinoid, anemia
Often have normal cardiac output
Right-Ventricular Failure

Seen with pulmonary hypertension, large RV infarctions.
The relation between pulmonary artery systolic pressure (PAS) by Doppler versus pressure
obtained by right heart catheterization is shown in the left panel (n=63; y=1.1x−0.8).
Nagueh S F et al. Circ Cardiovasc Imaging. 2011;4:220-227
Copyright © American Heart Association, Inc. All rights reserved.
The relation between pulmonary artery diastolic pressure (PAD) by Doppler versus pressure
obtained by right heart catheterization is shown in the left panel (n=25; y=0.62x+12.2).
Nagueh S F et al. Circ Cardiovasc Imaging. 2011;4:220-227
Copyright © American Heart Association, Inc. All rights reserved.
The relation between average E/e′ ratio and mean PCWP in patients without left bundlebranch block (LBBB) and without cardiac resynchronization therapy (CRT) is shown in the
left panel (n=45; y=2.1x−0.03x2−5.5; R2=0.56).
Nagueh S F et al. Circ Cardiovasc Imaging. 2011;4:220-227
Copyright © American Heart Association, Inc. All rights reserved.
The relation between mean RAP by Doppler echocardiography versus pressure obtained by
right heart catheterization is shown in the left panel (n=60; y=0.96x+1.69).
Nagueh S F et al. Circ Cardiovasc Imaging. 2011;4:220-227
Copyright © American Heart Association, Inc. All rights reserved.
Plot shows the relation between the change in average E/e′ ratio versus the change in mean
PCWP in the 12 repeat studies (y=1.2x−0.62).
Nagueh S F et al. Circ Cardiovasc Imaging. 2011;4:220-227
Copyright © American Heart Association, Inc. All rights reserved.
Fraction
– Randazzo, M. Academic Emergency Medicine,
2003
 Cross-sectional observational study, convenience sample
 115 patients, chest pain (45.1%), congestive heart failure (38.1%),
dyspnea (5.7%), and endocarditis (10.6%)
 Three-hour training session
 LVEF poor (<30%), moderate (30%-55%), or normal (>55%)
 Formal echo within four hours interpreted by cardiologist.
 LVEF correlation 86.1% overall agreement
 Highest (91%) in normal LVEF category, 70.4% poor LVEF, 47.8%
moderate LVEF
Imagerie multi modalités
 Écho plus commun
 MRI- precision, géometrie
complexe
JAmColl Cardiol Img 2008;1:652–62
 Autres test selon pathologie
Conclusion

L’ echocardiographie



Est important dans la prise en charge
du patient
Disponible et non effractif
Evaluation complete
Myocardique
 Valvulaire
 Pericardique


Cependant il faut percevoir les
limitations…