Echo assessment of the failing heart

Transcription

1 Echo assessment of the failing heart Mark K. Friedberg, MD The Labatt Family Heart Center The Hospital for Sick Children Toronto, Ontario, Canada

2 Cardiac function- definitions Cardiovascular function: delivery of blood (oxygen) to tissues at a rate commensurate with oxygen consumption Cardiac & ventricular function: pump activity resulting in adequate amount of cardiac output at low filling pressures Myocardial function: phasic shortening and force generation followed by lengthening and force decay

3 Quantifying function One of the biggest challenges is deciding how best to quantify cardiac function! No measurable quantity corresponds to integrated functional assessment Surrogates approximate individual aspects of cardiac function. It depends on what question you ask.

4 LV contractile function Bijnens, European Journal of Echocardiography (2009) 10,

5 Determinants of Function AFTERLOAD PRELOAD CONTRACTILITY

6 Also need to consider Acute versus chronic changes Adaptation (hypertrophy) Heart rate Interactions (ventricular-vascular; ventricularventricular)

7 A routine echo report (partial list).

8 Is this enough?

9 Eyeball assessment still a prevalent method Experienced operator Quick and easy Subjective Subtle findings overlooked

10 Eyeball assessment: Newborn with cyanosis-this echo diagnosed critical PS (near atresia) intact septum What is the LV function?

11 Sometimes the abnormality can be seen

12 Remodeling: Same SV with less contractility McMahon, Heart 2004;90:908

13 Measurement of LV dimensions Lopez, J Am Soc Echocardiogr 2010;23: Molina, Circ: HF 2013;6:1214 Friedberg, In progress

14 The shape of the ventricle is important! Friedberg, In progress

15 Mitral regurgitation Fernandes, Am J Cardiol ;107(

16 Ejection phase indices Fractional shortening Ejection fraction % = EDV - ESV/ EDV x 100 M-mode 2-D 3-D

17 Ejection fraction by 3-D Courtesy Manni Vannan, MD

18 JASE 2016

19 Ejection fraction limitations Technique limitations Visualization of endocardial borders (contrast) LV is 3-dimensional; most models for calculation based on 2 dimensions (3D echo) Physiologic limitations Preload dependency Afterload dependency Heart rate

20 Why do we still use EF? Any name, any study, any year Friedberg, In progress

21 Time intervals

22 Systolic time intervals

23 The myocardial performance index

24 The systolic to diastolic duration ratio Friedberg, AJC 2006;97:101

25 Prognostic Implications of the Systolic to Diastolic Duration Ratio in Children With Idiopathic or Familial Dilated Cardiomyopathy Tapas Mondal, Cameron Slorach, Cedric Manlhiot, Wei Hui, Paul F. Kantor, Brian W. McCrindle, Luc Mertens and Mark K. Friedberg Circ Cardiovasc Imaging. 2014;7: ; originally published online August 19, 2014; doi: /CIRCIMAGING Circulation: Cardiovascular Imaging is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX Copyright 2014 American Heart Association, Inc. All rights reserved. Print ISSN: Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at:

26 Myocardial performance

27 Tissue Doppler Imaging Molina, Circ: HF 2013;6:1214

28 LV myocardial contraction shortens thickens twists along long axis

29 Longitudinal strain Circumferential strain Radial strain

30 Global strain Courtesy B. Bijnens

31

32 Progressive LV dysfunction Cikes M, Eur Heart J 2015; Shah AM, Eur Heart J 2012

33 Contractile Reserve Systolic dysfunction more likely under stress. Regional dysfunction during stress can identify ischemic and nonischemic cardiomyopathy. In HF, contractile reserve, (dp/dt, EF%, cardiac output response) is related to outcome.

34 Diastolic function Filling at low pressures Better filling at high heart rates despite shorter filling times During exercise increase in filling at persistently low filling pressures

35 Mitral inflow

36 Delayed relaxation in HCM

37 e and E/e have prognostic significance Decreased e Increased E/e ratio Predicted SCD or VT in children Inversely related to peak VO 2 McMahon, Circulation, 2004

38 HCM with restrictive physiology

39 Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD Phone: Fax: journalpermissions@lww.com Interpretation of Left Ventricular Diastolic Dysfunction in Children With Cardiomyopathy by Echocardiography : Problems and Limitations Andreea Dragulescu, Luc Mertens and Mark K. Friedberg Circ Cardiovasc Imaging 2013;6; ; originally published online January 23, 2013; DOI: /CIRCIMAGING Circulation: Cardiovascular Imaging is published by the American Heart Association Greenville Avenue, Dallas, TX Copyright 2013 American Heart Association. All rights reserved. Print ISSN: Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at: Data Supplement (unedited) at: DC1.html Subscriptions: Information about subscribing to Circulation: Cardiovascular Imaging is online at

40 Figure 4 Systolic- diastolic coupling Friedberg, J Appl Physiol. 2016;120,

41 Systolic-diastolic coupling in children with DCM Figure 2B Figure 3A Within subject: r = 0.62, p<.001 Between subject: r = 0.80, p<.001 Peak systolic velocity, cm/sec Visit Peak early diastolic velocity, cm/sec Friedberg, J Appl Physiol. 2016;120,

42 5y, DORV, progressive LV enlargement, AI dysfunction and exercise intolerance QRS 130 msec

43 Summary Assessment of cardiac function is central to clinical management Echo is the mainstay of functional imaging Qualitative &quantitative measures should be used Well tested conventional measures should be combined with more recent modalities Often simple measures are very informative Systolic and diastolic function are tightly coupled and both should be assessed The reader s role is to integrate multiple parameters into a comprehensive picture of function

44 THANK YOU