Η ηχωκαρδιολογία στην διάγνωση κα πρόγνωση της καρδιακής ανεπάρκειας µε µειωµένο και φυσιολογικό κλάσµα εξώθησης

Transcription

1 Η ηχωκαρδιολογία στην διάγνωση κα πρόγνωση της καρδιακής ανεπάρκειας µε µειωµένο και φυσιολογικό κλάσµα εξώθησης Βασίλειος Σαχπεκίδης Επιµελητής Β Καρδιολογίας Γ.Ν. Παπαγεωργίου Θεσσαλονίκη

2 ESC Guidelines McMurray J et al. Eur Heart J 2012;33:

3 McMurray J et al. Eur Heart J 2012;33:

4 Information from echo EF LVEF, DD, RV, Valves

5 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

6 LV size and geometry Lang RM et al. J Am Soc Echocardiogr 2005;18: Much better validated for TTE than TOE (use analogous views)

7 M-mode vs 2D measurements of LV dimensions and wall thickness

8 Simpson s Biplane Method

9 Calculation of LV mass Linear method 2D method

10 Reference values of LV geometry Lang RM et al. J Am Soc Echocardiogr 2005;18: Most measurements presented are derived from fundamental imaging Harmonic imaging increased values In clinical practice wall thickness > 1.1 cm is considered abnormal

11 Reference values of LV size Lang RM et al. J Am Soc Echocardiogr 2005;18:

12 Prognostic importance of LV mass Quinones MA et al. J Am Coll Cardiol 2000;35:

13 LV geometric pattern is also important 2xPWTd/LVIDd Lang RM et al. J Am Soc Echocardiogr 2005;18:

14 Pts with concentric hypertrophy have the worse prognosis Muiesan M et al. Hypertension 2004;43:731-8

15 Concentric remodeling adversely impairs prognosis even if LV mass is normal Verdecchia P et al. J Am Coll Cardiol 1995;25:871-8

16 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)

17 Methods for assessing LVEF Visual estimation (eyeball method) From linear measurements of LV dimensions (M-mode or 2D) From volumetric 2D measurements

18 EF calculation by Simpson s Biplane Method Moderately reduced EF

19 Problems with 2D EF and volumes Poor acoustic windows Underestimation compared to MRI Load dependent index

20 Use of contrast Malm S et al. J Am Coll Cardiol 2004;44:1030-5

21 3D echocardiography Jacobs LD et al. Eur Heart J 2006;27:460-8

22 Deformation imaging TDI Wang M et al. J Am Coll Cardiol 2003;41:820-6

23 Deformation imaging Strain imaging Speckle tracking Validation? Incremental value?

24 Prognostic significance of EF Vasan RS et al. J Am Coll Cardiol 1999;33:

25 Prognostic significance of LV EDD and EF Wong M et al. J Am Coll Cardiol 2004;43:

26 Prognostic significance of LV dimensions and EF after MI Burns RJ et al. J Am Coll Cardiol 2002;39:30-6.

27 However LV dimensions and EF do not correlate well with HF symptoms, exercise capacity or myocardial oxygen consumption

28 Stroke volume Ejection Fraction Hachicha Z et al. Circulation 2007;115:

29 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

30

31 Nagueh S et al. J Am Soc Echocardiogr 2009;22:

32 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

33 E/e

34 E/e Ommen SR et al. Circulation 2000;102:

35 Diagnosis of HFPEF Paulus W et al. Eur Heart J 2007;28:

36 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

37 Persistence of restrictive filling pattern impairs survival Pinamonti B et al. J Am Coll Cardiol 1997;29:604-12

38 Restrictive filling pattern in patients with preserved EF Klein AL et al. Circulation 1991;83:808-16

39 Diastolic dysfunction and prognosis Redfield MM et al. JAMA 2003;289:

40 LA volume Abhayaratna WP et al. J Am Coll Cardiol 2006;47:

41 Hemodynamics

42 RA pressure 2.1 cm and >50% collapse Intermediate values >2.1 cm and <50% collapse 0 5 mmhg 5 10 mmhg mmhg Rudski L et al.j Am Soc Echocardiogr 2010;23:

43 PAP

44 E/e performs better than BNP in pts with cardiac disease Dokainish H et al. Circulation 2004;109:

45 Prognostic importance of E/e Kirkpatrick J et al. J Am Coll Cardiol 2007;50: Hillis G et al. J Am Coll Cardiol 2004;43:360 7

46 Prognostic importance of E/e Dokainish H et al. J Am Coll Cardiol 2005;45:1223 6

47 Nagueh S et al. J Am Soc Echocardiogr 2009;22:

48 Nagueh S et al. J Am Soc Echocardiogr 2009;22:

49 RV size RVD1>42 mm RVD2>35 mm Rudski L et al.j Am Soc Echocardiogr 2010;23:

50 RV function <16 mm <35% S<10 cm/s >0.40 Rudski L et al.j Am Soc Echocardiogr 2010;23:

51 RV dysfunction and prognosis Zornoff LA et al. J Am Coll Cardiol 2002;39:1450-5

52 Valvular Heart Disease Assessment of severity Vahanian A et al. Eur Heart J 2012;33:

53 Valvular Heart Disease Assessment of severity Vahanian A et al. Eur Heart J 2012;33:

54 Valvular Heart Disease Treatment Vahanian A et al. Eur Heart J 2012;33:

55 Valvular Heart Disease Prognosis Enriquez-Sarano M et al. N Engl J Med 2005;352: Grigioni F et al. Circulation 2001;103:

56 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:

57 Dyssynchrony assessment

58 Stress echocardiography Ischaemia viability Assessment of valvular disease Diastolic stress test

59 CAD assessment

60

61 Viability assessment Allman K et al. J Am Coll Cardiol 2002;39: Underwood SR et al. Eur Heart J 2004;25:815-36

62

63 Assessment of valvular disease Pibarot P et al. J Am Coll Cardiol 2012;60: Lancellotti P et al. Circulation 2003;108:1713-7

64 Diastolic stress test Nagueh S et al. J Am Soc Echocardiogr 2009;22:

65 Therapeutic guidance Medication ICD/CRT Valve surgery Ventricular reconstruction surgery/ventricular assist devices

66 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)

67 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)

68