The Role of Echocardiography in Hemodynamic Assessment in Heart Failure

doi:10.1016/j.hfc.2008.11.002

Heart Failure Clinics

Volume 5, Issue 2, April 2009, Pages 191-208

https://doi.org/10.1016/j.hfc.2008.11.002 Get rights and content

Echocardiography now is recommended as the most useful diagnostic test for routine evaluation and management of heart failure. This article reviews the role of echocardiography (M-mode, two-dimensional, spectral, and tissue Doppler) for qualitative and quantitative hemodynamic assessment of the patient who has heart failure. It highlights the echocardiographic parameters that have the most diagnostic and/or prognostic relevance for patients who have advanced heart failure. The importance of right heart failure and heart failure with preserved ejection fraction is increasingly recognized, and therefore the echocardiographic evaluation of these conditions is emphasized also.

Section snippets

Contractile function of the left ventricle

Muscle fiber shortening generates the ventricular stroke volume and thus cardiac output. The extent of muscle shortening, or contractility, is best described by pressure–volume loop analysis, but this method is not feasible in routine clinical practice.³ Clinical assessment of ventricular contractile performance thus has relied on imperfect and indirect measurements that are sensitive to changes in loading conditions, such as ventricular volumes, cardiac output, and ejection fraction (EF).

Chamber Geometry

Hemodynamic assessment by echocardiography should incorporate cardiac morphology. The heart has limited morphologic responses to pressure and volume overload—hypertrophy and/or dilatation. Chamber geometry provides insight into the nature, chronicity, and severity of adverse loading conditions, and the extent of remodeling is a strong determinant of prognosis. In an echocardiographic substudy of the Beta-blocker Evaluation of Survival Trial (BEST), for example, Grayburn and colleagues¹⁵ found

Diastolic filling/filling pressures

Diastole encompasses the period of the cardiac cycle from closure of the aortic valve to closure of the mitral valve. During isovolumic relaxation, the LV untwists and de-stiffens. The rate of de-stiffening or relaxation normally is rapid and is characterized by τ or negative dP/dt. The rate of LV filling after mitral valve opening is determined by the instantaneous pressure gradient between LA and LV and the LV compliance (dV/dP). Impaired LV relaxation or reduced LV compliance are fundamental

Early diastolic flow velocity/late diastolic flow velocity

Mitral inflow velocity curves reflect the instantaneous pressure gradient between the LA and LV during diastole. Pulse-wave Doppler at the mitral valve leaflet tips records an early diastolic flow velocity (E-wave velocity) followed by a late diastolic flow velocity (A-wave velocity) generated by atrial contraction. In the normal heart, approximately 85% of LV filling occurs during early diastole; therefore, E-wave velocity typically is greater than A-wave velocity. The time interval for the

Semi-quantitative Estimation of Filling Pressures

The mitral E-wave velocity is related directly to LAP and inversely to LV relaxation. In patients who have systolic HF, increased filling pressure (high LAP) and reduced LV relaxation co-exist, so that E-wave velocity alone correlates poorly with mean LAP. Correcting E-wave velocity for abnormal LV relaxation enables accurate estimation of LAP or mean PCWP. The mitral annular velocity (E_m) and the flow propagation velocity (V_p) on color M-mode cardiography have been validated as measures of LV

Pulmonary circulation and right heart function

RV dysfunction and secondary PH are critical determinants of functional capacity and survival in HF. Although PH in HF is caused primarily by pulmonary venous hypertension, there is little relationship between the degree of LV dysfunction and pulmonary artery pressure (PAP) because of the variable degree of diastolic impairment, MR, and LA size and compliance. Echocardiographic predictors of PH are a restrictive mitral inflow pattern and the severity of MR.³⁸

RV function is an independent and

Constriction versus restriction

CP and restrictive cardiomyopathy (RCM) must be considered in any patient who has symptoms and signs of HF and normal systolic function. The clinical distinction between these two entities can be difficult, but in most cases echocardiography can aid in the diagnosis. Two-dimensional echocardiography findings characteristic of infiltrative restrictive cardiomyopathy include significant TR and MR, marked bi-atrial enlargement, and normal systolic function. A myocardium that is thickened and has a

Summary

Qualitative and quantitative hemodynamic data can be obtained through echocardiography, making it a valuable noninvasive tool in the routine assessment of the patient who has HF. In addition to providing a hemodynamic profile, echocardiography provides unique and powerful prognostic data that cannot be obtained by catheterization. Thus, echocardiography is the diagnostic test of choice in the initial hemodynamic evaluation of HF.

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The aim of the present study was to explore the relation between right ventricular (RV) and left ventricular (LV) echocardiographic parameters with clinical outcome in patients with advanced heart failure referred for cardiac transplantation. Ninety-eight consecutive patients with advanced systolic heart failure, referred for cardiac transplant evaluation, were enrolled. All patients were prospectively followed for the development of new outcome events, which included hospitalization for acute heart failure, cardiovascular death, heart transplantation, intra-aortic balloon pump implantation, and ventricular assist device implantation. Conventional transthoracic echocardiography was performed in all subjects. RV longitudinal strain (RVLS) by speckle-tracking echocardiography was assessed by averaging all segments in apical 4-chamber view (global RVLS) and by averaging RV free-wall segments (free-wall RVLS). LV global longitudinal and global circumferential strains were also calculated. Of the 98 subjects at baseline, 46 had 67 new events during a mean follow-up of 1.5 ± 0.9 years. Free-wall RVLS, global RVLS, N-terminal fragment of the prohormone brain natriuretic peptide, RV fractional area change, and LV end-diastolic volume were independently predictive of combined outcomes (all p <0.0001). The overall performance for the prediction of cardiovascular events was greatest for free-wall RVLS (area under the curve free-wall RVLS: 0.87; global RVLS: 0.67; RV fractional area change: 0.60; N-terminal fragment of the prohormone brain natriuretic peptide, 0.62; global circumferential strain: 0.55; global longitudinal strain: 0.35; and LV ejection fraction: 0.26). Free-wall RVLS showed the highest adjusted hazards ratio. A graded association between the grade of RV dysfunction and the risk of cardiovascular events was only evident for free-wall RVLS and global RVLS. In conclusion, in patients referred for heart transplantation, RVLS is a stronger predictor of outcome than LV longitudinal strain and other conventional parameters, providing a stronger prognostic stratification.
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Overall, chest x-ray is of limited utility in the diagnostic workup of patients suspected to have HF. Echocardiography with Doppler examination has replaced the chest x-ray in the evaluation of HF, and it can provide useful hemodynamic measurements (Table 9) without cardiac catheterization [64,65]. The assessment is directed to determine cardiac anatomy (LV size, RV size, LV wall thickness), cardiac function (LVEF), severity of valvular disease, presence of pulmonary hypertension, RV function, estimation of RA pressure (Table 9) and Doppler indices of diastolic dysfunction, and the presence of pericardial effusion.
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Although the epidemiology, pathophysiology, and management of this disease are beyond the scope of this review, it is important for practitioners to understand the risk factors leading to the development of LV dysfunction, which is summarized nicely in Figure 1 by Kenchaiah et al [23]. Echocardiography offers a useful noninvasive means of assessing cardiac structure and function and possibly predicting the development of circulatory overload [24]. Left ventricular dilation and reduced ejection fraction correlate with the clinical syndrome of systolic heart failure, whereas increased LV mass, abnormal diastolic filling parameters, and left atrial enlargement correlate with the syndrome of diastolic heart failure.
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Right ventricular (RV) systolic function has a critical role in determining the clinical outcome and success of using left ventricular assist devices (LVADs) in patients with refractory heart failure. Tissue Doppler and M-mode measurements of tricuspid systolic motion (tricuspid S′ and tricuspid annular plane systolic excursion [TAPSE]) are the most currently used methods for the quantification of RV longitudinal function; RV deformation analysis by speckle-tracking echocardiography (STE) has recently allowed the analysis of global RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed at exploring the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) in patients referred for cardiac transplantation.
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The Role of Echocardiography in Hemodynamic Assessment in Heart Failure

Section snippets

Contractile function of the left ventricle

Chamber Geometry

Diastolic filling/filling pressures

Early diastolic flow velocity/late diastolic flow velocity

Semi-quantitative Estimation of Filling Pressures

Pulmonary circulation and right heart function

Constriction versus restriction

Summary

J Am Coll Cardiol

Mayo Clin Proc

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol