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Heart failure with preserved ejection fraction (HFPEF)

  • Mechanisms of heart failure - Is there a unifying theory of heart failure, presented by T H Marwick (Cleveland, US)  
  • Does the systemic vasculature play a role, presented by D Vinereanu (Bucharest, RO)  
  • What does the left ventricular ejection fraction tell us, presented by D H MacIver (Taunton, GB)  
  • Assessment of left ventricular diastolic function is a must, presented by G Di Salvo (Naples, IT)

HFPEF has been widely discussed over the last years and a lot of uncertainties regarding etiology, pathophysiology, diagnosis and management still persist.

This session was very informative, provocative and raised several important questions. In the first presentation Prof Tom Marwick from Cleveland, USA, addressed the topic of "Mechanisms of heart failure: Is there a unifying theory of HF?" He started by asking if it makes sense to discuss a unifying theory of heart failure considering its complexity, which may not be reasonable to put together into one theory. He made the point that HFPEF and HF with reduced EF are not a continuum and he illustrated several differences, such as a different ventricular and cellular remodelling. Also the heterogeneity of its pathogenesis was underlined. He then alluded to some of the new imaging methods and parameters, such as torsion and untwist, as well as the relation between untwisting and tau constant and the filling pressure gradient, which may help to understand the underlying pathophysiology as well as improve some of the diagnostic features. It was clearly stressed also the fact that the different underlying clinical entities that are responsible for heart failure with either preserved or impaired ejection fraction should be taken into account in the clinical ground and the author underlined the need to centre on the different phenotypic changes in heart failure.

Dr. Vinereanu from Bucharest, addressed the topic of "Does the systemic vasculature play a role?"  He cleared defined the need to assess arterial stiffness with parameters such as pulse wave velocity. He showed the relation of arterial stiffness with sub endocardial systolic and diastolic dysfunction and discussed the reasons why subendocardial dysfunction affects, in his view, only longitudinal function. It was also shown the relation with left atrial function. Several methods were discussed, including applanation tonometry. Finally it was discussed the importance of studying ventriculo-arterial coupling as a way to monitor treatment strategies.

Dr MacIver from Great Britain talked about “What does the left ventricular ejection fraction tell us?” In an elegant but provocative talk Dr MacIver went through several questions regarding the relevance and the meaning of EF. He started by saying that EF does not determine symptoms and even regarding the impact on survival it is controversial. Then he said that “The peripheral tissues don’t care about EF, they care about perfusion”. He then described a mathematical model that he used to test the different structural conditions, showing, for instance, the relation between EF, end diastolic wall thickness and strain. He showed in his model that an increase in EF occurs as end diastolic wall thickness increases but EF decreases when longitudinal shortening decreases. It was also shown the relation between left atrial shortening and EF.

Finally Dr DiSalvo from Naples, Italy gave a very didactic talk on “Assessment of left ventricular diastolic function is a must”. He went through the different parameters used today to assess diastolic function using flow Doppler, tissue Doppler, strain imaging and left atrial assessment. He described some of the technical details as well as some of the pitfalls. He cautioned, for instance, on the use of e/e’ in certain clinical conditions where its value may be reduced.




Heart failure with preserved ejection fraction

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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