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Heart failure with preserved ejection fraction - Role of imaging

Non-Invasive Imaging


Dr Bogdan Popescu spoke first, giving us a comprehensive overview of  the use of echocardiography to diagnose heart failure with preserved ejection fraction (HFPEF). He discussed the recent 2012 ESC Heart Failure guidelines (Eur Heart J 2012;33(14):1787-847) and the importance of excluding structural abnormalities and accurate measurements of cardiac dimensions. In particular, he stressed the use of left atrial (LA) volume index, which gives us prognostic information and is an important indicator of the chronicity of raised left ventricular filling pressures and may give more information than diastolic parameters, describing it as the “Cardiologist’s HbA1c”.
Assessment of diastolic function requires comprehensive analysis of all parameters, since so much of what we measure varies with age and is load dependent, with some measures being less accurate with normal ejection fractions such as the deceleration time. A measure that is sometimes forgotten is the pulmonary vein flow AR wave duration. Indeed, as he explained, if the AR amplitude is high and the duration prolonged, it is a good indicator of increased LV pressures. Finally he talked about the role of pulmonary pressures as a prognostic marker and the role of exercise testing in HFPEF.
Dr Careji gave an excellent overview of the pathophysiology of heart failure in the context of endothelial dysfunction, explaining that endothelial dysfunction independently correlated with future cardiovascular events, adding incremental clinical information to traditional risk factors. He also discussed the usefulness of exercise testing in assessing these patients and the importance of accurate assessment of Tissue Doppler Imaging (TDI) systolic velocity, which is often forgotten and has been shown to be associated with increased cardiovascular events when decreased.
Dr Carpenter stood in for Dr Pennell and spoke about the use of cardiac magnetic resonance imaging (CMR) in these patients. CMR is the ideal modality for accurately assessing left ventricular (LV) and LA volumes, but is infrequently used for measuring diastolic parameters. However, he explained that although parameters such as E/A, DP/DT and pulmonary vein flow can be measured using flow contrast, this is not done routinely as the temporal resolution of CMR is still suboptimal. Tagging software can allow assessment of myocardial deformation and strain, however, this is not quite mainstream at present. CMR can, however, provide further additive information in terms of aetiology of the heart failure with tissue characterisation making the identification of amyloid and iron overload disease etc possible, as well as assessing extra cardiac structures such as the renal arteries and the aorta.
Late gadolinium enhancement is a well known marker of fibrosis but CMR continues to develop and T1 mapping may enable more accurate assessment of the extracellular space and new technology, for example diffusion tractography, has the potential to examine actual myocardial fibre tracts.
 
Finally, Dr de Sutter reiterated the ESC guidelines and discussed the indications for catheterising patients with heart failure. He reminded us that diastolic parameters are very much age-related and that 20% of asymptomatic patients over 75 years have an E/E’ >15. He discussed the physiology of the measurements obtained behind flow volume loops and LV end diastolic pressure.
As non-invasive imaging is so good, only a minority of patients need to go to the cath lab, for example those with unexplained dyspnoea, unexplained pulmonary hypertension and of course, to exclude myocardial ischaemia. There may also be a role of invasive measurements for assessing the response to medical therapy.

Conclusion:

Overall, this session was highly information giving us insights into the difficulties and usefulness of the many tools available to us in the diagnosis of patients with HFPEF, a complex and challenging pathology.

References


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Heart failure with preserved ejection fraction - Role of imaging

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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