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Clinical imaging in heart failure

Imaging plays an important role in the assessment and management of patients with heart failure (HF), and provides an evaluation of both anatomy and function based on many parameters and techniques.
Dr Fraser pointed out that HFpEF and HFrEF represent a continuum and not two different entities. He supported the general idea that progression from health to disease is continuous and diagnostic cut-off points are arbitrary. Dr Fraser questioned the use of LVEF as the sole diagnostic criterion of HF. It has been shown that patients with normal LVEF frequently have abnormal longitudinal function. Diastolic HF is half way between systolic HF and normal. It appears that risk stratification in HF with reduced LVEF is more accurately done using global longitudinal strain (GLS). He presented data supporting the posit that cardiac response during exercise as well as peak VO2 are predictive of mortality in HFrEF and not the EF. Finally, he postulated that LVEF should no longer be used to diagnose HF.

Dr Hyung-Kwan focused on fibrosis imaging using CMR. Fibrosis leads to worsening systolic and diastolic function, remodeling and worse prognosis. CMR is the best way to assess myocardial fibrosis using delayed enhancement (DE) and extracellular volume (ECV) by T1 mapping. Different patterns of DE (focal, global, subendocardial, epicardial etc) may be diagnostic of specific types of cardiomyopathies. In apical hypertrophic cardiomyopathy (HCM), the apex commonly shows DE. The assessment of fibrosis with CMR is used in myocardial viability imaging. CMR due to its high spatial resolution can show areas of subendocardial scarring. Myocardial scar by CMR has shown to have adverse prognosis in HCM, in non-ischemic DCM and in amyloidosis. ECV by T1 mapping has been shown to be of prognostic value in amyloidosis.

Dr Schulz-Menger then analysed the importance of geometry in heart failure. The recent ESC guidelines on HF take into account the left atrial volume index (LAVI) and LV mass index. LV mass and geometry predict 10-year event rates. With CMR, 3D coverage of the entire LV from base to apex can be achieved. The LV mass-to-volume index allows differentiation between HCM and athlete’s heart. It is also related to reduced fitness in obese females. There is ongoing controversy as to how to measure wall thickness, for example to include or not to include papillary muscles? How to quantify? Also, the right heart is of great importance. CMR can provide accurate quantitative measurements of RV volumes. Experimental use of 7-Tesla MRI has shown that areas of hypertrophy are not homogeneous, but there are myocardial crypts in thick septal areas in HCM.

Lastly, Dr Von Lueder stated that there is a wide spectrum of imaging techniques proposed by the recent ESC guidelines on HF. These techniques include echocardiography, CMR, CT, SPECT, PET and coronary angiography. Serial imaging may also be used when appropriate. Imaging tests are indicated when they have a meaningful impact on management. The Echo CRT study, using Doppler parameters, was negative and resulted in the recommendation that CRT is contraindicated in patients with QRS duration < 130 msec. Worsening dyssynchrony, as measured by echo, is associated with worse prognosis. The most important data on new drugs come from LCZ696 (sacubitril/valsartan), an angiotensin- neprilysin inhibitor. Use of LCZ696 resulted in a greater reduction of hypertrophy and remodeling, as visualized by echo. A sub-analysis of the PARADIGM-HF data showed that LCZ696 resulted in improvement of outcomes in patients with HFrEF throughout the spectrum of LVEF. In addition, LCZ696 has favorable effects on remodeling in patients with HFpEF. Thus, imaging has the potential to depict the results of therapy in HF.

In summary, this very interesting session emphasized the importance of several modalities and several imaging parameters in addition to LVEF for assessment and management of patients with HF.

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.