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V SESSIONE SCOMPENSO CARDIACO 2015 Genova, 13-14 Novembre 2015 L’ecocardiografia nello Scompenso Cardiaco Acuto e cronico: vecchi dogmi e nuovi trends. Gian Paolo Bezante, MD, FACC UOC Clinica di Malattie dell’Apparato Cardiovascolare IRCCS Azienda Ospedale Università San Martino - Genova DEFINITION Heart failure (HF): A clinical syndrome of inadequate oxygen delivery to metabolizing tissues resulting from any cardiac structural or functional impairment of ventricular filling or ejection of blood Eur Heart J 2012;33:1787-1847. Circulation 2013;128:e240-327. HF PATHOPHYSIOLOGY Normal HFrEF HFpEF Echocardiographic examination showing dilated cardiomyopathy and depressed left ventricular (LV) systolic function in a patient admitted for acute dyspnoea. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Real Time 3D Volume Measurements NORMALE ECOCARDIOGRAFIA 3D systolic dyssynchrony index 0,62% Azienda Ospedaliera Universitaria - Ferrara DISSINCRONO systolic dyssynchrony index 11,22% Napoli 2011 Echo Right Heart Catheterization Schematic of pulse-wave Doppler of mitral inflow, color M-mode demonstrating mitral inflow propagation velocity, and tissue Doppler of the septal mitral annulus in normal diastolic function and various stages of diastolic dysfunction. J.K. Oh Eur J Echocardiogr 2007;8:4-14 Echocardiographic examination showing preserved left ventricular (LV) systolic function in a patient admitted for acute dyspnoea. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Diagnosis of heart failure with preserved left ventricular (LV) ejection fraction (EF) in a patient presenting with dyspnoea. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Three patients with a similar degree of shortness of breath. J.K. Oh Eur J Echocardiogr 2007;8:4-14 A: Parasternal long axis view from a middle-aged man with heart failure. J.K. Oh Eur J Echocardiogr 2007;8:4-14 Copyright © 2006, The European Society of Cardiology Practical approach to grade diastolic dysfunction by echocardiography. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 RADIAL STRAIN DYSSYNCHRONY Azienda Ospedaliera Universitaria - Ferrara Napoli 2011 Sample of regional longitudinal strain (APLAX: apical long-axis, 4CH: four-chamber view, 2CH: two-chamber view) a bulls-eye representation in a patient with cardiac amyloidosis. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Regional longitudinal strain (bulls-eye representation) in a patient with hypertrophic cardiomyopathy. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Fundamental and second harmonic signal separated by filter 250 250 80 50 60 200 100 150 200 40 200 150 250 150 20 300 1000 350 100 400 -20 450 0 1 50 2 3 50 4 5 x 10 6 20 40 60 80 100 Fundamental 0 -500 0 0 Signal from septum 500 -10 0 Noise from LV cavity 10 2. harmonic Second Harmonic TDI Fundamental, f=1.67MHz • Fundamental and second harmonic calculated from the same data set • No significant noise difference Second harmonic, f=3.33MHz • Second harmonic TDI gives more aliasing. Second Harmonic SRI Fundamental, f=1.67MHz Second harmonic, f=3.33MHz • Fundamental and second harmonic calculated from the same data set • Significant noise reduction when using the second harmonic frequency band • Aliasing is not a problem due to small velocity differences Myocardial velocity and strain rate with 300 frames/sec Velocity v1 v2 Strain rate Time SPECKLE-TRACKING ECHOCARDIOGRAPHY: Comprehensive assessment of myocardial deformation Longitudinal deformation Base LONGITUDINAL Circumferential deformation Radial deformation Radial deformation • Torsion TORSION Azienda Ospedaliera Universitaria - Ferrara CIRCUMFERENTIAL Apex Torsional deformation RADIAL Napoli 2011 Speckle-Tracking Echocardiography 2D Global Longitudinal strain 3D RT-STE - 4D Global Longitudinal Strain Limiti e Potenzialita’ HF PATHOPHYSIOLOGY Normal HFrEF HFpEF Transthoracic lung ultrasound reveals multiple sonographic B-lines (ultrasound lung comets, white arrows) in a patient with acute pulmonary oedema. Patrizio Lancellotti et al. Eur Heart J Cardiovasc Imaging 2015;16:119-146 Integrazione delle informazioni con ultrasuoni con parametri clinici e bioumorali per guidare interventi terapeutici