Download A common clinical problem

A common clinical problem
• The patient is a 72 year old woman with shortness of
breath. You appropriately order an echo. The report reads:
• Mild LVH
• LV ejection fraction 65%
• Grade 1 LV diastolic dysfunction
• Does this explain her symptoms?
• Is this heart failure with preserved ejection fraction
(HFpEF, formerly diastolic heart failure)?
Grades of Diastolic Dysfunction
• Grade 1
Delayed early relaxation with normal filling
pressure
• Grade 2
Delayed relaxation and increased LV end
diastolic pressure
• Grade 3
Progressive reduction in LV compliance and
elevation of LV filling pressures
Diastolic Heart Failure
• Heart failure with preserved LV ejection fraction (HFpEF)
is now more common than heart failure with reduced
ejection fraction
• Definition
• Symptomatic
Dyspnea
• Normal, or nearly normal LV ejection fraction (>45%)
• Evidence of diastolic dysfunction
Diastolic dysfunction
• It’s about left ventricular filling
• Passive relaxation of the LV in early diastole
• Characteristics of blood flow across the mitral valve in early
diastole
• Estimation of LV filling pressure
• Estimation of left atrial filling pressure
Normal LV and LA filling pressures
ASE Guidelines, April, 2016. (J Am Soc Echocardiogr 2016;29:277-314.)
Normal LV filling velocity and pressure
Mitral inflow patterns in diastole
Normal
Grade I Dysfunction
Heart Failure with Preserved EF?
Penicka M, et al. Heart 2014;100:68–76.
Diastolic parameters
• Tissue Doppler records the actual movement of the LV in
early diastole, and reflects LV relaxation
• The mitral flow characteristics reflect not only the flow
velocity, but the left ventricular filling pressure when that
flow occurs.
LV relaxation: tissue Doppler
Normal LV filling
ASE Guidelines, April, 2016. (J Am Soc Echocardiogr 2016;29:277-314.)
Diastolic parameters
• Tissue Doppler records the actual movement of the LV in
early diastole, and reflects LV relaxation
• The mitral flow characteristics reflect not only the flow
velocity, but the left ventricular filling pressure when that
flow occurs.
• The best estimate of the diastolic function takes into
account the mitral flow velocity (E wave) and the LV
relaxation (tissue Doppler), the tissue Doppler index (E/e’)
Heart Failure with Preserved EF
Penicka M, et al. Heart 2014;100:68–76.
HF preserved EF, Am Soc Echo, 2016
Summary, Heart Failure with preserved EF
• Heart failure with preserved ejection fraction (HFpEF) is a
disease characterized by co-morbidities
• The diagnosis of HFpEF is made in symptomatic
individuals and is based on a composite of
echocardiographic findings, which reflect not only LV
relaxation and LV filling pressures, but how the heart has
responded to these abnormalities:
• Left atrial size
• Pulmonary artery pressure
• (in Europe: atrial fibrillation, BNP, response to exercise)
CARDIAC VALVES
Cardiac valves
• Aortic valve
• Stenosis
• Regurgitation
• Mitral valve
• Stenosis
• Regurgitation
Severe aortic stenosis
• History. Three cardinal symptoms
• Angina
• Heart failure
• Syncope
• Physical exam
• Harsh, rasping systolic murmur, like clearing your throat
• EKG
• LVH
• Chest X Ray
• LVH
• Calcium in the valve on the lateral view
Bernoulli equation
Gradient = 4 x vel2
Calculation of AVA
Severe aortic stenosis
ACC/AHA 2006 guideline
• Peak aortic velocity > 4 m/s (> 64 mm Hg)
• Mean gradient > 40 mm Hg
• Aortic valve area < 1.0 cm2
Standard Indication for Surgery
• Typical symptoms of aortic stenosis
• Chest pain
• Shortness of breath with exertion
• Syncope (usually with exertion)
• Echocardiographic evidence of severe aortic stenosis
• Peak aortic velocity > 4 m/s (> 64 mm Hg)
• Mean gradient > 40 mm Hg
• Aortic valve area < 1.0 cm2
The biggest problem with AS
Now that we have the ability to replace the aortic valve by transcatheter techniques, we have a new problem with the elderly
patient:
Should we????
Consider:
cognitive decline/dementia
frailty
psychosocial support
The best decisions are made with collaboration between the primary
care physician, the cardiologist and the interventional (structural
heart disease) specialist
Example of aortic stenosis
Aortic regurgitation
• Examples
Mitral regurgitation
• Examples
Mitral stenosis
• Examples
Additional echocardiographic diagnoses
• Diseases of the aorta
• Pericardial disease
• Estimated pulmonary artery pressure
Summary
• The echocardiogram is the most frequently employed
cardiac diagnostic test, and therefore physicians are
under increasing pressure to order the test wisely.
• Understanding the echo report does call for some
background in cardiology…
• The best way to approach the echo report and patient
management is with direct communication with the
echocardiographer. Talk about it!
Summary, cont’d
• The echocardiogram is best used to assess
• Myocardial structure and function
• Systolic function
• Diastolic function
• Left atrial volume index
• Cardiac valves
• Pericardium
• Aorta