Application of Guideline-Based Echocardiographic Assessment of Left Atrial Pressure to Heart Failure with Preserved Ejection Fraction

Echocardiographic Alterations of Cardiac Geometry and Function in Patients with Familial Partial Lipodystrophy

BACKGROUND

Cardiomyopathy associated with partial lipodystrophy (PL) has not been well described yet.

OBJECTIVE

To characterize cardiac morphology and function in PL.

METHODS

Patients with familial PL and controls were prospectively assessed by transthoracic echocardiography and with speckle-tracking echocardiography (global longitudinal strain, GLS). The relationship between echocardiographic variables and PL diagnosis was tested with regression models, considering the effect of systolic blood pressure (SBP). Significance level of 5% was adopted.

RESULTS

Twenty-nine patients with PL were compared to 17 controls. They did not differ in age (p=0.94), gender or body mass index (p= 0.05). Patients with PL had statistically higher SBP (p=0.02) than controls. Also, PL patients had higher left atrial dimension (37.3 ± 4.4 vs. 32.1 ± 4.3 mm, p= 0.001) and left atrial (30.2 ± 7.2 vs. 24.9 ± 9.0 mL/m2,p=0.02), left ventricular (LV) mass (79.3 ± 17.4 vs. 67.1 ± 19.4, p=0.02), and reduced diastolic LV parameters (E' lateral, p= 0.001) (E' septal, p= 0.001), (E/E' ratio, p= 0.02). LV ejection fraction (64.7 ± 4.6 vs. 62.2 ± 4.4 %, p= 0.08) and GLS were not statistically different between groups (-17.1 ± 2.7 vs. -18.0 ± 2.0 %, p= 0.25). There was a positive relationship of left atrium (β 5.6, p<0.001), posterior wall thickness, (β 1.3, p=0.011), E' lateral (β -3.5, p=0.002) and E' septal (β -3.2, p<0.001) with PL diagnosis, even after adjusted for SBP.

CONCLUSION

LP patients have LV hypertrophy, left atrial enlargement, and LV diastolic dysfunction although preserved LVEF and GLS. Echocardiographic parameters are related to PL diagnosis independent of SBP.

Volume and function changes of left atrium and left ventricle in patients with ejection fraction preserved heart failure measured by a three dimensional dynamic heart model

The accurate diagnosis of HFpEF is still challenging and controversial. In this study, we used 3D-DHM technology to compare the differences of cardiac structure and function between HFpEF patients and healthy controls, as well as the differences of two-dimensional and three-dimensional cardiac function in HFpEF patients. Echocardiography with 3D-DHM and conventional two-dimensional (2D) methods were applied to measure the volume and function parameters of left atrium and ventricle of patients with HFpEF and healthy controls. Significant differences of 3D cardiac function indexes including LVESV, 3D-LVEF, ESL, SV, CI, EDmass, LAVmax, LAVmin, LAEF, and LAVI were observed between patients with HFpEF and controls (P < 0.05). However, no significant difference of LVEDV and EDL were observed (P > 0.05). In addition, we found no significant between-group difference in 2D cardiac function indexes such as LVDD and 2D-LVEF (P > 0.05), but the LAD, LVSD, LVPW, IVS, E, E/A, and E/e ' were significantly different between groups (P < 0.05). There was no significant difference between 3D-LVEF and 2D-LVEF in the control group (P > 0.05), while 3D-LVEF in the HFpEF group was lower than 2D-LVEF(P < 0.05). Among the two-dimensional and three-dimensional parameters of HFpEF patients, the parameters related to diastolic function changed more significantly than those of the normal group, and the three-dimensional LVEF of HFpEF patients decreased. The three-dimensional cardiac function parameters analyzed by DHM can provide more information regarding myocardial mechanics.

Left ventricular to left arial volume ratio in the assessment of filling pressure in patients with dyspnoea and preserved ejection fraction

Introduction

Assessing filling pressure (FP) remains a clinical challenge despite advancements in non-invasive imaging techniques. This study investigates the utility of echocardiographic left ventricular (LV) to left atrial (LA) volume ratio in estimating the resting FP in patients with dyspnoea and preserved ejection fraction (EF).

Methods

This study is a prospective, single-centre analysis of 53 consecutive patients with dyspnoea (New York Heart Association grade 2 or 3) and LVEF of ≥50% (mean age 71 ± 10 years) who underwent cardiac catheterisation, including direct measurement of LA pressure at rest using retrograde technique. Echocardiographic data were obtained 1.5 ± 1.0 h after cardiac catheterisation. The patients were divided into two groups: Group 1 consisted of individuals with elevated FP, indicated by a mean LA pressure or mean pulmonary capillary wedge pressure of >12 mmHg, and Group 2 comprised of patients with normal FP. The LV and LA volumes were measured at three specific points: the minimum volume (LVES, LAmin), the volume during diastasis (LVdias, LAdias), and the maximum volume (LVED, LAmax). The corresponding LV/LA volume ratios were analysed: end-systole (LVES/LAmax), diastasis (LVdias/LAdias), and end-diastole (LVED/LAmin).

Results

The patients in Group 1 exhibited lower LV/LA volume ratios compared with those in Group 2 (LVES/LAmax 0.44 ± 0.12 vs. 0.60 ± 0.23, P = 0.0032; LVdias/LAdias 1.13 ± 0.30 vs. 1.56 ± 0.49, P = 0.0007; LVED/LAmin 2.71 ± 1.57 vs. 4.44 ± 1.70, P = 0.0004). The LV/LA volume ratios correlated inversely with an increased FP (LVES/LAmax, r = -0.40, P = 0.0033; LVdias/LAdias, r = -0.45, P = 0.0007; LVED/LAmin, r = -0.55, P < 0.0001). Among all the measurements, the LVdias/LAdias ratio demonstrated the highest discriminatory power to distinguish patients with elevated FP from normal FP, with a cut-off value of ≤1.24 [area under the curve (AUC) = 0.822] for the entire group, encompassing both sinus rhythm and atrial fibrillation. For patients in sinus rhythm specifically, the cut-off value was ≤1.28 (AUC = 0.799), with P < 0.0001 for both. The LVdias/LAdias index demonstrated non-inferiority to the E/e' ratio [ΔAUC = 0.159, confidence interval (CI) = -0.020-0.338; P = 0.0809], while surpassing the indices of LA reservoir function (ΔAUC = 0.249, CI = 0.044-0.454; P = 0.0176), LA reservoir strain (ΔAUC = 0.333, CI = 0.149-0.517; P = 0.0004), and LAmax index (ΔAUC = 0.224, CI = 0.043-0.406; P = 0.0152) in diagnosing patients with elevated FP.

Conclusion

The study presents a straightforward and reproducible method for non-invasive estimation of FP using routine TTE in patients with dyspnoea and preserved EF. The LVdias/LAdias index emerges as a promising indicator for identifying elevated FP, demonstrating comparable or even superior performance to established parameters.

The prognostic value of the visually assessed time difference between mitral valve and tricuspid valve opening score for patients with heart failure with mildly reduced ejection fraction

BACKGROUND

The visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score was correlated with the increase of left ventricular filling pressure (LVFP).

HYPOTHESIS

We suspected that the VMT score might be a valuable prognostic biomarker for heart failure with mildly reduced ejection fraction (HFmrEF) patients. This study was to evaluate the predictive value of VMT score for 1-year all-cause and cardiovascular disease (CVD)-cause mortality in HFmrEF patients.

METHODS

This cohort study enrolled 379 patients aged ≥18 years old with HFmrEF. Univariable and multivariable Cox regression analysis was employed to assess the association between VMT score and all-cause or CVD-cause mortality in HFmrEF patients. Hazards ratio (HR), and 95% confidence interval (CI) were effect sizes. Kaplan-Meier curves showed the survival probability of patients. The area under the curve (AUC) evaluated the prognostic value of the VMT score.

RESULTS

The risk of all-cause mortality was increased in HFmrEF patients in the VMT score of 2 (HR = 2.80, 95%CI: 1.04-7.52) and 3 (HR = 4.29, 95%CI: 1.58-11.66). The VMT score of 3 was associated with an increased risk of 1-year CVD-cause mortality in patients with HFmrEF (HR = 7.63, 95%CI: 1.70-34.33). The AUC of VMT score for predicting 1-year all-cause mortality of HFmrEF patients was 0.724, and for predicting 1-year CVD-cause mortality of HFmrEF patients was 0.748. The survival probability of patients with the VMT score < 2 was higher than those with the VMT score of 2 and 3.

CONCLUSION

The VMT score might be a reliable prognostic index for 1-year all-cause or CVD-cause mortality of HFmrEF patients.

The cross-section of routine practice of echocardiographic diastolic evaluation in atrial fibrillation in a community hospital: A quality improvement project

BACKGROUND

The echocardiographic assessment of diastolic function in the context of atrial fibrillation (AF) has been controversial and can be challenging and labor-intensive. We aimed to assess the actual practice of diastolic evaluation in AF in our community hospital echocardiography laboratory and to improve clinical performance by a quality improvement project.

METHODS

We reviewed 244 echocardiograms in patients with AF at the time of echocardiography from November 2019 to November 2020 (pre-intervention phase). We classified cases into a complete versus incomplete evaluation group according to the completeness of diastolic parameter measurement. After an educational intervention, we reviewed 68 echocardiograms in patients with AF from August 2021 to October 2021 (post-intervention phase).

RESULTS

Our results demonstrated an improvement in a complete diastolic assessment from 69% to 91% after intervention (p < .001). In the pre-intervention phase, the four parameters (mitral inflow pulsed wave Doppler image, left atrium volume index, mitral annular tissue Doppler image [TDI], and tricuspid regurgitation Vmax), mitral annular TDI was not acquired in 71 out of 244 cases (29.1%) and those cases were classified as incomplete evaluation group. Interestingly, in the pre-intervention phase, 57 out of 162 cases (35%) with preserved EF (≥50%) received significantly more incomplete diastolic evaluation than 14 out of 82 patients (17%) with reduced EF (<50%) (p = .004). There were no statistically significant differences in age, BMI, the reason for requesting echocardiography, and patient level of care between the complete and incomplete evaluation groups. In the post-intervention phase, completeness of diastolic measurement in AF was significantly improved compared to the pre-intervention phase (29% vs. 9%, p < .001, respectively).

CONCLUSION

A quality improvement project effectively improved the clinical performance of diastolic evaluation in AF in our community echocardiography laboratory. After the intervention, we decreased an incomplete evaluation from 30% to 9%. More efforts should be needed to increase awareness and familiarity in evaluating diastolic function in AF.

Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction

Aims

Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF.

Methods and results

We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan–Meier curves showed that VMT ≥2 (n = 54) was associated with worse outcomes than the VMT ≤1 group (n = 256) (P < 0.001). Furthermore, VMT ≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (AF) (P = 0.026). In the adjusted model, VMT ≥2 was independently associated with the primary outcome (hazard ratio 2.60, 95% confidence interval 1.46–4.61; P = 0.001). Additionally, VMT scoring provided an incremental prognostic value over clinically relevant variables and diastolic function grading (χ² 10.8–16.3, P = 0.035).

Conclusions

In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF.