Contrast-enhanced Doppler hemodynamics for noninvasive assessment of patients with chronic heart failure and left ventricular systolic dysfunction

Patient phenotype profiling using echocardiography and natriuretic peptides to personalise heart failure therapy

Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamic phenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion (cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilization and to avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thus pursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventions according to patients' phenotypes even in an ambulatory setting.

Estimation of increased pulmonary wedge pressure by an algorithm based on noninvasively measured pulmonary diastolic pressure in cardiac patients independent of left ventricular ejection fraction

AIM

Pulmonary artery diastolic pressure (PADP) correlates closely with pulmonary wedge pressure (PAWP); therefore, we sought to evaluate whether an algorithm based on PADP assessment by the Doppler pulmonary regurgitation (PR) end-diastolic gradient (PRG) may aid in estimating increased PAWP in cardiac patients with reduced or preserved left ventricular (LV) ejection fraction (EF).

METHODS AND RESULTS

Right heart catheterization, with estimation of PAWP, right atrial pressure (RAP), PADP, and Doppler echocardiography, was carried out in 183 patients with coronary artery disease (n = 63), dilated cardiomyopathy (n = 52), or aortic stenosis (n = 68). One-hundred and seventeen patients had LV EF <50%. We measured the pressure gradients across the tricuspid and pulmonary valves from tricuspid regurgitation (TRV) and PR velocities. Doppler-estimated PADP (e-PADP) was obtained by adding the estimated RAP to PRG. An algorithm based on e-PADP to predict PAWP, that included TRV, left atrial volume index, and mitral E/A, was developed and validated in derivation (n = 90) and validation (n = 93) subgroups. Both invasive PADP (r = .92, P < .001) and e-PADP (r = .72, P < .001) correlated closely with PAWP, and e-PADP predicted PAWP (AUC: 0.85, CI: 0.79-0.91) with a 94% positive predictive value (PPV) and a 55% negative predictive value (NPV), after exclusion of five patients with precapillary pulmonary hypertension. The e-PADP-based algorithm predicted PAWP with higher accuracy (PPV = 94%; NPV = 67%; accuracy = 85%; kappa: 0.65, P < .001) than the ASE-EACVI 2016 recommendations (PPV = 97%; NPV = 47%; accuracy = 68% undetermined = 18.9%; kappa: 0.15, P < .001).

CONCLUSIONS

An algorithm based on noninvasively e-PADP can accurately predict increased PAWP in patients with cardiac disease and reduced or preserved LV EF.

Natriuretic Peptide and Clinical Evaluation in the Diagnosis of Heart Failure Hemodynamic Profile: Comparison with Tissue Doppler Echocardiography

Background

Physical examination and B-type natriuretic peptide (BNP) have been used to estimate hemodynamics and tailor therapy of acute decompensated heart failure (ADHF) patients. However, correlation between these parameters and left ventricular filling pressures is controversial.

Objective

This study was designed to evaluate the diagnostic accuracy of physical examination, chest radiography (CR) and BNP in estimating left atrial pressure (LAP) as assessed by tissue Doppler echocardiogram.

Methods

Patients admitted with ADHF were prospectively assessed. Diagnostic characteristics of physical signs of heart failure, CR and BNP in predicting elevation (> 15 mm Hg) of LAP, alone or combined, were calculated. Spearman test was used to analyze the correlation between non-normal distribution variables. The level of significance was 5%.

Results

Forty-three patients were included, with mean age of 69.9 ± 11.1years, left ventricular ejection fraction of 25 ± 8.0%, and BNP of 1057 ± 1024.21 pg/mL. Individually, all clinical, CR or BNP parameters had a poor performance in predicting LAP ≥ 15 mm Hg. A clinical score of congestion had the poorest performance [area under the receiver operating characteristic curve (AUC) 0.53], followed by clinical score + CR (AUC 0.60), clinical score + CR + BNP > 400 pg/mL (AUC 0.62), and clinical score + CR + BNP > 1000 pg/mL (AUC 0.66).

Conclusion

Physical examination, CR and BNP had a poor performance in predicting a LAP ≥ 15 mm Hg. Using these parameters alone or in combination may lead to inaccurate estimation of hemodynamics.

Discordant Doppler right heart catheterization pulmonary artery systolic pressures: importance of pulmonary capillary wedge pressure

BACKGROUND

Although the echo Doppler (D) estimation of pulmonary artery systolic pressure (PASP) was initially highly correlated with right heart catheterization (RHC), recent D-RHC studies have questioned its accuracy. The aim of this study was to reevaluate this relationship and to determine possible explanations for disparate D-RHC results.

METHODS

We retrospectively identified all patients at one institution who underwent RHC and had an echocardiogram within the prior month. Echocardiographic and catheterization hemodynamic factors were evaluated by regression and Bland-Altman analysis.

RESULTS

Of 69 patients, 52 (75.4%) had estimable D-PASP. D-RHC PASP r = 0.62 and 51.9% had a PASP difference >10 mmHg, comparable to other recent studies. The D-RHC difference correlated with pulmonary capillary wedge pressure (PCWP) (r = -0.60, P < 0.001) and right atrial pressure (r = -0.43, P = 0.002). Multivariate analysis including wedge pressure improved the relation between D and RHC for PASP (r = 0.86). These results were little changed using only the respective RV-RA pressure gradients from D and RHC.

CONCLUSION

Pulmonary capillary wedge pressure appears to be a significant covariate in the correlation between D and RHC PASP.

Diagnostic characteristics of combining phonocardiographic third heart sound and systolic time intervals for the prediction of left ventricular dysfunction

BACKGROUND

The third heart sound (S3) and systolic time intervals (STIs) are validated clinical indicators of left ventricular (LV) dysfunction. We investigated the test characteristics of a combined score summarizing S3 and STI results for predicting LV dysfunction.

METHODS AND RESULTS

A total of 81 adults underwent computerized phonelectrocardiography for S3 and STI (Audicor, Inovise Medical Inc), cardiac catheterization for LV end-diastolic pressure (LVEDP), echocardiography for LV ejection fraction (LVEF), and B-type natriuretic peptide (BNP) testing. LV dysfunction was defined as both an LVEDP >15 mm Hg and LVEF <50%. The STI measured was the electromechanical activation time (EMAT) divided by LV systolic time (LVST). Z-scores for the S3 confidence score and EMAT/LVST were summed to generate the LV dysfunction index. The LV dysfunction index had a correlation coefficient of 0.38 for LVEDP (P = .0003), -0.53 for LVEF (P < .0001), and 0.35 for BNP (P = .0008). This index had a receiver operative curve c-statistic of 0.89 for diagnosis of LV dysfunction; a cutoff >1.87 yielded 72% sensitivity, 92% specificity, 9.0 positive likelihood ratio, and 88% accuracy.

CONCLUSIONS

In this preliminary study, the LV dysfunction index combined S3 and STI data from noninvasive electrophonocardiography, and yielded superior test characteristics compared to the individual tests for the diagnosis of LV dysfunction.

Pulmonary regurgitation end-diastolic gradient is a Doppler marker of cardiac status: data from the Heart and Soul Study

BACKGROUND

Echocardiograms routinely sample pulmonary regurgitation signals from which it is possible to measure end diastolic gradients; these correlate with pulmonary artery diastolic pressures.

METHODS

We performed echocardiograms in 741 ambulatory adults with coronary artery disease who were recruited for the Heart and Soul Study. We compared indicators of cardiac status among individuals with normal (0-5.0 mm Hg) and elevated (> 5.0 mm Hg) end diastolic pulmonary regurgitation (EDPR) gradients.

RESULTS

Of the 481 participants with measurable EDPR gradients, 21% had elevated EDPR gradients (> 5.0 mm Hg). EDPR gradients > 5.0 mm Hg were associated with higher New York Heart Association functional class (P = .002), higher brain natriuretic peptide (P = .002), fewer metabolic equivalents achieved on treadmill testing (P < 0.001), and higher left ventricular mass (P < 0.001). The EDPR gradient > 5.0 mm Hg had a sensitivity of 25% (95% confidence interval 20-30%) and a specificity of 86% (80-91%) for detecting at least one of the following: systolic dysfunction, diastolic dysfunction, or abnormal wall motion score. The EDPR gradient > 5.0 mm HG was statistically equivalent to the tricuspid regurgitation (TR) gradient > 30 mm Hg in terms of diagnostic value (area under the receiver operating characteristic curve equaled 0.58 for each test). The EDPR gradient increased the yield of pulmonary artery pressures from 61% (TR gradient alone) to 84% (P < .0001).

CONCLUSION

The EDPR gradient provides valuable information independent of the TR gradient in evaluating pulmonary artery pressures and cardiac dysfunction.

Evaluation and monitoring of patients with acute heart failure syndromes

Advanced heart failure (HF) is associated with frequent hospitalizations, poor quality of life, and increased mortality. Despite optimal medical management, readmission rates remain high and account for approximately two thirds of all costs related to HF management. Evaluation of patients with HF is critical for the appropriate selection and monitoring of therapy as well as for the prevention of recurrent hospitalizations. This evaluation can be complex and relies on integration of the bedside evaluation and information available from invasive and other noninvasive diagnostic techniques. The clinical examination remains the cornerstone of HF evaluation. Key features of the history and physical examination can be used to assign hemodynamic profiles based on the absence or presence of congestion and adequacy of perfusion. These hemodynamic profiles provide prognostic information and may be used to guide therapy. Direct measurement of hemodynamics may be helpful in patients in whom the physical examination is limited or discordant with symptoms. Although the pulmonary artery catheter (PAC) is not recommended during routine therapy of patients hospitalized with HF, it is reasonable to consider the use of PAC monitoring to adjust therapy in patients who demonstrate recurrent or refractory symptoms despite ongoing standard therapy adjusted according to clinical assessment. This is particularly relevant in centers with experience in hemodynamic monitoring for HF. B-type natriuretic peptide (BNP) testing has been shown to facilitate diagnosis of the etiology of dyspnea in the urgent setting for patients without a prior diagnosis of HF. Furthermore, BNP levels provide important prognostic information in patients with chronic HF, but serial BNP testing has not been validated as a guide to inpatient or outpatient management. Echocardiographic assessment can provide prognostic information about ventricular function and size as well as information about hemodynamic status. Development of validated and reproducible noninvasive techniques to monitor patients with acute HF will be an important step in maximizing interventions to improve outcomes in this patient population.

Comparison of Different Methods for Detection of Diastolic Filling Abnormalities

OBJECTIVE

Heart failure is associated with poor prognosis and the differentiation of patients on the basis of diastolic filling patterns helps to identify several groups of patients with incrementally higher risk. However, this is reliant on accurate definition of filling patterns. The aim of this study was to compare preload reduction with contrast-enhanced pulmonary venous Doppler recordings for the correct assessment of diastolic filling pattern.

METHODS

In all, 20 patients with heart failure and 25 healthy volunteers were studied on 2 separate days. Preload reduction was achieved with the Valsalva maneuver (nonstandardized and standardized) and sublingual nitroglycerin. Responses were compared among the 3 methods and the filling patterns obtained on each day with the various methods compared.

RESULTS

Although pulmonary venous Doppler improved the diastolic classification over mitral Doppler, preload reduction resulted in better classification and improved sensitivity, specificity, and positive and negative predictive values. No advantage was observed for either the standardized Valsalva or pharmacologic preload reduction.

CONCLUSION

Preload reduction is an essential part of the assessment of diastolic filling grade in patients with heart failure as it can identify pseudonormal filling (mildly increased filling pressures), reversible restrictive filling (high filling pressures), and nonreversible restrictive filling pattern (very high filling pressures).

Noninvasive measurement of systemic vascular resistance using Doppler echocardiography

BACKGROUND

Systemic vascular resistance (SVR) is an integral therapeutic component of patients with heart failure and shock. We hypothesized that the ratio of the peak mitral regurgitant velocity (MRV) (m/s) to left ventricular outflow time-velocity integral (TVI(LVOT)) (cm) by Doppler would provide a noninvasive correlate of SVR.

METHODS

SVR was correlated to MRV/TVI(LVOT) in 33 patients undergoing right heart catheterization. Receiver operating characteristic curves were generated to determine the best-balanced sensitivity and specificity to identify SVR > 14 Wood units (WU) and <10 WU.

RESULTS

MRV/TVI(LVOT) correlated well with SVR (r = 0.842, 95% confidence interval 0.7-0.92, P <.001, Y = 0.459 + 49.397*X). By receiver operating characteristics, MRV/TVI(LVOT) > 0.27 had a 70% sensitivity and a 77% specificity to identify SVR > 14 WU. MRV/TVI(LVOT) < 0.2 had a 92% sensitivity and a 88% specificity to identify SVR < 10 WU.

CONCLUSION

Doppler echocardiography provides a reliable noninvasive assessment of SVR.

Diagnostic accuracy of new handheld echocardiography with doppler and harmonic imaging properties

BACKGROUND

The first generation of handheld echocardiography devices was evaluated with divergent results because of inherent technical limitations. New handheld devices with continuous/pulsed wave Doppler and tissue harmonic imaging were introduced recently. In this study, comparisons were drawn among standard echocardiography, invasively measured systolic pulmonary artery pressure, and these new devices.

OBJECTIVE

We sought to evaluate new handheld echocardiography and its diagnostic accuracy compared with standard echocardiography.

METHODS

Two consecutive echocardiographic examinations were performed by experienced and independent examiners using handheld and standard echocardiography. Systolic pulmonary artery pressure was measured by Swan-Ganz catheter.

RESULTS

In all, 177 (56.2%) patients had normal cardiac function; 138 (43.8%) had underlying cardiac pathology. Handheld echocardiography had an overall agreement of 94.8% and kappa of 0.89 to detect the main echocardiographic finding. Handheld echocardiography detected valve disease with an agreement of 96.7% and kappa of 0.93; global left ventricular function was assessed correctly in 85.6% of cases. Pericardial effusion was diagnosed with an agreement of 91.2%. Dyssynergy was found by handheld echocardiography with an agreement of 95.4% and kappa value of 0.88. Systolic pulmonary artery pressure measured by handheld echocardiography and Swan-Ganz catheter had a correlation of 0.97.

CONCLUSION

This study demonstrates the high diagnostic accuracy of handheld devices with continuous/pulsed wave Doppler and harmonic imaging, and that these devices broaden the diagnostic spectrum while allowing for enhanced mobility in everyday clinical applications.

Echocardiographic determination of mean pulmonary artery pressure

We performed a simultaneous Doppler and invasive study to validate the role of Doppler-derived peak pulmonary regurgitant velocity as a reliable noninvasive measure of pulmonary artery mean pressure. Assessment of right atrial pressure, as shown in this study, enhances the use of this Doppler parameter as a correlate of pulmonary artery mean pressure.