Walking the tightrope: Using quantitative Doppler echocardiography to optimize ventricular filling pressures in patients hospitalized for acute heart failure

Impact of Daily Bedside Echocardiographic Assessment on Readmissions in Acute Heart Failure: A Randomized Clinical Trial

Acute heart failure (AHF) management is challenging, with high morbidity and readmission rates. There is little evidence of the benefit of HF monitoring during hospitalization. The aim of the study was to assess whether daily bedside echocardiographic monitoring (JetEcho) improved outcomes in AHF. In this prospective, open, two parallel-arm study (clinicaltrials.gov: NCT02892227), participants from two university hospitals were randomized to either standard of care (SC) or daily treatment adjustment including diuretics guided by JetEcho evaluating left ventricular filling pressure and volemia. The primary outcome was 30-day readmission rate. Key secondary outcomes were six-month cumulative incidence death, worsening HF during hospitalization and increasing of myocardial and renal biomarkers. From 250 included patients, 115 were finally analyzed in JetEcho group and 112 in SC group. Twenty-two (19%) patients were readmitted within 30 days in JetEcho group and 17 (15%) in SC group (relative risk [RR] 1.26; 95% confidence interval [CI], 0.70−2.24; p = 0.4). Worsening HF occurred in 17 (14%) patients in the JetEcho group and 24 (20%) in the SC group (RR 0.7; 95% [CI] 0.39 to 1.2; p = 0.2). No significant difference was found between the two groups concerning natriuretic peptides and renal function (p > 0.05 for all). The cumulative incidence rate of death from any cause at six months from discharge was 8.7% in the JetEcho group and 11.6% in the SC group (HR 0.63, 95% [CI] 0.3−1.4, p = 0.3). In AHF patients, a systematic daily bedside echocardiographic monitoring did not reduce 30-day readmission rate for HF and short-term clinical outcomes.

“Takotsubo effect” in patients with ST segment elevation myocardial infarction

Background

Myocardial infarction can be a trigger of Takotsubo syndrome. We recently characterized imaging features of acute myocardial infarction-induced Takotsubo syndrome (“Takotsubo effect”). In this study, we investigate diagnostic and prognostic implications of Takotsubo effect in patients with anterior wall ST-segment elevation myocardial infarction.

Methods

We enrolled 111 consecutive patients who developed anterior wall ST-segment elevation myocardial infarction and received percutaneous coronary intervention, and studied systolic/diastolic function, hemodynamic consequences, adverse cardiac events, as well as 30-day and five-year outcomes in patients with and without Takotsubo effect.

Results

Patients with Takotsubo effect showed significantly worse average peak systolic longitudinal strain (–9.5 ± 2.6% vs –11.1 ± 3.6%, p = 0.038), left ventricular ejection fraction (38.5 ± 6.8% vs 47.7 ± 8.7%, p = 0.000) and myocardial performance index (0.54 ± 0.17 vs 0.37 ± 0.15, p = 0.000) within 48 h of myocardial infarction. There was no significant difference between the two groups in diastolic ventricular filling pressures, hemodynamic consequences, and 30-day rehospitalization and mortality (Gehan-Breslow-Wilcoxon test: p = 0.157). However, patients with Takotsubo effect developed more major adverse cardiac events (log-rank test: p = 0.019) when tested at the five-year follow-up. Cox regression analysis revealed that age, hypotension, tricuspid annular plane systolic excursion, and Takotsubo effect were independent prediction factors for five-year major adverse cardiac events. The Doppler/tissue Doppler parameter E/e’ correlated with MACE only in patients without Takotsubo effect.

Conclusion

Takotsubo effect secondary to anterior ST-segment elevation myocardial infarction predicts a worse long-term prognosis.

Management of acute heart failure: Contribution of daily bedside echocardiographic assessment on therapy adjustment with impact measure on the 30-day readmission rate (JECICA)

There are currently one million heart failure (HF) patients in France and the rate is progressively increases due to population aging. Acute decompensation of HF is the leading cause of hospitalization in people over 65 years of age with a 25% re-hospitalization rate in the first month. Expenses related to the management of HF in France in 2013 amounted to more than one billion euros, of which 65% were for hospitalizations alone. The management of acute decompensation is a challenge, due to the complexity of clinical and laboratory evaluation leading to therapeutic errors, which in turn leads to longer hospitalization, high early re-hospitalization and complications. Therapeutic adjustment, especially diuretic, in the acute phase (during hospitalization) affects early re-hospitalization rates (within 30 days). These adjustments can be based on clinical estimation and laboratory parameters, but echocardiography has been shown to be superior in estimating filling pressures (FP) compared to clinical and laboratory parameters.

We hypothesize that a simple daily bedside echocardiographic assessment could provide a reproducible estimation of FP with an evaluation of mitral inflow and the inferior vena cava (IVC). This could allow a more reliable estimate of the true blood volume of the patient and thus lead to a more suitable therapeutic adjustment. This in turn should lead to a decrease in early re-admission rate (primary endpoint) and potentially decrease six-month mortality and rate of complications.

Discrepant myocardial microvascular perfusion and mechanics after acute myocardial infarction: Characterization of the "Tako-tsubo effect" with real-time myocardial perfusion contrast echocardiograph

BACKGROUND

In patients with acute anterior myocardial infarction (MI), sometimes an "apical ballooning" contractile dysfunction pattern that exceeds factual myocardial injury is identified in the ventriculography and bedside echocardiography. The hemodynamic consequences/sequela of this "Tako-tsobu effect" has not been well delineated. Of note, this anatomic imaging finding often misleads frontline physicians who assume reciprocal causation of persistent cardiac pump failure and ventricular pressure overload.

METHODS AND RESULTS

Using real-time myocardial perfusion contrast echocardiography (MCE), we investigated myocardial (microvascular) perfusion in 60 patients after acute MI and coronary revascularization. Twenty-eight percent of the studied patients showed significantly mismatched myocardial perfusion and contractile defects. In these patients, an integrated imaging assessment with coronary angiography/ventriculography, deformation echocardiography, and MCE proved that the myocardial mechanic abnormalities significantly exceeded the defected perfusion areas. Compared with 72% of the patients without perfusion-contractility mismatch, apparently worse systolic functions (left ventricular ejection, wall motion score, and systolic longitudinal strain) in these patients did not change diastolic ventricular filling pressures (E/E' and E/A) or hemodynamic consequences/adverse events. Both systolic and diastolic functions in patients with perfusion-contractility mismatch appeared to be comparable with those in patients with Tako-tsubo syndrome.

CONCLUSIONS

Real-time MCE identifies discrepant myocardial microvascular perfusion and mechanics in patients with acute MI. The "Tako-tsubo effect" in patients with perfusion-contractility mismatch does not cause diastolic filling pressure change or worse hemodynamic consequence/cardiac event.

Mechanical interventricular dependency supports hemodynamics in tako-tsubo cardiomyopathy

Background

Although morphological abnormalities of the heart appear to be remarkable, most patients with tako-tsubo cardiomyopathy (TTC) remain clinically stable. We investigate real time changes in the left ventricular (LV) and right ventricular (RV) mechanics and function to explore the mechanism to preserve hemodynamics.

Methods

With deformation and Doppler echocardiography, we evaluated myocardial mechanics and ventricular function/hemodynamics simultaneously in 103 consecutive TTC patients admitted from 01/01/2008 through 12/31/2015. The coronary angiography and left ventriculography were performed to rule out culprit coronary artery stenosis (CAS). We included 66 patients in a control group with matched age, sex, and risk factors for coronary artery disease (CAD), and 41 patients in a group of myocardial infarction induced cardiogenic shock, who required circulatory supporting devices to maintain hemodynamic stability.

Results

Although systolic myocardial strain in most of the LV segments was significantly impaired, 4 basal LV segments remained functionally active during acute stage of TTC. The impairment in the myocardial strain of the RV apex could extend to the middle segments, but basal RV systolic strain was also preserved. Despites comparable apical to basal strain gradients, LV and RV displayed discrepant functional/hemodynamic status. In contrast to LV, RV functional/hemodynamic parameters appeared to be hyper-dynamic. This unique RV strain pattern remained unchanged in patients with atypical (mid-LV cavity) TTC. In 41 patients with myocardial infarction induced cardiogenic shock, RV exhibited comparable mechanic and functional features with those in TTC patients.

Conclusions

The identified LV and RV mechanic changes appear to support interventricular hemodynamic dependence during TTC, which may represent a universal rescue mechanism in a jeopardized or injured heart.