Contrast-enhanced quantitation of left ventricular ejection fraction: What is the best method?

The need to enhance the echocardiographic determination of left ventricular ejection fraction (LVEF) is greatest in patients with suboptimal images. We have previously demonstrated that in difficult-to-image patients, contrast-enhanced power harmonic imaging resulted in accurate calculation of LVEF by using Simpson's method. However, the incremental accuracy of contrast enhancement with other methods of determining LVEF has not been examined. This study prospectively assessed the comparative accuracy of LVEF determination by using the Quinones' method with fundamental imaging (FU), tissue harmonic imaging (TH), contrast-enhanced harmonic imaging [TH(CON)], as well as Quinones' method with contrast-enhanced power harmonic imaging [POW(QUIN)] in 62 patients with suboptimal images. LVEF was also calculated by using contrast-enhanced power harmonic imaging and Simpson's method [POW(SIMP)] in these patients. We demonstrated that LVEF calculated from the POW(QUIN) mode had the best agreement with radionuclide angiography (standard of comparison) compared with FU, TH, and TH(CON). However, POW(SIMP) was even more accurate. In conclusion, when the Quinones' method was used to calculate LVEF in difficult-to-image patients, POW(QUIN) mode was the most accurate. However, POW(SIMP) was even more accurate and should be the method of choice when a high degree of quantitative accuracy is required.     

Right ventricular ejection fraction during orthotopic liver transplantation: Does anesthetic technique make a difference?

PurposeThe objective of this study is to evaluate the right ventricular ejection fraction (RVEF) during orthotopic liver transplantation (OLT) under 2 different anesthetic regimens: propofol vs isoflurane anesthesia.MethodsWe retrospectively analyzed the hemodynamic data of 25 (n = 25) patients who underwent OLT during the last year (2008). All patients were monitored with a modified pulmonary artery catheter, which continuously measured the RVEF. Anesthetic technique consisted of either isoflurane or total intravenous anesthesia with propofol. Surgical technique was similar between groups.ResultsTen (n = 10) patients comprised the isoflurane group (I), whereas 15 (n = 15) patients received propofol anesthesia (P). The RVEF was not significantly different between groups (I vs P, baseline: 41% ± 9% vs 40% ± 6%; anhepatic phase: 36% ± 8% vs 35% ± 6%; postreperfusion: 41% ± 6% vs 41% ± 8%; P = not significant).ConclusionsThe choice between propofol and isoflurane seems to have minimal influence on the RVEF during OLT, which followed similar trends regardless of the anesthetic technique.     

Left ventricular ejection fraction: how to improve an established index?

The International Journal of Cardiovascular Imaging -     

How reliable are left ventricular ejection fraction cut offs assessed by echocardiography for clinical decision making in patients with heart failure?

We aimed to study the potential influence of the variability in the assessment of echocardiographically measured left ventricular ejection fraction (LVEF) on indications for the implantation of internal cardioverter defibrillator and/or cardiac resynchronization devices in heart failure patients. TIME-CHF was a multicenter trial comparing NT-BNP versus symptom-guided therapy in patients aged ≥60 years. Patients had their LVEF assessed at the recruiting centre using visual assessment, the area-length or biplane Simpson’s method. Echocardiographic data were transferred to the study core-lab for re-assessment. Re-assessment in the core-lab was done with biplane Simpson’s method, and included an appraisal of image quality. 413 patients had the LVEF analyzed at the recruiting centre and at the core lab. Image quality was optimal in 191 and suboptimal in 222. Overall, the correlation between LVEF at the recruiting centres and at the core-lab was good, independent of image quality (R² = 0.62). However, when a LVEF ≤30 % or ≥30 % was used as a cut-off, about 20 % of all patients would have been re-assigned to having either a LVEF above or below the cut-off, this proportion was not significantly influenced by image quality. We conclude that correlation between LVEF assessed by different centres based on the same ultrasound data is good, regardless of image quality. However, one fifth of patients would have been re-assigned to a different category when using the clinically important cut-off of 30 %.     

Does remote ischemic conditioning salvage left ventricular function after successful primary PCI?

The translation of ischemic preconditioning to a viable therapy that benefits patients has been slow. This has been largely due to the difficultly in preempting when ischemia will occur. Recent advances in the field have demonstrated that cardioprotection from brief episodes of ischemia is possible when applied immediately after reperfusion (ischemic postconditioning) or remotely in another tissue during myocardial ischemia, prior to reperfusion (remote ischemic conditioning). This has facilitated the therapeutic application to patients presenting with acute myocardial infarction. In this article, we will discuss the results of a recent study published by Munk et al., concerning the application of remote ischemic conditioning during primary percutaneous coronary intervention to salvage myocardial function following ST-elevation myocardial infarction.     

Determination of right ventricular ejection fraction by thermodilution technique — a comparison to biplane cineventriculography

Determination of right ventricular ejection fraction (RVEF) provides information about global right ventricular function, which may be important for the management of patients with various heart diseases. Right ventricular ejection fraction can be determined by new thermodilution techniques using fastresponse thermistors. To evaluate the validity of these methods, thermodilution measurements were compared with biplane cineventriculography in 22 patients undergoing cardiac catheterization. In all patients standard deviation of RVEF was below 5%. Mean RVEF, determined by thermodilution, was 52%±9%, ranging from 32% to 71% and correlated significantly with the results of angiography (RVEF: 52%±9%) (r=0.80, SEE±5%, n=22, p>0.001). Correlation was good especially in patients with small right ventricles (>60ml) (r=0.91, SEE±5%, n=13, p>0.001), lower heart rates (>65/min) (r=0.84, SEE=±6%, n=12, p>0.001) and cardiac output below 5.5 l/min (r=0.88, SEE±6%, n=11, p>0.001). Thus, if valid catheter placement is possible, right ventricular ejection fraction can be determined by thermodilution technique with good reproducibility and sufficient accuracy compared to biplane angio. Validation of this method in larger patient populations with various heart diseases is necessary.     

Analysis of combined detection of N-terminal pro–B-type natriuretic peptide and left ventricular ejection fraction in heart function in patients with acute CO poisoning

Objective

N-terminal pro–B-type natriuretic peptide (NT-proBNP) has been used in the evaluation on heart function in many heart diseases. However, little is known in patients with acute carbon monoxide poisoning (ACOP). Left ventricular ejection fraction (LVEF) can be applied as a preliminary test method to measure the left ventricular function. In the present study, we investigate the clinical significance of NT-proBNP combined with LVEF on heart function in 68 patients with ACOP.

Methods

A total of 68 ACOP patients hospitalized were divided into 3 groups: the mild, the moderate, and the severe group. During the same period, 30 healthy volunteers were chosen to represent the control group. The serum NT-proBNP was immediately measured and LVEF was monitored by an echocardiogram within 24 hours after admission. All data were analyzed and compared for the groups investigated.

Results

N-terminal pro–B-type natriuretic peptide showed a significant increase and LVEF a considerable decrease in all 3 clinic groups (P < .01) when compared with the control group. Levels of NT-proBNP are increased and levels of LVEF are decreased when the clinic group changed from mild, moderate, to severe. N-terminal pro–B-type natriuretic peptide is negatively correlated with LVEF (r = − 0.955, P = .045). Combined detection of NT-proBNP and LVEF in the diagnosis of heart function was found to be more sensitive compared with the single index after ACOP (χ² = 14.636, P < .05).

Conclusion

There are an increased level of NT-proBNP and a decrease of LVEF, which represents a clear sign of heart malfunction by ACOP. Combined NT-proBNP and LVEF detection technique has a significant advantage in the diagnosis of patients with myocardial contraction function damage after ACOP.     

Echocardiographic evaluation of ejection fraction by auto-AFI: faster and better?

The International Journal of Cardiovascular Imaging -     

Is E/E′ reliable in patients with regional wall motion abnormalities to estimate left ventricular filling pressure?

Background There is limited data on the diagnostic utility of the transmitral to mitral annular velocity (E/E′) by tissue Doppler imaging (TDI) in the presence of regional wall motion abnormalities (RWMA). We aimed to investigate whether the E/E′ is reliable in estimating left ventricular filling pressure (LVFP) despite RWMA. Methods One hundred thirty consecutive patients with myocardial infarction (MI) and subsequent RWMA referred for cardiac catheterization and echocardiography to measure LV pre-A pressure (LVP_PRE-A) and Doppler signals from the mitral inflow with tissue Doppler imaging (TDI) of the mitral annulus. All patients were classified into three groups according to RWMA of the segment adjacent to the E′-measuring point using TDI: 83 patients with normal wall motions of the basal septal and basal lateral segments (group A); 28 patients with RWMA of the basal septum (group B); and 19 patients with RWMA of the basal lateral segment (group C). Results Septal E/E′ correlated with LVP_PRE-A in groups A and C (r = 0.383, P < 0.001; r = 0.482, P = 0.037, respectively). Lateral E/E′ and LVP_PRE-A showed good correlation in groups A, B and C (r = 0.470, P < 0.001; r = 0.416, P = 0.028; r = 0.727, P < 0.001, respectively). The largest area under the receiver operating curve was obtained by the lateral E/E′ for the prediction of a high LVFP, irrespective of the location of RWMA. Conclusions In selected patients with abnormal wall motion of the basal septum, E/E′ measured at the septum was not representative for LVFP. Lateral E/E′ is reliable for the prediction of high LVFP, regardless of the site of RWMA.     

Pilot study for left ventricular imaging phenotype of patients over 65 years old with heart failure and preserved ejection fraction: the high prevalence of amyloid cardiomyopathy

This study sought to phenotype patients over 65 years old with heart failure and preserved ejection fraction (HFpEF) using clinical available comprehensive cardiovascular imaging modalities. Forty-nine patients with HFpEF and without coronary artery disease underwent clinical evaluation, electrocardiography, echocardiography, cardiac magnetic resonance (CMR) and ^99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy (^99mTc-DPD). The mean population age was 76?±?8 years. Most of the patients (53?%) were NYHA class II. Mean NT-Pro-NBNP level was 1961?±?2372 pg/ml. CMR exhibited a hypertrophic cardiomyopathy or infiltrative pattern in 3 (6?%) and 15 (31?%) patients, respectively. In the latter subgroup, ^99mTc-DPD was suggestive of transthyretin-related cardiac amyloidosis for nine (18?%) patients, while AL amyloidosis was proven in five patients (10?%) by extracardiac (n?=?3, 6?%) or endomyocardial (n?=?2, 4?%) biopsies—one patient declined tissue biopsy. Compared to patients with unspecified cardiomyopathy (n?=?31), patients with amyloid cardiomyopathy (n?=?15 or n?=?14/proven) had less hypertension, lower systolic blood pressure and higher NT-pro BNP level. Their electrocardiogram showed lowest QRS voltage and longer QRS duration. Left ventricular (LV) pattern was characterized by a more pronounced LV hypertrophy, a smaller ejection fraction and a decrease of global longitudinal strain associated with an increase of longitudinal strain apical-to-basal ratio. In patients over 65 years, HFpEF is a heterogeneous syndrome with at least a 29?% prevalence of amyloid cardiomyopathy. Combined CMR and ^99mTc-DPD are helpful imaging tools for accurate phenotyping of patients amenable to histopathological diagnosis or genetic testing, and should be considered for proper management of this population. Further longitudinal investigations are needed to better clarify these preliminary results.     

Heart failure with preserved ejection fraction: A distinct heart failure phenotype?

The present work discusses the serious confusion resulting from the arbitrary nomenclature of heart failure with preserved ejection fraction (HFpEF), the presumed underlying pathophysiology, and the supposed features. A consequence of this misconception is that HFpEF trials have recruited patients with entirely different characteristics rendering the extrapolation of the results of one study to the other infeasible and dramatically affecting diagnosis and treatment.     

Do we need a definition of acute heart failure with preserved ejection fraction?

Heart failure with preserved ejection fraction (HFpEF) might soon become the most prevalent type of acute heart failure. Still, despite more than 30 years of research on HFpEF, not only do we lack specific treatment, but also a generally accepted definition of HFpEF. Since 2016, several definitions and algorithms have been proposed for diagnosing both diastolic dysfunction and overt HFpEF. However, all of them focus exclusively on chronic (and not acute) HFpEF. Recent studies showed that acute HFpEF may be overdiagnosed in patients presenting with acute dyspnoea. The aim of our article was to address two questions: (1) why there is a need for specific diagnostic criteria for acute HFpEF, and (2) what such definition of acute HFpEF should encompass.

KEY MESSAGES:

• Several scores and algorithms have been proposed for diagnosing chronic heart failure with preserved ejection fraction (HFpEF), however, so far, there is no definition of acute HFpEF.
• Acute HFpEF seems to be overdiagnosed in patients presenting with acute dyspnoea.
• Definition of acute HFpEF should comprise both (1) features of chronic HFpEF and (2) markers of increased left ventricular filling pressures and/or of pulmonary congestion.

     

Does second harmonic imaging improve left ventricular endocardial border identification at higher heart rates during dobutamine stress echocardiography?

BACKGROUND: The increased heart rate during dobutamine stress echocardiography (DSE) may impair endocardial border visualization. Second harmonic imaging (SHI) enhances left ventricular (LV) border visualization compared with conventional fundamental imaging (FI) at rest. However, its role during DSE is not well established yet. OBJECTIVE: Our objective was to compare the additional value of SHI to FI for the LV endocardial border visualization during various stages of DSE. METHODS: Eighty patients underwent DSE. Imaging was performed with both FI and SHI at rest and at low-and peak-dose dobutamine infusion. Endocardial border visualization was assessed by using a 16-segment/3-point score (0 = well visualized; 1 = poorly visualized; 2 = not visualized). RESULTS: Heart rate increased from rest (70 +/- 13 bpm) to low-dose dobutamine (77 +/- 17, P <.01) and showed further increase at peak dose (129 +/- 16, P <.001 versus low dose). There was a higher prevalence of segments with an invisible LV endocardial border with FI compared with SHI at rest (9.4% versus 6.2%, P <.0001), at low dose (10.8% versus 6.3%, P <.0001), and at peak dose (15.0% versus 8.2%, P <.0001). There was an increase in the number of segments with an invisible border from rest to peak stress by FI (P =.0001), whereas the difference was less significant for SHI (P =.07). CONCLUSION: Second harmonic imaging improves visualization of the LV endocardial border compared with FI during DSE. The advantage of SHI over FI is more marked at higher heart rates than at rest.