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9/16/2016
1
Imaging in Heart Failure:A Multimodality Approach
Thomas Ryan, MD
Heart Failure
HFrEF HFpEF
EF<40% EF>50%
Lifetime risk – 20%Prevalence ≈ 6M AmericansSocietal costs - $30B50% 5-year survival
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Systolic Heart Failure
Risk Factors
Myocardial Injury
RemodelingReduced
EF
Pump Failure
Arrhythmias
Chronic Heart
Failure
Symptoms
HypertensionDiabetesCADValve disease
Diastolic Heart Failure
Risk Factors
LVHFibrosis
Diastolic dysfunction
Preserved EF
Inc LVEDP
Arrhythmias
Chronic Heart
Failure
Symptoms
HypertensionDiabetesCAD
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Heart Failure Stages
End-Stage HF
End-Stage HF
Symptomatic HF
Symptomatic HF
Asymptomatic LV dysfunction
Asymptomatic LV dysfunction
High risk for developing HFHigh risk for developing HFA
B
C
D
Hunt et al, ACC/AHA Heart Failure Guidelines, 2001
Wang et al, Circ ‘03
Effect of LV Dysfunction on Survival
Normal subjects
ASx, mild LV dysfcn
ASx, mod/sev LV dysfcn
Pts w/ CHF
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LV Pressure-Volume LoopsLV Pressure-Volume Loops
Pre
ssu
re
Volume
Normal
Stroke Volume
Stage B Stage C Stage D
Inc LVEDP
Key Questions in Heart Failure
• Are the Sx due to heart failure?
• Can I exclude heart failure as a Dx?
• If it is heart failure, how bad is it?
• Can the imaging results help with therapy?
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Noninvasive Diagnostic Testing
Class I Recommendations:1. Laboratory studies, including BNP2. ECG3. CXR4. 2D Echo
Class IIa Recommendations:1. Viability/ischemia assessment, in selected pts2. MUGA or MRI, when echo is inadequate3. MRI to assess infiltrative process or scar
Class III Recommendations:1. Routine repeat assessment of LV function
Yancy et al, ACC/AHA Heart Failure Guidelines, 2013
Differential Dx of heart failure Sx• Pulmonary Causes:
• COPD• Pulmonary hypertension• Pulmonary embolus
• Non-cardiopulmonary Causes:• Anemia, anxiety, etc
• Cardiac Causes:• Valve disease• Pericardial disease, including
constriction• Diastolic heart failure – restrictive CM• Systolic heart failure• Hypertensive heart disease
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Goals of Initial Evaluation
1. Determine the etiology of HF
2. Assess prognosis
3. Determine functional status
4. Measure ventricular function
5. Assess volume status
Echo in Heart Failure• Systolic function
‒ EF‒ Wall motion‒ LV volume‒ Remodeling‒ New approaches – strain, torsion
• Diastolic function – filling pressure‒ Restrictive CM
• Valve disease
• Pericardial disease - constriction
• Viability
• Resynchronization therapy
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Ischemic vs Nonischemic?
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MRI in Heart Failure• Systolic function
‒ Precise quantitation (gold standard)‒ LV mass
• Diastolic function ‒ Scar burden
• Etiology‒ Ischemia, infarction‒ Htn‒ Myocarditis‒ Infiltrative – Iron, amyloid, sarcoid,
etc‒ Genetic – ARVC, HCM
• Viability
Shah, Judd, Kim, Clinical MRI, ‘06
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Late Gadolinium Enhancement ImagingDiffuse hyperenhancement of both ventricles
Dark signal within cardiac chambers due to T1 shortening of amyloid protein in blood
Where CMR Adds the Most Value: Myocardial Characterization
• T1 T2 T2*
• Magnetic resonance parameters that reflect intrinsic tissue properties‒ Coronary artery disease, hypertension‒ Myocarditis‒ Infiltrative (iron overload, amyloidosis,
sarcoidosis)‒ Genetic (HCM, ARVC, Anderson-Fabry, lamin
A/C, dystrophin, etc.)
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Imaging Approach to HF
Measure global LV systolic function
r/o valve disease
Assess the pericardium
Evaluate diastolic function
Estimate filling pressures
Assess the right heart
Differential Dx of heart failure Sx• Pulmonary Causes:
• COPD• Pulmonary hypertension• Pulmonary embolus
• Non-cardiopulmonary Causes:• Anemia, anxiety, etc
• Cardiac Causes:• Systolic heart failure• Pericardial disease, including
constriction• Diastolic heart failure – restrictive CM• Hypertensive heart disease• Valve disease
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Can heart failure be “ruled out” with echo?
• Measure LV function
• LA size, LVH
• E/A, Decel time, E/e’
• Septal motion, atria, IVC, hepatic veins
Yes, with a few simple
steps
Can heart failure be “ruled out” with echo?
• Measure LV function
• LA size, LVH
• E/A, Decel time, E/e’
• Septal motion, atria, IVC, hepatic veins
If EF >50%, systolicdysfunction hasbeen ruled out
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LV Systolic Function
How to Measure LV Ejection Fraction
2D single plane
2D biplane
Real-time 3D
D
A = r2
L
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Corsi et al, Circ ‘05
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MRI for LV Function
Precise Quantitation of Function
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Echo vs MRI?
T2 Increases with Myocardial Water Content…
Scholz TD et al. 1992. also – Higgins CB et al. 1983, Karolle BL et al. 1991.
3 – 30% in T2
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Is It Heart Failure???
Is the LVEFnormal?
No, <50% Yes, >50%
Measure EFAssess FPTherapy?
Rule outother causes Septal
motion
LVH/IVC
Atrial size
E/A, E/e’
Valves
Con Per
RCM
Htn
ValveDisease
Can heart failure be “ruled out” with echo?
If normal, Htn and diastolic dysfunctionare unlikely
• Measure LV function
• LA size, LVH
• E/A, Decel time, E/e’
• Septal motion, atria, IVC, hepatic veins
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LA Volume and Diastolic Dysfunction
Tsang et al, AJC ‘02
IndexedLA Volume
M-modeLA Dimension
Can heart failure be “ruled out” with echo?
If normal,diastolic fcn andfilling pressureare probably Nl
• Measure LV function
• LA size, LVH
• E/A, Decel time, E/e’
• Septal motion, atria, IVC, hepatic veins
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Diastolic Heart Failure
Normal Impaired Relaxation Pseudonormal Restrictive
E
A
E’A’
IVRT
MitralInflow
Mitral annularvelocity
Mitral Annulus TDI
E’ A’
E A
Increasing mean LV dias pressure
E/E’ = 5 to 15Normal
E/E’ = 20 to 40High LVDP
10 cm/s
80 cm/s
Mitral Annulus
Mitral Inflow
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Mitral Annulus TDI
84 cm/s
10 cm/s
E/E’ = 8.4
E/E’ = 100/4 = 25
Range of SeverityRange of Severity
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Mitral Annulus TDI
Nagueh et al, JACC ‘97
‘
Mitral Annulus TDI
Nagueh et al, JACC ‘97
E/E’ < 10: Normal
E/E’ > 15: High PCWP
‘
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LG
E S
core
= 0
LG
E S
core
= 4
LG
E S
core
= 8
LG
E S
core
= 1
2
Moreo A et al. Circ: Imaging 2009.
Normal Grade IIIGrade II Grade I
Increasing Fibrosis Progressive Diastolic Dysfunction
TAGGED CINE CMR DENSE CMR
Advanced Measures of LV Function: Strain, Rotation, Torsion
Refined Measures esp. for HFpEF
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Can heart failure be “ruled out” with echo?
This excludesconstriction and
restriction ascauses
• Measure LV function
• LA size, LVH
• E/A, Decel time, E/e’
• Septal motion, atria, IVC, hepatic veins
• Rigid, noncompliant pericardium
• Equalization of pressures
• Intrathoracic and intrapericardial pressures are dissociated
• Increased ventricular interdependence
Constrictive Pericarditis
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Constrictive Pericarditis
Constrictive Pericarditis
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Healing hearts
Changing lives
>25% respiratory variation in mitral E velocity
Reciprocal respiratory relationship between LV and RV
TricuspidValve
MitralValve
Constrictive Pericarditis
Healing hearts
Changing lives
High E’ indicates preserved myocardial function
Mitral Annulus DTIMitral Annulus DTI
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• Diastolic dysfunction – “restrictive filling”‒ High E wave, increased E/A‒ Short deceleration time‒ Little or no respiratory variation
• Normal or slightly decreased LV systolic function
• Dilated LA and RA
• Normal or slightly increased LV mass
Restrictive Cardiomyopathy
Restrictive Cardiomyopathy
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Very Low e’
Restrictive MV filling
Restrictive Cardiomyopathy
Constriction
Increased E wave
High E/A
Short decel time
Marked resp variation
High E’ = Low E/E’
Constriction vs Restriction
Restrictive CM
Increased E wave
High E/A
Short decel time
No resp variation
Low E’ = High E/E’
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Myocardial Amyloidosis
Sig
nal
in
ten
sity
SI eTE/T2*
Echo time (TE)
Myocardium T2* = 32 ms
Liver T2* = 3.5 ms
TE: 2.0 8.3 15.7 20.0 ms
T2* - Measure of Tissue Iron Content
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Summary• Heart failure is a clinical diagnosis
• Imaging provides diagnostic support,
information on etiology, severity and
prognosis
• Echo is the backbone of HF assessment
• MRI is becoming increasingly important
55
Heart Failure Present?
Low EF Normal EF
Measure EFE/e’ – filling press.
MR severity?CRT candidate
Assess valvesLVH, atrial sizeE/A, decel time
E/e’Septal motion, IVC
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Cases