Ηχωκαρδιολογικός προμεταμοσχευτικός έλεγχος Ε.Δ.ΛΕΟΝΤΙΑΔΗΣ Επιμελητής Β Α Καρδιολογικό Τμήμα Ωνάσειο Καρδιοχειρουργικό Κέντρο
Treatment Overview
Role of echocardiography in the pre-htx pt Initial evaluation and diagnosis Prognostic evaluation Guiding and monitoring treatment
Etiology of HF
Echocardiographic abnormalities in cardiomyopathy LV dilatation Increasing sphericity (L=D) Apical/Lateral displacement of papillary muscles functional MR LV thrombus Normal/reduced wall thickness Hypokinesis, akinesis, dyskinesis Increased EPPS( E-point E to septal separation, nl=6 mm) B-bump in MV closure LA dilatation AFib LAA thrombosis PHTN Tricuspid regurgitation RV dilatation, RVEF
L V = a i b 4 i 20 i=1 ai bi LV dimensions and LVEF DO NOT correlate with HF symptoms Exercise capacity MVO2 but they do provide prognostic information Wong M et al. JACC 2004;43:2022 Grayburn PA et al. JACC 2005;45:1064
SWTd LVIDd PWTd TEI index Systolic AND diastolic cardiac Fx Left AND Right cardiac Fx Correlates with LV dp/dt (cath lab) Prognostic value in PHTN, infiltrative CM, DCM, preserved HF LV mass Increased in the remodeled, failing heart (LVH or increased volumes with myocardial thinning) Prognostic marker in Pts with-w/out CAD Independent of LVEF
Predictors of mortality-morbidity in severe HF 336 pts, LVEF<35%, NYHA III-IV IV Placebo vs bucindolol (echo substudy,, BEST) Endpoints Death, HF hospitalization, HTX Results Predictors were LVEDVI, DT, MR Vena contracta Grayburn PA et al. JACC 2005;45:1064
Functional MR An apical displaced coaptation point with failure of the mitral leaflets to reach the level of the mitral annulus and without apparent intrinsic leaflet abnormalities.
ICM-DCM Tethering forces Annular dilatation LV dilatation Papillary muscles (PM) displacement LV sphericity Closing forces LVEF Global LV dyssynchrony PM dyssynchrony Altered MV systolic annular contraction Symmetric (ICM-post MI)- Asymmetric (ICM ant and post MI or DCM) Functional MR Agricola E et al. EJ Echo 2008;9:207
Functional MR Lancellotti P et al. EJ Echo 2010;11:307 Agricola E et al. EJ Echo 2008;9:207
ΔΙΑΣΤΟΛΙΚΗ ΛΕΙΤΟΥΡΓΙΑ ΦΥΣΙΟΛΟΓΙΚΗ Επαρκής όγκος πλήρωσης ΑΚ φυσιολογική καρδιακή παροχή Χαμηλή πίεση πλήρωσης (<12 mmhg) κατά την ηρεμία και άσκηση ΔΥΣΛΕΙΤΟΥΡΓΙΑ Αδυναμία πλήρωσης χωρίς αύξηση της πίεσης πλήρωσης Ανάγκη αύξησης της πίεσης του αριστερού κόλπου
Therapeutic guidance Hemofiltration Maximal medical treatment
Prognostic significance of echocardiographic diastolic dysfunction measures Kirkpatrick JN et al. JACC 2007;50:381
Noninvasive estimation of LVEDP after myocardial infarction 250 pts with MI F/Up 13 months Endpoint All cause mortality Results E/e > 15 was the most powerful independent predictor for all cause mortality E/e > 15 added prognostic information when added to conventional echo parameters Hillis G et al. JACC 2004;43;360
49 pts, DCM, F/U 4 yrs RHC vs 2D echo Endpoint Cardiac death, urgent HTx Results E/e highest predictive value and gives prognostic information independent of PCW PCW does not provide independent prognostic information Rossi et al. EJ Echo 2011; 12:112
Stroke volume-cardiac Output SV = CSA x TVI = D² x 0.785 x TVI CO = SV x HR SV if AR, LVOT
Εκτίμηση πίεσης ΔΕΞΙΟΥ ΚΟΛΠΟΥ Η ταχύτητα (TDI) του βασικού τμήματος του ελεύθερου τοιχώματος της δεξιάς κοιλίας (φάση ισοογκωτικής συστολής) σχετίζεται με την μέση πίεση του δεξιού κόλπου. Ταχύτητα <6cm/sec υποδηλώνει αυξημένη πίεση δεξιού κόλπου (>6mmHg), με ευαισθησία και ειδικότητα 100% και 78% αντίστοιχα. P.Lindqvist et al. Eur J Echo 2005
Εκτίμηση τηςπίεσηςτου κ από την κάτω κοίλη φλέβα Inferior Vena Cava Diameter Change RAP (mmhg) diameter with Inspiration Small (<1.5cm) Collapse 0-50 Normal (1.5 to 2.5) >50% decrease 5-105 Dilated (>2.5cm) < 50% decrease 10-15 15 Dilated inferior vena No change >20 cava and hepatic veins
Εκτίμηση των πνευμονικών αγγειακών αντιστάσεων (PVR) PVR = TRV max / TVI RVOT x 10 + 0.16 Abbas et al JACC 2003
Υπολογισμός μέσης πίεσης πνευμονικής αρτηρίας (MPAP) από το χρόνο επιτάχυνσης στο χώρο εξόδου της ΔΚ (AcT) M PAP = 79 0.45 x (AcT) 23 mm Hg 47 mm Hg
Εκτίμηση πιέσεων Πνευμονικής Αρτηρίας Υπολογισμός συστολικής πίεσης δεξιάς κοιλίας (RVSP) (επί ανεπάρκειας τριγλώχινος βαλβίδας) RVSP = 4 x V (TR) 2 + RA PR-ED Υπολογισμός τελοδιαστολικής (PAEDP) και μέσης πίεσης της πνευμονικής αρτηρίας (MPAP) (επί ανεπάρκειας πνευμονικής βαλβίδος) PA EDP = 4 x V (PR-ED) 2 + RA M PAP = (RVSP + 2 PAEDP) / 3 Masuyama et al Circulation 1986
Systolic annular velocity (Sa) was related to RNA RVEF. Sa<11.5 cm/sec 90% sensitivity, 85% specificity for RVEF<45%
Independent predictors of survival in pts with moderate HF were NYHA MVO2 and RVEF De Groote P. JACC 1998;32:948
Prognostic value of RV function in Heart failure Haddad F et al. Circulation 2008;117:1717
Diverse systems Abiomed BVS Biomedicus BerlinHeart Excor Medos IVAD HeartMate II INCOR DuraHeart CorAide HeartQuest
Right ventricular function Right heart failure occurs frequently after LVAD implantation (up to 30-39% of patients) RV failure is the leading cause of mortality after L- VAD implantation because Inability to pump sufficient blood to the LVAD Major contributing factor to SAE (i.e bleeding, renal failure, prolonged hospitalization) Dang NC et al. J Heart Lung Transplant 2006; 25: 1 Kavarana MN et al. Ann Thorac Surg 2002;73:745 Shuhaiber JH et al. J Heart Lung Transplant 2008;27:158 Kormos RL et al. J Thorac Cardiovasc Surg 2010;139:1316
Right ventricular function Evaluation of the RV is difficult because of its complex anatomical structure contractility pattern The function of the RV can be easily affected by preload afterload Ventricular interdependence No uniform, echocardiographic method of the assessment of the RV function Haddad F et al. Circulation 2008;117:1717 Ho YS, Nihoyannopoulos P. Heart 2006;92:2
Predictors of RV failure or need for R-VAD after LVAD implantation Female gender, Nonischemic HF Elevated CVP Low mean PA pressure Low RV-stroke work index RV size, severe TR, RV longitudinal contractility TAPSE sign. higher short/long axis of the RV Dang NC et al. J Heart Lung Transplant 2006;25:1 Fukamachi K et al. Ann Thorac surg 1999;68:2181 Ochiai Y et al. Circulation 2002;106:1198 Slaughter MS. JHLT 2010;29:S1 Puwanant S et al. JHLT 2008; 27:1275 Potapov EV et al. JHLT 2008;27:1102
RV DIMENSIONS (RVD1) 2.0-2.8 2.8 (RVD2) 2.7-3.3 (RVD3) 7.1-7.9 7.9 RVOT-SF RVOT1 2.5-2.9 2.9 RVOT2 1.7-2.3 PA1 1.5-2.1 TAPSE 20 mm ~ EF 50% TDI RV FAC (%) 32-60 % (end-diastolic area) (end-systolic area) / (end-systolic area) RMPI
L-VAD
Conclusions Echocardiography for the pt with end- stage heart failure is essential Serial assessment of systolic/diastolic HF, mitral regurgitation, RV function Identify echo markers for adverse prognosis Useful in monitoring therapeutic management