Echo

1. O L E H :
D Z I K R U L H A Q K , M D
P E M B I M B I N G :
D R . VA L E R I N N A Y O G I B U A N A , S P. J P

2. Introduction
• Acutely decompensated heart failure has become the most common reason for
hospitalization in patients older than 65 years.
• Clinicians strive to seek innovative ways to provide effective cost-conscious care, aiming
to shorten length of stay, reduce readmission rates, and improve quality of life.
• This review discuss the emerging role of real-time quantitative Doppler
echocardiography in identifying inappropriate cardiac preload, monitoring volume status
during the management, and improving quality of care in patients with acute HF.
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3. Dilemma in the assessment of cardiac preload/volume status(1)
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Outpatient
Titrate
neurohormonal
antagonists
Decelerate
myocardial
remodeling
improve patient
survival
Inpatient
Optimize
cardiac preload

4. Dilemma in the assessment of cardiac preload/volume status(2)
 Although clinicians can use physical exam signs, plasma
electrolyte/biomarker values, and radiographic studies, accurate clinical
judgment on intravascular volume status is often difficult in acute settings,
such as emergency rooms and intensive care units.
 Common cause for faulty assessment of LV filling pressure is discordance
between RV and LV pressures (R-L mismatch).
 Identification of R-L mismatch with objective diagnostic tools is crucially
needed during acute HF management.
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5. Dilemma in the assessment of cardiac preload/volume status(3)
Factors that can result in R-L mismatch :
 Pulmonary hypertension
 RV dysfunction
 Mitral/tricuspid regurgitation
 Obstructive sleep apnea
 Diastolic dysfunction with decreased LA compliance
 AV dyssynchrony due to atrial fibrillation
 Dynamic left ventricular outflow obstruction
 Pericardial disorders
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6. New challenge to keep appropriate preload in
the contemporary inpatient HF management
 Preload reduction remains one of the primary therapeutic strategies in
patients with decompensated HF.
 New research shows that inappropriate low cardiac preload
significantly accelerates deleterious myocardial remodeling and causes
adverse long-term outcome.
 It’s very important to integrate quantitative real time hemodynamic
information into the bedside titration of volume therapy, so it will be a
very valuable approach.
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7. “Noninvasive pulmonary artery catheter (PAC)”: DE (1)
 For decades, the PAC was the gold standard for assessing
hemodynamic status in acutely and critically ill patients.
 Recently, evidence is mounting that the accuracy of quantitative DE
measurements for LV filling pressure are comparable to those
obtained by PAC.
 With its noninvasive and portable and features, quantitative DE can be
used as a real-time bedside tool to monitor instantaneously changing
hemodynamic status, and therapeutic response during HF
management.
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8. “Noninvasive pulmonary artery catheter (PAC)”: DE (2)
Obstacle for integrating quantitative DE into bedside practice :
omeasurements have not been customary,
oindications/limitations have not been specified,
oclinical stepwise risk stratification have not been established,
ofeasible protocols have not been standardized.
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9. Stepwise algorithms and approaches to use of
quantitative DE in acute HF management
 More objective and detailed hemodynamic analysis with quantitative DE
may help guide further decisions such as using inotropic therapy or more
vigorous fluid resuscitation.
 Serial hemodynamic measurements with DE can more accurately quantify
and monitor the real-time intravascular volume status change.
 Main hemodynamic information needed to identify R-L mismatch can be
obtained by simultaneously measuring three Doppler based parameters:
o stroke volume,
o LV filling pressure,
o RV systolic pressures (RVSP).
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14. Illustration of quantitative DE utilization in common clinical
scenarios
Case 1:
• A 60-year-old man with chronic obstructive pulmonary disease
(COPD), chronic renal disease, and HFrEF (LVEF 35–40%) secondary to
non-ischemic cardiomyopathy, presented with worsened dyspnea on
exertion.
• The previous cardiac workup ruled out obstructive coronary artery
disease (CAD).
• The etiologies of his cardiomyopathy are multi-factorial, including
alcohol abuse.
• In the past year, he has been admitted to the hospital almost every
other month, for HF exacerbation.
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15. Case 1 (cont..)
 DE study was performed :
o The ratio of E/A were measured to monitor the change in LV filling pressure.
o The quantitative DE measurements ruled out the existence of significant PH.
 Under this condition, the RVSP can proportionally reflect the change in pulmonary
venous pressure (LV filling pressure).
 When his LV filling pressure became low, both E/A ratio and RVSP decreased; when
his LV filling pressure became high, both E/A ratio and RVSP increased.
 Therefore, volume therapy, particularly diuretic dosages, could be titrated in real-
time using quantitative DE data.
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17. Case 2
• A 69-year-old man with known history of CAD and ICM presented with dyspnea,
tachycardia, and hypotension.
• He had previously undergone PCI and further revascularization was not technically
feasible.
• He had NYHA class III congestive HF symptoms and a low LVEF (less than 30%).
• He received an ICD for primary prevention of sudden cardiac death, but was not a
candidate for CRT due to narrow QRS wave on ECG.
• He did not qualify for heart transplantation because of co-morbidities.
• He had been treated with lisinopril, carvedilol, spironolactone, and various dosages of
furosemide, but was frequently hospitalized because of decompensated HF.
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18. Case 2 (cont…)
 Since it was difficult to judge his hemodynamic/volume status, based on
JVP, plasma electrolytes, and chest X-ray, bedside DE was performed.
 Increased pulmonary arterial pressure was found and identified as the
main reason responsible for his jugular venous dilation and edema.
 Quantitative DE measurement also suggested both low LV filling pressure
and low cardiac output.
 Although dobutamine treatment increased his heart rate, stroke volume
significantly decreased, thus overall cardiac output did not improve.
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19. Case 2 (cont…)
 Bolus fluid challenge was followed by continuous intravenous fluid
repletion under the monitoring of serial DE-derived LV filling pressure
measurements.
 His hemodynamic status started to improve without worsening oxygen
demand.
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20. Case 2 (cont…)
 The DE-derived hemodynamic data during his multiple hospitalizations
revealed that his cardiac output could not sufficiently support
hemodynamics until the transmitral flow Doppler measurement (E/e’)
turned into the pattern indicating “higher” LV filling pressure.
 Despite severely depressed LVEF, his cardiac pump function (measured
by myocardial performance index) appeared to be still highly preload
dependent, and correlated well with simultaneous LV filling pressure.
 The outpatient over-diuresis was found to be the major reason
resulting in his multiple hospital admissions.
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22. Obstacles of quantitative DE utilization
in HF management
 Lack of confidence or experience to perform or interpret bedside
handheld quantitative DE measurements.
 Inter-operator/inter-interpreter variability.
 Excessive time consumption for quantitative DE measurement and
cost effectiveness of serial DE studies to monitor hemodynamic
change during HF management.
 Correlation between quantitative DE measurement and LV filling
pressure was found to be highly variable in patients with normal LVEF
(HFpEF).
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23. Solutions
 Currently, there are at least three established strategies to reduce
inter-operator/interinterpreter’s errors:
(a) use newly available echocardiographic contrast to enhance Doppler
signals and increase the feasibility of their acquisition.
(b) obtain Doppler signals (with or without contrast enhanced) from
multiple windows.
(c) establish and standardize protocols to integrate the measurements from
multiple well-established quantitative DE methods for one single
parameter.
Developing robotic techniques to reduce inter-operator variability is
also under ongoing investigation.
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24. Prospects of quantitative DE utilization
in HF management
oThe LV filling pressures from quantitative DE measurement are
recently proven to be comparable to those directly obtained by
either PAC or implanted left atrial device
oThe EURO-FILLING Study : hemodynamic DE measurement was found
to have independent prognostic values in patients with chronic HF.
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26. Summary
o Novel pharmacological therapies, devices and interventions have prompted substantial
advances in the management of chronic HF and the improvement in the prognosis of
patients with HFrEF.
o With DE’s noninvasive and potable properties, and ability to provide real time
hemodynamic information, quantitative DE helps us identify inappropriate cardiac
preload and titrate volume therapy in a timely way during acute HF management.
o Specify its indications/limitations, establish clinical stepwise algorithms, and
standardize the feasible protocols, will be the key to successfully translate DE utilization
into bedside HF care.
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27. TERIMA KASIH
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