Echocardiography is a useful tool for diagnosing and monitoring heart failure patients. It can assess left ventricular ejection fraction, ventricular sizes and wall thickness, valve function, diastolic function, and pulmonary pressures. New techniques such as 3D echocardiography and strain imaging provide more accurate measurements of cardiac structure and function compared to older 2D techniques. Echocardiography is also used to differentiate the causes of heart failure, monitor for complications, and predict patient outcomes. It remains an important part of the evaluation and management of patients with heart failure.

1. Chronic Heart Failure –
Role of
Echocardiography
DR.N.PRAVEEN

2. Introduction
 Echocardiography is the investigation of choice in imaging
of the heart failure patient.
 Readily available, low cost
 Useful for diagnosis, prognostification
 Limitations – inter observer variability, assumptions of
geometric shapes, heart rate, load dependency.

3. Use of echocardiography in Heart Failure
 1.Assessment of ejection fraction
 2.Quantification of Mitral Regurgitation, LV shape
assessment
 3. RV function assessment
 4. LV diastolic function
 5. LV stress – differentiation of ischemic vs nonischemic
 6. Relative wall thickness, LV mass
 7. Handheld USG – intravascular volume, pulmonary
congestion

4. Left ventricular systolic function
 M mode – accurate assessment of wall, chamber
dimensions.
 2D echo – valve imaging
 Usually qualitative assessment of EF  Quantitative
assessment
 Misleading in irregular rhythm, large and small LVs,
extremes of heart rate (tachycardia, bradycardia)
 Most widely used quantitative method – Biplane Simpson’s
method.
 Repeated testing lead to variable volumes – EF results.

5. Unfortunately in 2D Echo
All measurements are susceptible to
 Load dependence
 Inaccurate tracing
 Poor test-retest reliability
 Limited prognostic value ( when EF is close to normal
range).

7. 3D Echo is the future – for
assessment
 Accurate assessment of LV volumes, Ejection fraction
 Less test- retest variation
 EF by geometric assumptions of LV is avoided.

9. HFPEF
 Half of patients with heart failure
 It should not be a diagnosis of exclusion.
 Can be precisely called as disorder of inadequacy of EF
than normal systolic function.

10. Apart from LVEF… what to be
assessed in HFPEF
 LV performance is dependent on contractility, loading
 During evaluation of ejection phase parameters – systolic
blood pressure (SBP) to be taken into account however
preload assessment is more difficult.
 Two LV function parameters outside the LVEF
 LV myocardial performance index
 LV isovolumic acceleration

11. Systolic wall stress (  )
 It combines force (SBP), LV size, LV wall thickness
Oversimplification due to
 Peak stress ( early systole)
 Absence of central blood pressure
 Lack of geometric measurements

12.  LVESWS= (0.334 P(LVID)/PWT [1 + PWT/LVID])
 LVESWS – LV end systolic wall stress
 LVID – Left ventricle inner diameter
 PWT – posterior wall thickness
 P – SBP

13. Mean cardiac power
 Stroke volume
 Mean arterial pressure
 Heart rate
 CPO = MAP *CO /451
 Prognostic marker of mortality in cardiogenic shock patients
( SHOCK trial)

14. Peak instantaneous power
 Peak product of LV outflow and pressure during systole
 VO2max
 Prognostic marker

15. LV mid wall shortening
 Less dependent on LV geometry


16. Pressure volume loops
 Optimal marker of contractility
 End systolic elastance
 Peak systolic pressure/ end systolic volume

17. Preload recruitable stroke work
 Stroke work
 LV volume
 Altering loading without altering inotropy

18. DSE,exercise
 Difficult in dilated failing heart
 Can be used for LV, RV contractile reserve

19. LV diastolic function
 Assessment of DD – LV filling pressures is limited in
patients with preserved EF
 Septal tissue velocities (preserved)

21. E/e’ unreliable
parameter conditions
E Tachycardia
Significant MR
Significant MS
Significant AR
e’ Severe MAC
MVr/MVR
RWMA
LBBB
Biventricular pacing

22. Assessment of subclinical
dysfunction
 Global longitudinal strain (GLS)
 Quantitative measure of myocardial deformation
 LV synchrony in overt HF
 RV assessment
 Preclinical phase of HF
 High frequency sampling of strain rate as a marker of
contractility.
 Speckle tracking of grey scale images – since 10 years.

24. LV morphology
 Sphericity index by 3D ECHO
 LV volumes by 2D echo - geometric assumptions, off-
axis imaging
 Basal septal hypertrophy – hypertensive heart disease
 Amyloidosis- decreased QRS amplitudes, e’< 5 cm/sec,
strain < 10%, apical sparing pattern of LV strain
 Contrast echo – for LV thrombus

25. Hemodynamics
 LV filling pressures – transmitral flow
 PASP – by TRJV
 RVSP = PASP + RAP
 Underestimated PASP in severe TR, RAP overestimated
 Stroke volume with doppler derived stroke volume
 dp/dt > 1200mmhg/sec- in case of MR

27. Left atrial volumes
 LA dilates in non uniform fashion
 Time averaged marker of LV filling pressures
 Left atrial function by transmitral, pulmonary vein doppler
 Left atrial strain – prognostic markers
 Total strain – reservoir function
 Active strain – contractile function

28. RV function
 Limited reproducibility due to RV shape assessment
 Qualitative
 Quantitative- TAPSE, FAC, MPI, TAPSV
 RV free wall strain

29. Valvular assessment
 MR quantitatively
 Decreased LVEF + severe MR vs severe MR
 MV morphology
 Regurgitant jet direction
 Functional MR – central jet
 Ischemic MR – commisural jet

31. Thank you