Diastolic dysfunction and diastolic heart failure: diagnostic, prognostic and therapeutic aspects

Left ventricular (LV) diastolic dysfunction (DD) and diastolic heart failure (HF), that is symptomatic DD, are due to alterations of myocardial diastolic properties. These alterations involve relaxation and/or filling and/or distensibility. Arterial hypertension associated to LV concentric remodelling is the main determinant of DD but several other cardiac diseases, including myocardial ischemia, and extra-cardiac pathologies involving the heart are other possible causes. In the majority of the studies, isolated diastolic HF has been made equal to HF with preserved systolic function (= normal ejection fraction) but the true definition of this condition needs a quantitative estimation of LV diastolic properties. According to the position of the European Society of Cardiology and subsequent research refinements the use of Doppler echocardiography (transmitral inflow and pulmonary venous flow) and the new ultrasound tools has to be encouraged for diagnosis of DD. In relation to uncertain definitions, both prevalence and prognosis of diastolic heart failure are very variable. Despite an apparent lower death rate in comparison with LV systolic HF, long-term follow-up (more than 5 years) show similar mortality between the two kinds of HF. Recent studies performed by Doppler diastolic indexes have identified the prognostic power of both transmitral E/A ratio < 1 (pattern of abnormal relaxation) and > 1.5 (restrictive patterns). The therapy of LV DD and HF is not well established but ACE-inhibitors, angiotensin inhibitors, aldosterone antagonists and β-blockers show potential beneficial effect on diastolic properties. Several trials, completed or ongoing, have been planned to treat DD and diastolic HF

The non-invasive documentation of coronary microcirculation impairment: role of transthoracic echocardiography

Transthoracic Doppler echocardiographic-derived coronary flow reserve is an useful hemodynamic index to assess dysfunction of coronary microcirculation. Isolated coronary microvascular abnormalities are overt by reduced coronary flow reserve despite normal epicardial coronary arteries. These abnormalities may occur in several diseases (arterial hypertension, diabetes mellitus, hypercholesterolemia, syndrome X, aortic valve disease, hypertrophic cardiomyopathy and idiopathic dilated cardiomyopathy). The prognostic role of impaired microvascular coronary flow reserve has been shown unfavourable especially in hypertrophic or idiopathic dilated cardiomyopathies. Coronary flow reserve reduction may be reversible, for instance after regression of left ventricular hypertrophy subsequent to valve replacement in patients with aortic stenosis, after anti-hypertensive treatment or using cholesterol lowering drugs. Coronary flow reserve may increase by 30% or more after pharmacological therapy and achieve normal level >3.0. In contrast to other non invasive tools as positron emission tomography, very expensive and associated with radiation exposure, transthoracic Doppler-derived coronary flow reserve is equally non invasive but cheaper, very accessible and prone to a reliable exploration of coronary microvascular territories, otherwise not detectable by invasive coronary angiography, able to visualize only large epicardial arteries

Additive Prognostic Value of Coronary Flow Reserve in Patients With Chest Pain Syndrome and Normal or Near-Normal Coronary Arteries

In patients with angiographically normal coronary arteries and chest pain, pharmacologic stress echocardiography can identify a subgroup of patients with a less benign prognosis. Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can currently be combined with wall motion analysis during vasodilator stress echocardiography. The aim of this study was to assess the prognostic value of CFR response in patients with normal coronary arteries and normal wall motion during stress. We selected 394 patients (171 men, 61 11 years of age) who underwent dipyridamole stress echocardiography (0.84 mg/kg over 6 minutes) with 2-dimensional echocardiography and CFR evaluation of the LAD by Doppler. All had angiographically nonsignificant (<50% quantitatively assessed) stenosis in any major vessel, normal left ventricular function (wall motion score index 1), and test negativity for conventional wall motion criteria. Images were independently read by a core laboratory for wall motion and a core laboratory for CFR. Mean CFR was 2.5 0.6 and 87 patients (22%) had an abnormal CFR <2. During a median follow-up of 51 months, 31 events occurred, namely 4 deaths and 27 nonfatal myocardial infarctions (3 ST-elevated myocardial infarctions and 24 non-ST-elevated myocardial infarctions). Kaplan-Meier survival estimates for hard events showed a better outcome for those patients with a normal CFR compared with those with an abnormal CFR (96% vs 55%, p 0.001, at 48 months of follow-up). In conclusion, in patients with angiographically normal or near-normal coronary arteries and preserved at-rest regional and global left ventricular function at baseline and during stress, CFR adds incremental value to the prognostic stratification achieved with clinical and angiographic data

Prognostic implication of coronary flow reserve in diabetic and nondiabetic patients with negative dipyridamole stress echo by wall motion criteria

Objectives: Aim of this prospective, multicenter, observational study was to assess the prognostic value of Doppler echocardiographic derived coronary flow reserve (CFR) in diabetic and nondiabetic patients with known or suspected coronary artery disease (CAD) and negative dipyridamole stress echo. Methods: The study group consisted of 1130 patients (207 diabetics) with known (n=418) or suspected (n=712) CAD and negative stress echo by wall motion criteria. All underwent dipyridamole (up to 0.84 mg/kg over 6\u27) echo with CFR evaluation of left anterior descending artery by Doppler. A value of CFR <2.0 was considered abnormal. Results: CFR was normal in 821 (63%) and abnormal in 309 (27%) patients. During a median follow-up of 16 months, 98 events (8 deaths, 24 STEMI, and 66 NSTEMI) occurred. In addition, 89 patients underwent revascularization and were censored. Multivariable prognostic indicators were abnormal CFR (HR=4.95; 95% CI=3.26-7.50; p<0.0001), antianginal therapy at the time of testing (HR=1.96; 95% CI=1.29-2.98; p=0.002), age (HR=1.02; 95% CI=1.00-1.04; p=0.02), and resting wall motion abnormalities (HR=1.50; 95% CI=1.00-2.25; p=0.05). The 36-month event rate was lower (p<0.0001) for either diabetics and nondiabetics with normal CFR as compard to diabetics and nondiabetics with abnormal CFR (Figure). Conclusion: CFR provides effective prognostic information in diabetic and nondiabetic patients with known or suspected CAD and negative dipyridamole stress echo. In particular, a reduced CFR is associated with worse outcome in both populations

Predictive Value of Left Ventricular Myocardial Deformation for Left Ventricular Remodeling in Patients With Classical Low-Flow, Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

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Real-time three dimensional transesophageal echocardiography: technical aspects and clinical applications

Real-time three-dimensional transesophageal echocardiography (RT3DTEE) is now commonly used in daily clinical practice. The transesophageal, compared to the transthoracic approach, allows the visualization of the whole spectrum of the mitral valve apparatus and the posterior cardiac structures. Moreover, images obtained by RT 3D TEE provide a unique and complete visualization of the mitral valve prosthetic elements. Indeed, the possibility to visualize guidewires and catheters in cardiac chambers and their relationship with cardiac structures during percutaneous transcatheter procedures reduces the time of radiation exposure and simplifies the approach becoming the reference method for monitoring. This review aims to underline the potential clinical applications and the advantages of RT3DTEE compared to other methods