Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Abstract

Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. evidence supporting the diagnosis of HF. Echocardiography is the most commonly used modality for this purpose because of its ease of application, noninvasive nature, safety, and ability to provide a vast amount of information about cardiac structure and function. Additionally, echocardiography also plays an important role in guiding therapeutic decision-making and in monitoring response to therapy. Over the past 3 decades, numerous advancements have occurred in the field of echocardiography that have helped improve our understanding of the morpho-functional aberrations occurring in HF. This review summarizes the recent advances in echocardiography as applicable to the evaluation and management of HF. Classification of Heart FailureTo facilitate clinical management, several attempts have been made to divide HF patients into categories that unify them according to their dominant clinical presentations. Thus, HF has often been described as low output failure or high output failure; forward failure or backward failure; systolic HF or diastolic HF; HFrEF or HF with preserved ejection fraction (HFpEF); and so on. More recently, HF has also been classified according to alterations in the mechanical function of the left ventricle (LV; Table 1). 6The classification of HF into systolic or diastolic HF appeared to be intuitive, categorizing patients based on the primary pathogenic abnormality, that is, impairment of cardiac contractility or impairment of filling. However, this description has now been abandoned with the recognition that these 2 entities are not mutually exclusive and have considerable overlap. Significant LV diastolic dysfunction is a ubiquitous occurrence in patients with systolic HF, whereas systolic dysfunction...

Relationship of Transmural Variations in Myofiber Contractility to Left Ventricular Ejection Fraction: Implications for Modeling Heart Failure Phenotype With Preserved Ejection Fraction

“…Our findings support the hypothesis that HFpEF could be a result of lower subendocardial contractility linked with increased subepicardial contractility (Sengupta and Narula, 2008; Shah and Solomon, 2012; Omar et al, 2016, 2017). When subendocardial contractility was zero, LVEF decreased by 23.9% (Table 2: 53.2% in scenario 1 vs. 40.5% in scenario 2).…”

“…Recent studies have suggested that HFpEF is associated with transmural changes in myocardial deformation (Shah and Solomon, 2012; Omar et al, 2016, 2017). Understanding the transmural variations in left ventricular (LV) mechanics associated with HFpEF may offer pathophysiological insights for developing potential therapeutic targets.…”

Unmasking of oestrogen‐dependent changes in left ventricular structure and function in aged female rats: a potential model for pre‐heart failure with preserved ejection fraction

“…This is a poorly understood disease and there are no therapies identified as clearly effective in mitigating its pathology (Omar et al . ; Barandiarán Aizpurua et al . ).…”

Left ventricular twist in patients with left bundle branch block: Missing the obvious in electromechanical coupling

“…Such relationships are closely related to the disruption of the sequence of LV rotation mechanics, which may contribute to LV dysfunction. Future studies, besides focusing on the relationships between LVT–UT and electromechanical coupling in patients with LBBB, should also look into how such complex pathological relationships may influence the intraventricular flow dynamics and LV vortex formations, another important part of an efficient LV pumping (2). These regional electrophysiological, electromechanical, and hemodynamic observations can help to differentiate causes of cardiomyopathy associated with LBBB and may also add to the understanding and selection for cardiac resynchronization therapy with a better responder outcome.…”

“…The recent advent of imaging modalities capable of myocardial mechanical assessment, such as speckle tracking echocardiography, has offered insight for understanding the earlier and subclinical phases of cardiac dysfunction beyond the conventional parameters, such as ejection fraction (EF), and Doppler based methods (1, 2). However, myocardial functions are equally dependent on myocardial electrical properties because electromechanical coupling is crucial for an efficient cardiac contraction-relaxation cycle.…”