Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Bombardini, Tonino; Zagatina, Angela; Ciampi, Quirino; Arbucci, Rosina; Merlo, Pablo; Haber, Diego M. Lowenstein; Morrone, Doralisa; D’Andrea, Antonello; Djordjevic‐Dikic, Ana; Beleslin, Branko; Tešić, Milorad; Bošković, Nikola; Pretto, José Luis de Castro e Silva; Daros, Clarissa Borguezan; Amor, Miguel; Mosto, Hugo; Monte, Ines; Citro, Rodolfo; Симова, Яна; Samardjieva, Martina; Wierzbowska−Drabik, Karina; Kasprzak, Jarosław D.; Gaibazzi, Nicola; Cortigiani, Lauro; Scali, Maria Chiara; Pepi, Mauro; Antonini‐Canterin, Francesco; Torres, Marco Antônio Rodrigues; Nes, Michele De; Ostojić, Miodrag; Carpeggiani, Clara; Kovačevic-Preradović, Tamara; Lowenstein, Jorge; Arruda‐Olson, Adelaide M.; Pellikka, Patricia A.

doi:10.3390/jcm10132906

Cited by 7 publications

(6 citation statements)

References 31 publications

(50 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Relative wall thickness > 0.48 < 0.37 [7,34] Small EDV < 50 mL > 100 mL [7,34] Small ESV < 16 mL > 30 mL [7] High force > 5 mmHg/mL 3-5 mmHg/mL [35] High EF > 60-70% [7,31] < 60% [31] Arterial elastance (SBP/SV) More frequently high (> 4) More frequently normal (< 4) [31] SV More frequently low (< 30 mL) More frequently normal (35-50 mL) [35] GLS Normal-supernormal (> 25%) Normal-abnormal (< 20%) […”

Section: Clinical Featuresmentioning

confidence: 99%

Noninvasive identification and therapeutic implications of supernormal left ventricular contractile phenotype

Wang,

Yin

2024

Explor Cardiol

View full text Add to dashboard Cite

Left ventricular (LV) function is typically evaluated through LV ejection fraction (EF), a robust indicator of risk, showing a nonlinear increase in mortality rates below 40%. Conversely, excessively high EF values (> 65%) also correlate with elevated mortality, following a U-shaped curve, with its nadir observed between 50% and 65%. This underscores the necessity for improved identification of the hypercontractile phenotype. However, EF is not synonymous with LV contraction function, as it can fluctuate independently of contractility due to variations in afterload, preload, heart rate, and ventricular-arterial coupling. Assessing the contractile status of the LV requires more specific metrics, such as LV elastance (or contractile force) and global longitudinal strain. Current guidelines outline various parameters for a more precise characterization of LV contractility, yet further research is warranted for validation. The true hypercontractile phenotype is evident in cardiac pathologies such as hypertrophic cardiomyopathy, ischemia with angiographically normal coronary arteries, Tako-tsubo syndrome, heart failure with preserved EF, and may also stem from systemic disorders including anemia, hyperthyroidism, liver, kidney, or pulmonary diseases. The hypercontractile phenotype constitutes a distinctive hemodynamic substrate underlying clinical manifestations such as angina, dyspnea, or arrhythmias, presenting a target for intervention through beta-blockers or specific cardiac myosin inhibitors. While EF remains pivotal for clinical classification, risk stratification, and therapeutic decision-making, integrating it with other indices of LV function can enhance the characterization of the hypercontractile phenotype.

show abstract

Section: Clinical Featuresmentioning

confidence: 99%

Noninvasive identification and therapeutic implications of supernormal left ventricular contractile phenotype

Wang,

Yin

2024

Explor Cardiol

View full text Add to dashboard Cite

show abstract

“…It is independent of preload and afterload changes [43], which instead affect LVEF. Additionally, with all modalities of SE, LV CR is more prognostically effective than LVEF changes in identifying patients at higher risk, including both those with normal and those with noticeably abnormal resting LV function [44][45][46]. Systolic blood pressure should be added to the peak AV gradient in AS patients to evaluate LV force.…”

Section: Stress Echo In Discordant Severe Asmentioning

confidence: 99%

ABCDEG Stress Echocardiography in Aortic Stenosis

Ciampi

Cortigiani²,

Ruiz

et al. 2023

Diagnostics

Self Cite

View full text Add to dashboard Cite

Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as “classical” low-flow low-gradient (LFLG) AS or normal LVEF “paradoxical” LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.

show abstract

“…Cardiac output and SV were normalized to body surface area to obtain SV index and cardiac index (CI). Preload reserve impairment was defined as peak stress EDV < rest EDV (12). MR was evaluated with semi-quantitative method and graded as: none or trivial (0), mild (1), moderate (2), and severe (3) (13).…”

Section: Hemodynamic Measurementsmentioning

confidence: 99%

Pulmonary congestion during Exercise stress Echocardiography in Hypertrophic Cardiomyopathy

Peteiro

Tešić

et al. 2022

Int J Cardiovasc Imaging

Self Cite

View full text Add to dashboard Cite

Background B-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, have not been systematically evaluated in patients with hypertrophic cardiomyopathy (HCM). Aim To assess the clinical, anatomical and functional correlates of pulmonary congestion elicited by exercise in HCM. Methods We enrolled 128 HCM patients (age 52 ± 15 years, 72 males) consecutively referred for ESE (treadmill in 46, bicycle in 82 patients) in 10 quality-controlled centers from 7 countries (Belgium, Brazil, Bulgaria, Hungary, Italy, Serbia, Spain). ESE assessment at rest and peak stress included: mitral regurgitation (MR, score from 0 to 3); E/e’; systolic pulmonary arterial pressure (SPAP) and end-diastolic volume (EDV). Change from rest to stress was calculated for each variable. Reduced preload reserve was defined by a decrease in EDV during exercise. B-lines at rest and at peak exercise were assessed by lung ultrasound with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥ 2. Results LUS was feasible in all subjects. B-lines were present in 13 patients at rest and in 38 during stress (10 vs 30%, p < 0.0001). When compared to patients without stress B-lines (n = 90), patients with B-lines (n = 38) had higher resting E/e’ (14 ± 6 vs. 11 ± 4, p = 0.016) and SPAP (33 ± 10 vs. 27 ± 7 mm Hg p = 0.002). At peak exercise, patients with B-lines had higher peak E/e’ (17 ± 6 vs. 13 ± 5 p = 0.003) and stress SPAP (55 ± 18 vs. 40 ± 12 mm Hg p < 0.0001), reduced preload reserve (68 vs. 30%, p = 0.001) and an increase in MR (42 vs. 17%, p = 0.013) compared to patients without congestion. Among baseline parameters, the number of B-lines and SPAP were the only independent predictors of exercise pulmonary congestion. Conclusions Two-thirds of HCM patients who develop pulmonary congestion on exercise had no evidence of B-lines at rest. Diastolic impairment and mitral regurgitation were key determinants of pulmonary congestion during ESE. These findings underscore the importance of evaluating hemodynamic stability by physiological stress in HCM, particularly in the presence of unexplained symptoms and functional limitation.

show abstract

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Cited by 7 publications

References 31 publications

Noninvasive identification and therapeutic implications of supernormal left ventricular contractile phenotype

Noninvasive identification and therapeutic implications of supernormal left ventricular contractile phenotype

ABCDEG Stress Echocardiography in Aortic Stenosis

Pulmonary congestion during Exercise stress Echocardiography in Hypertrophic Cardiomyopathy

Contact Info

Product

Resources

About