Invasive Hemodynamic Assessment in Heart Failure
Section snippets
Cardiac contractility: looking beyond the ejection fraction
The most universally accepted index of contractility used in practice, the EF, unfortunately is also one of the least specific.1 As with any parameter measuring the extent of muscle shortening or thickening, it is highly sensitive to afterload and really is an expression of ventricular–arterial coupling rather than of contractility alone. EF also is affected by heart size, because its denominator is end-diastolic volume (EDV), leading many to propose that EF is more a parameter of remodeling
Diastole—more than end-diastolic pressure
Diastolic function is determined from active and passive processes, and both contribute to relaxation and chamber filling.3 Left heart filling pressures, either pulmonary artery occlusion (wedge pressure) or left ventricle (LV) end-diastolic pressure (EDP), are central to standard cardiac catheterization, and their elevation is taken to reflect abnormal loading and/or abnormal chamber compliance. One cannot determine whether the elevation reflects abnormal loading or abnormal chamber compliance
Afterload and ventricular–arterial interaction
Adequate pressure and flow to the body depends both on cardiac performance and on the nature of the vascular load into which it ejects. This load traditionally has been conceived of as equivalent to mean or systolic blood pressure, although this notion can lead to ambiguous interpretations. Unlike isolated muscle (for which the term “afterload” was first defined), where one can fix a constant force during contraction, the intact heart generates varying stress (and pressures) during ejection,
The right heart
Pulmonary hypertension and accompanying right heart dysfunction is increasingly common in patients who have heart failure, regardless of EF, and potently affect exercise capacity and clinical outcome.47, 48 Pulmonary hypertension generally is defined as a mean pulmonary arterial pressure higher than 25 mm Hg at rest (30 mm Hg with exercise), whereas pulmonary arterial hypertension (ie, pulmonary vascular disease) further requires an elevated pulmonary vascular resistance while maintaining a
Invasive hemodynamics: A re-emerging role in the evaluation of patients who have possible heart failure and preserved ejection fraction
Most cardiologists are fairly confident in making the diagnosis of heart failure when a patient who has severe LV enlargement and an EF of 25% presents with dyspnea, but a significant group of patients present with exertional dyspnea, clinical euvolemia (or only mild hypervolemia), and a normal EF. The differential diagnosis is fairly broad, including noncardiac causes (deconditioning, obesity, anemia, and other possibilities) and a variety of cardiogenic sources. These conditions may include
Summary
A few years after fading from the forefront of cardiology, interest in cardiovascular hemodynamics is returning, especially as newer devices are developed that help measure these parameters in patients chronically. Invasive assessment of cardiovascular properties provides greater insight into the mechanisms of disease in disorders such as HFpEF and can explain how patients who have different forms of heart failure respond to various therapies or to certain forms of stress. This information may
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2020, Journal of the American College of CardiologyCitation Excerpt :Lacking from all the definitions is the recognition that advanced HF requires different treatment strategies for the simple reason that a key component in many patients with advanced stages of the disease is the decreased forward flow that defines the syndrome of low cardiac output. In stage D, a reduction in SV becomes evident, often accompanied by further LV dilatation (26,27) (Figure 1). This progressive impairment in LV systolic function is frequently associated with varying degrees of functional mitral regurgitation, which further impairs forward SV.
Invasive Hemodynamic Assessment in Heart Failure With Preserved Ejection Fraction
2020, Diastology: Clinical Approach to Heart Failure with Preserved Ejection FractionDiastology for the clinician
2019, Journal of CardiologyCitation Excerpt :These patients are difficult to diagnose, as there may be multiple other etiologies for exertional symptoms including pulmonary disease, deconditioning, and other non-cardiac problems. The gold standard for the diagnosis of HFpEF in these patients is a right heart catheterization with exercise [23]. The pulmonary artery wedge pressure may be normal or only mildly elevated at baseline (over 40% with HFpEF have a normal resting wedge pressure), but will rise to over 25 mmHg with exercise, accompanied by a blunted cardiac output response.
The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging?
2019, Heart Failure ClinicsCitation Excerpt :Thus diastolic dysfunction is considered to be the cornerstone of HFpEF pathophysiology.8 Diastolic dysfunction is defined by prolongation of relaxation in early diastole, an increase in viscoelastic LV diastolic chamber stiffness, or some combination of the two.15 Declines in LV relaxation and compliance are part of normal aging, and accordingly not all patients with diastolic dysfunction have or will go on to develop clinical HFpEF.16–18
This article originally appeared in Heart Failure Clinics, volume 5, number 2.