Abstract 15545: Exercise-stress Real-time Cardiac Magnetic Resonance Imaging for Non-invasive Characterisation of Heart Failure With Preserved Ejection Fraction: The Hfpef Stress Trial

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Soeren Jan Backhaus ◽  
Torben Lange ◽  
Elisabeth George ◽  
Kristian Hellenkamp ◽  
Roman Gertz ◽  
...  
Keyword(s):  
Heart Failure ◽  
Magnetic Resonance ◽  
Ejection Fraction ◽  
Real Time ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Volume Index ◽  
Diastolic Filling ◽  
Preserved Ejection Fraction ◽  
Non Invasive

Introduction: Invasive right heart catherization (RHC) using exercise-stress is the reference-standard for the diagnosis of heart failure with preserved ejection fraction (HFpEF) but carries the risk of the procedure. Real-time cardiovascular magnetic resonance (RT-CMR) imaging allows bicycle exercise CMR with unprecedented temporal and spatial resolution and may represent a novel non-invasive alternative. Methods: The HFpEF stress trial (NCT03260621) prospectively included 75 patients with echocardiographic signs of diastolic dysfunction and dyspnoea on exertion (E/E’>8, NYHA≥II) who underwent echocardiography, RHC and RT-CMR at rest and exercise-stress. HFpEF was defined according to pulmonary capillary wedge pressure (PCWP ≥15mmHg at rest or ≥25mmHg during exercise stress). RT-CMR functional assessments included time-volume-curves for total and early (1/3) diastolic left ventricular (LV) filling or left atrial (LA) emptying and LV/LA long axis strain (LAS). Results: HFpEF patients (n=34, mean PCWP rest 13mmHg, stress 27mmHg) had higher E/e’ (12.5 vs 9.15), NT-proBNP (255 vs 75ng/l) and LA volume index (43.8 vs 36.2ml/m 2 ) compared to non-HFpEF patients (n=34, rest 8mmHg, stress 18mmHg, p≤0.001 for all). There were no differences in RT-CMR LV total and early diastolic filling at rest and during exercise-stress (p≥0.164). In contrast, RT-CMR revealed impaired stress LA total (p=0.033) and early (p<0.001) diastolic emptying in HFpEF. LA LAS was the only impaired parameter at rest (p<0.001) and emerged as the best predictor for the presence of HFpEF during exercise-stress testing (AUC rest 0.82 vs stress 0.93, p=0.029). Conclusions: RT-CMR allows highly accurate identification of HFpEF during physiological exercise and may establish itself as a novel non-invasive diagnostic alternative for routine clinical use.

scholarly journals Exercise-Stress Real-time Cardiac Magnetic Resonance Imaging for Non-Invasive Characterisation of Heart Failure with Preserved Ejection Fraction: The HFpEF Stress Trial

Circulation ◽  
2021 ◽  
Author(s):  
Sören J. Backhaus ◽  
Torben Lange ◽  
Elisabeth F. George ◽  
Kristian Hellenkamp ◽  
Roman J. Gertz ◽  
...  
Keyword(s):  
Heart Failure ◽  
Magnetic Resonance ◽  
Ejection Fraction ◽  
Real Time ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Volume Index ◽  
Preserved Ejection Fraction ◽  
Non Invasive ◽  
Right Heart Catheterisation

Background: Right heart catheterisation (RHC) using exercise-stress is the reference standard for the diagnosis of heart failure with preserved ejection fraction (HFpEF) but carries the risk of the invasive procedure. We hypothesized that real-time cardiovascular magnetic resonance (RT-CMR) exercise imaging with pathophysiologic data at excellent temporal and spatial resolution may represent a contemporary non-invasive alternative for diagnosing HFpEF. Methods: The HFpEF stress trial (DZHK-17, NCT03260621) prospectively recruited 75 patients with echocardiographic signs of diastolic dysfunction and dyspnea on exertion (E/e'>8, New York Heart Association (NYHA) class ≥II) to undergo echocardiography, RHC and RT-CMR at rest and during exercise-stress. HFpEF was defined according to pulmonary capillary wedge pressure (PCWP ≥15mmHg at rest or ≥25mmHg during exercise stress). RT-CMR functional assessments included time-volume curves for total and early (1/3) diastolic left ventricular (LV) filling, left atrial (LA) emptying and LV/LA long axis strain (LAS). Results: HFpEF patients (n=34, median PCWP rest 13mmHg, stress 27mmHg) had higher E/e' (12.5 vs. 9.15), NT-proBNP (255 vs. 75ng/l) and LA volume index (43.8 vs. 36.2ml/m 2 ) compared to non-cardiac dyspnea patients (n=34, rest 8mmHg, stress 18mmHg, p≤0.001 for all). Seven patients were excluded due to the presence of non HFpEF cardiac disease causing dyspnea on imaging. There were no differences in RT-CMR LV total and early diastolic filling at rest and during exercise-stress (p≥0.164) between HFpEF and non-cardiac dyspnea. RT-CMR revealed significantly impaired LA total and early (p<0.001) diastolic emptying in HFpEF during exercise-stress. RT-CMR exercise-stress LA LAS was independently associated with HFpEF (adjusted odds ratio 0.657, 95% confidence interval [0.516; 0.838], p=0.001) after adjustment for clinical and imaging parameters and emerged as the best predictor for HFpEF (area under the curve rest 0.82 vs. exercise-stress 0.93, p=0.029). Conclusions: RT-CMR allows highly accurate identification of HFpEF during physiological exercise and qualifies as a suitable non-invasive diagnostic alternative. These results will need to be confirmed in multi-centre prospective research studies to establish widespread routine clinical use. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT03260621

scholarly journals Non-invasive intraventricular pressure differences estimated with cardiac MRI in subjects without heart failure and with heart failure with reduced and preserved ejection fraction

Open Heart ◽  
2019 ◽  
Vol 6 (2) ◽  
pp. e001088 ◽  
Author(s):  
Francisco Londono-Hoyos ◽  
Patrick Segers ◽  
Zeba Hashmath ◽  
Garrett Oldland ◽  
Maheshwara Reddy Koppula ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Systolic Function ◽  
Left Ventricular ◽  
Diastolic Filling ◽  
Spatiotemporal Pattern ◽  
Intraventricular Pressure ◽  
Preserved Ejection Fraction ◽  
Non Invasive ◽  
Echocardiographic Parameters

ObjectiveNon-invasive assessment of left ventricular (LV) diastolic and systolic function is important to better understand physiological abnormalities in heart failure (HF). The spatiotemporal pattern of LV blood flow velocities during systole and diastole can be used to estimate intraventricular pressure differences (IVPDs). We aimed to demonstrate the feasibility of an MRI-based method to calculate systolic and diastolic IVPDs in subjects without heart failure (No-HF), and with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).MethodsWe studied 159 subjects without HF, 47 subjects with HFrEF and 32 subjects with HFpEF. Diastolic and systolic intraventricular flow was measured using two-dimensional in-plane phase-contrast MRI. The Euler equation was solved to compute IVPDs in diastole (mitral base to apex) and systole (apex to LV outflow tract).ResultsSubjects with HFpEF demonstrated a higher magnitude of the early diastolic reversal of IVPDs (−1.30 mm Hg) compared with the No-HF group (−0.78 mm Hg) and the HFrEF group (−0.75 mm Hg; analysis of variance p=0.01). These differences persisted after adjustment for clinical variables, Doppler-echocardiographic parameters of diastolic filling and measures of LV structure (No-HF=−0.72; HFrEF=−0.87; HFpEF=−1.52 mm Hg; p=0.006). No significant differences in systolic IVPDs were found in adjusted models. IVPD parameters demonstrated only weak correlations with standard Doppler-echocardiographic parameters.ConclusionsOur findings suggest distinct patterns of systolic and diastolic IVPDs in HFpEF and HFrEF, implying differences in the nature of diastolic dysfunction between the HF subtypes.

scholarly journals How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

2019 ◽  
Vol 40 (40) ◽  
pp. 3297-3317 ◽  
Author(s):  
Burkert Pieske ◽  
Carsten Tschöpe ◽  
Rudolf A de Boer ◽  
Alan G Fraser ◽  
Stefan D Anker ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Natriuretic Peptide ◽  
Diagnostic Algorithm ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Preserved Ejection Fraction ◽  
Ventricular Ejection Fraction

Abstract Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the ‘HFA–PEFF diagnostic algorithm’. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), left ventricular (LV) filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2–4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

scholarly journals Exercise Training Improved Longitudinal Intrinsic Left Ventricle Function in Heart Failure with Preserved Ejection Fraction

2019 ◽  
Vol 28 (01) ◽  
pp. 044-049
Author(s):  
Sidhi Purwowiyoto ◽  
Budhi Purwowiyoto ◽  
Amiliana Soesanto ◽  
Anwar Santoso
Keyword(s):  
Quality Of Life ◽  
Heart Failure ◽  
Exercise Training ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
World Health ◽  
Volume Index ◽  
Lv Function ◽  
Preserved Ejection Fraction

Exercise improves morbidity, fatality rate, and quality of life in heart failure with low ejection fraction, but fewer data available in heart failure with preserved ejection fraction (HFPEF).The purpose of this study is to test the hypothesis that exercise training might improve the longitudinal intrinsic left ventricular (LV) function in HFPEF patients.This quasi-experimental study had recruited 30 patients with HFPEF. Exercise training program had been performed for a month with a total of 20 times exercise sessions and evaluated every 2 weeks. Echocardiography was performed before sessions, second week and fourth week of exercise training. Six-minute walk tests (6MWTs) and quality-of-life variables using Minnesota living with HF scoring and the 5-item World Health Organization Well-Being Index scoring were measured before and after exercise as well.Left ventricular filling pressure, represented by the ratio of early diastolic mitral flow velocity/early diastolic annular velocity and left atrial volume index, improved during exercise. The longitudinal intrinsic LV function, represented by four-chamber longitudinal strain, augmented during exercise (p < 0.001). Aerobic capacity, measured by 6MWT, increased significantly (p = 0.001). Quality of life improved significantly during exercise (p < 0.001).Exercise training was suggested to improve the longitudinal intrinsic LV function and quality of life in HFPEF. Clinical Trial Registration: ACTRN12614001042639.

Abstract 87: Alterations to Cardiac Mechanics Do Not Preserve Normal Cardiac Function in a Novel Ossabaw Swine Model of Heart Failure with Preserved Ejection Fraction

2017 ◽  
Vol 121 (suppl_1) ◽  
Author(s):  
Jenna C Edwards ◽  
Madeleine Dionne ◽  
T. D Olver ◽  
Jan R Ivey ◽  
Pamela K Thorne ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cardiac Function ◽  
Strain Rate ◽  
Pressure Overload ◽  
Left Ventricular ◽  
Volume Index ◽  
Lv Function ◽  
Swine Model ◽  
Preserved Ejection Fraction

Introduction: Heart failure with preserved ejection fraction (HFpEF) is clinically characterized by an increased incidence in females and many comorbidities including type 2 diabetes (T2D) and obesity. Animal models accurately representing clinical HFpEF are lacking; thus, the purpose of this study was to examine left ventricular (LV) mechanics in a novel Ossabaw swine model of chronic pressure-overload (aortic-banding; AB) and T2D (Western diet; WD) using two dimensional speckle tracking echocardiography (2D-STE). We hypothesized that global LV strain would be decreased primarily in the longitudinal direction in WD-AB animals. Methods: Female Ossabaws were randomly divided into 2 groups: CON (n=5) and WD-AB (n=5). LV function and strain were measured at 1 year of age after 6 mo. of AB and 9 mo. of WD via pressure-volume relations and 2D-STE. Significance was set at P < 0.05 using t-test vs. CON. Results: In the WD-AB group, ejection fraction (EF%) and end diastolic volume were normal (>50%), and observed in parallel with increased LV weight, lung weight, and LV diastolic wall thickness (i.e. concentric hypertrophy). WD-AB group had increased HOMA-IR and body surface area, two common features in T2D. In WD-AB animals, although global longitudinal systolic strain rate and end systolic displacement were increased, stroke volume index was decreased. Early diastolic rotation rate was decreased, while global longitudinal late diastolic strain rate was increased in the WD-AB group. These changes, considered in parallel with an increased end diastolic pressure-volume relationship in WD-AB animals, are consistent with diastolic dysfunction. In contrast, longitudinal, radial, and circumferential early diastolic strain rates increased in the WD-AB group. Conclusion: Contrary to our hypothesis, LV longitudinal strain was increased during both systole and diastole, and observed in parallel with decreased early diastolic untwisting in WD-AB animals. Our results suggest alterations to LV mechanics do not preserve normal systolic and diastolic cardiac function, despite normal resting EF%, in this novel translational model of pressure-overload HF with potential relevance to human HFpEF including associated clinical comorbidities (sex, obesity, and T2D).

scholarly journals Differential left ventricular and left atrial remodelling in heart failure with preserved ejection fraction patients with and without diabetes

2019 ◽  
Vol 10 ◽  
pp. 204201881986159 ◽  
Author(s):  
Gaurav S. Gulsin ◽  
Prathap Kanagala ◽  
Daniel C. S. Chan ◽  
Adrian S. H. Cheng ◽  
Lavanya Athithan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Left Atrial ◽  
Left Ventricular ◽  
Volume Index ◽  
Preserved Ejection Fraction ◽  
Cox Regression Analysis ◽  
Markers Of Inflammation ◽  
Lv Mass ◽  
Mass Volume

Background: Attempts to characterize cardiac structure in heart failure with preserved ejection fraction (HFpEF) in people with type 2 diabetes (T2D) have yielded inconsistent findings. We aimed to determine whether patients with HFpEF and T2D have a distinct pattern of cardiac remodelling compared with those without diabetes and whether remodelling was related to circulating markers of inflammation and fibrosis and clinical outcomes. Methods: We recruited 140 patients with HFpEF (75 with T2D and 65 without). Participants underwent comprehensive cardiovascular phenotyping, including echocardiography, cardiac magnetic resonance imaging and plasma biomarker profiling. Results: Patients with T2D were younger (age 70 ± 9 versus 75 ± 9y, p = 0.002), with evidence of more left ventricular (LV) concentric remodelling (LV mass/volume ratio 0.72 ± 0.15 versus 0.62 ± 0.16, p = 0.024) and smaller indexed left atrial (LA) volumes (maximal LA volume index 48 ± 20 versus 59 ± 29 ml/m2, p = 0.004) than those without diabetes. Plasma biomarkers of inflammation and extracellular matrix remodelling were elevated in those with T2D. Overall, there were 45 hospitalizations for HF and 22 deaths over a median follow-up period of 47 months [interquartile range (IQR) 38–54]. There was no difference in the primary composite endpoint of hospitalization for HF and mortality between groups. On multivariable Cox regression analysis, age, prior HF hospitalization, history of pulmonary disease and LV mass/volume were independent predictors of the primary endpoint. Conclusions: Patients with HFpEF and T2D have increased concentric LV remodelling, smaller LA volumes and evidence of increased systemic inflammation compared with those without diabetes. This suggests the underlying pathophysiology for the development of HFpEF is different in patients with and without T2D. ClinicalTrials.gov identifier: NCT03050593.

scholarly journals Multimodality approach by cardiac magnetic resonance and biological markers in left ventricular non-compaction with heart failure with preserved ejection fraction - revealing the unknown

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
IS Visoiu ◽  
RC Rimbas ◽  
LS Magda ◽  
S Mihaila-Baldea ◽  
P Balanescu ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Endothelial Dysfunction ◽  
Ejection Fraction ◽  
Myocardial Fibrosis ◽  
Cystatin C ◽  
Left Ventricular ◽  
Preserved Ejection Fraction ◽  
Galectin 3

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PN-III-P1-1-TE-2016-0669, within PNCDI III Background Left ventricular non-compaction (LVNC) is associated with an increased risk of heart failure (HF). The presence of a real LVNC with HF with preserved ejection fraction (HFpEF), is still controverted. Methods We evaluated prospectively 42 patients with HFpEF, 21 with LVNC (61 ± 9 years) and 21 without LVNC (LVC), aged and risk factor matched, by cardiac magnetic resonance (CMR) 1.5T. LVNC diagnosis was confirmed by Petersen and Jacquier criteria (NC/C ratio and the percentage of NC myocardium). We performed myocardial T1 mapping (normal value of 950 ± 21ms). We calculated a mean value of all native T1 (T1mean), and also for apical (apicalT1) and basal segments (basalT1). We also calculated ECV mean, basal and apical. All patients had NTproBNP and biomarkers for systemic inflammation (hsCRP, IL6, cystatin C and sST2), endothelial dysfunction: VCAM, von Willebrand factor (vWf), vWF metalloproteinase-ADAMTS13, and myocardial fibrosis: vascular peroxidase (VPO), and Galectin-3. Results In the LVNC, mean NC/C ratio was 2.9 ± 0.5 mm and the percentage of NC myocardium was 24.41 ± 8.8%. LVNC patients had significantly higher T1apical, higher ECVmean, ECV basal and apical (Table) by comparison with LVC group, suggesting an extensive fibrosis in LVNC group with significantly higher apical fibrosis.  Inflammatory markers were similar between groups, LVNC patients had lower values of ADAMTS13, suggesting endothelial dysfunction, and higher values of Galectin-3, suggesting increased myocardial fibrosis (Table). Galectin-3 correlated positively only with apicalT1 (R = 0.49, p = 0.04). NTproBNP significantly correlated with VPO, a promotor of fibrosis (r = 0.61, p = 0.009) in LVNC group, whereas in LVC group correlated with cystatin C (r = 0.62, p = 0003) and VCAM (r = 0.4, p = 0.05). Native apical T1 cut off &gt;1021 ms provided the highest sensibility and specificity to differentiate segments with and without NC in HFpEF (p = 0.002) (Figure). Conclusion  HFpEF patients with LVNC have significant higher NTproBNP, higher fibrosis than patients without LVNC, more extensive in non-compacted apical segments. Galectin-3 level correlates only with apical fibrosis on CMR, expressed by apicalT1 time. Moreover, endothelial dysfunction seems to play an important role in HFpEF generation in LVNC. All findings suggests that LVNC is a stand alone condition, not an adaptive hyper-trabeculation in HFpEF. Table.Comparison between groups NTproBNP (pg/ml) Galectin3 (ng/ml) ADAMTS13 (ng/ml) T1mean (ms) basalT1 (ms) apicalT1 (ms) ECV mean (%) ECV basal (%) ECV apical (%) LVNC 294 ± 282 8.44 ± 3.45 767.35 ± 335.56 1013.8 ± 31.8 1002.8 ± 27.2 1059 ± 73 27.2 ± 2.9 26.2 ± 2.9 29.6 ± 3.9 LVC 163 ± 71 6.67 ± 2.88 962.33 ± 253.78 1003.2 ± 28.1 1004.3 ± 29.5 1007 ± 40 24.3 ± 2.5 24.2 ± 2.7 25.2 ± 2.8 P value 0.031 0.048 0.049 0.26 0.865 0.007 0.002 0.033 &lt;0.001 Abstract Figure

scholarly journals Epicardial Adipose Tissue and Outcome in Heart Failure With Mid-Range and Preserved Ejection Fraction

2021 ◽  
Author(s):  
Gijs van Woerden ◽  
Dirk J. van Veldhuisen ◽  
Olivier C. Manintveld ◽  
Vanessa P.M. van Empel ◽  
Tineke P. Willems ◽  
...  
Keyword(s):  
Heart Failure ◽  
Adipose Tissue ◽  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Ejection Fraction ◽  
Epicardial Adipose Tissue ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Preserved Ejection Fraction ◽  
All Cause Mortality

Background: Epicardial adipose tissue (EAT) accumulation is thought to play a role in the pathophysiology of heart failure (HF) with mid-range and preserved ejection fraction, but its effect on outcome is unknown. We evaluated the prognostic value of EAT volume measured with cardiac magnetic resonance in patients with HF with mid-range ejection fraction and HF with preserved ejection fraction. Methods: Patients enrolled in a prospective multicenter study that investigated the value of implantable loop-recorders in HF with mid-range ejection fraction and HF with preserved ejection fraction were analyzed. EAT volume was quantified with cardiac magnetic resonance. Main outcome was the composite of all-cause mortality and first HF hospitalizations. Hazard ratios (HR) and 95% CI are described per SD increase in EAT. Results: We studied 105 patients (mean age 72±8 years, 50% women, and mean left ventricular ejection fraction 53±8%). During median follow-up of 24 (17–25) months, 31 patients (30%) died or were hospitalized for HF. In univariable analysis, EAT was significantly associated with a higher risk of the composite outcome (HR, 1.76 [95% CI, 1.24–2.50], P =0.001), and EAT remained associated with outcome after adjustment for age, sex, and body mass index (HR, 1.61 [95% CI, 1.13–2.31], P =0.009), and after adjustment for New York Heart Association functional class and N-terminal of pro-brain natriuretic peptide (HR, 1.53 [95% CI, 1.04–2.24], P =0.03). Furthermore, EAT was associated with all-cause mortality alone (HR, 2.06 [95% CI, 1.26–3.37], P =0.004) and HF hospitalizations alone (HR, 1.54 [95% CI, 1.04–2.30], P =0.03). Conclusions: EAT accumulation is associated with adverse prognosis in patients with HF with mid-range ejection fraction and HF with preserved ejection fraction. This finding supports the importance of EAT in these patients with HF. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01989299.

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