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
References (60)
- et al.
Mechanisms of diastolic dysfunction in heart failure
Trends Cardiovasc Med
(2006) - et al.
Pathobiology of left ventricular dyssynchrony and resynchronization
Prog Cardiovasc Dis
(2006) - et al.
Ventricular-vascular interaction in heart failure
Heart Fail Clin
(2008) - et al.
Noninvasive single-beat determination of left ventricular end-systolic elastance in humans
J Am Coll Cardiol
(2001) - et al.
Comparison of ventricular pressure relaxation assessments in human heart failure: quantitative influence on load and drug sensitivity analysis
J Am Coll Cardiol
(1999) - et al.
Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography
J Am Coll Cardiol
(2006) Assessment of diastolic dysfunction. Invasive modalities
Cardiol Clin
(2000)- et al.
Ventricular structure and function in hypertensive participants with heart failure and a normal ejection fraction: the Cardiovascular Health Study
J Am Coll Cardiol
(2007) - et al.
Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction
J Am Coll Cardiol
(2007) - et al.
Ventricular-arterial and ventricular-ventricular interactions and their relevance to diastolic filling
Prog Cardiovasc Dis
(2007)
Diastolic ventricular interaction in chronic heart failure
Lancet
Impact of arterial load and loading sequence on left ventricular tissue velocities in humans
J Am Coll Cardiol
Prognostic importance of pulmonary hypertension in patients with heart failure
Am J Cardiol
Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines
Chest
Efficacy and safety of sildenafil in the evaluation of pulmonary hypertension in severe heart failure
Am J Cardiol
Unexplained pulmonary hypertension in elderly patients
Chest
Hemodynamic effects of sildenafil in patients with congestive heart failure and pulmonary hypertension: combined administration with inhaled nitric oxide
Chest
Long-term use of sildenafil in the therapeutic management of heart failure
J Am Coll Cardiol
Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide in the general community: determinants and detection of left ventricular dysfunction
J Am Coll Cardiol
Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory
J Am Coll Cardiol
Comparative influence of load versus inotropic states on indexes of ventricular contractility: experimental and theoretical analysis based on pressure-volume relationships
Circulation
ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society
Circulation
Control of in vivo left ventricular [correction] contraction/relaxation kinetics by myosin binding protein C: protein kinase A phosphorylation dependent and independent regulation
Circulation
Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure
Circulation
Instantaneous pressure-volume relationships and their ratio in the excised, supported canine left ventricle
Circ Res
From ‘Emax’ to pressure-volume relations: a broader view
Circulation
Estimation of preload recruitable stroke work relationship by a single-beat technique in humans
Am J Physiol Heart Circ Physiol
Sildenafil inhibits beta-adrenergic-stimulated cardiac contractility in humans
Circulation
Age- and gender-related ventricular-vascular stiffening: a community-based study
Circulation
Cardiac structure and ventricular-vascular function in persons with heart failure and preserved ejection fraction from olmsted county, Minnesota
Circulation
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Hemodynamic Assessment in Takotsubo Syndrome
2023, Journal of the American College of CardiologyHemodynamics for the Heart Failure Clinician: A State-of-the-Art Review
2022, Journal of Cardiac FailureCitation Excerpt :The opposite occurs with a vasoconstrictor (data not shown), which can markedly impair SV. Inotropes and temporary mechanical circulatory support devices, used in low-output and cardiogenic shock (CS) states, also have distinct effects on the HFrEF LV pressure–volume loop.3,5 Inotropes (eg, dobutamine and milrinone) augment the ESPVR while decreasing systemic vascular resistance; the net effect is an increased SV, decreased Ea, and decreased EDP (Fig. 1D).3
Advanced Heart Failure in a Special Population: Heart Failure with Preserved Ejection Fraction
2021, Heart Failure ClinicsAre pressure-volume loops relevant for hemodynamic assessment during ex vivo heart perfusion?
2020, Journal of Heart and Lung TransplantationCan Biomarkers Provide Right Ventricular-Specific Prognostication in the Perioperative Setting? Future of RV-Specific Biomarkers in Cardiac Surgery
2020, Journal of Cardiac FailureCitation Excerpt :Unlike the left ventricle (LV), there is no universally accepted definition of RVF, especially in the perioperative setting.9 To date, no practical, accurate or reproducible measure of perioperative RV function is available in the clinical setting.10–12 The routine use of pulmonary artery catheters is decreasing in many centers, while central venous pressure monitoring has important limitations; it is easily influenced by mechanical ventilation and respiratory pathology as well as by changes in preload that accompany various phases of cardiac surgery.11
Global and Regional Systolic Function of the Left Ventricle
2020, Diastology: Clinical Approach to Heart Failure with Preserved Ejection Fraction