Multimodality imaging in decompensated heart failure

Abstract

Heart failure (HF) is usually suspected by clinical history, symptoms, physical examination, electrocardiogram findings, and natriuretic peptides' values. However, echocardiography and other imaging techniques play an essential role in supporting HF diagnosis. Thanks to its non-invasiveness and safety, transthoracic echocardiography is the first-level technique of choice to assess myocardial structure and function, trying to establish the diagnosis of HF with reduced, mildly reduced, and preserved ejection fraction. The role of echocardiography is not limited to diagnosis but it represents a crucial tool in guiding therapeutic decision-making and monitoring response to therapy. Over the last decades, several technological advancements were made in the imaging field, aiming at better understanding the morphofunctional abnormalities occurring in cardiovascular diseases. The purpose of this review article is to summarize the incremental role of imaging techniques (in particular cardiac magnetic resonance and myocardial scintigraphy) in HF, highlighting their essential applications to HF diagnosis and management.

Keywords: Cardiac magnetic resonance; Echocardiography; Fibrosis; Heart failure; Myocardial scintigraphy; Scar; Strain.

Figure 1

Cardiac MRI in non-compaction cardiomyopathy.

Figure 2

Representative cases showing global longitudinal strain (A–E), myocardial work Index (B–F), myocardial work efficiency (C–G) and pressure–strain loops in a patient with HFpEF (upper) and in a healthy subject (lower) at rest.

Figure 3

The HyperDoppler in a normal subject and in a dilated cardiomyopathy patient. This technique provides different possibilities to analyze and represent intracardiac flow data: vortices are represented as compacted regions in blue (clockwise rotation) or in red (counterclockwise rotation).

Figure 4

Cardiac MRI in a patient with ischaemic dilated cardiomyopathy. LGE shows transmural myocardial scar tissue of the anterior wall, with an apical thrombus.

Figure 5

Cardiac MRI in a patient with previous NSTEMI (left) and in a patient with idiopathic dilated cardiomyopathy (right). LGE shows sub-endocardial myocardial scar tissue of the lateral wall in the NSTEMI patient, and absence of myocardial scar tissue in the idiopathic dilated cardiomyopathy patient.

Figure 6

Myocardial scintigraphy of a patient with ischaemic heart disease. By this technique, it is possible the quantitative assessment of the extension of the area of ​​altered post-stress perfusion (summed stress score, SSS, 44 in this case) and at rest (summed rest score, SRS, 19 in this patient). The weighted difference between the two makes it possible to obtain the ischaemic risk area (summed defect score, SDS, 22 in this patient).

Figure 7

Peak atrial longitudinal strain (PALS) detects the maximum elongation of the LA during LV systole, at the end of the reservoir phase.

Figure 8

Three-dimensional TOE is the gold standard method for full assessment of the mitral valve and scallops compared with surgical findings and offers quantification of leaflet geometry throughout the cardiac cycle, with a surgical-like point of view.

Figure 9

The mitral annulus changes configuration throughout the cardiac cycle to maintain leaflet coaptation, from D-shaped in mid-systole to a more circular shape in early diastole, reducing annular area by 20–30% across the cardiac cycle. All these changes can be tracked by high spatial and temporal resolution imaging using 3D TOE.