Is there the phenotype of chronic heart failure with “intermediate” left ventricular ejection fraction? Additional echocardiographic criteria for left ventricular systolic dysfunction in patients with chronic heart failure of ischemic origin with ejection fraction in the “gray area”

Abstract

Patients with chronic heart failure (CHF) with left ventricular ejection fraction (LV EF) in the range of 40–55 % form a separate group with “intermediate” or “moderately reduced” LV EF. Since there are a number of additional criteria in echocardiography other than EF for determining LV systolic function (TEI, MAPSE, systolic velocity of the fibrous ring of the mitral valve (S’), E/e’, dP/dt mitral regurgitation, etc.), their use may be helpful in the final identification of systolic dysfunction in CHF patients with LV EF within the “gray area”. The aim of the work – to find out the possibility of using ultrasound parameters of LV systolic function as additional diagnostic criteria for systolic dysfunction and to develop an algorithm for its diagnosis in CHF patients with LV EF within the “gray zone” (40–55 %). Materials and methods. The study included 79 patients (men – n = 49; women – n = 30) with CHF of ischemic origin with LV EF from 40 % to 55 % (main group) who were divided into two subgroups: the first subgroup (n = 40) – patients with LV EF within the “gray area 45–55 %”, the second subgroup (n = 39) – patients with LV EF less than 45 %. The comparison group – 90 patients with coronary heart disease without signs of CHF (men – n = 40, 44.5 %; women – n = 50, 55.5 %). The patient groups were age-, sex-, height-, weight-, body surface area-matched. Doppler echocardiographic examination was performed on the device Esaote MyLab Eight (Italy). Results. According to our results, 90 % (71/79) of CHF patients with reduced LV EF had mitral regurgitation. Additional examination of the systolic index dP/dT of less than 1200 mm Hg/s on the flow of mitral regurgitation allowed to classify CHF patients from the “gray area” (LV EF 40–55 %) to the CHF phenotype with reduced LV EF, and that was almost half of patients – 50.6 % (40/79). Cut off points were established for Myocardial Performance Index TEI of the LV >0.56 r. u., the right ventricle >0.51 r. u., decrease in systolic dP/dT ≤1000 mm Hg/s, systolic velocity of the medial (S med ≤7 cm/s) and the lateral (S lat ≤7 cm/s) fibrous ring of the mitral valve, the amplitude of the medial (MAPSE med ≤11.7 mm) and the lateral (MAPSE lat ≤11.1 mm) fibrous ring of the mitral valve. Conclusions. The cohort of CHF patients with “intermediate” LV EF is a heterogeneous group, which includes patients according to one formal criterion – LV EF in the range of 40–55 %. LV EF is a surrogate marker, insufficient for the final determination of the CHF phenotype. Additional criteria for systolic dysfunction include ventricular TEI, dP/dT mitral regurgitation, systolic velocity (S), and amplitude (MAPSE) of the medial and lateral fibrous ring of the mitral valve. In the presence of two or more additional ultrasound criteria for systolic LV dysfunction, CHF patients with LV EF within 40–55 % should be considered as patients with reduced LV EF.