Vitarelli A, Gheorghiade M
Department of Cardiology, La Sapienza University of Rome, Italy.
Am J Cardiol. 2000 Aug 17;86(4A):36G-40G. doi: 10.1016/s0002-9149(00)00990-5.
All methods for estimating the severity of heart failure, such as clinical and radiographic examination, measures of ventricular performance, and exercise capacity, when used independently, have major limitations. Echocardiography can be used, not only to assess left-ventricular ejection fraction but also other determinants of prognosis (i.e., left-ventricular size and shape, estimation of left atrial and pulmonary artery pressures, right side involvement). The availability of continuous-wave Doppler has permitted us to evaluate pulmonary artery systolic pressure from tricuspid regurgitation, and this contributes to additional powerful data. In long-standing heart failure, pulmonary artery wedge pressure is a predictor of survival, and aggressive therapy to reduce wedge pressure improves survival. Noninvasive estimation of left-atrial pressure and left-ventricular filling pressure have been attempted by continuous-wave Doppler echocardiography in patients with heart failure and mitral regurgitation and by tissue Doppler imaging at the mitral annulus level. A significant relation has been reported between profiles of pulmonary venous flow and left-atrial pressure, but pulmonary venous flow indexes can be better assessed by transesophageal echocardiography (TEE) in terms of detection rate. It has recently been recognized that TEE can provide valuable information on intracardiac hemodynamics and ventricular function. Two-dimensional evaluation of ventricular function and pulsed- and continuous-wave Doppler recordings from the pulmonary artery, pulmonary vein, and mitral inflow are combined to provide these data, which are both qualitative and quantitative, and permit estimation of ventricular ejection fraction, left-atrial pressure, and cardiac output. It would be important to be able to stratify patients with congestive heart failure according to groups with the highest risk for early death because heart transplantation or aggressive medical treatment could be specifically applied to this population. Serial echocardiographic evaluations of the classic variables of systolic left-ventricular function as well as Doppler transmitral flow may be useful in monitoring the progression of the disease and the effects of medical treatment. The degree of pulmonary hypertension is independently associated with the restrictive left-ventricular diastolic filling pattern and with the degree of functional mitral regurgitation. Future studies on the impact of these hemodynamic variables on the outcome of patients with left-ventricular dysfunction are desirable.
所有用于评估心力衰竭严重程度的方法，如临床和影像学检查、心室功能指标以及运动能力，单独使用时都存在重大局限性。超声心动图不仅可用于评估左心室射血分数，还可用于评估其他预后决定因素（即左心室大小和形状、左心房和肺动脉压力估计、右侧受累情况）。连续波多普勒的应用使我们能够通过三尖瓣反流评估肺动脉收缩压，这为获取更多有力数据提供了帮助。在长期心力衰竭中，肺动脉楔压是生存的预测指标，积极降低楔压的治疗可提高生存率。对于心力衰竭合并二尖瓣反流的患者，已尝试通过连续波多普勒超声心动图和二尖瓣环水平的组织多普勒成像对左心房压力和左心室充盈压进行无创估计。已有报道称肺静脉血流频谱与左心房压力之间存在显著关系，但就检测率而言，经食管超声心动图（TEE）能更好地评估肺静脉血流指标。最近人们认识到，TEE可提供有关心内血流动力学和心室功能的有价值信息。将心室功能的二维评估与来自肺动脉、肺静脉和二尖瓣流入道的脉冲波和连续波多普勒记录相结合，可提供这些定性和定量的数据，从而能够估计心室射血分数、左心房压力和心输出量。能够根据早期死亡风险最高的组别对充血性心力衰竭患者进行分层非常重要，因为心脏移植或积极的药物治疗可专门应用于这一人群。对左心室收缩功能的经典变量以及多普勒二尖瓣血流进行系列超声心动图评估，可能有助于监测疾病进展和药物治疗效果。肺动脉高压程度与左心室舒张期限制性充盈模式以及功能性二尖瓣反流程度独立相关。未来需要开展研究，探讨这些血流动力学变量对左心室功能不全患者预后的影响。
