EDITORIAL COMMENT
Do We Need New Echocardiographic Prognosticators for the Management of Heart Failure Patients?*
Stephane Lafitte, MD, PhD*
Cardiologic Hospital and Inserm 828, Bordeaux University Hospital Center, Pessac, France
* Reprint requests and correspondence: Dr. Stephane Lafitte, Service des Echocardiographies, Hopital Cardiologique, Avenue Magellan, Pessac, Gironde 33600, France (Email: stephane.lafitte{at}chu-bordeaux.fr).
Key Words: congestive heart failure • prognosis • ventricular function • strain
Cardiac insufficiency is a major public health problem. Thanks to progress made in the field of heart failure pharmacotherapy during the last 3 decades, mortality rates have decreased by 30% (1). However, despite perfectly defined recommendations concerning heart failure drug treatment (2,3), follow-up remains insufficient (4) for reasons relating both to poor drug tolerability or incompatibility and suboptimal prescription practices (5). It has been shown that, for heart failure patients, better adherence to recommendations allows the reduction of cardiovascular events (6). To help the prescriber, clinical risk stratification can be improved using biological parameters, such as brain natriuretic peptide (7), functional tests (oxygen consumption per minute) (8), or cardiac imaging, that will influence heart failure patient management by identifying the most severely ill patients.
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Echocardiographic risk evaluation and deformation analysis
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Because of its accessibility, reliability, and low price, echocardiography has been the subject of numerous publications on heart failure patient risk evaluation. Established criteria may associate left (9,10) and right (11,12) ventricular function parameters, mitral insufficiency quantification (13), and an asynchrony assessment (14).
In this issue of the Journal, the study by Cho et al. (15) identified an additional prognostic factor in heart failure patients using a recent technique that enabled the echocardiographic analysis of myocardial deformations. This new approach to myocardial contraction measurement allows ventricular function analysis by distinguishing radial, longitudinal, and circumferential contraction components on the basis of the orientation of myocyte fibers. Study results show that this technique also boasts high feasibility and reliability rates as compared with common echocardiographic measurements (longitudinal and circumferential strain feasibilities: 88% to 92%, variabilities: 3.6% to 6.3%). It should be noted that these reproducibility data are comparable to those reported in literature, regardless of the cardiopathy investigated (16–18). In the analysis, the authors demonstrated that the circumferential deformation parameter was a stronger predictor of cardiovascular events than both conventional systolic or diastolic parameters and the longitudinal deformation parameter.
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Longitudinal versus circumferential strain
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The superiority of circumferential deformation merits a more profound explanation so as not to underestimate the pertinence of the longitudinal component. As Cho et al. (15) reported, the longitudinal deformation component mainly refers to the exploration of the contraction caused by subendocardial and subepicardial fibers, which have an oblique-longitudinal orientation and curl up around the heart's longitudinal axis in a double helix. Contrarily, circumferential deformation originates in the mid-wall layers, where transversally oriented fibers are situated. These fibers are responsible for myocardial thickening, also called radial contraction or deformation. Studies based on tissue Doppler, and more recently deformation analysis, show that regardless of the physiopathological model, the initial deformation of ventricular contraction affects the longitudinal axis, whereas radial function is preserved in the early phase (17–20). The typical example of this is aortic stenosis, the early and isolated longitudinal function alteration of which was described 30 years ago by Dumesnil et al. (21) and confirmed recently through deformation analysis (22). This early unidirectional contraction anomaly likely has a multifactorial origin, including a greater longitudinal fiber susceptibility to myocardial ischemia, elevated parietal constraints, and ventricular remodeling. In the second phase of ventricular dysfunction progression, the initially compensating mid-wall fibers alter their contraction, leading first to the deterioration of circumferential and then radial deformations (23). It is not surprising that these 2 deformation components are a stronger prognostic factor than the longitudinal deformation, which is a less severe but earlier visible marker of myocardial contraction alteration.
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Multiparametric approach
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The question of multiplying parameters and their clinical application is legitimate. Taking into account the report by Cho et al. (15), which favors a specific criterion over others, logic would suggest focusing on this criterion. However, each echocardiographic criterion has its limitations, including feasibility, diagnostic precision, and reproducibility. Deformation analysis based on speckle tracking is not an exception to this rule, and the quality of information obtained is highly dependent on the echocardiographic window. In addition to the imperfect reliability rate, longitudinal deformation obtained during apical data acquisition is more reproducible than radial or circumferential deformation obtained during parasternal data acquisition. It should be noted that the combination of complementary clinical, biological, and echocardiographic criteria allows the circumvention of analysis limitations, and this convergence enables the best possible risk evaluation in heart failure patients.
The principal limitation of the work of Cho et al. (15), which proposes a multicriteria echocardiographic analysis, is that it lacks comparisons with right ventricular function parameters. Considering the strong clinical impact of these components on the prognosis of heart failure patients (24), it is conceivable that the statistical weight of deformation parameters would have been diminished had Cho et al. (15) taken them into account. The difficulty in obtaining right ventricular ejection fraction limits the use of this echocardiographic parameter, though this could be surmounted by applying the tissue Doppler imaging criterion to the tricuspid annulus (12).
Table 1
summarizes the principal echocardiographic criteria, which have been shown to be prognosticators for heart failure patients, and their threshold values.
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Conclusions
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Echocardiography has a position of choice in the follow-up of heart failure patients, especially for the stratification of patient risk. Regardless of any single criterion's weight, the clinical approach needs to be multiparametric, as the sum of different positive parameters permits an improved patient risk diagnosis (25,26). This approach allows high-risk patients to be identified noninvasively and may provide guidance for special patient treatment with intensified monitoring and optimized drug therapy.
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Footnotes
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* Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. 
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References
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