Advances in Multimodality Cardiovascular Imaging in the Diagnosis of Heart Failure With Preserved Ejection Fraction

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  Figure 1. A 71-year-old male patient complained dyspnea on mild effort, fatigue, and lower limb edemas, 7 years before he was diagnosed with AL amyloidosis. More recently, he was subjected to implantation of bicameral pacemaker and after that he presented persistent atrial fibrillation. ECG showed atrial fibrillation with a ventricular paced rhythm (mean ventricular rate: 75 bpm) and low-voltage QRS complexes in limb leads. So, according to the proposed Heart Failure Association (HFA) algorithm, the pretest assessment resulted suggestive of heart failure with preserved ejection fraction (HFpEF). 2D transthoracic echocardiography (TTE) apical 4-chamber view showed significant thickening of the both ventricles (ventricular septum wall thickness = 14 mm, LV posterior wall thickness = 16 mm, right wall thickness (RWT) = 0.83, left ventricle mass indexed (LVMi) = 150 g/m2), biatrial enlargement [left atrium volume index (LAVI) = 40 mL/m2], and thickening of atrioventricular valves. 2D TTE showed preserved systolic function of left ventricle assessed by biplane Simpson's method [left ventricular ejection fraction (LVEF) 55%]. 2D TTE apical 4-chamber view with pulsed wave Doppler showed peak E…

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  Figure 2. Strengths and limits of each cardiac imaging modality, and their principal applications in the diagnosis of HFpEF.

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  Figure 3. Cardiovascular magnetic resonance (CMR) in a patient with dyspnea and cardiac amyloidosis. An 80-year-old man with a history of ischemic heart disease was referred to the cardiology clinic because of dyspnea. Clinical examination was unremarkable. CMR showed increased left ventricular wall thickness [(A,B), bSSFP images showing three- and four-chamber view respectively], increased left ventricular mass (115.9 g/m2), and small pleural and pericardial effusion. Native T1 values were significantly increased, up to 1,200 ms (C). Late gadolinium enhancement showed diffuse left ventricular subendocardial enhancement, also involving the atria [(D,E), three- and four-chamber view, respectively]. ECV was markedly increased (F). Patient was diagnosed with cardiac amyloidosis.

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  Figure 4. Cardiac CT in a patient with dyspnea and apical hypertrophic cardiomyopathy (left ventricular long-axis views, top row; left ventricular short axis views, bottom row). A 79-year-old woman with hypertension was referred to the cardiology clinic because of dyspnea. Clinical examination was unremarkable. Resting ECG showed anterior T wave inversion. A cardiac CT ruled out obstructive coronary artery disease, while showing hypertrophy (maximal wall thickness 15 mm at end-diastole) of the inferior and lateral apical segments, and of the inferior mid-ventricular segment (arrowhead). Moreover, there was fatty infiltration in the apical lateral segment (asterisk). Patient was diagnosed with apical hypertrophic cardiomyopathy.