Is an 89-year-old female with severe left atrial dilation, an ejection fraction (EF) of 54%, normal left ventricular size, moderate posterior wall thickening, mild septal thickening, normal wall motion, and mild pulmonary hypertension considered to have compensated heart failure?

Assessment of Compensated Heart Failure in an Elderly Female with Severe Left Atrial Dilation

Yes, the echocardiographic findings in this 89-year-old female are consistent with compensated heart failure with preserved ejection fraction (HFpEF). The combination of severe left atrial dilation, preserved ejection fraction (54%), ventricular wall thickening, and mild pulmonary hypertension strongly indicates HFpEF in a compensated state.

Key Diagnostic Findings Supporting HFpEF

• Left atrial dilation: Severe left atrial dilation is a hallmark finding in HFpEF and represents a key structural abnormality 1. Left atrial enlargement (left atrial volume index ≥34 mL/m²) is a diagnostic marker for HFpEF 2.

• Preserved ejection fraction: The EF of 54% meets criteria for preserved ejection fraction (≥50%) 2, distinguishing this from heart failure with reduced ejection fraction.

• Ventricular wall thickening: The moderate posterior wall thickening and mild septal thickening indicate left ventricular hypertrophy, which is commonly associated with HFpEF 1. This finding suggests longstanding pressure overload, likely from hypertension.

• Mild pulmonary hypertension: The RVSP of 33 mmHg indicates mild pulmonary hypertension, which is common in HFpEF. According to guidelines, a tricuspid regurgitation velocity >2.8 m/s (corresponding to RVSP ≥35 mmHg) is indicative of pulmonary hypertension in the context of heart failure 2.

Pathophysiological Interpretation

The gradual progression of diastolic dysfunction in this patient has resulted in progressive dilatation of the left atrium 1. The left atrial dilation occurs as a compensatory mechanism to maintain adequate left ventricular filling despite increased filling pressures. This represents a classic finding in the compensated phase of HFpEF.

The normal left ventricular size with preserved ejection fraction (54%) indicates that systolic function remains adequate, while the wall thickening suggests ventricular remodeling in response to increased afterload. This pattern is typical in elderly females with HFpEF 1.

Clinical Context

HFpEF is particularly prevalent in elderly women, most of whom have hypertension, diabetes mellitus, or both 1. The aging process has a greater impact on ventricular filling characteristics than on ejection fraction 1, which explains why this 89-year-old female presents with preserved EF despite evidence of heart failure.

According to the European Heart Journal, women are far more likely to develop heart failure with preserved ejection fraction than men 1. Sex differences in cardiac structure, metabolism, vascular aging, and myocardial adaptation to traditional cardiovascular disease risk factors have been proposed as possible causes of the higher prevalence of HFpEF in women 1.

Compensated vs. Decompensated State

The patient's condition represents compensated heart failure because:

1. The left ventricle maintains normal size and preserved ejection fraction
2. The pulmonary hypertension is only mild (RVSP 33 mmHg)
3. The heart has developed compensatory mechanisms (left atrial dilation) to maintain adequate cardiac output

In contrast, decompensated heart failure would typically show more severe pulmonary hypertension, potentially reduced ejection fraction, and clinical signs of fluid overload that are not mentioned in this case.

Conclusion

The echocardiographic findings in this 89-year-old female are consistent with compensated heart failure with preserved ejection fraction. The severe left atrial dilation, preserved EF, ventricular wall thickening, and mild pulmonary hypertension form a constellation of findings that characterize HFpEF in a compensated state, particularly common in elderly women.