Is a left ventricular ejection fraction (LVEF) of 50% with cardiac valves regurgitation and pulmonary hypertension consistent with systolic heart failure?

LVEF of 50% with Cardiac Valves Regurgitation and Pulmonary HTN is Not Consistent with Systolic Heart Failure

An LVEF of 50% with cardiac valve regurgitation and pulmonary hypertension is not consistent with systolic heart failure, as systolic heart failure (HFrEF) is defined by an LVEF ≤40%. According to current guidelines, this clinical presentation would be classified as heart failure with preserved ejection fraction (HFpEF) 1.

Classification of Heart Failure Based on LVEF

Heart failure is classified according to left ventricular ejection fraction as follows:

• HFrEF (Heart Failure with reduced EF): LVEF ≤40%
• HFmrEF (Heart Failure with mildly reduced EF): LVEF 41-49%
• HFpEF (Heart Failure with preserved EF): LVEF ≥50% 1, 2

With an LVEF of 50%, this patient falls into the HFpEF category, not systolic heart failure.

Understanding the Clinical Picture

The combination of:

• LVEF of 50%
• Cardiac valve regurgitation
• Pulmonary hypertension

Represents a common clinical scenario in HFpEF where:

1. Valve Regurgitation: May be contributing to or resulting from the heart failure syndrome. Mitral regurgitation in particular can develop as a consequence of left ventricular remodeling or primary valvular disease 1.

2. Pulmonary Hypertension: Often develops in HFpEF due to elevated left ventricular filling pressures that are transmitted backward to the pulmonary circulation. This is classified as pulmonary venous hypertension (postcapillary pulmonary hypertension) 3, 4.

Diagnostic Considerations

The 2016 ESC guidelines on heart failure indicate that for HFpEF diagnosis, additional evidence of diastolic dysfunction or increased LV filling pressures should be present 1:

• E/e' ratio ≥14
• Average e' velocity <9 cm/s
• Elevated natriuretic peptides
• Left atrial enlargement
• Evidence of LV hypertrophy

Importance of Valve Assessment

The presence of valve regurgitation requires careful evaluation:

• The severity of regurgitation should be quantified using parameters such as effective regurgitant orifice area (EROA), regurgitant volume, and regurgitant fraction 1
• Secondary (functional) mitral regurgitation in the setting of preserved LVEF may have different thresholds for severity compared to primary MR 1
• Valve regurgitation can contribute to pulmonary hypertension and heart failure symptoms even with preserved LVEF 4

Right Ventricular Function Assessment

Given the presence of pulmonary hypertension, assessment of right ventricular function is critical:

• RV dysfunction can develop as a consequence of pulmonary hypertension even with preserved LVEF 3
• Parameters such as TAPSE <16 mm indicate RV systolic dysfunction 1
• Tricuspid regurgitation peak velocity >3.4 m/s suggests significant pulmonary hypertension 1

Clinical Implications

This patient likely has heart failure with preserved ejection fraction (HFpEF) with valvular heart disease and pulmonary hypertension. The management approach would differ significantly from that of systolic heart failure (HFrEF):

• Treatment would focus on managing volume status and addressing the valvular disease
• Negative inotropic agents that might be used in HFpEF could be harmful in HFrEF
• Surgical intervention for valve disease would be considered based on different criteria than for patients with reduced LVEF 1

Conclusion

The clinical picture of LVEF 50% with valve regurgitation and pulmonary hypertension is consistent with heart failure with preserved ejection fraction (HFpEF) rather than systolic heart failure. This distinction is crucial for appropriate management decisions.