What is the clinical significance of a left ventricular ejection fraction (LVEF) of 48% by the Biplane Method of Discs, with associated grade II diastolic dysfunction, moderate mitral valve regurgitation, moderate tricuspid valve regurgitation, and moderate pulmonary hypertension?

From the Guidelines

The patient's cardiac profile suggests heart failure with mildly reduced ejection fraction, valvular disease, and pulmonary hypertension, and would benefit from cardiology consultation for management, which might include diuretics, ACE inhibitors or ARBs, beta-blockers, and possibly aldosterone antagonists depending on symptoms and clinical context. The echocardiogram shows a left ventricular ejection fraction of 48% by Biplane Method of Discs, indicating mild systolic dysfunction. The patient has grade II diastolic dysfunction, suggesting impaired relaxation and filling of the left ventricle. Right ventricular function remains normal with preserved systolic parameters (S' 12.2 cm/s and TAPSE 2.4 cm). The left atrium is enlarged, which often occurs as a consequence of increased filling pressures. There is moderate mitral and tricuspid valve regurgitation, indicating significant valvular disease. Moderate pulmonary hypertension is present with an estimated pulmonary arterial systolic pressure of 56 mmHg, which is concerning and requires attention, as suggested by the 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation 1. Despite these findings, the inferior vena cava shows normal right atrial pressure (8 mmHg) with appropriate respiratory variation. No pericardial effusion is noted.

The management of patients with heart failure and valvular disease, such as this patient, depends on an accurate diagnosis and assessment of the severity of the disease, as outlined in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. The patient's symptoms, clinical context, and echocardiographic findings should guide the management strategy. The use of diuretics, ACE inhibitors or ARBs, beta-blockers, and possibly aldosterone antagonists may be beneficial in managing the patient's heart failure and reducing symptoms, as suggested by the 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure 1.

Key considerations in the management of this patient include:

• The severity of the mitral and tricuspid valve regurgitation and its impact on left ventricular function
• The presence of pulmonary hypertension and its effect on right ventricular function
• The patient's symptoms and clinical context, including the presence of heart failure symptoms and the severity of the disease
• The potential benefits and risks of surgical intervention, such as valve repair or replacement, as outlined in the 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation 1.

Overall, the patient's cardiac profile suggests a complex clinical scenario that requires careful evaluation and management by a cardiologist, taking into account the latest evidence-based guidelines and recommendations, such as those outlined in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1 and the 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation 1.

From the Research

Patient's Condition

The patient has a fraction by Biplane Method of Discs of 48%, indicating left ventricular systolic dysfunction.

• The left ventricular diastolic function is grade II diastolic dysfunction, which means the left ventricle has difficulty relaxing and filling with blood during diastole.
• The right ventricular systolic function is normal, with an S' of 12.2 cm/s and a TAPSE of 2.4 cm, indicating preserved right ventricular function.
• The left atrial chamber dimension is enlarged, which can be a sign of increased pressure or volume overload in the left atrium.
• There is moderate mitral valve regurgitation and moderate tricuspid valve regurgitation, indicating blood is flowing backward through these valves.
• Moderate pulmonary hypertension is present, with an estimated pulmonary arterial systolic pressure of 56 mmHg.
• The inferior vena cava is dilated with >50% collapse upon inspiration, consistent with normal right atrial pressure, estimated at 8 mmHg.
• There is no pericardial effusion.

Treatment Options

According to the studies, the use of beta-blockers and ACE inhibitors can be beneficial in patients with cardiovascular diseases, including heart failure and hypertension 2, 3, 4, 5, 6.

• Beta-blockers can help manage arrhythmias, treat angina pectoris, and improve heart failure symptoms, while ACE inhibitors provide cardioprotection and treat congestive heart failure 2.
• The combination of beta-blockers and ACE inhibitors may be more effective than either agent alone in reducing cardiovascular events and improving outcomes 2, 6.
• However, the choice between beta-blockers and ACE inhibitors as first-line therapy may depend on individual patient characteristics and clinical presentation 6.