Review of Diastolic Function Fundamentals PDF

Review of Diastolic Function Normal vs Abnormal Diastolic Function Normal Diastolic Function The ability of the heart to fill to a normal end diastolic volume without an increase end diastolic filling pressure both at rest and with exertion Abnormal Diastolic Function The heart...

Review of Diastolic Function Normal vs Abnormal Diastolic Function Normal Diastolic Function The ability of the heart to fill to a normal end diastolic volume without an increase end diastolic filling pressure both at rest and with exertion Abnormal Diastolic Function The heart is unable to fill to the normal volume needed to produce an adequate stroke volume without an abnormal increase in filling pressures Components of Diastolic Function Two major components intrinsic to the left ventricle 1. Active Myocardial Relaxation 2. Passive chamber compliance vs. stiffness  Components of Diastolic Function 1. Active relaxation Energy dependent process in early diastole Occurs during IVRT and Early, rapid filling Decrease of LV pressure Faster decrease = better relaxation (younger heart) Slower decrease = impaired relaxation (occurs with age)  Components of Diastolic Function 2. Passive compliance or stiffness Refers to how accepting the LV is to the blood flow Occurs as the ventricle is filling (early filling, diastasis, and atrial contraction) Components of Diastolic Function Passive compliance or stiffness Compliant ventricle allows blood flow without a large increase in pressure “sucks blood in” Noncompliant (stiff) ventricle requires large increase in pressure to increase ventricular volume “pushes blood in” Key Points about Diastolic Function 1. Myocardial relaxation is abnormal in all patients with diastolic dysfunction 2. Myocardial stiffness (non-compliance) results in increased filling pressures 3. Echocardiography measures myocardial relaxation and filling pressure 4. If systolic dysfunction is present, diastolic dysfunction will also be present Echo Assessment of Diastolic Function Left Atrial Volume Index Mitral Valve Inflow Pulmonary Vein Flow Tissue Doppler Imaging Pulmonary Pressures Left Atrial Volume Index As left atrial pressures increase to help fill a noncompliant left ventricle, the LA will enlarge Left Atrial Volume Index LA volume index = LA volume/BSA LA Volume Index Ranges of Severity (ASE Guidelines) Normal: 16-34 cc/m2 Mildly enlarged: 35-41 cc/m2 Moderately enlarged: 42-48 cc/m2 Severely enlarged: > 48 cc/m2  Mitral Inflow PW Doppler Use small SV size (1-3 mm) Optimize scale/baseline Low filter and gain settings Sweep speed: 100 mm/s Align Parallel to flow MV Inflow E velocity A velocity E/A ratio Deceleration Time A duration Mitral Valve Inflow: E and A waves E wave: peak velocity of early filling A wave: peak velocity of atrial contraction Mitral Valve Inflow Deceleration Time: (decel time, DT) The amount of time for the peak velocity of early filling to reach the zero baseline DT is influenced by LV relaxation, DT Filling pressures, and LV compliance Question: What happens to deceleration time when grade 1 diastolic dysfunction is present? DT becomes longer DT DT Normal DT: 150-200 ms Grade 1 DT: >200 ms Question: What happens to deceleration time when grade 3 (restrictive) diastolic dysfunction is present? DT becomes shorter DT DT Normal DT: 150-200 ms Grade 3 DT: < 150 ms (restrictive) Question: What happens to the E/A ratio in a Grade 1 pattern compared to normal diastolic function? E/A ratio will decrease E/A ratio: 1-2 E/A ratio < 0.8 Question: What happens to the E/A ratio in a Grade 3 pattern compared to normal diastolic function? E/A ratio will increase E/A ratio: 1-2 E/A ratio > 2 Mitral Valve Inflow Diastasis: period of time between E wave and A wave (slow filling phase) In normal setting this flow should be <.2 m/s E Diastasis A L wave Normal flow (increased filling pressure) Question: What effect will a faster HR have on diastasis? Increased HR = decreased diastasis HR: 66bpm HR: 90 bpm Question What Doppler signals do you need to calculate E/e’ ratio? Mitral Inflow  Tissue Doppler Imaging of the MV Annulus Movement of mitral valve annulus reflect relaxation properties of the heart Not affected by preload Helpful in determining filling pressures GrepMed Tissue Doppler Imaging of the MV Annulus Tissue Doppler Imaging adjusts the Doppler signal to demonstrate the movement of tissue rather than the movement of blood flow Tissue velocities are much lower than the blood flow velocities This is still a Doppler technique, so it is angle dependent… must be parallel to flow  Tissue Doppler Imaging Use Apical 4 chamber view, PW doppler Larger SV (5 -10 mm) Align cursor parallel to motion of the annulus making sure SV placed at level of highest “bounce” Obtain TDI from both medial and lateral MV annulus Bonita Anderson, real time images  Tissue Doppler Imaging Use Apical 4 chamber view, PW doppler Larger SV (5 -10 mm) Align cursor parallel to motion of the annulus making sure SV placed at level of highest “bounce” Obtain TDI from both medial and lateral MV annulus Bonita Anderson, real time images Tissue Doppler Imaging s’ e’ a’ Tissue Doppler of the Mitral Annulus Normal Values* medial lateral e’ velocity: >0.10 m/s >0.13 m/s E/e’ ratio: D If there are 2 components to systolic flow (S1,S2), the S2 velocity is measured Adapted from: Cardioserv  Figure 12 Journal of the American Society of Echocardiography 2019 32216-232.e2DOI: (10.1016/j.echo.2018.11.011) Copyright © 2018 American Society of Echocardiography Terms and Conditions Pulmonary Pressures Left ventricular diastolic dysfunction will result in increased pulmonary pressures RVSP = 4 (TR vel.)2 + RAP RVSP is equal to pulmonary pressure (in the setting of NO pulmonary stenosis or RVOT obstruction) Pulmonary pressures may be increased for other reasons Right Heart / Pulmonary Pressures TR velocity and IVC assessment 4 (VTR)2 + RAP if there is significant diastolic dysfunction, there will be elevated pulmonary pressure (TR velocity > 2.8 m/s) However: Diastolic Dysfunction is not the only cause of elevated pulmonary pressures  Right Heart /Pulmonary Pressures Calculate RVSP Estimated RAP of 3mmHg RVSP = 31 mmHg 4 (VTR)2 + RAP  Right Heart /Pulmonary Pressures Practice: Estimated RAP: 10 mmHg RVSP = 44 mmHg TR vel: 2.9 m/s 4 (VTR)2 + RAP  Normal Diastolic Function Tissue Doppler MV Annulus* Pulmonary Veins* Mitral Valve* medial lateral e’ velocity: >0.10 m/s >0.13 m/s Systolic > diastolic E/A ratio: 1-2 E/e’ ratio: A e’ velocity: < 0.07 m/s Larger atrial reversal E/A ratio: < 1.0-1.5 E/e’ ratio: > 14 Decel time: 150 - 200 ms L wave might be present LA index enlarged TR velocity > 2.8 msec *Values will vary by publication  Grade 3 and 4 Diastolic Dysfunction (restrictive) Pulmonary Veins* Tissue Doppler MV Annulus* Systolic < diastolic Mitral Valve* e’ and velocity: < 0.07 m/s (systolic may be blunted) E>A E/e’ ratio: > 14 (usually significantly high E/e’) Large atrial reversal E/A ratio: > 2 Decel time: < 150 ms LA index severely enlarged TR velocity > 2.8 msec *Values will vary by publication  LA index: 42cc/m2 Practice TR vel: 3.0 m/sec Mitral Valve* TDI MV annulus Pulmonary Veins* E velocity: 1.1 m/s D>S e’ : 0.06 Normal? no A velocity: 0.9 m/s E/e’ ratio: 18 Decel time: 180 ms E/A ratio: 1.2 Grade 2  LA index: 28cc/m2 Practice TR vel: 2.4 m/sec E:.7 Mitral Valve* TDI MV annulus Pulmonary Veins* E velocity: 0.7 m/s S>D e’ : 0.10 Normal? yes A velocity: 0.6 m/s E/e’ ratio: 7 Decel time: 175 ms E/A ratio: 1.2 Normal  LA index: 22 cc/m2 Practice TR vel: 2.2 m/sec Mitral Valve* TDI MV annulus Pulmonary Veins* E velocity: 0.6 m/s S>D e’ : 0.08 Normal? yes A velocity: 0.5 m/s E/e’ ratio: 8 Decel time: 186 ms E/A ratio: 1.2 Normal  LA index: 50 cc/m2 Practice TR vel: 3.6 m/sec Mitral Valve* E velocity: 1.2 m/s TDI MV annulus Pulmonary Veins* D>S A velocity: 0.5 m/s e’ : 0.03 Normal? no Decel time: 140 ms E/e’ ratio: 40 E/A ratio: 2.4 Grade 3/4  Practice Patient #10 EF: 68% E velocity.9 m/sec A velocity:.6 m/sec E/A ratio: 1.5 DT: 170 Septal e’: 5 cm/s (.05 m/s) Lateral e’: 8 cm/s (.08 m/s) E/e’ ratio (S): 18 E/e’ ratio (L): 11 Average E/e’ ratio: 15  Practice Patient #10 LA size: 47ml/m2 TR velocity: 3.6 m/sec Assume RA pressure: 10mmHg RVSP = 4(3.6)2 + 10mmHg RVSP = 52 mmHg + 10mmHg RVSP = 62 mmHg Diastolic function grade? Grade 2 Questions?