Echocardiography

1. Echocardiography Diastolic Function

2. Basic Principle • Definition of Diastole • the interval from aortic valve closure to mitral valve closure • Phases • Isovolumic relaxation • Rapid filling • Diastasis • Atrial contraction • At the point where LV pressure falls below LA atrial pressure, the mitral valve opens, ending IVR period.

3. Basic Principle • The rate and time course of blood flow from LA to LV is determined by • Pressure difference along the path • Ventricular relaxation • Relative compliances of the two chambers

4. Basic Principle

5. Basic Principle

6. Parameters of Diastolic Function • Clinically relevant parameters: • Ventricular relaxation • Myocardial compliance and Chamber Compliance • Left Ventricular end diastolic pressure (LV-EDP) • Ventricular Diastolic filling • Atrial Pressures and Filling

7. Parameters of Diastolic Function • Ventricular Relaxation • occurs during IVR and early diastolic filling • active process involving utilization of energy of the myocardium. • The measure of Ventricular Relaxation include the following: • Isovolumic relaxation time (IVRT) • The maximum rate of pressure decline (- dP/dt)

8. Parameters of Diastolic Function

9. Parameters of Diastolic Function -dP/dT dt -dP

10. Parameters of Diastolic Function Ventricular Compliance Compliance is the ratio of change in volume to change in pressure (dV/dP). Stiffness is the inverse of compliance: the ratio of change in pressure to change in volume (dP/dV)

11. Parameters of Diastolic Function • Compliance can be divided into: • Myocardial compliance – characteristics of the isolated myocardium • Chamber Compliance – characteristics of the entire chamber

12. Parameters of Diastolic Function

13. Parameters of Diastolic Function • Chamber compliance is influenced by: • Ventricular size and shape • Characteristics of the myocardium • Extrinsic factors: • pericardium • right ventricular volume • pleural pressure

14. Parameters of Diastolic Function Ventricular Diastolic Pressure Measurements of left ventricular end-diastolic pressure (LV-EDP) or PCWP is the most commonly available measure of diastolic function. (Review Swan Ganz Catheter).

15. Parameters of Diastolic Function • Ventricular Diastolic Filling (Volume) curves • Clinically available measure related to diastolic function is the time course of ventricular filling. • Can be measured using • Angiography • Computed tomography (Cat Scab) • Magnetic Resonance Imaging (MRI) • Doppler Echocardiaography

16. Parameters of Diastolic Function • Factors that affect Diastolic filling • Early filling • Ventricular Diastolic Function • Changes in the pressure difference between the ventricle and atrium due to changes in preload. • Changes in Transmitral volume flow rate (increased in mitral regurgitation). • Change in left atrial pressure.

17. Parameters of Diastolic Function • Late filling • Ventricular Diastolic function • Cardiac rhythm • Atrial contractile function • Ventricular end-diastolic pressure • Heart rate • Time of atrial Contraction

18. Parameters of Diastolic Function The utility of ventricular diastolic filling patterns for assessing diastolic function is valid only in the absence of obstruction at the atrioventricular valve level (mitral stenosis).

19. Parameters of Diastolic Function Atrial Pressure and Filling Curves Elevation in ventricular diastolic pressures will be reflected in elevated pressures in the atrium.

20. Parameters of Diastolic Function Atrial filling patterns are closely linked with diastolic ventricular function, especially in early diastole, when the AV valve is open, since the atrium serves as a conduit for flow from the venous circulation to the ventricle.

21. Left Atrial Filling • Left atrial filling • Small reversal of flow following atrial contraction (a wave). • Systolic filling phase. • Blunting of flow or brief reversal at end-systole. • Diastolic filling phase. • .

22. Left Atrial Filling

23. Atrial Filling Normal Respiratory Changes The patterns of right and left ventricular filling show normal respiratory variation.

24. Left Atrial Filling . Left side Left atrium filling does not increase with inspiration, since pulmonary venous return is entirely intra-thoracic and thus not affected significantly by respiratory changes in intra-thoracic pressure.

25. Left Atrial Filling . Left side The left atrial and consequently, left ventricular diastolic filling is slightly higher at end-expiration than during inspiration.

26. LV Diastolic Function • 2D/M-Mode Evaluation • Increased LV wall thickness (M-mode and 2D) • Degree and rate of motion of the LVPW (M-mode) • Pericardial thickening (M-mode and 2D) • Pattern of ventricular septal motion with respiration (M-mode) • Dilatation of IVC and hepatic veins (2D)

27. LV Diastolic Function • 2D.M-Mode Evaluation • Increased LV wall thickness (M-mode and 2D) • Degree and rate of motion of the LVPW (M-mode) • Pericardial thickening (M-mode and 2D) • Pattern of ventricular septal motion with respiration (M-mode) • Dilatation of IVC and hepatic veins (2D)

28. Left Ventricular Filling

29. Left Ventricular Filling

30. Left Ventricular Filling

31. Left Ventricular Filling

32. Left Ventricular Filling • Factors that Affect Doppler Left • Ventricular Filling • Technical • Normal Variations • Physiologic • Technical • Sample volume location • Doppler modality • Intercept angle

33. Left Ventricular Filling • Normal Variation • Respiration – Increase filling during inspiration on • the right, increase filling at end of expiration on the • left.

34. Left Ventricular Filling • Normal Variation • Heart rate – Increase heart rate shortens diastasis • so that the A velocity more closely follow the E • velocity.

35. Left Ventricular Filling

36. Left Ventricular Filling PR interval Longer PR interval results in an A velocity early in diastole.

37. Left Ventricular Filling Age As age increase E velocity diminishes and the atrial contribution becomes more prominent with equalization of the E and A velocities age 60 years and reversal of the E/A ratio after that age in normal individuals.

38. Left Ventricular Filling

39. Left Ventricular Filling • Physiological Factors • LA pressure (preload) • Volume flow rate (MR) • Left ventricular systolic function (LV-ESV) • Atrial contractile function

40. Left Ventricular Filling

41. Left Ventricular Filling • Pattern • Impaired Relaxation: • Prolong IVRT • Decreased early deceleration slope. • Decreased E wave • Increased A wave

42. Impaired Relaxation

43. Reduced Compliance • Pattern • Reduced Compliance: • Shorten IVRT • Increased E wave • Steep early deceleration slope • Decreased A wave

44. Reduced Compliance

45. Atrial Fibrillation

46. Left Atrial Filling • Left Atrial Filling • Window and Plane – Apical 4 chamber view • Vein interrogated – Right superior pulmonary vein.

47. Left Atrial Filling • Pattern • Small reversal of flow following atrial contraction (a wave) • Systolic filling phase • Blunting of flow or brief reversal at end-systole • Diastolic filling phase

48. Left Atrial Filling • From Transthoracic approach it is difficult • to obtain Doppler information due to poor • signal strength. Pay careful attention to • Sample volume placement • Wall filters setting • Gain setting

49. Left Atrial Filling • On TEE • The systolic inflow pattern is biphasic with an • early peak related to atrial relaxation and a • second late systolic peak related to displacement • of the mitral annulus toward the apex of the LV.

50. Left Atrial Filling • Factors that affect LA filling Pattern • Systolic Atrial Filling • Age • LA size • LA pressure • LA contractile function