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Assessment of Diastolic function by echo

Assessment of Diastolic function by echo. Dr Shreetal Rajan Nair. Diastolic function. Physiology Epidemiology of diastolic dysfunction Diastolic heart failure – definitions Etiology of diastolic dysfunction Echo assessment of diastolic function - present guidelines

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Assessment of Diastolic function by echo

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  1. Assessment of Diastolic function by echo Dr Shreetal Rajan Nair

  2. Diastolic function • Physiology • Epidemiology of diastolic dysfunction • Diastolic heart failure – definitions • Etiology of diastolic dysfunction • Echo assessment of diastolic function - present guidelines - newer concepts

  3. Diastolic dysfunction defined as an inability of the left ventricle (LV) to attain a normal end-diastolic volume without an inappropriate increase in LV end-diastolic pressure (LVEDP)

  4. Epidemiology – Heart Failure with Preserved Ejection Fraction (HF-PEF) • Accounts for 50% of cases of heart failure • older , more in females and more incidence in obese • Associated with hypertension,T2DM,dyslipidemia, and atrial fibrillation (AF). Patients with HF-PEF have • a worse prognosis than those with Heart Failure with Reduced Ejection Fraction (HF-REF)

  5. HF- PEF - DIAGNOSIS • 1. Symptoms typical of HF • 2. Signs typical of HF • 3. Normal or only mildly reduced LVEF and LV not dilated • 4. Relevant structural heart disease (LV hypertrophy/LA enlargement) and/or diastolic dysfunction ESC 2012

  6. ACCF/AHA 2013 a) clinical signs or symptoms of HF b) evidence of preserved or normal LVEF c) evidence of abnormal LV diastolic dysfunction that can be determined by Doppler echocardiography or cardiac catheterization

  7. Physiology The ventricle has two alternating functions: • systolic ejection • diastolic filling Diastole can be divided into four phases:   ▪Isovolumic relaxation▪   The early rapid diastolic filling phase▪Diastasis▪   Late diastolic filling due to atrial contraction Left atrium functions as a RESERVOIR during systole, CONDUIT during early diastole and PUMP during late diastole

  8. Atrial Pressures and Filling Curves

  9. RA filling • Right atrial filling is characterized by  ▪   Small reversal of flow following atrial contraction (a wave)▪   Systolic phase : when blood flows from the superior and inferior vena cava into the atrium▪   Small reversal of flow at end-systole (v wave)▪   Diastolic filling phase when the atrium serves as a conduit for flow from the systemic venous return to the RV

  10. LA fiiling • LA filling from the pulmonary veins also is characterized by : ▪   Small reversal of flow following atrial contraction (a wave)▪   Systolic filling phase▪   Blunting of flow or brief reversal at end-systole (v wave)▪   Diastolic filling phase

  11. Determinants of diastolic function • Ventricular relaxation and compliance • LA volume and function • Heart rate • Pericardium Derangement of any of the above will lead to abnormal filling pressures and diastolic dysfunction

  12. Factors affecting diastolic filling • Early diastolic filling affected by preload transmitral volume flow rate atrial pressure Late diastolic filling is affected by: Cardiac rhythm Atrial contractile function Ventricular end-diastolic pressure

  13. Etiology of diastolic dysfunction

  14. Classification: diastolic dysfunction Grade 1 (mild dysfunction) : impaired relaxation with normal filling pressure Grade 1a : impaired relaxation with increased filling pressure Grade 2 (moderate dysfunction): pseudonormalized mitral inflow pattern Grade 3 (severe reversible dysfunction): reversible restrictive (high filling pressure) Grade 4(severe irreversible dysfunction): irreversible restrictive (high filling pressure)

  15. Echo assessment of diastolic function Echocardiographic assessment of diastolic filling pressure has been aptly described as “ noninvasive Swan-Ganz catheter ” • 2D • Doppler – PW,CW and TDI • M mode • Newer modalities

  16. Diastolic function assessment Anatomic correlates Functional correlates

  17. 2D • LV mass and dimensions LV hypertrophy is the commonest cause of diastolic dysfunction Relative wall thickness : • LA volume and LA volume index

  18. LA volume and LA volume index • LA volume index >34ml/m2 - independent predictor of death, heart failure, atrial fibrillation and ischemic stroke • Limitations: dilated left atria – bradycardia,anemia and other high-output states, atrial flutter or fibrillation and significant mitral valve disease

  19. Ventricular Relaxation • IVRT • the maximum rate of pressure decline(–dP/dt) • the time constant of relaxation (tau or τ)

  20. Tau and ventricular relaxation

  21. Tau and Weiss formula • t corresponds to the time it takes for LVP to fall to 1/e (36%) of its initial value. • The formula also indicates that LVP fall, and therefore relaxation, will be 97% complete 3.5*t after dP/dt • Diastolic dysfunction is present when tau is >48 ms • Pt=(P0-P‘)e-t/t+P‘ • where Pt is LVP at time t; P0 is LVP at dP/dt min (time 0); P‘ is the asymptotic pressure, to which relaxation would lead if completed without LV filling. • P‘ is negative in normal ventricles, which means that the non-filling ventricle develops diastolic suction.

  22. Ventricular Compliance and stiffness • 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)

  23. SURROGATE MESUREMENTS of ventricular stiffness • DT of mitral velocity Stiffness [in millimeters of mercury per ml] is calculated as K = [70ms/(DT- 20ms) A wave transit time

  24. The slope (Kc) of this line is the chamber stiffness constant and can be used to quantify chamber stiffness.

  25. Acquisition of mitral inflow • apical 4 chamber, PW • 1 mm – 3mm sample volume between mitral valve tips • initially obtained at sweep speeds of 25 to 50 mm/s for the evaluation of respiratory variation of flow velocities • If variation is not present, the sweep speed is increased to 100 mm/s, at end-expiration, averaged over 3 consecutive cardiac cycles

  26. Mitral inflow Primary measurements • the peak early filling (E-wave) • late diastolic filling (A-wave) velocities • the E/A ratio • deceleration time (DT) of early filling velocity • the IVRT derived by placing the cursor of CW Doppler in the LV outflow tract to simultaneously display the end of aortic ejection and the onset of mitral inflow

  27. Mitral inflow Secondary measurements • mitral A-wave duration (obtained at the level of the mitral annulus) diastolic filling time • the A-wave velocity-time integral and the total mitral inflow velocity-time integral (and thus the atrial filling fraction) • Mid diastolic flow is an important signal to recognize. Low velocities can occur in normal subjects but when increased (>20 cm/s)- represent markedly delayed LV relaxation and elevated filling pressures

  28. The mitral L wave • distinct forward flow velocity after the E wave with a peak velocity >20cm/s • Marker of advanced diastolic dysfunction • Delayed and prolonged LV relaxation • Increased LA pressure • Effect of valsalva and leg elevation • More frequently seen in AF patients Eur J Echocardiography (2006) 7, 16-21; Ha et al Circ J 2007; 71: 1244–1249; Nakai et al

  29. The mitral L wave

  30. IVRT • time interval between aortic valve closure and mitral valve opening • normal IVRT is approximately 80 to 100 ms • Impaired relaxation associated with prolonged IVRT • Decreased compliance and elevated filling pressures associated with shortened IVRT Useful in determining the severity of diastolic dysfunction particularly in serial studies of patients on medical therapy or with disease progression

  31. IVRT CW Doppler in the LV outflow tract to simultaneously display the end of aortic ejection and the onset of mitral inflow.

  32. Limitations of mitral inflow measurement • sinus tachycardia • conduction system disease • Arrhythmias Sinus tachycardia and first-degree AV block can result in partial or complete fusion of the mitral E and A waves (mitral DT cannot be measurable; IVRT can be measured

  33. Limitations of mitral inflow measurement In atrial flutter • Unable to measure E velocity, E/A ratio or DT In AV blocks • multiple atrial filling waves are seen, with diastolic mitral regurgitation (MR) interspersed between non conducted atrial beats • PA pressures calculated from Doppler TR and PR

  34. Valsalva maneuver Clinical applications • A pseudo normal mitral inflow pattern is caused by a mild to moderate increase in LA pressure in the setting of delayed myocardial relaxation • Because the Valsalva maneuver decreases preload during the strain phase, pseudo normal mitral inflow changes to a pattern of impaired relaxation • In cardiac patients, a decrease of >/= 50% in the E/A ratio is highly specific for increased LV filling pressures, but a smaller magnitude of change does not always indicate normal diastolic function.

  35. QUANTITATIVE ANALYSIS • 1 . MAXIMUM VELOCITIES • 2 . VELOCITY TIME INTEGRALS • 3 . TIME INTERVALS • 4 . ACCELERATION AND DECELERATION

  36. TDI - acquisition • PW apical view • The sample volume should be positioned at or 1 cm within the septal and lateral insertion sites of the mitral leaflets. • sweep speed of 50 to 100 mm/s at end-expiration ; average of >/= 3 consecutive cardiac cycles. • For the assessment of global LV diastolic function, it is recommended to acquire and measure tissue Doppler signals at least at the septal and lateral sides of the mitral annulus and their average. • In patients with cardiac disease, e’ can be used to correct for the effect of LV relaxation on mitral E velocity, and the E/e’ ratio can be applied for the prediction of LV filling pressures. • The E/e’ ratio is not accurate as an index of filling pressures in normal subjects or in patients with heavy annular calcification, mitral valve disease and constrictive pericarditis

  37. TDI • Early diastolic filling velocity (e′) • Filling velocity after atrial contraction (A′) • Ratio of early to atrial diastolic myocardial velocity (e′/A′) • Ratio of transmitral blood flow velocity to tissue Doppler velocity (E/e′)

  38. Medial vs lateral annular velocities • use the average (septal and lateral) e´ velocity in the presence of regional dysfunction • septal E/e´ ratio <8 is usually associated with normal LV filling pressures a ratio >15 is associated with increased filling pressures • between 8 and 15, other echocardiographic indices should be used. • In normal EFs, lateral tissue Doppler signals(E/e ánd e´/a´) have the best correlations with LV filling pressures and invasive indices of LV stiffness.

  39. TE-e´is particularly useful in situations in which the peak e´velocity has its limitations the E/e´ ratio is 8 to 15. • an IVRT/TE-e´ratio ,2 has reasonable accuracy in identifying patients with increased LV filling pressures

  40. PCWP and E/e’

  41. PCWP and E/e’

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