C3: Diastolic Dysfunction Flashcards
relaxation phase of ventricular filling includes which phases
IVRT, early filling only
what is compliance
change in volume over change in pressure (Dv/Dp)
compliance is inverse to what
stiffness (Dp/Dv)
filling pressure include which 2 values
LVEDP - pressure after the ventricle has filled
Mean LA pressure - avg press during the filling period of the LA
IVRT is influenced by what 3 things
conduction abnormalities or mechanics loading conditions (pre load and LAP) age
what causes the ‘sucking’ in early filling
elastic recoil properties of ventricular relaxation
why does DT occur
the LA/LV press gradient starts to fall which slows down blood entering the LV
rapid filling in influenced by what 4 things
rate of LV relaxation
elastic recoil of LV
chamber compliance
LAP
what determines the length of diastasis
HR
slow = longer fast = short or absent
is atrial kick abscent w/ afib
yes
is diastolic dysfunction and increased LV filling pressure the same thing
no… elevated filling pressures occur as a result of diastolic dysfunction
describe a compliant ventricle
can increase its volume w/o increasing its pressure significantly
review pressure and volume graphs
/
how does high preload effect pressure
ventricle will have an increased EDP
2D changes to the LV mass w/ diastolic dysfunction
LV will hypertrophy making it less compliant, then when the heart starts to fail, the LV will dilate
does LV mass increase w/ either an increase in wall thickness or w/ an increase in chamber dimension?
yes
2D changes to the LA volume w/ diastolic dysfunction
Mean LA pressures will start to increase and the LA will dilate
in diastolic dysfunction, does the LA dilate before the LV
yes, it has thinner walls (2-3mm)
when can the LA volume appear normal when it really isnt?
if the patient is obese, LA volume is indexed to BSA, so this value will be inaccurate
norm value for LA volume index
severely abnorm
N: = 34 ml/m^2
AB: >/= 48ml/m^2
4 causes of diastolic dysfunction
- Primary myocardial disease
- Secondary myocardial disease/hypertrophy
- CAD
- Extrinsic factors
which cause of diastolic dysfunction is most common
Secondary hypertrophy/myocardial disease
How does primary myocardial disease cause diastolic dysf.
give examples
Through changes to the ventricle muscle itself
eg. dilated cardiomyopathy (CMO)
infiltrative myocardial disease
hypertrophic CMO
How does secondary myocardial disease cause diastolic dysf.
give examples
changes to the ventricle muscle, due to another disease cause the dysf.
eg. HTN
AS
severe MR
What is the most common cause of secondary myocardial disease
HTN
why does CAD cause diastolic dysf.
give examples
wall segments can’t contract or properly properly due to lack of blood supply
eg. ischemia
infarction
what extrinsic factors can cause diastolic dysf.
pericardial tamponade
pericardial constriction
these conditions constrict the heart
7 factors effecting all diastolic measures
HR rhythm preload LV systolic function respiration age PR interval/conduction of the heart
what can artificially increase the height of the E wave on mitral inflow
Anything that increased preload: MR too much sodium pregnancy obesity
what are the grades of diastolic dysfunction for the LV
normal
Grade I: impaired relaxation (mild)
Grade II: pseudo-normal (moderate)
Grade III: restrictive filling (severe)
4 parameters assessed to grade diastolic dysfunction (DD) of the LV in all patients (normal OR depressed EF)
MV inflow (E/A ratio)
Avg E/e pime ratio
LA volume index
TR jet velocity (RVSP)
these are the minimum requirements to grade DD and LA pressure
in patients w/ normal EF, how can we determine if LV DD is present
look at:
- Avg E/e pime ratio
- septal and lateral e’ velocities
- TR velocity
- LA volume index
<50% + = norm func.
50% + = indeterminate
>50% + = DD
is LAP elevated in grade 1 DD
grade II an III
GI: no
GII and III: yes
what one parameter can indicate the patient has grade III DD of the LV
E/A ratio >/= 2
norm value for LV diastolic press and LAMP
3-12 mmHg
norm value for E/A ratio
norm value for E velocity
E/A: 0.8-2
E: 0.6-1.3 m/s
norm value for DT
160-220ms
describe the changes seen w/ grade I DD on MV inflow and TDI
theres a smaller press gradient b/w the LV and LA due to a stiffer ventricle which causes delayed or slowed myocardial relaxation w/ norm filling press…
- reduced e/a ratio
- reduced E velocity
- IVRT and DT are prolonged
- reduced TDI
what determines the height of the E inflow wave
press gradient b/w the LV and LA
when would it be norm for the E/A ratio to be revered/reduced
> 60 years of age
norm value for E/e ratio
<8…. 8-12 may be indeterminate in terms of diagnosing DD
describe the changes seen w/ grade I DD on MV TDI
both e prime values will be reduced (< 7 cm/s and <10 cm/s)
whats the only way to tell the difference b/w pseudo normal and normal
compare the E wave of MV inflow to the e prime TDI.
w/ pseudo-normal, patient will have norm E wave and reduced e prime because the ventricle is stiff
which parameters will still be norm w/ grade I DD of the LV
E/e prime
TR jet velocity
symptoms (Sx) of GI DD of the LV
mild shortness or breath w/ exertion
when theres no pulmonary or R heart disease, TR jet velocity is an accurate reflection of what?
left heart filling pressures
when the Tr jet is > 2.8 m/s, what does that indicate
increased filling press and ore severe grade of DD
describe GII LV DD
pseudo-normal
-impaired relaxation and moderate reduction of LV compliance which increases LAP
why does the MV inflow look norm w/ GrII DD
the increased LAP increases the driving press across the MV when it opens which makes it look normal….
….basically both pressures are elevated so the press. gradient b/w the LV and LA is essentially the same as w/ a norm heart.
MV inflow and TDI characteristics w/ Gr II DD
everything looks normal except e’ prime which is reduced and the E/e prime ratio is elevated (~ 10-14)
which MV inflow parameter shortens in duration as LAP increases
A wave
Sx of Gr II LV DD
SOB and lower levels of activity than G I
w/ Gr II LV DD, how can you force the MV inflow to look abnormal
how does this work
valsalva…
this reduces venous return to the RT heart, then the LT heart, which reduced preload…..
…. if you reduce preload you reduce the LA pressure and Gr II MV inflow will convert to a Gr I MV inflow appearance
E wave will reduce >50% in velocity if +
why would you see mid diastolic flow with Gr II LV DD
the LV/LA pres gradient can sometimes be maintained into diastasis which results in flow across the MV is this phase
name of the wave seen during diastasis w/ Gr II LV DD
when is it commonly seen
L wave (think ELA, names of waves, to remember)
if the patient has LVH and lower HR
with higher HR’s would you still see the L wave?
no
E and L would fuse
what is a B bump?
extra bump seen on MV M-mode tracing, b/w the A and C waves (think A,B,C, names of waves, to remember)
what do the B bump and L wave indicate
increased LAP
describe Gr III LV DD
what are the most important parameters that will be altered?
reduced Lv compliance and increased filling press, LAP ++
see waveforms and list on page 40 of DD.... (-reduced DT -E/A ratio >2 -increased E/e prime -small e prime)
symptoms of Gr III LV DD
dyspnea w/ minimal exertion and reduced exercise tolerance
pedal or abdo seems
why is IVRT shortened w/ Gr III LV DD
LAP ++ so the press gradient b/w LV and LA is increased, and blood moves very quick into the LV
how will MV inflow of Gr III LV DD change
increase e velocity
short DT
short IVRT
E/A ratio >2
how will MV TDI of Gr III LV DD change
very small e prime and a prime
E/e prime ratio increased (over 14)
how will pulmonary venous flow change w/ Gr III LV DD
larger a wave velocity
a wave reversal increases in duration
s will become very small
diastolic dominant flow…. d wave will get larger
is the PV flow profile useful in LV DD patients w/ normal EF
no, it will look normal
what happens to the duration of the A wave on MV inflow w/ Gr III LV DD
why
decreases in duration and has a lower velocity
the LA cant empty into the LV easily due to high press so the blood takes the path of least resistance and travels back into the PV instead
where should you place your SV when measuring the MV A wave duration
MV annulus
norm PV a - MV A duration
severely abnormal value (indicating Gr III DD)
N: < 20 ms
> /= 30 ms
PV profile w/ Gr I LV DD
taller S and smaller D
PV profile w/ Gr II LV DD
normal
PV profile w/ Gr III LV DD
small S, tall D and larger A
treatment for LV DD
treat the underlying condition (HTN, obesity, etc)… otherwise exercise is the only treatment that directly alters DD
key differences b/w RV and LV DD
- RV inflow velocites vary w/ breathing due to intrathoracic press
- Rv inflow velocities are lower b/c the TV is larger
- RV diastolic filling time in longer, Tv opens before and closes after the MV
grades of DD for RV
GI: impaired relaxation (mild)
GII: pseudo-normal
GIII: restrictive filling
criteria for GI DD of RV
E/A <0.8
criteria for GII DD of RV
E/A 0.8-2.1
E/e prime >6 ( or HV diastolic flow predominance
criteria for G III DD of RV
E/A >2.1
DT <120 ms
how will RV DD effect the IVC
will be dilated and won’t collapse
what does norm HV flow look like
abnormal?
like PV flow but inverted
DIASTOLIC FLOW PREDOMINANCE
smaller S wave
larger D wave
larger A wave
