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Echo 2 > C3: Diastolic Dysfunction > Flashcards

C3: Diastolic Dysfunction Flashcards

1
Q

relaxation phase of ventricular filling includes which phases

A

IVRT, early filling only

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2
Q

what is compliance

A

change in volume over change in pressure (Dv/Dp)

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3
Q

compliance is inverse to what

A

stiffness (Dp/Dv)

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4
Q

filling pressure include which 2 values

A

LVEDP - pressure after the ventricle has filled

Mean LA pressure - avg press during the filling period of the LA

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5
Q

IVRT is influenced by what 3 things

A 
conduction abnormalities or mechanics
loading conditions (pre load and LAP)
age
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6
Q

what causes the ‘sucking’ in early filling

A

elastic recoil properties of ventricular relaxation

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7
Q

why does DT occur

A

the LA/LV press gradient starts to fall which slows down blood entering the LV

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8
Q

rapid filling in influenced by what 4 things

A

rate of LV relaxation
elastic recoil of LV
chamber compliance
LAP

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9
Q

what determines the length of diastasis

A

HR

slow = longer
fast = short or absent
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10
Q

is atrial kick abscent w/ afib

A

yes

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11
Q

is diastolic dysfunction and increased LV filling pressure the same thing

A

no… elevated filling pressures occur as a result of diastolic dysfunction

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12
Q

describe a compliant ventricle

A

can increase its volume w/o increasing its pressure significantly

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13
Q

review pressure and volume graphs

A

/

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14
Q

how does high preload effect pressure

A

ventricle will have an increased EDP

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15
Q

2D changes to the LV mass w/ diastolic dysfunction

A

LV will hypertrophy making it less compliant, then when the heart starts to fail, the LV will dilate

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16
Q

does LV mass increase w/ either an increase in wall thickness or w/ an increase in chamber dimension?

A

yes

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17
Q

2D changes to the LA volume w/ diastolic dysfunction

A

Mean LA pressures will start to increase and the LA will dilate

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18
Q

in diastolic dysfunction, does the LA dilate before the LV

A

yes, it has thinner walls (2-3mm)

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19
Q

when can the LA volume appear normal when it really isnt?

A

if the patient is obese, LA volume is indexed to BSA, so this value will be inaccurate

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20
Q

norm value for LA volume index

severely abnorm

A

N: = 34 ml/m^2

AB: >/= 48ml/m^2

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21
Q

4 causes of diastolic dysfunction

A
  1. Primary myocardial disease
  2. Secondary myocardial disease/hypertrophy
  3. CAD
  4. Extrinsic factors
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22
Q

which cause of diastolic dysfunction is most common

A

Secondary hypertrophy/myocardial disease

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23
Q

How does primary myocardial disease cause diastolic dysf.

give examples

A

Through changes to the ventricle muscle itself

eg. dilated cardiomyopathy (CMO)
infiltrative myocardial disease
hypertrophic CMO

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24
Q

How does secondary myocardial disease cause diastolic dysf.

give examples

A

changes to the ventricle muscle, due to another disease cause the dysf.

eg. HTN
AS
severe MR

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25
Q

What is the most common cause of secondary myocardial disease

A

HTN

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26
Q

why does CAD cause diastolic dysf.

give examples

A

wall segments can’t contract or properly properly due to lack of blood supply

eg. ischemia
infarction

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27
Q

what extrinsic factors can cause diastolic dysf.

A

pericardial tamponade
pericardial constriction

these conditions constrict the heart

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28
Q

7 factors effecting all diastolic measures

A 
HR
rhythm
preload
LV systolic function
respiration
age
PR interval/conduction of the heart
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29
Q

what can artificially increase the height of the E wave on mitral inflow

A 
Anything that increased preload:
MR
too much sodium
pregnancy
obesity
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30
Q

what are the grades of diastolic dysfunction for the LV

A

normal
Grade I: impaired relaxation (mild)
Grade II: pseudo-normal (moderate)
Grade III: restrictive filling (severe)

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31
Q

4 parameters assessed to grade diastolic dysfunction (DD) of the LV in all patients (normal OR depressed EF)

A

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

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32
Q

in patients w/ normal EF, how can we determine if LV DD is present

A

look at:

  1. Avg E/e pime ratio
  2. septal and lateral e’ velocities
  3. TR velocity
  4. LA volume index

<50% + = norm func.
50% + = indeterminate
>50% + = DD

33
Q

is LAP elevated in grade 1 DD

grade II an III

A

GI: no

GII and III: yes

34
Q

what one parameter can indicate the patient has grade III DD of the LV

A

E/A ratio >/= 2

35
Q

norm value for LV diastolic press and LAMP

A

3-12 mmHg

36
Q

norm value for E/A ratio

norm value for E velocity

A

E/A: 0.8-2

E: 0.6-1.3 m/s

37
Q

norm value for DT

A

160-220ms

38
Q

describe the changes seen w/ grade I DD on MV inflow and TDI

A

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
39
Q

what determines the height of the E inflow wave

A

press gradient b/w the LV and LA

40
Q

when would it be norm for the E/A ratio to be revered/reduced

A

> 60 years of age

41
Q

norm value for E/e ratio

A

<8…. 8-12 may be indeterminate in terms of diagnosing DD

42
Q

describe the changes seen w/ grade I DD on MV TDI

A

both e prime values will be reduced (< 7 cm/s and <10 cm/s)

43
Q

whats the only way to tell the difference b/w pseudo normal and normal

A

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

44
Q

which parameters will still be norm w/ grade I DD of the LV

A

E/e prime

TR jet velocity

45
Q

symptoms (Sx) of GI DD of the LV

A

mild shortness or breath w/ exertion

46
Q

when theres no pulmonary or R heart disease, TR jet velocity is an accurate reflection of what?

A

left heart filling pressures

47
Q

when the Tr jet is > 2.8 m/s, what does that indicate

A

increased filling press and ore severe grade of DD

48
Q

describe GII LV DD

A

pseudo-normal

-impaired relaxation and moderate reduction of LV compliance which increases LAP

49
Q

why does the MV inflow look norm w/ GrII DD

A

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.

50
Q

MV inflow and TDI characteristics w/ Gr II DD

A

everything looks normal except e’ prime which is reduced and the E/e prime ratio is elevated (~ 10-14)

51
Q

which MV inflow parameter shortens in duration as LAP increases

A

A wave

52
Q

Sx of Gr II LV DD

A

SOB and lower levels of activity than G I

53
Q

w/ Gr II LV DD, how can you force the MV inflow to look abnormal

how does this work

A

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 +

54
Q

why would you see mid diastolic flow with Gr II LV DD

A

the LV/LA pres gradient can sometimes be maintained into diastasis which results in flow across the MV is this phase

55
Q

name of the wave seen during diastasis w/ Gr II LV DD

when is it commonly seen

A

L wave (think ELA, names of waves, to remember)

if the patient has LVH and lower HR

56
Q

with higher HR’s would you still see the L wave?

A

no

E and L would fuse

57
Q

what is a B bump?

A

extra bump seen on MV M-mode tracing, b/w the A and C waves (think A,B,C, names of waves, to remember)

58
Q

what do the B bump and L wave indicate

A

increased LAP

59
Q

describe Gr III LV DD

what are the most important parameters that will be altered?

A

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)
60
Q

symptoms of Gr III LV DD

A

dyspnea w/ minimal exertion and reduced exercise tolerance

pedal or abdo seems

61
Q

why is IVRT shortened w/ Gr III LV DD

A

LAP ++ so the press gradient b/w LV and LA is increased, and blood moves very quick into the LV

62
Q

how will MV inflow of Gr III LV DD change

A

increase e velocity
short DT
short IVRT
E/A ratio >2

63
Q

how will MV TDI of Gr III LV DD change

A

very small e prime and a prime

E/e prime ratio increased (over 14)

64
Q

how will pulmonary venous flow change w/ Gr III LV DD

A

larger a wave velocity
a wave reversal increases in duration

s will become very small
diastolic dominant flow…. d wave will get larger

65
Q

is the PV flow profile useful in LV DD patients w/ normal EF

A

no, it will look normal

66
Q

what happens to the duration of the A wave on MV inflow w/ Gr III LV DD

why

A

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

67
Q

where should you place your SV when measuring the MV A wave duration

A

MV annulus

68
Q

norm PV a - MV A duration

severely abnormal value (indicating Gr III DD)

A

N: < 20 ms

> /= 30 ms

69
Q

PV profile w/ Gr I LV DD

A

taller S and smaller D

70
Q

PV profile w/ Gr II LV DD

A

normal

71
Q

PV profile w/ Gr III LV DD

A

small S, tall D and larger A

72
Q

treatment for LV DD

A

treat the underlying condition (HTN, obesity, etc)… otherwise exercise is the only treatment that directly alters DD

73
Q

key differences b/w RV and LV DD

A
  1. RV inflow velocites vary w/ breathing due to intrathoracic press
  2. Rv inflow velocities are lower b/c the TV is larger
  3. RV diastolic filling time in longer, Tv opens before and closes after the MV
74
Q

grades of DD for RV

A

GI: impaired relaxation (mild)
GII: pseudo-normal
GIII: restrictive filling

75
Q

criteria for GI DD of RV

A

E/A <0.8

76
Q

criteria for GII DD of RV

A

E/A 0.8-2.1

E/e prime >6 ( or HV diastolic flow predominance

77
Q

criteria for G III DD of RV

A

E/A >2.1

DT <120 ms

78
Q

how will RV DD effect the IVC

A

will be dilated and won’t collapse

79
Q

what does norm HV flow look like

abnormal?

A

like PV flow but inverted

DIASTOLIC FLOW PREDOMINANCE
smaller S wave
larger D wave
larger A wave

Echo 2 (15 decks)

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