Diastolic Dysfunction Flashcards
Left ventricular diastolic dysfunction (DD) is defined as the inability of the ventricle to fill to a normal end-diastolic volume, both during exercise as well as at rest, while left atrial pressure does exceed ________
12 mmHg
*Normal LAP: 8-10 mmHg
most common cause of DD?
HTN
What are the causes of DD?
- HTN *main cause
- CAD: ischemia, myocardial fibrosis
- DM (Diabetes mellitus): hyperglycemia *coexistent CAD & HTN
- HCM (hypertrophic cardiomyopathy): fibrosis, afterload, myocardial disarray (Myocardial disarray, also known as myocyte disarray, is a term to describe the loss of the normal parallel alignment of myocytes (the muscle cells of the heart). Instead, the myocytes usually form circles around foci of connective tissue)
- RCM (restrictive cardiomyopathy): fibrosis, direct cellular injury, infiltration
Diastolic Dysfunction Criteria for diagnosis:
abnormal relaxation without increased LV end-diastolic filling pressure (decreased E/A ration <0.75)
diagnosis?
mild diastolic dysfunction
Diastolic Dysfunction Criteria for diagnosis:
abnormal relaxation with increased LV end-diastolic filling pressure (E/A 0.75 to 1.5, deceleration time > 140 ms, plus 2 other Doppler indices of elevated end-diastolic filling pressure)
moderate or “psedonormal”
Diastolic Dysfunction Criteria for diagnosis:
advanced reduction in compliance, (i.e. markedly increased stiffness) with restrictive filling (E/A ration of > 1.5, deceleration time < 140 ms, and Doppler indices of elevated LV end-diastolic filling pressure)
severe
Diastolic Dysfunction Criteria for diagnosis:
Atrial fibrillation patients: diastolic function is indeterminate unless restrictive physiology:_________
E/A > 1.5, deceleration time < 140 ms
Left Ventricle Diastole: Physiology
process 1-10
- Begins with AV closure
- LV pressure decreases
- IVRT – time between AV closure and MV opening
- LV pressure is dropping – Volume is unchanged (NO MR or AR!) *pressure gradient may decrease in the presence of MR/AR
- MV opens (LV pressure drops below LA pressure)
- LV fills during early diastolic filling - E wave ( LV relaxation allows positive transmitral pressure gradient)
- LV is filling, LA pressure drops & LA pressure rises
- Decreased transmitral pressure gradient and LV filling decreases - between E & A
- Rate of LV filling in early diastolic is related to LV stiffness (Increased LV stiffness = faster deceleration of LV filling)
- LA contracts in late diastole to create another positive transmitral pressure gradient and more LV filling in late diastole *atrial kick
4 stages of diastole
- isovolumetric relaxation
- rapid early LV filling
- slow LV filling = diastasis (In physiology, diastasis is the middle stage of diastole during the cycle of a heartbeat, where the initial passive filling of the heart’s ventricles has slowed, but before the atria contract to complete the active filling)
- atrial contraction
What happens during stage 1 of diastole?
stage 1: Isovolumetric relaxation
LV pressure rapidly drops below LAP without change in volume
What happens during stage 2?
stage 2: rapid early LV filling
After MV opens, LV pressure lower than LA
*E wave occurs
What happens during stage 3?
stage 3: diastasis (slow LV filling)
after initial filling of blood
Pressures in LV & LA equalize; Blood transfer slowed due to equalizing pressures
*the stage circled in yellow
What happens during stage 4?
stage 4: atrial contraction
after LV & LA pressure equalize, LA pressure starts to increase
*P-wave (in ECG)– 2nd quick pressure gradient occurs between LV/LA results in the remaining blood in LA being pushed into LV. LV pressure exceeds LA
MV closes-Diastole ends
Left Ventricle diastolic pressure volume relationship
Normal heart chamber - as pressure increases, volume _________
increases
Left Ventricle diastolic pressure volume relationship
Abnormal heart chamber - as stiffness increases, pressure ______ (abnormal relaxation)
increases
What is TTN?
The TTN gene provides instructions for making a very large protein called titin. This protein plays an important role in muscles the body uses for movement (skeletal muscles) and in heart (cardiac) muscle.
myocardial tension primarily determined by _____.
It determines passive tension and passive stiffness
Titin
*cellular indices for CHF (congestive heart failure) patients
______ and higher level of _____ contribute to increase stiffness
Titin
collagen
*collagen does not affect tension on normal heart
What is DT (deceleration time)?
the rate of decrease of E wave in early diastole
factors affecting DT
- LA/LV pressure gradient at the time of MV opening
- LA chamber compliance
- LV chamber compliance
- Grade of left ventricle relaxation
- Visco-elastic forces of myocardial wall
- Pericardial restraint
- LV/RV interaction (Left ventricular relaxation-similar to contraction-is an energy-dependent process, because it requires the re- uptake of calcium into the sarcoplasmic reticulum)
Echo Analysis of normal DD
explain the steps
- acquire A4C mitral inflow
- PW Doppler with SV at MV leaflet tips
- low wall-filter
- measure peak E/A velocity
Echo Analysis of pseudonormal DD
explain the steps
- PW Doppler at Mitral leaflet tips - Valsalva=E>A
- Have patient suspend breathing and strain down 10 seconds
- Evaluate E/a reversal
E/A – Ratio E wave & A wave
grade 1
≤ 0.8
E/A – Ratio E wave & A wave
grade 2
0.9 - 1.9
E/A – Ratio E wave & A wave
grade 3
≥ 2
Annular Velocities Assessment via TDI
explain the steps
- Apical 4 chamber
- PW Tissue Doppler
- SV (sample volume) on Septal and Lateral Basal regions
- Individual Measures
- Septal (medial) e’
- Lateral e’
Annular Velocities Assessment via TDI
septal e’ cut-off value
< 7 cm/s
Annular Velocities Assessment via TDI
lateral e’ cut-off value
< 10 cm/s
*Lateral e’ normally higher velocity
E (PW Doppler at MV) / e’ ( TDI, PW at annulus) Ratio
normal value?
cut-off value?
normal < 8
cut-off > 14
E (PW Doppler at MV) / e’ ( TDI, PW at annulus) Ratio
*For labs that only measure septal or lateral e’ (not both)
Lateral E / e’ cut-off value?
Septal E / e’ cut-off value?
Lateral E / e’ > 13 = abnormal
Septal E / e’ > 15 = abnormal
What is LAVI ?
LAVI = LA Volume / BSA
Left Atrial Volume Index (LAVI) has been found to correlate with mortality from cardiovascular disease and may be measured at the end-ventricular systole, when the LA is at its maxim size.
Gender differences are then accounted for by indexing the volume to body surface area (BSA) via the Mosteller equation.
LAVI method:
explain the steps
- Apical 4 & 2 chamber
- End-systole
- Trace from level of MV annulus
- Length perpendicular to width
LAVI cur-off value
>34 mL/m2 for both M/F
TR Vmax
explain how to obtain
- Taken from multiple views
- HIGHEST velocity
- CW Doppler
- Cursor parallel to flow
- Well defined Doppler signal
TR Vmax
cut-off value
>2.8 m/s
- mild < or = 5 m/s
- moderate 6-9 m/s
- severe > 7 m/s
How to Analyze DD
diastolic function cannot be evaluated with patients with the following conditions:
- AFib
- HCM
- restrictive CM
- sinus tachycardia
- moderate - severe MR
- severe AR
- MS
- heart transplant
DD
Grade?
- slow early diastolic filling and diminished E-wave velocities
- prolonged DT >200 ms (0.2s)
- increased IVCT > 90ms
- reduced LA vol ejected in late diastole
- large A wave and a ratio of E/A less than 0.8
- normal for 75 yrs and older
- common in HTN, ischemic heart disease, obesity & compensated CHF
grade 1
DD
Grade?
- High velocities during early diastole & lower velocities with atrial kick
- E / A may appear normal
- E-wave is actually increased due to chronic elevation of LA volume
- Deceleration time is slow due to decreased compliance of LV chamber
- Decrease in IVRT and MV opens prematurely due to elevated LA pressure
- Tissue Doppler will help to unmask DD
grade 2 or psedonormal
Analysis of pulmonary vein flow will help with diagnosis of DD.
Normal PV flow demonstrates systolic predominance __ wave during atrial diastole and ventricular systole.
S
Progressive diastolic dysfunction and increasing LA pressure leads to increased reliance on atrial contraction to empty LA volume
Pulmonary veins demonstrate increased_____ velocity
D-wave
DD
grade?
- Marked elevation in LA and LV filling pressure with decreased LV compliance
- chronically elevated LA pressure
- premature opening of the MV and a decreased IVRT(< 90msec)
- elevated LVEDP causing the rapid early filling time in diastole to shorten to 150 msec or less due to rapid equalization of LA and LV pressures
- small A wave velocity - LV is already filled in late diastole so that final atrial contraction has no impact
- E/A ration is greater than 2
- Tissue Doppler e’ velocities are reduced E/e’ ration is 15 or greater (increased LVEDP)
grade 3
Color M-mode slope DD
- Color –mode represents the velocity of blood as it travels from the LA to the LV in early diastole
- Flow propagation velocity (Vp) is the slope of the first aliasing velocity during early LV filling
- Normal – Vp is 0.5 m/sec or greater
- Mitral inflow E-wave to Vp ration is a Semiquantitative estimate of the mean LA pressure
- E/Vp of 2.5 or greater indicates LV end-diastolic pressure greater than 15 mmHg
ASE guidelines recommend that mitral inflow velocity ratios of E/A, e’ as an estimation of LV filling pressure, and ________ are the highest value in the assessment of the presence and grade of diastolic dysfunction.
deceleration time
Color M-Mode Slope method is ______ method for quantifying Diastolic Dysfunction
Least Variable
Explain the color M-mode slope method
- Apical 4 chamber view
- M-mode cursor is placed in long axis through the mitral inflow tract and the LV apex (approximately 4mm within the LV chamber)
- The Nyquist limit is then set so that the highest velocity along the central jet appears blue
- Flow propagation velocity (Vp) is defined as the slope of the first aliasing velocity during early LV filling.
- Normal = Vp 0.5 m/sec or greater
- Abnormal = ratio of E/Vp of 2.5 or greater indicates that the LV end-diastolic pressure is greater than 15 mmHg
Doppler Parameters DD Normal Population
E/A ratio
normal young/adult
1-2
Doppler Parameters DD Normal Population
E/A ratio
grade 1 (impaired)
< 1.0
Doppler Parameters DD Normal Population
E/A ratio
Grade 2 (psedonormal)
1-1.5
*reverses with valsalva
Doppler Parameters DD Normal Population
E/A ratio
grade 3 (restrictive/reversible)
>1.5
Doppler Parameters DD Normal Population
E/A ratio
grade 4 (restrictive, irreversible)
1.5-2.0
*Doppler values similar to grade 3 except not change with Valsalva maneuver
Doppler Parameters DD Normal Population
DT
normal young
<240 ms
Doppler Parameters DD Normal Population
DT
grade 1 (impaired)
≥240
Doppler Parameters DD Normal Population
DT
normal adult
150-240
Doppler Parameters DD Normal Population
DT
grade 2 (psedonormal)
150-200
Doppler Parameters DD Normal Population
DT
grade 3 (restrictive, reversible)
<150
Doppler Parameters DD Normal Population
DT
grade 4 (restrictive, irreversible)
<150
Myocardial Performance Index (TEI)
equation
Myocardial performance (Tei) index = sum of IVCT and IVRT divided by the LVET (LV ejection time)
*note: MCOT - mitral valve closure to opening time in ms
Myocardial Performance Index (TEI)
normal value?
abnormal value?
normal: <0.40
abnormal: >0.40 correlated with more pathologic states of overall cardiac dysfunction
Abnormal LV Relaxation
- Low EF ( < 45%)
- Abnormal regional wall motion 3. Concentric LVH
- Reduced e’
- Advanced age (> 85 years)
- Presence of S3 or S4 sound in patient with dyspnea and age > 50 years
Evaluation of LAP
*note: E/Vp = peak E wave velocity to flow propagation velocity
LV Diastolic Dysfunction Evaluation
HCM (Hypertrophic Cardiomyopathy) Diastolic Dysfunction Assessment Characteristics
- Impaired relaxation
- Decreased compliance
- Increased LVEDP
- Decreased E/A ration
- A normal filling pattern suggests:
- Normalization by MR
- Normalization by increased LA pressure
According to the ASE, LV diastolic dysfunction is usually the result of impaired LV _____ and increased LV chamber ______, which increase cardiac filling pressure.
relaxation
stiffness
The diastolic function parameters include ____
- CWD of the mitral inflow
- CWD of the pulmonary venous inflow
- TDI of the mitral annular motion
- LA linear dimension
3
The mitral inflow provides critical information pertaining to diastolic function, to include _____.
E to A ratio
The mitral inflow E wave deceleration time must be measured from the peak E wave all the way down to the baseline because ______
It a measurement of time, not slope
While acquiring the diastolic function parameters, such as the mitral inflow, it is advised that the Doppler sweep speed be decreased from 50 mm/s to 25 mm/s.
T or F ?
F
*increase sweep speed
The E wave peak velocity _____
- represents the early diastolic LA-LV pressure gradient
- increases with age
- is not affected by changes in LV relaxation
- is equal to the pulmonary vein “a” wave peak velocity
1
Tissue Doppler imaging of the mitral annular motion measures the velocity of myocardial movement toward the Doppler cursor as it passes through the sample gate.
T or F ?
T
Normally, pulsed wave tissue Doppler imaging of the mitral annulus is a mirror image of the mitral inflow waveform.
T or F ?
T
E/e’ ratio ______
<8 usually predicts normal LV filling pressure
*>14 indicates increased LV filling pressure
The LAVi via the Biplane method of Disks is acquired via LA planimetry of the LAX and 4C.
T or F ?
F
*4C & 2C
*LAVi (LA Vol index) = LA Vol/BSA
The normal LAVi is ______
16-34 mL/m2
Increased LAVi predicts patient outcome, usually reflects increased LAP, and is a sign of ________
diastolic dysfunction
The pulmonary venous flow into the left atrium is dependent upon the pressure difference between the pulmonary veins and the left atrium.
T or F ?
T
PWD of the pulmonary venous flow should be acquired ______
- 3-4 cm into the right or left upper pulmonary vein
- with a decreased sweep speed of 25 mm/s
- with a large sample size of 3-4 cm
- with a small PWD gate, 1-2cm into the pulmonary vein
4
The pulmonary vein S-wave decreases and the D-wave increases when the LAP increases and LA compliance decreases.
T or F ?
T
*S/D ratio - S wave & D wave opposite when LAP increases and/or LA compliance decreases
*S/D ratio = divide S wave by the D wave
normal ratio 0.7-1.2
The Valsalva maneuver can unmask abnormal mitral inflow in the presence of a pseudonormal mitral inflow pattern.
T or F ?
T
If the patient has normal LVEF, TDI e’ (lateral wall) = 15 cm/s, E/e’ (average lateral & septal wall) = 10, LAVi = 28 mL/m2, and peak TRV = 2.4 m/s, report _____ DD.
normal
*note: LAVi normal ≤34 mL/m2
E/e’ normal <14
In patient with reduced LVEF, the MV inflow pattern can usually predict elevated LAP.
T or F ?
T
If the patient has normal LVEF, e’ (lateral wall) = 6cm/s, E/e (lateral wall) = 12, LAVi=36mL/m2, and peak TRV is 2.7m/s, report ______ DD.
inconclusive DD
The primary right ventricular diastolic function parameters include:
- LAVi and LAP
- linear dimensions
- TDI of PV annulus
- tricuspid inflow E/A and DT
4
What is AR (atrial reversal wave) and its normal value?
150ms
- AR is created by atrial contraction *corresponds with the P wave on ECG
- atrial contraction forces small amount of blood back into pulmonary vein creating a small waveform below the baseline
- normally MV A wave duration ≥PV AR duration
*
