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Echo > Diastolic Dysfunction > Flashcards

Diastolic Dysfunction Flashcards

1
Q

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 ________

A

12 mmHg

*Normal LAP: 8-10 mmHg

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2
Q

most common cause of DD?

A

HTN

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3
Q

What are the causes of DD?

A
  • 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
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4
Q

Diastolic Dysfunction Criteria for diagnosis:

abnormal relaxation without increased LV end-diastolic filling pressure (decreased E/A ration <0.75)

diagnosis?

A

mild diastolic dysfunction

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5
Q

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)

A

moderate or “psedonormal”

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6
Q

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)

A

severe

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7
Q

Diastolic Dysfunction Criteria for diagnosis:

Atrial fibrillation patients: diastolic function is indeterminate unless restrictive physiology:_________

A

E/A > 1.5, deceleration time < 140 ms

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8
Q

Left Ventricle Diastole: Physiology

process 1-10

A
  1. Begins with AV closure
  2. LV pressure decreases
  3. IVRT – time between AV closure and MV opening
  4. LV pressure is dropping – Volume is unchanged (NO MR or AR!) *pressure gradient may decrease in the presence of MR/AR
  5. MV opens (LV pressure drops below LA pressure)
  6. LV fills during early diastolic filling - E wave ( LV relaxation allows positive transmitral pressure gradient)
  7. LV is filling, LA pressure drops & LA pressure rises
  8. Decreased transmitral pressure gradient and LV filling decreases - between E & A
  9. Rate of LV filling in early diastolic is related to LV stiffness (Increased LV stiffness = faster deceleration of LV filling)
  10. LA contracts in late diastole to create another positive transmitral pressure gradient and more LV filling in late diastole *atrial kick
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9
Q

4 stages of diastole

A
  1. isovolumetric relaxation
  2. rapid early LV filling
  3. 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)
  4. atrial contraction
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10
Q

What happens during stage 1 of diastole?

A

stage 1: Isovolumetric relaxation

LV pressure rapidly drops below LAP without change in volume

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11
Q

What happens during stage 2?

A

stage 2: rapid early LV filling

After MV opens, LV pressure lower than LA

*E wave occurs

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12
Q

What happens during stage 3?

A

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

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13
Q

What happens during stage 4?

A

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

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14
Q

Left Ventricle diastolic pressure volume relationship

Normal heart chamber - as pressure increases, volume _________

A

increases

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15
Q

Left Ventricle diastolic pressure volume relationship

Abnormal heart chamber - as stiffness increases, pressure ______ (abnormal relaxation)

A

increases

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16
Q

What is TTN?

A

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.

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17
Q

myocardial tension primarily determined by _____.

It determines passive tension and passive stiffness

A

Titin

*cellular indices for CHF (congestive heart failure) patients

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18
Q

______ and higher level of _____ contribute to increase stiffness

A

Titin

collagen

*collagen does not affect tension on normal heart

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19
Q

What is DT (deceleration time)?

A

the rate of decrease of E wave in early diastole

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20
Q

factors affecting DT

A
  • 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)
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21
Q

Echo Analysis of normal DD

explain the steps

A
  • acquire A4C mitral inflow
  • PW Doppler with SV at MV leaflet tips
  • low wall-filter
  • measure peak E/A velocity
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22
Q

Echo Analysis of pseudonormal DD

explain the steps

A
  • PW Doppler at Mitral leaflet tips - Valsalva=E>A
  • Have patient suspend breathing and strain down 10 seconds
  • Evaluate E/a reversal
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23
Q

E/A – Ratio E wave & A wave

grade 1

A

≤ 0.8

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24
Q

E/A – Ratio E wave & A wave

grade 2

A

0.9 - 1.9

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25
Q

E/A – Ratio E wave & A wave

grade 3

A

≥ 2

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26
Q

Annular Velocities Assessment via TDI

explain the steps

A
  • Apical 4 chamber
  • PW Tissue Doppler
  • SV (sample volume) on Septal and Lateral Basal regions
  • Individual Measures
    • Septal (medial) e’
    • Lateral e’
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27
Q

Annular Velocities Assessment via TDI

septal e’ cut-off value

A

< 7 cm/s

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28
Q

Annular Velocities Assessment via TDI

lateral e’ cut-off value

A

< 10 cm/s

*Lateral e’ normally higher velocity

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29
Q

E (PW Doppler at MV) / e’ ( TDI, PW at annulus) Ratio

normal value?

cut-off value?

A

normal < 8

cut-off > 14

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30
Q

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?

A

Lateral E / e’ > 13 = abnormal

Septal E / e’ > 15 = abnormal

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31
Q

What is LAVI ?

A

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.

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32
Q

LAVI method:

explain the steps

A
  • Apical 4 & 2 chamber
  • End-systole
  • Trace from level of MV annulus
  • Length perpendicular to width
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33
Q

LAVI cur-off value

A

>34 mL/m2 for both M/F

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34
Q

TR Vmax

explain how to obtain

A
  • Taken from multiple views
  • HIGHEST velocity
  • CW Doppler
  • Cursor parallel to flow
  • Well defined Doppler signal
35
Q

TR Vmax

cut-off value

A

>2.8 m/s

  • mild < or = 5 m/s
  • moderate 6-9 m/s
  • severe > 7 m/s
36
Q

How to Analyze DD

diastolic function cannot be evaluated with patients with the following conditions:

A
  • AFib
  • HCM
  • restrictive CM
  • sinus tachycardia
  • moderate - severe MR
  • severe AR
  • MS
  • heart transplant
37
Q

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
A

grade 1

38
Q

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
A

grade 2 or psedonormal

39
Q

Analysis of pulmonary vein flow will help with diagnosis of DD.

Normal PV flow demonstrates systolic predominance __ wave during atrial diastole and ventricular systole.

A

S

40
Q

Progressive diastolic dysfunction and increasing LA pressure leads to increased reliance on atrial contraction to empty LA volume

Pulmonary veins demonstrate increased_____ velocity

A

D-wave

41
Q

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)
A

grade 3

42
Q

Color M-mode slope DD

A
  • 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
43
Q

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.

A

deceleration time

44
Q

Color M-Mode Slope method is ______ method for quantifying Diastolic Dysfunction

A

Least Variable

45
Q

Explain the color M-mode slope method

A
  • 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
46
Q

Doppler Parameters DD Normal Population

E/A ratio

normal young/adult

A

1-2

47
Q

Doppler Parameters DD Normal Population

E/A ratio

grade 1 (impaired)

A

< 1.0

48
Q

Doppler Parameters DD Normal Population

E/A ratio

Grade 2 (psedonormal)

A

1-1.5

*reverses with valsalva

49
Q

Doppler Parameters DD Normal Population

E/A ratio

grade 3 (restrictive/reversible)

A

>1.5

50
Q

Doppler Parameters DD Normal Population

E/A ratio

grade 4 (restrictive, irreversible)

A

1.5-2.0

*Doppler values similar to grade 3 except not change with Valsalva maneuver

51
Q

Doppler Parameters DD Normal Population

DT

normal young

A

<240 ms

52
Q

Doppler Parameters DD Normal Population

DT

grade 1 (impaired)

A

≥240

53
Q

Doppler Parameters DD Normal Population

DT

normal adult

A

150-240

54
Q

Doppler Parameters DD Normal Population

DT

grade 2 (psedonormal)

A

150-200

55
Q

Doppler Parameters DD Normal Population

DT

grade 3 (restrictive, reversible)

A

<150

56
Q

Doppler Parameters DD Normal Population

DT

grade 4 (restrictive, irreversible)

A

<150

57
Q

Myocardial Performance Index (TEI)

equation

A

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

58
Q

Myocardial Performance Index (TEI)

normal value?

abnormal value?

A

normal: <0.40
abnormal: >0.40 correlated with more pathologic states of overall cardiac dysfunction

59
Q

Abnormal LV Relaxation

A
  1. Low EF ( < 45%)
  2. Abnormal regional wall motion 3. Concentric LVH
  3. Reduced e’
  4. Advanced age (> 85 years)
  5. Presence of S3 or S4 sound in patient with dyspnea and age > 50 years
60
Q

Evaluation of LAP

A

*note: E/Vp = peak E wave velocity to flow propagation velocity

61
Q

LV Diastolic Dysfunction Evaluation

A
62
Q

HCM (Hypertrophic Cardiomyopathy) Diastolic Dysfunction Assessment Characteristics

A
  • Impaired relaxation
  • Decreased compliance
  • Increased LVEDP
  • Decreased E/A ration
  • A normal filling pattern suggests:
    • Normalization by MR
    • Normalization by increased LA pressure
63
Q

According to the ASE, LV diastolic dysfunction is usually the result of impaired LV _____ and increased LV chamber ______, which increase cardiac filling pressure.

A

relaxation

stiffness

64
Q

The diastolic function parameters include ____

  1. CWD of the mitral inflow
  2. CWD of the pulmonary venous inflow
  3. TDI of the mitral annular motion
  4. LA linear dimension
A

3

65
Q

The mitral inflow provides critical information pertaining to diastolic function, to include _____.

A

E to A ratio

66
Q

The mitral inflow E wave deceleration time must be measured from the peak E wave all the way down to the baseline because ______

A

It a measurement of time, not slope

67
Q

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 ?

A

F

*increase sweep speed

68
Q

The E wave peak velocity _____

  1. represents the early diastolic LA-LV pressure gradient
  2. increases with age
  3. is not affected by changes in LV relaxation
  4. is equal to the pulmonary vein “a” wave peak velocity
A

1

69
Q

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 ?

A

T

70
Q

Normally, pulsed wave tissue Doppler imaging of the mitral annulus is a mirror image of the mitral inflow waveform.

T or F ?

A

T

71
Q

E/e’ ratio ______

A

<8 usually predicts normal LV filling pressure

*>14 indicates increased LV filling pressure

72
Q

The LAVi via the Biplane method of Disks is acquired via LA planimetry of the LAX and 4C.

T or F ?

A

F

*4C & 2C

*LAVi (LA Vol index) = LA Vol/BSA

73
Q

The normal LAVi is ______

A

16-34 mL/m2

74
Q

Increased LAVi predicts patient outcome, usually reflects increased LAP, and is a sign of ________

A

diastolic dysfunction

75
Q

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 ?

A

T

76
Q

PWD of the pulmonary venous flow should be acquired ______

  1. 3-4 cm into the right or left upper pulmonary vein
  2. with a decreased sweep speed of 25 mm/s
  3. with a large sample size of 3-4 cm
  4. with a small PWD gate, 1-2cm into the pulmonary vein
A

4

77
Q

The pulmonary vein S-wave decreases and the D-wave increases when the LAP increases and LA compliance decreases.

T or F ?

A

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

78
Q

The Valsalva maneuver can unmask abnormal mitral inflow in the presence of a pseudonormal mitral inflow pattern.

T or F ?

A

T

79
Q

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.

A

normal

*note: LAVi normal ≤34 mL/m2

E/e’ normal <14

80
Q

In patient with reduced LVEF, the MV inflow pattern can usually predict elevated LAP.

T or F ?

A

T

81
Q

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.

A

inconclusive DD

82
Q

The primary right ventricular diastolic function parameters include:

  1. LAVi and LAP
  2. linear dimensions
  3. TDI of PV annulus
  4. tricuspid inflow E/A and DT
A

4

83
Q

What is AR (atrial reversal wave) and its normal value?

A

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
    *

Echo (35 decks)

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