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)

Diastolic Dysfunction Flashcards by Yoshiko Peterson

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

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most common cause of DD?

HTN

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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

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Diastolic Dysfunction Criteria for diagnosis:

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

diagnosis?

mild diastolic dysfunction

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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”

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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

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Diastolic Dysfunction Criteria for diagnosis:

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

E/A > 1.5, deceleration time < 140 ms

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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

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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

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What happens during stage 1 of diastole?

stage 1: Isovolumetric relaxation

LV pressure rapidly drops below LAP without change in volume

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What happens during stage 2?

stage 2: rapid early LV filling

After MV opens, LV pressure lower than LA

*E wave occurs

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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

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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

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Left Ventricle diastolic pressure volume relationship

Normal heart chamber - as pressure increases, volume _________

increases

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Left Ventricle diastolic pressure volume relationship

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

increases

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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.

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myocardial tension primarily determined by _____.

It determines passive tension and passive stiffness

Titin

*cellular indices for CHF (congestive heart failure) patients

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______ and higher level of _____ contribute to increase stiffness

Titin

collagen

*collagen does not affect tension on normal heart

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What is DT (deceleration time)?

the rate of decrease of E wave in early diastole

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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)

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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

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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

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E/A – Ratio E wave & A wave

grade 1

≤ 0.8

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E/A – Ratio E wave & A wave

grade 2

0.9 - 1.9

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_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)](https://www.mdapp.co/body-surface-area-bsa-calculator-29/) 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.

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

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

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

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 \_\_\_\_\_ 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

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 ?

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

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 ?

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

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 ?

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 ?

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

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** *