Diastolic Function Flashcards
What is the normal lateral mitral valve e’ velocity?
e’ >/= 10cm/sec
e’<8cm/sec = bad
What E/e’ ratio is consistent with Grade 1 diastolic dysfunction?
E/e’ <10
What E/e’ ratio is consistent with Grade 3 diastolic dysfunction?
E/e’ >14
What E/e’ ratio is consistent with Grade 2 diastolic dysfunction?
10-14
What are the 4 stages of diastole?
- Isovolumetric relaxation (begins at AV closure and ends when MV opens)
- Early filling (E wave velocity)
- Diastasis (LAP=LVP, no flow across MV)
- Late filling (atrial contraction, causes LAP>LVP again and contributes 15-20% LV preload normally but up to 50% in diastolic dysfunction)
How are the 4 stages of diastole reflect on MVI Doppler?
Time before E wave = IVRT
E wave = early filling
Time between E and A waves = diastasis
A wave = late filling
What are the two components of diastolic dysfunction?
Impaired active ventricular relaxation
Decreased ventricular compliance
What causes the S1 and S2 waves on pulmonary venous Doppler?
S1 = atrial relaxation
S2 = RV stroke volume + atrial compliance + mitral annulus descent
What are the limitations of transmitral and pulmonary venous inflow profiles?
- Sensitive to loading conditions
- MR (increases LAP)
- MS (increases LAP)
- Arrhythmias (if the atrium contracts against a closed mitral valve)
- HR
How is color M-mode flow Vp measured?
- ME 4C view
- CFD with narrow sector width
- M-mode scan line
- Measure slope of first aliasing velocity from MV annulus to LV apex (4cm into ventricle)
What is normal propagation velocity (Vp)?
> 50 cm/sec
What does Vp depend on?
Preload (it is load dependent)
When can Vp be used to predict PCWP, and what is the equation?
- Can only be used if LVEF is reduced
- equation is E/Vp >/= 2.5 predicts PCWP >/= 15
How does E/e’ work in normal patients?
E/e’ is unreliable in normal patients, so check first whether the e’ is abnormal before measuring E/e’.
How does e’/a’ change with worsening diastolic dysfunction?
e’/a’ decreases with worsening diastolic dysfunction (e’/a’ <1 is bad)
What type of diastolic dysfunction is characterized by E < A?
Impaired relaxation
- normal compliance and ISOLATED impaired active relaxation
What type of diastolic dysfunction is characterized by E»_space; A and S-wave blunting in the pulmonary veins?
Restrictive dysfunction
- decreased compliance and impaired active relaxation
What type of diastolic dysfunction is characterized by E > A and S-wave blunting in the pulmonary veins?
Pseudonormal
- decreased compliance and impaired active relaxation
What are the limitations of Vp for evaluating diastolic function?
-Preload dependent
- can only be used to predict PCWP if LVEF abnormal
- Less reproducible than other measurements
How can tissue Doppler be used to distinguish abnormal MVI from tamponade or constrictive pericarditis from other forms of diastolic dysfunction?
Lateral mitral annular tissue doppler is NORMAL in tamponade and constrictive pericarditis but ABNORMAL in restrictive infiltrative cardiomyopathy.
What MVI pattern is seen in tamponade?
Impaired relaxation pattern (E<A)
What MVI pattern is seen in constrictive pericarditis?
Restrictive patern (E»A)
What E/E’ ratio is associated with elevated LV filling pressures?
> 14
What IVRT/Te’-E is associated with elevated LV filling pressures?
<2
What E/Vp ratio is associated with elevated LV filling pressures?
> /= 2.5 (predicts PCWP>15 in patients with reduced LVEF)
What Ardur-Adur is associated with elevated LV filling pressures?
> 30msec
What MVI E/A ratio is normal?
> /= 0.8
What peak TR velocity is normal (for diastolic function assessment)?
<2.8 m/sec
What is the normal LA volume index?
<34 mL/m2
What MVI E/A ratio is consistent with restrictive (Grade 3) diastolic dysfunction?
> 2
How does age affect active LV relaxation?
There is a progressive decrease in active LV relaxation with age, even in healthy adults.
- E/A decreases
- e’ decreases
When is the lateral e’ less than the septal e’?
Only in constrictive pericarditis. Known as annulus reversus and is due to tethering of the lateral mitral annulus by the pericardium.
How do you calculate Te’-E?
Measure time from peak of QRS complex to start of e’ (on TDI)
Measure time from peak of QRS complex to start of E wave (on MVI PWD)
Subtract time to E wave from time to e’ (this is Te’-E)
This is prolonged with impaired LV relaxation.
What is the normal Te’-E?
0-4msec
What are the limitations of tissue Doppler?
- Angle dependent
- Can’t reliably measure mitral annulus velocity if MAC present or prosthetic valve/annular ring
- e’ is sensitive to preload in NORMAL patients (load independent in patients w/ diastolic dysfunction)
What is annular reversus?
When the lateral e’ is less than septal e’ (seen in constrictive pericarditis)
What is a normal a’?
a’ <10cm/sec
a’ should be < e’
What is a normal S’?
S’ >8cm/sec = normal
S’ <5cm/sec = bad
How do you calculate isovolumic acceleration?
Measure how long it takes to get from end of a’ to max isovolumic velocity
(how long it takes to generate max isovolumic acceleration)
TDI detection of ischemia: what changes are seen?
S’, e’, a’, etc.
- S’ decreases
- e’ decreases
- a’ increases
- max isovolumic velocity decreases
e’/a’ ratio becomes <1
Now have a new peak after the S’ before the e’; known as post-systolic shortening
What is post-systolic shortening?
Indicates myocardial ischemia; peak that occurs after S’ before e’
