Diastology Flashcards
simplified algorithm for determining diastolic function
e’ velocity > 10 then normal
If less than 10 then use E/e’
E/e’ <8 grade 1
E/e’ 9-12 grade 2
E/e’ >13 grade 3
4 phases of diastole
isovolemic relaxation, early filling, diastasis, late filling (atrial contraction)
transmitral inflow
two main mechanisms = active relaxation and LV compliance
Active relaxation- uses ATP to suck or pull blood into it
LV compliance- decrease compliance equals increased LAP and earlier opening and decreased deceleration time and smaller a wave
What is responsible for changes between grade 1 and 3 diastolic dysfunction when relaxation is impaired in all?
Decreased compliance and increase in LAP
A S1 S2 and D wave contributors on pulm vein flow
A - atrial contraction , retrograde flow into pulm vein
S1 - atrial relaxation
S2 - RV stroke volume, descent of annulus
D - mitral valve opens and allows early filling
S wave and D wave correlations
LAP waveform
S = x descent
D = y descent
How is A reversal wave on pulm vein different in grade 2 and 3 diastolic dysfunction
Longer in time than A wave mitral inflow. Higher velocity
limitations of pulmonary venous inflow
MR, MS, arrythmias, heart rate, loading conditions
how will valsalva change pseudonormal pattern on mitral inflow
change it to grade 1 with decrease in preload
Propagation velocity Vp
Normal >50 cm/s
4 cm into LV
Load dependent, increases with increases in preload
E/Vp >2.5 predicts >15 PCWP if LVEF is reduced
Tissue doppler
High amplitude , low velocity signals
s’ , e’, a’
Angle dependent (keep it less than 20)
Load independent with diastolic dysfunction
avg over 3 cardiac cycles
TDI e’
less than 8 is bad
greater than 10 normal
e’/a’ less than 1 is bad, independent of angle
E/e’
> 13 used for patients with normal for grade 3
15 used for patients that are dysfunctional for grade 3
VP limitations
hard to reproduce
preload dependent
tissue doppler
best modality to measure diastolic function
angle dependent, average over 3 cardiac cycles
Load independent if you have diastolic dysfunction
Te’ prolonged with impaired relaxation
Te’-e prolonged with impaired relaxation
limitations of tissue doppler
mitral annular disease/tethering
time intervals require regular rhythm and stable hr
normal patients are preload dependent
regional wall motion abnormalities
angle dependent
tamponade transmitral inflow
impaired relaxation pattern
lateral mitral normal tissue doppler
constrictive pericarditis inflow
restrictive pattern
lateral mitral normal tissue doppler
Estimating filling pressure
E/E’ >15
IVRT/Te’-e <2
E/Vp >2.5 if LVEF reduced
Ardur-Adur >30 ms
ardur-adur
pulmonary venous a wave duration - mitral inflow a duration
Diastolic dysfunction
All forms have impaired LV relaxation
LAP elevated in grade 2 and 3
E/A ratio<0.8 grade 1, E/A >2 grade 3, between is either normal or grade 2
average E/e’ <10 grade 1, 10-14 grade 2, >14 grade 3
Peak TR V >2.8 in grade 2 and 3
LA volume index >34ml/m2 in grade 2 and 3
patients with normal ef
E/e’ >14
lateral e’< 10
TR velocity >2.8
La vol index >34
2/4 inderminate
3-4 diastolic dysfunction
0-1 normal
E/A and e’ changes with age
E/A increases and e’ decreases
4 variables recommended by 2016 evaluation of diastolic function
e’
E/e’
LA max volume index
TR peak velocity
How does Ar and A duration indicate elevated LAP
when PV Ar duration > Mitral A duration by 30 msec
S/D pulmonary venous ratio changes in diastolic dysfunction
less than 1 when LAP is high
