Diastology Flashcards
Grade I Diastolic Dysfunction
Impaired relaxation due to increased LV stiffness
- Diminished E-wave
- Residual LA volume is ejected in LV, resulting in a large A wave
E/A 200ms
IVRT > 90ms
e’
Grade II Diastolic Dysfunction
E/A 0.8-1.5 (pseudonormal), decreases > 50% w/ valsalva
e’ = 30 ms (in some this may be the only abnormality)
S Wave
Pulmonary venous antegrade flow into the LA during atrial diastole and ventricular systole
PVS1 = Atrial relaxation, LA pressure PVS2 = Increase in pulmonary venous pressure propagated through the pulmonary arterial tree from the right side of the heart AND/OR apical systolic motion of the mitral annulus
D Wave
Pulmonary vein wave that corresponds with Mitral E wave, or Mitral valve opening and LV diastole
Influenced by LV filling and compliance
Ar wave
Corresponds with Mitral A wave, which creates atrial reversal velocity in the pulmonary vein due to atrial contraction
Influenced by diastolic pressures in the LV, atrial preload, and LA contractility
Duration increases with increased filling pressure
Atrial Fibrillation’s effect on pulmonary venous velocities
Blunted S wave
Absent Ar velocity
A wave
Late diastolic filling
Affected primarily by the compliance and contractility of the LV
LVEDP
Ar - IVRT
L wave
A prominent mid-diastolic filling “hump” can be seen in healthy individuals with bradycardia OR it may be a pathological change in patients with advanced diastolic dysfunction with elevated LV filling pressures.
Increased is >= 20cm/s
E wave
Early diastolic filling
Represents the gradient between LA and LV
Highly affected by preload and relaxation of LV
e’
Peak annular velocity in early diastole
Depends on LV relaxation
W/ diastolic dysfunction, e’ is independent of preload
NL diastolic function, e’ increases with increasing filling pressures
Impaired myocardial relaxation w/ lateral
Tau
Invasive measure of the rate of LV relaxation, which is 95% complete at 3.5tau after dP/dT(min)
Diastolic dysfunction is present when tau > 48 ms
PASP
4*TRV^2 + RAP
PADP
4*PREDV^2 + RAP
RAP Estimation
Insert picutre!
E wave DT
Influenced by:
- LV Relaxation
- LV Diastolic pressures following MV opening
- LV compliance
(I.e. The relationship between LV pressure and volume)
What can cause partial or complete fusion of mitral E and A waves?
Sinus tachycardia and/or first-degree AV block
Vp
Color m-mode flow propogation
> 50 cm/s is considered normal
E/Vp >= 2.5 predicts PCWP > 15 mmHg
Most reliable w/ depressed EFs and dilated LVs
E/e’
Used to predict LV filling pressures
Medial: > 12 = PCWP > 18 mmHg
Lateral: > 10 = PCWP > 18 mmHg
NOT good in normal subjects, heavy annular calcification, MV disease, and constrictive pericarditis
Diastolic Stress Test
E and e’
Normal: E and e’ increase proportionately, therefore E/e’ remains unchanged
Abnormal: e’ increases less than E, therefore E/e’ increases
Diastolic Stress Test
Mitral DT
Normal: decreases slightly
Abnormal: Shortens > 50 ms (pts w/ marked elevations of filling pressures)
Diastolic stress test indication
Unexplained exertional dyspnea who have mild diastolic dysfunction and normal filling pressures at rest
Constrictive Pericarditis
Mitral Inflow
Pseudo normal or restrictive filling, with E/A > 1 and short DT
Respiratory variation in mitral E velocity: a >= 25% increase with expiration (although > 50% may not always show this)
Constrictive Pericarditis
Hepatic Venous Flow
Dilated
Diastolic flow reversal during EXPIRATION
(Restrictive CM is with inspiration!!)
Ar - A
> 30 ms is predictive of an LVEDP of > 20 mmHg
This is the first hemodynamic abnormality seen with diastolic dysfunction
Pulmonary Hypertension
Hepatic Veins
Do not have augmentation of diastolic flow reversals with respiration
Septal e’ velocity to differentiate constrictive pericarditis vs restrictive
> = 7 cm/s
Limitation: significant annular calcification and coexisting myocardial disease
Assessment of filling pressures in the setting of MR
Normal EF: Ar-A, IVRT, IVRT/T(E-e’)
Depressed EF: E/e’
Diastolic Screening
LV Size/Function
LA Volume Index (>34)
E/A
DT
E/e’
Grade Ia Diastolic Dysfunction
Impaired relaxation pattern with elevated filling pressures
Same parameters as Grade I except E/e’ (medial) is > 15
Small E, Large A
E/A
