Diastology

Question 1

Grade I Diastolic Dysfunction

Answer 1

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’

Question 2

Grade II Diastolic Dysfunction

Answer 2

E/A 0.8-1.5 (pseudonormal), decreases > 50% w/ valsalva

e’ = 30 ms (in some this may be the only abnormality)

Question 3

S Wave

Answer 3

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

Question 4

D Wave

Answer 4

Pulmonary vein wave that corresponds with Mitral E wave, or Mitral valve opening and LV diastole

Influenced by LV filling and compliance

Question 5

Ar wave

Answer 5

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

Question 6

Atrial Fibrillation’s effect on pulmonary venous velocities

Answer 6

Blunted S wave

Absent Ar velocity

Question 7

A wave

Answer 7

Late diastolic filling

Affected primarily by the compliance and contractility of the LV

Question 8

LVEDP

Answer 8

Ar - IVRT

Question 9

L wave

Answer 9

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

Question 10

E wave

Answer 10

Early diastolic filling

Represents the gradient between LA and LV

Highly affected by preload and relaxation of LV

Question 11

e’

Answer 11

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

Question 12

Tau

Answer 12

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

Question 13

PASP

Answer 13

4*TRV^2 + RAP

Question 14

PADP

Answer 14

4*PREDV^2 + RAP

Question 15

RAP Estimation

Answer 15

Insert picutre!

Question 16

E wave DT

Answer 16

Influenced by:

• LV Relaxation
• LV Diastolic pressures following MV opening
• LV compliance

(I.e. The relationship between LV pressure and volume)

Question 17

What can cause partial or complete fusion of mitral E and A waves?

Answer 17

Sinus tachycardia and/or first-degree AV block

Question 18

Vp

Answer 18

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

Question 19

E/e’

Answer 19

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

Question 20

Diastolic Stress Test

E and e’

Answer 20

Normal: E and e’ increase proportionately, therefore E/e’ remains unchanged

Abnormal: e’ increases less than E, therefore E/e’ increases

Question 21

Diastolic Stress Test

Mitral DT

Answer 21

Normal: decreases slightly

Abnormal: Shortens > 50 ms (pts w/ marked elevations of filling pressures)

Question 22

Diastolic stress test indication

Answer 22

Unexplained exertional dyspnea who have mild diastolic dysfunction and normal filling pressures at rest

Question 23

Constrictive Pericarditis

Mitral Inflow

Answer 23

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)

Question 24

Constrictive Pericarditis

Hepatic Venous Flow

Answer 24

Dilated

Diastolic flow reversal during EXPIRATION

(Restrictive CM is with inspiration!!)

Question 25

Ar - A

Answer 25

> 30 ms is predictive of an LVEDP of > 20 mmHg

This is the first hemodynamic abnormality seen with diastolic dysfunction

Question 25

Pulmonary Hypertension

Hepatic Veins

Answer 25

Do not have augmentation of diastolic flow reversals with respiration

Question 27

Septal e’ velocity to differentiate constrictive pericarditis vs restrictive

Answer 27

> = 7 cm/s

Limitation: significant annular calcification and coexisting myocardial disease

Question 28

Assessment of filling pressures in the setting of MR

Answer 28

Normal EF: Ar-A, IVRT, IVRT/T(E-e’)

Depressed EF: E/e’

Question 29

Diastolic Screening

Answer 29

LV Size/Function

LA Volume Index (>34)

E/A

DT

E/e’

Question 30

Grade Ia Diastolic Dysfunction

Answer 30

Impaired relaxation pattern with elevated filling pressures

Same parameters as Grade I except E/e’ (medial) is > 15

Small E, Large A
E/A