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Diastology Flashcards

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USMLE® Step 1 flashcards
1
Q

Define diastolic dysfunction

A
  • Inability of the ventricle to fill to an adequate end-diastolic volume at normal pressure
  • abnormality of LV diastolic:
    • distensibility
    • filling
    • relaxation
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2
Q

LV diastolic dysfunction is usually the result of this:

A
  • impaired LV relaxation with or without reduced restoring forces (and early diastolic suction)
  • increased LV chamber stiffness

Both of which lead to increased cardiac filling pressures

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3
Q

Describe the algorithm differentiating CP and Restrictive Cardiomyopathy?

A
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4
Q

How will pulmonary venous Doppler flow pattern immediately change in the case of left atrial stunning (e.g. after cardioversion for persistent A-fib)?

A

A decrease of the systolic filling fraction, particularly S1

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5
Q

Define LV filling pressure

A

Can refer to:

  • mean PCWP (which is an indirect estimate of LV diastolic pressures)
  • mean left atrial pressure (LAP)
  • LV pre-A pressure
  • mean LV diastolic pressure
  • LV end-diastolic pressure (LVEDP)
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6
Q

What is the diagnosis in patient with:

  • Normal systolic function
  • PCWP: significant V-waves
  • Echo: no evidence of MR
A

Loss of left atrial reservoir function

or

severely decreased left atrial compliance

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7
Q

61 year old male with PMH HTN with complaints of exercise intolerance.

  • LFT’s normal
  • HR 60 bpm
  • LVEF normal, mild LVH

What is the diagnosis? Next step?

A
  • Diastolic stress test
    • Normal myocardial relaxation –> E/e’ will remain unchanged because both E and e’ velocities increase proportionally
    • Impaired myocardial relaxation –> increase in e’ is much less than that of E –> E/’e increases
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8
Q

When performing PW Doppler imaging in the A4C view to acquire mitral annular velocities, where should the sample volume be positioned?

A

At or 1 cm within the septal and lateral insertion sites of the mitral leaflets

  • Should be adjusted as necessary (usually 5-10 mm) to cover the longitudinal excusion of the mitral annulus in both systole and diastole
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9
Q

What are supportive findings of CP with mixed mitral medial e’ (6-8 cm/s) in assessment of CP vs. RC?

A
  • Annulus reversus
    • Mitral lateral e’ < medial e’
    • Most likely constriction if present
  • Hepatic vein expiratory end-diastolic reversal velocity / forward flow velocity = > 0.8
    • ​definitely constriction if present
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10
Q

What are the elements of a basic diastolic function assessment?

A
  • Left atrial volume index
  • Mitral inflow Doppler
  • Mitral annular tissue doppler (medial and lateral)
    • medial is sufficient in most instances, also easier to align
  • Right ventricular systolic pressure
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11
Q

What is two echo machine adjustment that should be made when obtaining annular velocities?

A
  • Doppler spectral gain settings
    • usually automatic
    • velocity scale should be set at ~ 20 cm/s above and below the zero-velocity baseline
      • lower settings may be needed in severe LV dysfunction
  • Minimal angulation - < 20 degrees
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12
Q

Describe the findings of Grade II diastolic dysfunction

A
  • LV relaxation - impaired
  • LAP - Elevated
  • Mitral E/A ratio - > 0.8 - < 2
  • Average E/e’ ratio - 10-14
  • Peak TR velocity (m/s) - > 2.8
  • LAVI - Increased
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13
Q

What is the best way to estimate LV filling pressures in A-fib?

What indicates elevated LV filling pressures?

A
  • E/e’ ratio
  • E/e’ > 11 –> LVEDP > 15 mmHg
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14
Q

Define LV untwisting

A
  • Major determinant of the isovolumic relaxation time (IVRT)
    • measurable manifestation of elastic recoil
    • ​energy generated by helically oriented fibers and stored in the heart’s elastic tissue during systole is released before end-systole
    • creating early diastolic suction
    • filling the LV for the next cardiac cycle
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15
Q

What is second step in assessment of CP vs. RC?

A

Ventricular interdependence (with respiration)

  • No –> suspicion still high –> further imaging or cardiac cath
  • Yes –> Mitral medial e’
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16
Q

What mitral deceleration time is associated with elevated LV filling pressures?

A

< 150 ms in the presence of LV dysfunction

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17
Q

What is the best two-dimensional (2D) and doppler echo finding to differentiate restrictive cardiomyopathy from constrictive pericarditis?

A

Early diastolic mitral annular velocity

  • mitral medial e’ velocity > 8 cm/s
  • normal mitral e’ velocity (in patient with heart failure) –> CP
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18
Q

What is the optimal sample volume size in PW Doppler assessment:

  • Mitral valve inflow
  • Pulmonary vein doppler flow
A
  • 1-3 mm at mitral valve tips
  • 2-3 mm placed > 0.5 cm into pulmonary vein
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19
Q

What is first step in assessment of CP vs. RC?

A

Mitral inflow E/A > 0.8

+

Dilated IVC

  • No –> Constriction / Restriction unlikely
  • Yes –> Next step
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20
Q

Describe the findings in Grade III diastolic dysfunction

A
  • LV relaxation - impaired
  • LAP - Elevated
  • Mitral E/A ratio - > 2
  • Average E/e’ ratio - > 14
  • Peak TR velocity (m/s) - > 2.8
  • LAVI - Increased
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21
Q

Describe the diagnosis

A

Restrictive cardiomyopathy

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22
Q

What deceleration time of the pulmonary venous diastolic velocity indicates elevated LV filling pressures?

A

< 220 ms

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23
Q

Describe pulmonary venous Doppler flow pattern:

AR wave

A
  • AR wave
    • atrial flow reversal velocity and duration
    • influencenced by LV late diastolic pressures, atrial preload, LA contractility
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24
Q

What are supportive findings of RC in assessment of CP vs. RC?

A
  • DT < 150 ms
  • IVRT < 50 ms
  • PV Systolic Fraction < 40%
  • E/e’ > 15
  • LAVI > 48 mL/m2
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25
Q

Describe pulmonary venous Doppler flow pattern:

S1 and S2

A
  • S1
    • related to atrial relaxation
    • most noticeable with prolonged PR
    • influenced by changes in LAP (relaxation and contratction)
  • S2
    • related to SV, pulse wave propagation in pulmonary arterial tree
    • should be used to compute the ratio of peak systolic to peak diastolic velocity

***A-fib or atrial stunning –> blunted S wave, mainly due to a loss of S1 with a decreased systolic fraction and absence of AR velocity

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26
Q

What is third step in assessment of CP vs. RC?

A

Mitral medial e’

  • > 8 cm/s –> CP
  • 6 - 8 cm/s –> Mixed constriction/restriction
  • < 6 cm/s –> RC
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27
Q

Describe findings of Grade I diastolic dysfunction

A
  • LV relaxation - impaired
  • LAP - low or normal
  • Mitral E/A ratio - < 0.8
  • Average E/e’ ratio - < 10
  • Peak TR velocity (m/s) - < 2.8
  • LAVI - Normal or increased
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28
Q

Define E/A wave ratio of Mitral inflow measurements

A

represents the ratio of:

  • E wave: peak velocity blood flow from gravity in early diastole
    • to
  • A wave: peak velocity flow in late diastole caused by atrial contraction
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29
Q

Describe pulmonary venous Doppler flow pattern:

D wave

A

D wave

  • diastolic velocity
  • influenced by changes in LV filling and compliance
    • related to LV relaxation
    • young individuals can exhibit large D waves
  • changes in parallel with mitral E velocity
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30
Q

Describe the diagnosis

A

Constrictive pericarditis

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31
Q

What are comorbidities that confound assessment of diastolic function?

A
  • Tachycardia (causes E-A fusion)
  • A-fib
  • AR
  • MR
  • Mitral annular calcification
  • Mitral stenosis
  • Ventricular pacing
  • Prior surgery / procedure
    • MAZE procedure
    • Pulmonary vein isolation
    • Mitral valve surgery
    • LVAD
    • Cardiac transplant
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32
Q

What mitral annular velocity values (usually) indicate normal diastolic function?

A
  • septal (E’) = ≤ 7
  • lateral (E’) = ≤ 10
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33
Q

What LA volume values (usually) indicate normal diastolic function?

A

LA < 34 ml/m2

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34
Q

What does mitral inflow pattern provide?

A

insight into the pressure gradient between the left atrium and the left ventricle

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35
Q

How do you differentiate between a normal and pseudonormal mitral inflow pattern?

A

EF

  • If EF is impaired –> diastolic dysfunction is present and can classify based on pattern
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36
Q

What are the first two parameters to check in the assessment of diastolic function?

A
  • LA volume indexed (LAVI)
  • Doppler Tissue Imaging –> E’ (septal and lateral)

*** if both normal then most likely normal diastolic function

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37
Q

What is an easy way to determine normal LA pressure when assessing Left Atrial Inflow or Pulmonary Vein Flow (PVF) in assessment of diastolic function?

A

S > D

  • 85% have normal LA pressure
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38
Q

What is another method for determining normal vs. Pseudonormal filling pattern for diastolic dysfunction?

A

Valsalva maneuver

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39
Q

In the assessment of diastolic function:

  • How is the valsalva response obtained/measured?
  • What does it determine?
  • How can the Valsalva maneuver help to distinguish between normal/pseudonormal?
A
  • Continuously recording mitral inflow (PW doppler) for 10s during the straining phase of the maneuver
  • whether restrictive LV filling is reversible or not
  • decrease in E/A ratio of ≥ 50%, not caused by E and A velocities fusion, is highly specific for increased LV filling pressures (supporting presence of diastolic dysfunction)

***Continuous recording of mitral inflow during standardized Valsalva maneuever for 10s –> decrease in E/A ratio with straining, which is consistent with elevated LV filling pressures

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40
Q

What pulmonary vein doppler flow atiral reversal velocity is usually consistent with elevated LV filling pressures particularly at end diastole?

A

≥ 35 cm/s

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41
Q

In the assessment of diastolic function, explain the relation of the S and D wave in PVF or LAI?

A
  • S wave
    • related to LV contractility, atrial function, atrial pressure and mitral regurgitation
  • D wave
    • related to LV relaxation
    • young, healthy individuals can exhibit large D waves indicating forceful elastic recoil of the LV rather than high left atrial pressure
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42
Q

When are Mitral and Pulmonary inflow patterns reliable for the assessment of LV filling pressures?

A

Only with a reduced LV function

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43
Q

Pulmonary venous atrial reversal wave can be obtained in what percentage of patients?

A

> 70%

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44
Q

What is the most accurate method to quantify the left atrial size and provide useful prognostic data?

A
  • direct measurement of the left atrial volume using the biplane method of disks
  • measured in A2C and A4C views
  • LA volume should preferably be indexed
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45
Q

What is the movement on TTE to transition for PLA to a better view of the ascending aorta?

A

shift the probe up one interspace without changing the location of the index marker (notch)

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46
Q

What is the main utility of the assessement of diastolic function?

A

to predict filling pressures

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47
Q

What does fractional shortening tell you?

How is it obtained?

What is the equation for FS?

A
  • Gives a rough estimate of LV systolic function using linear dimensions
  • PLA at or below the level of the mitral leaflet tips using 2D or M-mode –> linear internal measurements of the LV at end-diastole and end-systole are obtained
  • FS% = (LVIDd - LVIDs) / LVIDd x 100
    • normal values 25-45%
      • 10% is consistent with severe LV dysfunction
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48
Q

In assessment of the AV/Aorta which measurements should be measured:

  • leading edge to leading edge
  • inner edge to inner edge
A
  • Leading-to-leading edge (during mid-systole)
    • LVOT diameter
    • Aortic valve annulus
  • Inner-to-inner edge
    • sinuses of Valsalva
    • sinotubular junction
    • ascending aorta
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49
Q

What conduction disturbances must be ruled out prior to initiatiation of flecainide therapy?

A
  • 2nd or 3rd degree AV block
  • LBBB
  • RBBB + left hemiblock
  • NSVT (asymptomatic)
50
Q

What is a major contraindication to flecainide therapy?

A

structural heart disease

51
Q

How long should a patient be monitored after initiation of Flecainide?

What should be monitored?

A
  • 8 hours (check local practices)
  • QRS duration
52
Q

When should Flecainide be dc or dose decreased?

A
  • increase in QRS duration > 25%
    • potential risk of proarrhythmia
53
Q

What is height of the E wave correspond to?

A
  • transmitral pressure gradient
    • does not necessarily convey information about the mean LA (or PCWP)
54
Q

What does the magnitude of the A wave (in transmitral flow) correspond to?

A
  • force of atrial stystole
    • in turn, is related to atrial contractility
55
Q

Describe the pathophysiology in Grade 1 (mild diastolic dysfunction)

A
  • abnormally slow LV relaxation
  • reduced early transmitral (E wave) veolocity
  • coupled with a compensatory increase in velocity associated with atrial systole
56
Q

What are transmitral (E and A) flow velocities dependent on?

When are they not useful?

A
  • transmitral pressure gradients and indirectly on the integrity of ventricular relaxation
  • Preserved EF
    • patterns of E and A waves have limited ability to predict filling pressures
57
Q

Recording the velocity of the mitral annulus in early diastole using TDI (e’) in both the septal and lateral annuli of the mitral valve gives insight into what?

A

ventricular relaxation

***relatively insensitive to preload

**** particularly in patients with heart disease

58
Q

(Transmitral) E / e’ (TDI)

can be used to reliabiably predict what?

A

mean PCWP

59
Q

What affect dose LVEF have on transmitral E velocity?

A
  • Reduced LVEF (dilated cardiomyopathy)
    • correlate better with LV filling pressures, functional class, and prognosis than LVEF
  • Normal EF
    • correlates poorly with LV filling pressures
60
Q

What are additional limitations to transmitral E velocity?

A
  • more challenging to apply with arrhythmias
  • affected by alterations in LV volumes and elastic recoil
  • age dependent (decreasing with age)
61
Q

What are the four principal measurements in assessing presence of diastolic function in a patient with normal LVEF?

A
  • E/e’ ratio > 14
    • e’ averaged between septal and lateral annulus
  • Tissue Doppler velocity (medial and lateral annuli) - e’
    • medial < 7 cm/s
    • lateral < 10 cm/s
  • Peak continuous wave TR velocity > 2.8 m/s
  • LA volume index > 34 cc/m2

**diastolic dysfunction present if > 50% positive

***indeterminate if 50% positive

****nromal diastolic function if < 50% positive

62
Q

What are three special populations in which grading diastolic function is very difficult?

A
  • Mitral annular calcification
  • Atrial Fibrillation
  • Coexistent mitral regurgitation
63
Q

What are the three functions of the left atrium throughout the cardiac cycle?

A
  • Reservoir function during ventricular systole and isovolumic relaxation
    • reflected by the pulmonary venous S wave
  • Conduit phase from the moment the mitral valve opens until onset of atrial contraction
    • reflected by the pulmonary venous D wave
  • Contractile phase during atrial systole
    • reflected by pulmonary venous AR wave and mitral A wave
64
Q

What populations of patient’s should grading of diastolic dysfunction occur?

A
  • reduced LVEF
  • heart disease (known) and normal LVEF
65
Q

Describe the initial step in the grading of diastolic dysfunction

(in patients with depressed LVEF’s and patients with myocardial disease and normal EF)?

A
  • Transmitral Inflow ratio
    • E/A ≤ 0.8 + E ≤ 50 cm/s
      • –> normal LAP, Grade I DD
      • if symptomatic –> consider CAD, or diastolic stress test
  • E/A ≤ 0.8 + E > 50 cm/s or E/A > 0.8 - < 2
    • –> 3 criteria to be evaluated
  • E/A ≥ 2
    • –> increase LAP, Grade III DD
66
Q

Describe the algorithm for grading diastolic dysfunction (in patients with impaired LV or normal LV with known CAD)

A
67
Q

Describe the parameters to evaluated in grading diastolic function for those with:

E/A ≤ 0.8 + E > 50 cm/s or E/A > 0.8 - < 2

A
  • Average E/e’ > 14
  • TR velocity > 2.8 m/s
  • LAVI > 34 ml/m2
68
Q

Describe the second step in determining diastolic function grade when all 3 parameters are known?

A
  • 2/3 or 3/3 positive –> increased LAP or Grade 2 diastolic dysfunction
  • 2/3 or 3/3 negative –> normal LAP or Grade I diastolic dysfunction
69
Q

Describe the second step in determining diastolic function grade when only 2 parameters are known?

A
  • 2 positive –> increased LAP or Grade 2 diastolic dysfunction
  • 1 positive/1 negative –> indeterminate
  • 2 negative –> normal LAP or Grade I diastolic dysfunction
70
Q

Describe the findings

A

LA stunning after cardioversion

  • Day 0 (cardioversion) = markedly reduced mitral A velocity and apparent “restrictive filling” pattern (basis of E/A ratio)
  • Day 3 = LA function improves with increased A velocity and a decreased E/A ratio consistent with impaired LV relaxation but normal LV filling pressures
71
Q

Color Doppler M-mode (CMM) echocardiography provides infomration on flow propagation (Vp) which is unique in that it is relatively independent of this?

A

Loading conditions

72
Q

What is one of the key limitations of Vp?

A
  • Predictive ability regarding filling pressures is predominantly in systolic dysfunction
    • E / Vp > 2.5 –> predices PCWP > 15 mmHg
73
Q

What is a normal Vp?

A

> 50 cm/s

74
Q

Describe the findings

A

Color M-mode with white line tracing Vp

75
Q

What is the strongest determinant of mitral decelration time?

A

LV operating stiffness

  • changes in LV compliance (relationship between LV pressure and volume) and also ventricular relaxation (or early diastolic pressures)
76
Q

In patients with dilated cardiomyopathy, PW Doppler mitral flow velocity variables and filling patterns correlate with these variables to what degree when compared to LV function?

  • Cardiac filling pressure
  • Functional Class
  • Prognosis
A

PW Doppler mitral flow velocity > > > LVEF

in regards to filling pressure, functional class and prognosis

77
Q

Describe the diastolic filling pattern

A

Grade 3-4 diastolic dysfunction

Restrictive

78
Q

Describe the diastolic filling pattern?

A

Grade 2 diastolic dysfunction

Pseudonormal

79
Q

What patterns of diastolic dysfunction are most commonly associated with acute myocardial infarction?

A

Pseudonormal

or

Restrictive

80
Q

What finding on Valsalva maneuver, in the assessment of diastolic dysfunction, will indicate increased LV filling pressures?

A

decrease E/A ratio ≥ 50%

81
Q

What are two findings that indicate an adequate Valsalva maneuver?

A
  • Forceful expiration - generating 40 mmHg of pressure
  • Decrease mitral PV ≥ 20 cm/s
    • in patients without restrictive filling
82
Q

When is Valsalva maneuver utilized in the assessment of diastolic function?

A
  • Stage 2 diastolic dysfunction
    • differentiating normal vs. pseudonormal
83
Q

Patient with Cardiac Amyloidosis, which stage of disease will A-fib be most problematic?

A
  • A - Impaired relaxation (may be asymptomatic at rest or with mild exercise) –> LV has become more dependent on atrial contraction (low E/A ratio)
    • most likely to feel a change in symptoms with sudde onset of A-fib due to loss of atrial kick

****Atrial contraction hardly contributes to LV filling in most advanced stages of diastolic dysfunction (diminutive A wave in restrictive filling)

84
Q

Describe the diastolic filling pattern?

A

Normal diastolic filling pattern

85
Q

Describe the findings and diagnosis

A

Markedly delayed relaxation –>

preload reduction will reveal stage 1 diastolic dysfunction

  • L-wave: transmitral flow during diastasis
86
Q

Describe mitral “L-wave”

A
  • L-wave: transmitral flow during diastasis
    • triphasic mitral inflow pattern that can be seen in patients without structural heart disease
    • Associated with bradycardia
    • represents advanced diastolic dysfunction (elevated filling pressures + loss of compliance + very delayed relaxation)
87
Q

Describe the diastolic filling pattern?

A

Grade I diastolic dysfunction

Impaired relaxation

88
Q

What is one way to unmask underlying relaxation abnormalities in diastolic function assessment?

A
  • Preload reduction
    • decreases LAP and decreases operating stiffness of the LV
89
Q

Patient with severe LV dysfunction due to long-standing untreated hypertension is referred for medical therapy. Based on Doppler findings:

  • What is the diagnosis?
  • What medical therapy should one be cautious of starting? Why?
A
  • Grade 3-4 diastolic dysfunction
  • Beta-blockers
    • long term prognosis better with BB (need careful titration)
    • But, operating stiffness of heart is very high –> CO is dependent on HR (impossible to augment SV without HR)
90
Q

Patient with Doppler tracing of AR, presents with SOB. What is the cause?

  • SBP 154/78 mmHg
A

LVEDP is in the normal range - consider alternative etiology

  • LVEDP = DBP - 4Vend diastolic velocity2
  • LVEDP = 78 - 4 (4)2
  • LVEDP = 78 - 64 = 14 mmHg
91
Q

61 year old woman with ischemic cardiomyopathy is referred for cardiac resynchronization therapy. TTE prior to implantation (A) and post-implantation (B) with Doppler findings. What is the conclusion?

A

LV stiffness has increased

  • Increased E/e’ and E/Vp ratio –> increased LV filling pressures
  • Shorter DT –> increased LV operating stiffness
  • Decreased A-wave velocity –> reduced LA contractility
  • M-mode Vp and tissue Doppler e’ are unchanged
92
Q

Describe the findings and diagnosis

A

60 year old man with hypertensive heart disease

  • Large difference ( > 30 ms) between duration of mitral A-wave velocity and duration of the late diastolic pulmonary venous flow reversal, AR –> Elevated end-diastolic LV filling pressures
    • ​usually seen in patients with grade 2 or 3 diastolic dysfunction
93
Q

What is the effect of A-fib on mitral A waves?

A

they will be absent

94
Q

What is the effect of MR on the pulmonary vein flow S wave?

A

reversal or at least blunting of the S wave (with significant MR)

95
Q

Mitral inflow pattern by itself is suggestive of elevated filling pressures if:

A

Reduced LVEF ​

96
Q

What will effect changes in the mitral inflow pattern, in patients with reduced EF and diastolic dysfunction?

A

changes in preload

  • volume overload, changes in medical therapy
97
Q

In the presence of moderate-severe MR and diastolic dysfunction, what are the effects on E velocity and DT?

A
  • Increased peak E velocity
  • Normal DT
98
Q

What are the four components of hepatic vein Doppler velocities?

A
  • Systolic forward flow (S)
  • Diastolic forward flow (D)
  • Systolic flow reversal (VR)
  • Atrial flow reversal (AR)
99
Q

What two conditions are diastolic flow reversal seen most commonly?

How do you differentiate between the two (with flow reversal alone)?

A
  • CP and Pulmonary hypertension
  • Respiratiory variation –> CP
    • augmentation of diastolic flow reversal
100
Q

48 year old male with newly diagnosed NICM, what can you conclude about LV compliance?

  • ECG: ST - 108 bpm
  • BP 90 / 50 mmHg
  • Audible S3
  • BNP 1530
A

Decreased LV compliance

  • Mitral Inflow
    • Appears to have fused E/A wave but more likely increased E wave with shortened DT
  • Pulmonary vein flow
    • Blunted systolic to diastolic flow with a large AR confirms –> E wave with restrictive physiology, decreased LV compliance and elevated LV filling pressures
  • ​Decreased annular velocity and delayed Vp confirms impaired relaxation
  • E/e’ = 17 and E/Vp = 5 –> both confirm elevated LV filling pressure
101
Q

48 year old male with newly diagnosed NICM, what can you conclude after 1 week of intensive therapy?

  • ECG: ST - 108 bpm
  • BP 90 / 50 mmHg
  • Audible S3
  • BNP 1530
A

LV filling pressures are now normal

  • E/e’ is now < 10 –> suggesting that LV filling pressures have been lowered
102
Q

What is one way to correlate or determine which wave is present on mitral inflow?

A
  • Pulmonary vein flow
    • positive relationship of mitral E wave and pulmonary vein D wave
    • larger the E wave, the larger the D wave
103
Q

What are confirmatory measures of elevated LV filling pressures (in patients with reduced EF and diastolic function)?

A
  • E/e’ > 15
  • E/Vp > 2
104
Q

What are the hallmarks of restrictive cardiomyopathy?

A
  • Advanced diastolic dysfunction
  • Atrial dilatation

****In spite of normal LV size and function

105
Q

48 year old male presents with SOB, abdominal swelling, lower extremity edema over the past 6 months. Recurrent admissions over the last 2 years with syncope and A-fib (on Holter)

  • EKG: ST - 100 bpm
  • BP: 100/74 mmHg
  • JVD - 8 cm
  • PE: pitting edema of bilateral lower extremities

What is the diagnosis?

What can explain the Doppler/Echo findings?

A
  • Restrictive cardiomyopathy
  • Progressive myocardial stiffening
  • Restrictive physiology
    • shortened mitral E wave DT
    • E/A ratio markedly increased ~ 20
    • Grade 3 diastolic filling with normal systolic function
    • Ventricular filling is notable for decreased LV compliance
106
Q

What is the pathophysiology of restrictive cardiomyopathy?

A
  • As LAP increases with disease progression
  • MV opens at a higher pressure –> decrease in the IVRT
  • In addition, there is increased transmitral pressure gradient –>
    • increased E velocity
    • decreased systolic pulmonary venous flow velocity
    • systolic/diastolic ratio < 1
107
Q

Patient with known CAD, presented with abnormal stress test, given SL NTG –> junctional bradycardia (HR = 40 bpm) and hypotension (BP 75/43 mmHg)

  • What is the grade of diastolic dysfunction?
A

Extreme Grade 1 diastolic dysfunction

  • Mitral E/A < 1
    • severely decreased mitral E wave
  • Vp is reduced (50 cm/s)
  • Septal E’ < 7 cm/s
  • E/e’ < 8
    • filling pressures are likely not increased
108
Q

Why do nitrates in patients with (extreme grade 1) diastolic dysfunction result in hemodynamic abnormalities?

A
  • Decreased preload:
    • causes reduced end-diastolic volume –>
    • patients are dependent on atrial contractility –>
    • reduced SV/CO
109
Q

What are the Doppler findings in Grade 1 (extreme) diastolic dysfunction?

A
  • Mitral E velocity < 50 cm/s
  • DT > 200 ms
  • Mitral A velocity increased
  • E/A < 1
  • IVRT increased
  • e’ usually < 7 cm/s
  • Vp < 50 cm/s
110
Q

What finding on TTE is associated with worsening prognosis in amyloidosis patients?

A

Short DT - < 150 ms

Increased E/A > 2.1 (also with decreased survival at 1 year)

111
Q

What is one finding which can differentiate amyloidosis from other causes of LV hypertrophy?

A

“Apical sparing” longintudinal strain pattern

112
Q

What is a desirable result after AV optimization?

A

Grade 1 LV diastolic filling pattern

113
Q

What is one variable that remains constant in alteration of paced AV delay (in AV optimization)?

A

Heart rate

114
Q

Describe the findings and grade

A

Pulmonary vein Doppler flow

Normal

115
Q

Describe the findings and grade

A

Pulmonary vein doppler flow

Grade 1 - Impaired relaxation

116
Q

Describe the findings and grade

A

Pulmonary vein doppler flow

Grade 2 - Pseudonormal

117
Q

Describe the findings and grade

A

Pulmonary vein doppler flow

Grade 3 - Restrictive

118
Q

Describe the findings and grade

A

TDI

Normal

119
Q

Describe the findings and grade

A

TDI

Grade 1 - Impaired relaxation

120
Q

Describe the findings and diagnosis

A

TDI

Grade 2 - Psuedonormal

121
Q

Describe the findings and diagnosis

A

TDI

Grade 3 - Restrictive

Medical (69 decks)

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