Diastology Lecture and PowerPoint

Question 1

What are the normal limits for E/A Ratio

Answer 1

1.31 +/- 0.42

Question 2

What are the four stages of Diastolic Filling?

Answer 2

1) IVRT
2) Rapid Passive Filling
3) Diastasis
4) Atrial Contraction ( a-kick)

Question 3

Define Diastole by Echo

Answer 3

Begins with Closure of the Aortic Valve and ends with Closure of the Mitral Valve.

Question 4

Define Diastole by EKG

Answer 4

Begins with the end of the T wave and Ends with the beginning of the QRS.

Question 5

Define Diastole by Pressure

Answer 5

When pressure in the Aorta is greater than the LV, the Aortic valve closes. Pressure rapidly drops in the LV until it drops below the LA pressure, at which time the Mitral valve opens and Rapid Passive Filling ensues. The Mitral leaflets drift toward closing as the pressure gradient between the LV and LA equalize. The Atrium contracts and increases its pressure and contributes the last mLs of diastolic filling. The now higher pressure in the LV closes the Mitral valve just as ventricular contraction begins. The beginning of IVCT is the end of diastole and the beginning of systole.

Question 6

What happens to IVRT if disease causes changes in the ventricles ability to relax?

Answer 6

IVRT becomes prolonged and results in a reduction of the early peak filling rate.

Normal IVRT = 63ms (+/- 11ms)

Question 7

Is Ventricular Relaxation Passive or Active?

Answer 7

LV relaxation and early diastolic filling is an active process and utilizes energy by the myocardium.

Internal conditions, extrinsic conditions, non-uniformity in spatial and temporal conditions can all affect myocardial relaxation and inhibit efficient filling of the ventricle.

Question 8

How does disease affect E Velocity and Deceleration Time.

Answer 8

Disease is reflected by a prolongation in IVRT, a decrease in E velocity an increase in deceleration time.

Question 9

What is Compliance?

Answer 9

The property of altering size and shape in response to force. -Myocardial: the ease with which the heart muscle relaxes as it fills with blood.

Physically, Compliance is the ratio of ∆Volume/∆ Pressure ( ∆V/∆P ). Compliance it the inverse of Stiffness ( ∆P/∆V ) Less Compliance is More Stiffness and More Compliance = Less Stiffness.

Question 10

How are Myocardial Characteristics related to Compliance?

Answer 10

Myofibril health affects compliance; their ability to reset is directly related to relaxation, from the Fibrils themselves to the myocardial cells ability to exchange ions.
Muscle Thickness as in hypertrophy adversely affect compliance.
Medications can affect compliance.

Question 11

How are Chamber Characteristics related to Compliance?

Answer 11

Size, Shape, Normal, Fibrotic, Aneurysmic, Necrotic, Hypertrophied, Hypotrophied….

Anything that affects the stiffness of the walls will adversely affect compliance and therefore diastolic filling.

Question 12

How does the Aging Process affect Compliance and diastolic filling?

Answer 12

Age naturally causes the ventricular walls to become more stiff/less compliant, so it’s natural to see a decrease in E velocity and and increase in Decel time with older patients. To compensate the A component will increase to make up the difference.

Also, Pulm. V flow with mirror these changes and Ar velocity will increase too.

Question 13

What are the parameters evaluated by doppler in diastology?

Answer 13

1) MV Flow
2) Pulmonary Vein Flow
3) Tissue Doppler (TDI)
4) MV Decel Time
5) Ar-A Time

Question 14

Early Peak Rapid Passive Filling is affected by what parameters?

Answer 14

1) Change in Preload
2) Change in the flow rate across the AV Valve.
3) Change in Atrial Pressure

Question 15

Late Diastolic Filling is affected by what Parameters?

Answer 15

Late Diastole is affected by the Atrial contraction, so…

1) Stenosis/Valvular disease
2) Atrial Dilation
3) Atrial Fibrillation or conduction defects
4) LA Size, Volume, Pressures, Compliance (age)

Question 16

List the Causes of Diastolic Dysfunction

Answer 16

1) Primary Myocardial Disease
- dilation, hypertrophies, cardiomyopathies…
2) Secondary Hypertrophy
- HTN, AS, Congestive Heart Disease.
3) Coronary Artery Disease
- wall motion abnormalities, ischemia, dead tissue
4) Extrinsic constraints
- Tamponade, constrictive pericarditis, abnormally thickened pericardium, effusions either pleural or pericardial….

Anything that interferes with ventricular filling.

Question 17

What are some causes for effusions?

Answer 17

Response to surgery, infection, chemotherapy, cancer.

Question 18

What is the Equation for Calculating LAP?

Answer 18

LAP= E/e’ x 1.25 + 1.9 = mmHg

Question 19

What are the components of the LV Diastolic Doppler Exam?

Answer 19

PV Flow
-S/D Ar Profile and velocities
-Ar duration
MV Flow
-E/A Ratio
-MV Decel TIme
-Peak and Mean Velocities and Pressure Gradients
MV TDI (Velocity of Myocardium)
-e' and a' velocities
-look at profile, e/a relationship
LA Volumes
Cardiac Filling Pressures
PHTN
LV Systolic Performance

Question 20

What are the components of the RV Diastolic Doppler Exam?

Answer 20

Hepatic Vein Flow
-same rules for Pulm. V. apply
TV Flow
-visually evaluate flow profile
-E/A Ratio; same rules apply as MV
-TV Decel Time
-VTI: Peak and Mean Velocities and Pressure Grads
TV TDI: 4 Chamber Freewall: Velocity >10cm/s
RA Volumes
Cardiac Filling Pressures
PHTN
RV Systolic Performance

Question 21

Regarding Pulmonary Vein Flow, what is:

1) S Wave
2) D Wave
3) Ar velocity
4) Ar duration

Answer 21

1) S Wave is velocity of pulmonary vein flow during systole
2) D Wave is velocity of pulmonary vein flow during diastole
3) Ar velocity is the velocity of pulmonary vein flow reversal during Atrial Contraction.
4) Ar duration in the duration of flow reversal during Atrial Contraction.

Question 22

Regarding Pulmonary Vein Flow, the S Wave may have two components, S1 and S2. What dysfunctions affect which wave and why?

Answer 22

S1 is decreased by left atrial dysfunction.
S2 is increased by LV contractility.
S2 is decreased by elevated LAP
S2 is decreased by Mitral Regurgitation

Question 23

Regarding Pulmonary Vein Flow, what dysfunction affect the Ar Wave and why?

Answer 23

Ar is increased by atrial contractility, LV stiffness and LVEDP

-essentially, because the veins have no valve changes in the LA and the interaction between the LV and LA are reflected in reverse flow. Anything that restricts LV inflow, increases Ar Velocity and duration.

Question 24

Regarding Pulmonary Vein Flow, what dysfunction affects the D Wave?

Answer 24

Impaired LV relaxation decreases the D Wave.

Question 25

What are the characteristics of Mild Diastolic Impairment?

Answer 25

Decreased E Wave
Increased IVRT
Increase in Decel Time
Decreased Tissue Velocity ( e' < 10 cm/s )
Ar stays fairly normal

Question 26

What are the characteristics of Moderate (Pseudonormal) Diastolic Impairment?

Answer 26

E Wave normalized
IVRT may shorten
Tissue velocity reversal ( e'< a' )
S wave is smaller than the D wave
Ar velocity increases

Question 27

What are the characteristics of Severe Restrictive Diastolic Impairment?

Answer 27

Increase E wave (or single component)
Decreased Decel Time ≤ 160ms
Decreased TDI: both e' & a' < 10 cm/s
E/e' ratio >15
Severely decreased S wave, greatly increased D wave.