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Diastology Notes Flashcards

1
Q

How many patients > 45yrs old have mild diastolic dysfunction?

A

appox. 30%

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2
Q

Is diastolic dysfunction synonymous with HF pEF?

A

No

<50% patients with diastolic dysfunction have symptomatic HF

But, diastolic dysfunction will be present in HF patients

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3
Q

What percentage of HF patients will have preserved LV systolic function?

A

30-50%

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4
Q

What does the presence of Diastolic Dysfunction signify?

A

increased morbidity and mortality

potential for haemodynamic instability, APO and difficulty weaning from CPB

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5
Q

What Doppler waveforms are used to assess for Diastolic Dysfunction?

A
  1. Transmitral Doppler
  2. Pulmonary Venous Doppler
  3. Mitral Annular Doppler
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6
Q

When is “diastole” and what occurs during this process?

A

occurs from AV closure -> MV closure

  1. Early Active Phase:
    - isovolumetric relaxation
  2. Later Passive Phase:
    - early filling
    - diastasis
    - atrial systole
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7
Q

What is the driving force for ventricular filling?

A

LA to LV Pressure Gradient

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8
Q

What occurs during isovolumetric relaxation?

A
  • decrease in LV pressure by ACTIVE LV relaxation
  • no change in LV volume
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9
Q

What lengthens isovolumetric relaxation?

A
  • prolonged by any condition that impairs active myocardial relaxation
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10
Q

What shortens isovolumetric relaxation?

A
  • shortened by raised LA pressure which causes early MV opening
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11
Q

What happens during Early Diastolic Filling?

A
  • opening of the MV valve
  • due to a drop in LV pressure from active myocardial relaxation
  • greatest gradient between LA and LV created here (approx 80% LV filling)
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12
Q

What factors influence Early Diastolic Filling?

A
  1. Active Relaxation
  2. Recoil of Elastic Myocardial Elements
  3. LA Pressures
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13
Q

What happens during Diastasis (mid-diastole)?

A
  1. The LA-LV pressure gradient declines
  2. minimal LV filling
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14
Q

What influences the Diastasis phase?

A
  1. LV Compliance (intrinsic myocardial stiffness)
  2. Ventricular Mass
  3. Loading Conditions (Preload/Afterload)
  4. Pericardial Restraint
  5. RV Size
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15
Q

What occurs during Atrial Systole phase?

A

Increased transmitral pressure gradient - contributes normally 15-20% to ventricular filling

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16
Q

What conditions affect atrial systole contribution?

A

conditions that impair active relaxation (eg, AS) mean that atrial systole contributes more to ventricular filling

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17
Q

What is the pathophysiology of early phase diastolic dysfunction?

A

active phase

delayed re-uptake of Ca2+ ions into the SR -> prolonged relaxation time

Eg. MI, HTN, AS, Hypertrophic Cardiomyopathy (these cause impaired relaxation) in early phases

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18
Q

What is the pathophysiology of later phase diastolic dysfunction?

A

passive phase

due to a decrease in chamber compliance

Eg. infiltrative procresses (amyloidosis) and myocardial fibrosis (widespread infarction)

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19
Q

How does Diastolic Dysfunction progress?

A

Initially an impaired relaxation -> decrease in compliance -> increase in LA pressure

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20
Q

How do you assess for Diastolic Dysfunction on TOE?

A
  1. LV Hypertrophy?
  2. Enlarged Atria?
  3. Doppler (transmitral, pulmonary veins and lateral annular TDI)
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21
Q

What does transmitral doppler show?

A

2 peaks

  1. larger E wave: early diastolic filling
  2. smaller A wave: atrial contraction
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22
Q

What do you measure when using transmitral doppler?

A
  1. Max E wave velocity
  2. E wave deceleration time
  3. Max A wave velocity
  4. E/A Ratio
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23
Q

What are the three abnormal patterns/dysfunction grades that are seen on transmitral doppler?

A
  1. impaired relaxation
  2. pseudonormalisation
  3. restricted filling
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24
Q

What is impaired relaxation and how does the transmitral velocity trace appear? [normal finding in older pts > 60 yrs old)

A

there is delayed LV myocardial relaxation with normal LA pressure

there is higher LV pressure in early diastole so a smaller LA:LV gradient (deccreased E wave velocity) with an increased E wave deceleration time

Decreased early diastolic filling means more filling occurs during atrial systole (increased A wave velocity)

E/A ratio decreased

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25
What is pseudonormalisation and how does the transmitral velocity trace appear?
There is decreased myocardial relaxation and a mild-mod increase in left atrial pressure this increases the gradient for early diastolic filling -> increases the E wave velocity back up again (compensation mechanism?) this increase in E filling augents the LV pressure mid-late diastole so: - decrease in E wave deceleration time - decrease in A wave velocity
26
What is restrictive filling and how does the transmitral velocity trace appear?
Decrease in LV compliance and further increase in LAP during early diastole the increase in LAP will cause an increase in the gradient between LA and LV -> increased E wave velocity the reduced LV compliance causes an abrupt increase in LV pressure during mid-late diastolic filling - decreased E wave deceleartion time - decreased A wave velocity - E/A ratio > 2
27
Is Grade III Diastolic Dysfunction seen in both types of LV EF?
Yes - normal LVEF: restrictive cardiomyopathy - decreased LVEF: dilated cardiomyopathy
28
Does LA pressure affect LA filling?
Yes
29
How does a normal pulmonary venous doppler waveform appear?
S: Systole (may be biphasic) D: Diastole (forward flow -> LA) A: End-Diastole (minor peak due to atrial systole, reverse of flow back to pulmonary veins) diastolic venous flow = diastolic transmitral flow
30
What do you measure when you assess pulmonary venous doppler?
1. Maximum S,D,A velocities 2. A wave duration 3. S/D Ratio
31
In what ways can the pulmonary venous flow be abnormal?
Abnormal Relaxation -> increased S wave, decreased D wave (mirroring decreased E wave velocity) S:D ratio < 1 Increased LAP (pseudonormal, restrictive filling): progressively decreasing S wave and increasing D wave velocity, S:D < 1 A wave velocity > 35m/s and duration increased > 200ms
32
How do you differentiate Pseudonormalisation from Restrictive Filling with pulmonary venous doppler?
Increased venous A wave on Pulmonary Doppler (due to increased LAP) but "Normal" appearing transmitral waveform
33
What does TDI of the Mitral Annulus measure?
the longitudinal shortening of LV during systole (decent of mitral annulus) and longitudinal relaxation of LV during diastole (annulus returning to original position) the TDI shows the velocity of these changes mitral annulus moves towards the TOE during diastole -> positive deflection
34
How does the doppler profile appear?
Also a biphasic motion during diastole early filling (e') and atrial contraction (a') analogous to E and A of transmitral doppler waves
35
What do you measure during TDI of mitral annulus?
Maximum e' velocity (>8-10m/s) E/a' Ratio
36
When can you not use TDI of the mitral annulus?
in patients with severe mitral annular calcification, Mitral Stenosis or MV prosthesis
37
How does diastolic dysfunction affect the e' wave?
As diastolic dysfunction increases, the velocity of the e' wave will decrease
38
How do you differentiate pseudonormalisation from normal waveforms using TDI of the mitral annulus?
Pseudonormalisation will have an e' wave < 8m/s, whereas normal LV filling will have an e' > 8m/s
39
How is the mitral annulus e' affected by loading conditions?
It is less affected by loading conditions in comparison to the transmitral E wave velocity
40
What does the E/e' ratio provide?
useful information on LA Pressure
41
What is Colour M-Mode Flow?
M-mode shows the position of structures along a vertical line over time Colour mode superimposes coloured blood velocity data onto the scan line LV inflow used to assess diastolic dysfunction
42
What is the Propagation Velocity (Vp) of blood in the LV?
The slope of any isovelocity line connecting the mitral leaflets to some point within the ventricle normally > 50cm/s
43
What factors affect the diastolic dysfunction doppler waveforms?
1. position of sample volume 2. age 3. loading conditions 4. heart rate and rhythm 5. aortic and mitral valve disease 6. spontaneous vs. IPPV
44
Where do you place the sample volume for transmitral doppler?
at level of the open leaflet tips
45
Where do you place the sample volume for pulmonary venous doppler?
1cm into the pulmonary vein
46
Where do you place the sample volume for mitral annular TDI doppler?
2-3mm into the ventricular myocardium to ensure it remains in the myocardium during the entire cardiac cycle (ME 4 Chamber view)
47
How does decreased age affect doppler waveforms?
LV relaxation is rapid - often complete in the first phase
48
How does increased age affect doppler waveforms?
LV relaxation is decreased transmitral and pulmonary venous dopplers mitral annular e' wave decreased, a'wave increased
49
How does increased preload affect diastolic dysfunction and doppler curves?
increased preload shifts the working position on LV diastolic pressure/volume to the right, the less compliant part of the curve Transmitral: E wave increased, shorter deceleration time and increased A wave (similar to restrictive pattern) Pulmonary Venous: increased S and D waves Reverse A waves Increased A wave duration
50
How does decreased preload/hypovolaemia affect diastolic dysfunction and doppler curves?
Transmitral: decreased E wave increased A wave decreased E/A ratio (similar to impaired relaxation) E wave decleration unlikely prolonged due to increase in HR Pulmonary Venous: decreased velocity of all three waves (S,D and A) shortened A wave duration
51
Does Preload have an effect on Mitral Annular TDI?
Preload has a less marked effect on mitral annular TDI if pt has abnormal ventricular relaxation -> LV filling no e'changes if normal diastolic function -> increase in preload: modest increase in e' velocity decrease in preload: modest decrease in e' velocity
52
How does Valsalava affect transmitral doppler?
During the strain phase there will be a decrease in preload - this can then be used to differentiate normal from pseudonormal filling Normal heart: E and A waves will decrease proportionally (so E/A will be relatively unchanged) In pseudonormalisation there will never be a decrease in the E/A ratio during the strain phase of the Valsalva End of Valsalva - increase afterload? will cause a decrease in E wave velocty, prolonged E wave deceleration time and decrease in pulmonary S and D wave velocities
53
How does Heart Rate affect transmitral dopplers?
Sinus Tachycardia: - decreaed E wave - increase A wave - decreased E/A HR > 100 or First Degree Block: - E-A fusion occurs so impossible to measure the E wave deceleration time
54
How does Heart Rate affect pulmonary venous dopplers?
Sinus Tachycardia - Increase in S wave - Decrease in D wave Sinus Bradycardia - Decrease in S wave - Increase in D wave
55
How does Heart Rhythm affect transmitral dopplers?
A fib - no transmitral or pulmonary A waves - E wave velocity and deceleration time will vary on cycle length AV dissociation/VVI pacing: - dissociated E and A waves RV Epicardial Pacing: - asynchronous - prolonged LV relaxation -> decrease in transmitral E wave
56
How does MR affect the transmitral doppler?
MR causes LV volume overload and increased LAP cannot assess LV diastolic dysfunction if severe MR - increase transmitral E wave and E wave deceleration time moderate MR: decrease S wave due to systolic blunting and increase D wave (S/D <1) severe MR: causes S wave reversal - this may be unequal in the right and left pulmonary veins due to the direction of the eccentric jets
57
How does mitral stenosis affect diastolic dysfunction dopplers?
Increase in transmitral E and A wave velocities Increase E wave deceleration time Changes in pulmonary venous doppler consistent with increases in LAP
57
How does aortic regurge affect diastolic dysfunction dopplers?
Increase in LAP Rapid increase in early diastolic LV pressure Pattern will be similar to that of restrictive filling
58
How does SV affect diastolic dysfunction dopplers?
inspiration -> decreased intrathoracic pressure which augments systemic vascular return - this increases Tricuspid E and A wave velocitites small inspiratory decrease in transmitral E and A wave velocity due to pooling of blood in the lungs these changes are reversed with expiration
59
What causes exaggerated normal respiratory variations?
1. constrictive pericarditis 2. pericardial tamponade 3. tension ptx 4. actue asthma
60
How does IPPV affect transmitral dopplers?
Increased PEEP -> progressive decrease in E and A waves (also e' and a' waves) so, little change in E/A or E/e' ratios
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