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Spring '24 > Otto notes, Exam #2 > Flashcards

Otto notes, Exam #2 Flashcards

Diastolic Filling and Function

1
Q

isovolumic relaxation time is the interval from

A

aortic valve closure to MV opening (pressure in LV rapidly falls during this) opposite is true for IVCT, where a rapid rise in LV pressure occurs

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2
Q

isovolumic contraction time (IVCT) is the interval

A

between mitral valve closure and aortic valve opening

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3
Q

4 phases of diastole:

A

isovolumic relaxation, early rapid diastolic filling, diastasis, late diastolic filling caused by atrial contraction

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4
Q

When LV pressure falls below LA pressure, this opens and _______ ends.

A

MV
IVRT ends

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5
Q

at the end of IVRT, the MV opens. MV opening is followed by

A

rapid early diastolic filling with the rate and tie course of LA to LV flow determined by several factors, including the pressure difference along the flow stream, ventricular relaxation, and the relative compliances of the two chambers

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6
Q

following early diastolic filling, the ventricle fills, and pressures in the atrium and ventricle equalize, resulting in a period called ___________.

A

diastasis, during which little movement of blood between the chambers occurs and the MV leaflets remain in a semi open position.

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7
Q

the duration of diastasis is totally dependent on the

A

HEART RATE…

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8
Q

Can diastasis be absent completely at faster heart rates?

A

YES

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9
Q

With atrial contraction, (the last phase in diastole), _____ pressure exceeds _________ pressure, thus resulting in further ___________ opening and a second pulse of _________ filling.

A

LA
LV
MV leaflet
ventricular

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10
Q

Are the 4 phases of diastole as described exactly the same for both the LV and RV?

A

For the most part, YES!
ONE DIFFERENCE… the duration of diastole for the RV is is slightly shorter in normal individuals because of a slightly longer systolic ejection period

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11
Q

the 3 most clinically relevant parameters of diastolic function are

A

ventricular relaxation, myocardial or chamber compliance, filling pressures

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12
Q

LV relaxation is not passive as it involves

A

the use of energy by the myocardium.

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13
Q

LV relaxation occurs during when

A

occurs during isovolumic relaxation and the early diastolic filling period

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14
Q

isovolumic relaxation includes internal loading forces such as _________ and external conditions such as _________, and inactivation of myocardial contraction (metabolic, neurohumoral, and pharmacologic)

A

internal: cardiac fiber length
external: wall stress, arterial impedance

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15
Q

abnormal ventricular relaxation results in prolongation of the______, a slower rate in decline in _________________, and a consequent reduction in the _____________.

A

IVRT
ventricular pressure
early peak filling rate (due to a smaller pressure difference between the atrium and the ventricle when the AV valve opens)

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16
Q

Measures of LV relaxation (3)

A

IVRT
maximum rate of pressure decline (-dP/dt)
time constant of relaxation (tau)

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17
Q

tau reflects what

A

reflects the rate of pressure decline from the point of maximum -dP/dt to mitral valve opening

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18
Q

ventricular relaxation is one of many factors that indirectly affect

A

peak rapid filling

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19
Q

compliance is the ratio of

A

change in volume to change in pressure (dV/dP)

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20
Q

what is the inverse of compliance?

A

stiffness; it is the ratio of change in pressure to change in volume (dP/dV)

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21
Q

conceptually, compliance can be divided into two heart components

A
  1. myocardial components
  2. chamber components (influenced by ventricular size/shape)

extrinsic factors can also affect compliance (ex. pericardium, RV volume, pleural pressure)

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22
Q

Diastolic “filling” pressures include (2)

A

LV end-diastolic pressure
mean LA pressure

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23
Q

LV end diastolic pressure reflects ________ pressure after _________ is complete.

A

ventricular, filling

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24
Q

LA pressure reflects the average pressure in the LA during __________.

A

diastole

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25
Q

Clinically LA pressure is estimated by the (2)

A
  1. pulmonary wedge pressure - single point (cath lab)
  2. Swan-Ganz indwelling right heart catheter - multiple points (cath lab)
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26
Q

remember, ventricular DIASTOLIC FUNCTION and DIASTOLIC FILLING are not the same exact thing. The park early diastolic filling rate will be affected by (3)

A
  1. changes in preload that affect the initial pressure difference between the ventricle and atrium (increased with volume loading, decreased with volume depletion)
  2. change in transmitral volume flow rate (ex increased with coexisting mitral regurgitation)
  3. change in atrial pressure (ex elevated LV end-diastolic pressure or a v-wave caused by MR)
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26
Q

Late diastolic filling is affected by (6)

A
  1. cardiac rhythm
  2. atrial contractile function
  3. ventricular end-diastolic pressure
  4. heart rate
  5. the timing of atrial contraction (PR interval)
  6. ventricular diastolic function
27
Q

Remember, late diastolic filling is what wave on a rhythm strip

A

P wave

28
Q

looking at ventricular diastolic filling patterns to assess diastolic function is useless if there is

A

mitral stenosis; severity of valve obstruction affects LV filling velocity and timing

29
Q

with atrial pressures, the atrium serves as a ________ for flow from the ________ circulation to the ventricle, especially in early diastole, when the atrium is not contracting.

A

conduit, venous

30
Q

Right atrial filling characterized by (5)

A
  1. a small reversal of flow following atrial contraction (a-wave)
  2. a systolic phase (which is effectively “diastole” for the atrium) when blood flows from the superior and inferior vena cava into the atrium
  3. a small reversal of flow at end systole
  4. a diastolic filling phase when the atrium serves as a conduit for flow from the systemic venous return to the RV

these filling phases are reflected in the patterns of jugular venous pulsation

31
Q

right atrial filling phases are reflected in the patterns of jugular venous pulsation… the a-wave, x descent, v wave, y descent

A

a- wave: follows atrial contraction
x-descent: corresponding to atrial filling during ventricular systole
v-wave: end systole
y-descent: corresponding to atrial filling during ventricular diastole

32
Q

LA filling from the pulmonary veins is also characterized by (4):

A
  1. a small reversal of flow following atrial contraction (a-wave)
  2. a systolic filling phase
  3. a blunting of flow or brief reversal at end-systole
  4. a diastolic filling phase
33
Q

Normal RA pressures are quite low…

A

0-5 mmHg

34
Q

Normal LA pressure is low

A

5-10 mmHg (slight increase in pressure following a-wave and v-wave contraction

35
Q

Normal LV and RV diastolic filling shows respiratory variation TRUE OR FALSE

A

TRUE
20% increased venous return to RA upon inspiration vs expiration

36
Q

Does LA filling increase with inspiration?

A

No because pulmonary venous return is entirely intrathoracic; therefore not significantly affected by respiratory changes

37
Q

four basic mechanisms of dz that lead to diastolic dysfunction are

A
  1. primary myocardial dz
  2. secondary lv hypertrophy
  3. coronary artery dz
  4. extrinsic constraint
38
Q

evaluation of ventricular ______________ dimensions and _________ thickness is an integral part of the echo evaluation of diastolic function

A

chamber, wall

39
Q

most patients with systolic dysfunction have som degree of __________dysfunction

A

diastolic

40
Q

The presence and severity of LA enlargement reflect

A

chronically elevated filling pressures, so that measurement of LA size or volume is inertial to evaluation of diastolic function

41
Q

patients with heart failure primarily due to systolic ventricular dysfunction have what type of EF

A

heart failure with reduced ejection fraction
- also typically have a dilated LV w/ global and regional dysfunction

42
Q

LA volume is a key element in the evaluation of diastolic dysfunction… it is accurate and a strong predictor of clinical outcome. BUT IT IS NONSPECIFIC. In addition to diastolic dysfunction, these things also increase LA volume:

A

age
athletic conditioning
cardiac arrhythmias
high-output states - ex. anemia
mitral valve dz

43
Q

Other imaging findings that raise the question of diastolic dysfunction include

A

pericardial thickening (ex constrictive pericarditis), the pattern of ventricular septal motion, with respiratory (esp with tamponade physiology), and dilation of inferior vena cava and hepatic veins (consistent with elevated RA pressures). Elevated pulmonary artery systolic pressures, in the absence of another cause such as mitral valve dz or primary pulmonary dz, also raise concern for LV diastolic dysfunction.

44
Q

Immediately following mitral valve opening, rapid acceleration of blood flow from the LA to the ventricle occurs with an early peak filling velocity, This early maximum filling velocity is known as

A

E velocity - it occurs simultaneously with the max pressure gradient between the atrium and the ventricle.

Normal 0.6 to 0.8 m/s 90 to 110 ms after onset of flow in young healthy patients

After this max velocity, flow decelerates rapidly in normal individuals with a normal deceleration slope of 4.3 to 6.7 m/s². Decel time ranges from 140 to 200 ms

45
Q

After the early maximum filling velocity (E velocity) and the deceleration time, then to minimal flow (diastasis)… diastasis depends on total duration of diastole, what happens next?

A

Atrial contraction, LA pressure again exceeds ventricular pressure with a resulting second velocity peak (late diastolic or atrial velocity) which ranges from 0.19 to 0.35 m/s in young, normal individuals.

46
Q

inflow velocities should be recorded using pulsed Doppler with the sample gate positioned either at the mitral leaflet tips (ventricular side) or the mitral annulus (atrial side)… depending on

A

at mitral valve leaflet tips - PW to evaluate diastolic dysfunction, walk sample gate, its usu at tips on ventricular side
@ annulus on atrial side - PW to measure volume flow rates and the duration of atrial filling

47
Q

Tissue Doppler myocardial velocities are less dependent on _______ than are transmitral flow velocities… and are therefore useful in evaluating diastolic dysfunction

A

preload

48
Q

Compared with transmitral blood flow velocity, the myocardial velocity curve is similar but _________ and lower in __________.

A

inverted, velocity

49
Q

E’ or E prime… AKA

A

e’
Em (for mitral annular)
Ea (annular)

E’ is the early diastolic velocity.
The second velocity peak is seen (A’) with a normal ratio of E’/A’ greater than 1.0

50
Q

A reduced E’/A’ ratio indicates

A

impaired relaxation
less than 1.0 in difference indicates impaired relaxation

51
Q

For evaluation of diastolic function, recordings from the ________annulus are typically used.

A

medial or septal
(lateral can be used but slightly higher in velocity and not as easily reproducible)

52
Q

E / E’ is

A

the ratio of transmitral blood flow velocity to tissue Doppler velocity

E (E velocity) reflects both the LA to LV opening pressure gradient and the amount of blood entering the ventricle in diastole

E’ (Tissue Doppler velocity) reflects only the amount of blood entering the ventricle (the volume increase in ventricular size)

This ratio normalizes the E velocity for volume flow rate, thus providing a measure of filling pressure.

53
Q

Respiratory variation seen in left heart filly patterns and right heart filling patterns, but there is a difference.

A

Left is less prominent than variation seen in the right and it is directionally opposite. Inspiration slightly diminishes left heart filling due to blood pooling in the expanded pulmonary veins which empty during expiration

54
Q

True or False, from a TEE approach, LA inflow patterns of the four pulmonary veins in the transverse plane can be imaged

A

TRUE

55
Q

For a TTE approach, viewing the pulmonary veins are done from an _________ window, and this specific specific pulmonary vein is recorded with spectral doppler

A

apical 4, right superior pulmonary vein flow (easiest to achieve parallel flow)

**signal strength is a limiting factor at this depth of interrogation (typically about 14 cm) so careful attention to sample volume position, wall filters, and gain settings is needed to optimize velocity data

(side note, for TEE the left upper pulmonary vein shows a more laminar flow pattern than the right)

56
Q

standard clinical measures of pulmonary venous inflow include

A

peak systolic velocity (PVs)
peak diastolic velocity (PVd)
peak atrial reversal velocity (PVa)
Duration of pulmonary vein atrial reversal (Adur)

57
Q

A normal IVRT is appx between

A

50 to 100 ms

58
Q

impaired relaxation is associated with an IVRT that is _______, whereas decreased compliance and elevated filling pressures are associated with a ___________IVRT.

A

prolonged,
shorter

59
Q

where to place the sample gate for IVRT measurement… what window too

A

placed at an apical 4-chamber view angulated anteriorly to show the outflow tract and aortic valve. Using pulsed Doppler, a 3-5mm sample volume is positioned midway between the aortic and mitral valves to obtain a clear signal showing both aortic outflow and mitral inflow, optimally with a defined aortic valve closing click. Adjust gain, decrease wall filters. Measured as time interval in milliseconds from middle of aortic closure click to the onset of mitral flow.

60
Q

Color Doppler M-mode recordings of LV inflow from an apical approach can be used to measure the

A

propagation velocity as blood moves from the annulus to the apex…

61
Q

Color Doppler M-mode recordings of LV inflow from an apical approach … flow propagation velocity is decreased with ___________ and increased with ____________.

A

restrictive ventricular filling,
constrictive pericarditis

62
Q

Where to place cursor in color Doppler m-mode

A

apical 4-chamber… place a color M-mode cursor parallel to mitral inflow in the center of the flow stream…

narrow sector, minimum depth needed to include annulus and apex, aliasing velocity of 0.5 to 0.7 m/s, sweep speed 100 to 200 mm/s.

Normal diastolic function the blood will flow quickly from annulus to apex resulting in nearly vertical M-mode color pattern.

63
Q

What is termed the propagation velocity in m-mode color doppler…?

A

the slope of the line along the edge of the color doppler m-mode in early diastole

normal value is greater than 50 cm/s (would be slower with decreased relaxation… therefore you’d see a prolonged slope of color m-mode)

64
Q
A
65
Q

Know this chart

A

Spring '24 (9 decks)

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