Tracy Exam #2 Flashcards
Diastolic Dysfunction, Pericardial Dz, Pregnancy related cardiac problems
There is an increasing number of patients with heart failure but have a preserved
EF!
Diastolic heart failure (HF) accounts for what percentage of all HF patients
50%
Why is assessing diastolic function important? (general)
it is an early sign of cardiac dz (HTN)… it shows up before systolic dysfunction
What little measurement can assess diastolic function?
IVRT
isovolumic relaxation time
it is important… it can elongate…
clinical definition of diastole
the interval from aortic valve closure (end systole) to mitral valve closure (end diastole)
IVCT is or is not included in diastole
IS NOT…
isovolumic contraction period is the time from the closure of the mitral valve to the opening of the aortic valve
4 phases of diastole
- isovolumic relaxation
- early rapid diastolic filling
- diastases
- late diastolic filling due to atrial contraction
what is diastasis?
the space between early and late diastolic filling… those with higher heart rates diastasis starts to disappear…
in those with higher heart rates what phase of diastole starts to disappear?
diastasis… you’ll just have one spike because there is no break in-between
Fill in the blanks
what is the IVRT exactly?
it is the time it takes the ventricle to relax (pressure) low enough so that the mitral valve can open… any issues in relaxation is going to delay that time
during IVRT (as long as there is no MR or AI) the LV pressure is
decreasing while its volume is unchanged
sequence of events for IVRT (4)
- closure of aortic valve
- LV ventricular pressure falls rapidly
- LV pressure falls below LA pressure
- Mitral valve opens
what event in the sequence of events triggers the end of IVRT?
mitral valve opens
In very simplistic terms (8 words) the IVRT is
time the AoV closes and the MV opens
think… diastole sounds like another “dia” word
“dilate”… the heart is literally dilating
what happens in early rapid diastolic filling?
blood flows from LA to LV
the rate of flow during early rapid diastolic filling depends on (3) things
- pressure difference along flow path
- ventricular relaxation
- compliance of both chambers
the rate of decline in early diastole is related to
LV stiffness… the higher LV stiffness leads to faster deceleration of LV filling
In the majority of normal patients… most of LV ventricular filling happens during
early diastole
Remember late diastolic filling is the what wave? (on EKG)
p wave
E-A reversal is normal in older patients (65 yo and up) true or false
TRUE
very stiff, non compliant LV can lead to very high what and rapid what
very high E waves and rapid deceleration
diastasis in a more detailed description (4)
- results because pressure difference in LA and LV equalize
- There is little blood movement
- Mitral leaflets remain in semi open position (drift back toward one another, don’t completely close) **then atrial systole pops them back open - this part is not part of diastasis but is late diastolic filling (on another slide)
- duration of this phase depends on heart rate (long in slow HR, absent in rapid HR)
late diastolic filling more detailed description (4)
- LA pressure exceeds LV pressure
- MV opens
- Second pulse of LV filling occurs
- This is responsible for only about 20% of ventricular filling
what happens with the right ventricle in diastole? is it similar to the LV? what will you see? Any change in velocities? Are the annulus sizes the same? Is the duration of diastole shorter or longer?
- similar to left ventricle, yes
- will see reciprocal respiratory variation with RV filling
- Lower velocities in TV
- TV annulus is larger
- Total duration of diastole is shorter - this is bc there is a longer RV systolic ejection period
Why will an A wave be higher in a patient that doesn’t have an LV that relaxes
that initial opening during early diastole isn’t going to get as much blood out so when the atria contracts there is more blood left in the LA so that’s why your A wave will be higher…. there is more toothpaste in the the tube to squeeze out
Anything higher than ______cm/s at the TV starts to get iffy…
70 cm/sec… shouldn’t be that high…
Respiratory variation normal for a TV but not for a MV because
IVC goes into the right side of heart, not the left side.. and IVC - RA inflow is affected by inspiration
Parameters of diastolic fx
- ventricular relaxation (happens at IVRT and early diastole)
- myocardial compliance (ability of myocardial cells themself to relax, like some infiltrative diseases)
- chamber compliance (ability of chamber to relax)
what is the definition of compliance
the measure of a hollow organ to resist recoil towards its original dimensions upon removal of a distending or compressing force.
ventricular relaxation occurs during _________ relaxation and _________.
isovolumic relaxation (IVRT) and early diastolic filling
ventricular relaxation is what kind of process?
an active process - myocardium uses energy
what factors can affect LV relaxation (specific)
- load
- inactivation of myocardial contraction (metabolic, neurohumoral, pharmacologic)
- asynchrony
how can load affect lv relaxation? does it affect directly or indirectly? Does it affect internally or externally?
can affect LV relaxation directly AND indirectly because it can aggravate dyssynchrony..
affects internal AND external
Internal loading forces (cardiac fiber length)
External loading conditions - wall stress, arterial impedance, increased after load (LV end systolic wall stress) leads to delayed and slow relaxation
when talking about wall stress (an external factor that can affect LV relaxation) what causes wall stress or wall tension
tension of the LV wall determined by LV pressure, radius of the LV and wall thickness
abnormal relaxation is going to prolong your (4)
IVRT… measurement of it will be longer because ventricle is not dropping its pressure quick enough. can come from a multitude of factors. 1) prolongs the IVRT 2) ventricular pressure has a slower rate of decline 3) results in reduction in early peak filling rate 4) pressure difference between LA and LV is not as great when AV valve opens
reduction in E wave… increase in A wave
reduction in E wave… increase in A wave means
an increased A wave means more blood left over at atrial contraction… more than there should be
________ / Impaired Relaxation
Amyloidosis
LV relaxation time can be measured how (3)
- using IVRT
- maximum rate of pressure decline
(-dP / dt) negative change in pressure over change in time
IVRT acquisition from what window? multiple or one?
apical long axis or 5-chamber
******Describe IVRT Acquisition in echo exam
use apical long axis or 5 chamber
1. use CW and place sample volume in LVOT to get aortic and mitral flow (position it in between mitral inflow and left ventricular outflow) - can do it from PW too bc ur not measuring a velocity but the book says CW
2. Put sweep speed at 100 mm/sec
3. normal is less than or equal to 70 msec
4. impaired relaxation with normal LV filling pressure (IVRT is prolonged)
5. Increased LAP - IVRT shortens and is inversely related to LV filling pressure in pts with cardiac dz
Two things to consider when talking about ventricular compliance
- compliance: ratio of change in volume to change in pressure (dV/dP)
- stiffness - inverse of compliance, ratio of change in pressure to change in volume (dP/dV)
When talking about the components of compliance specifically, it could be ________ compliance or it could be __________ compliance or it could be both.
myocardial compliance: characteristics of isolated myocardium
chamber compliance: characteristics of the entire chamber
compliance defined
a property of a heart ventricle in its resting state that determines the relation between the filling of the ventricle and its diastolic pressure
what factors affect chamber compliance / stiffness? (general) (3)
- LV geometry (ventricle size + shape)
- myocardial stiffness
- extrinsic factors outside LV - ex. pericardium, rv interactions with LV, Pleural pressure
outside the heart, talk about extrinsic factors outside the LV that can affect the chamber compliance/stiffness
pericardium
pericardial dz that results in impaired cardiac filling due to extrinsic compression of heart such as
- pericardial tamponade
- pericardial constriction
RV interactions with LV (RVVO - causes RV to be a bully and pushes on the LV)
Pleural pressure (affects hearts ability to move too - don’t usu go into tamponade from pleural effusion but it can affect heart mobility)
in any situation where there is decreased SV, heart will compensate with increased HR
some invasive methods for assessing diastolic function.. what parameters are evaluated invasively?
left heart cath (cath lab)
parameters evaluated invasively?
- Tau (time constant): relation between LV pressure and time
- IVRT
- End diastolic pressure
- Compliance of LV chamber stiffness using dP/dT
diastolic function assessment NONINVASIVE
2D / m-mode evaluation!!!!!!
it’s limited but some indicators can be seen… a patient with heart failure, normal wall thickness, normal chamber size, and normal systolic function
What are some 2D / M-mode indicators of diastolicdysfunction (7)
- could be present with systolic dysfunction
- motion of the posterior wall on m-mode
- pericardial thickening
- septal motion w /respiration (sign of tamponade)
- dilated IVC and hepatic veins (sign of elevated R sided pressures) can happen with congestive heart failure… plumbing backs up all the way to the right side of heart
- tissue characterization of myocardium
- LA maximum volume index is the most useful 2D measurement method
LA remodeling: changes in adaptive to maladaptive range often occurring as a result of pressure or volume overload… this can happen from (4)
- diastolic dysfunction
- tachycardia
- ischemia
- valve disease (MS or AS)
In LA remodeling due to diastolic dysfunction, LA pressure ______ to maintain adequate LV filling. Would be associated with increased _______ and decreased _________.
increases… associated with increased LV stiffness and decreased LV compliance
Diastolic dysfunction can affect the LA size… (3)
increases filling pressures and causes LAE
the severity of diastolic function correlates well with LA volume
longstanding effects of LA dilatation is a decrease in LA function
In addition to the 3 main reasons for diastolic dysfunction, LA enlargement can ALSO be from… (7) - CLUES: type of regurg, type of fistula, high out states like _______, special type of heart that is healthy, slow heart rhythm, enlargement of how many chambers, and an irregular heart rhythm
- volume overload from MR
- arteriovenous fistula (ex. coronary fistula)
- high output states like anemia
- athletes heart w/ no cardiovascular dz
- bradycardia
- 4 chamber enlargement (could be part of a cardiomyopathy ex. dilated cardiomyopathy)
- fib or flutter
the bigger the LA, the worse the
diastolic dysfunction
LA volumes are a good predictor of outcomes in a number of different conditions (7)
- hypertensive heart dz
- a-fib
- cardioversion success
- dilated cardiomyopathy
- hypertrophic cardiomyopathy
- ischemic stroke
- coronary events
LA volumes reflect immediate or cumulative effects of filling pressure?
cumulative effects
For LA volumes, 2D and m-mode measurement are
no longer standard
LA volume measurements are preferred over linear measurements due to asymmetric remodeling of the chamber… they correlate well with
CT and MRI methods
2 methods of assessment for LA volumes
- biplane area-length method
- simpsons biplane method
normal LA volume indexed by dividing it by
Body surface area
abnormal is > 34 ml/m2
how do you measure area LA? from what to what?
annulus to annulus during systole… its biggest volume
measure 1-2 frames before MV opening
Make sure view maximizes LA length and transverse diameter
Do not include the LAA or pulmonary veins in the trace from the apical 4 and 2 chamber view
Parameters to measure diastolic function
Peak E and A velocity of MV
MV A duration
MV E/A ratio
MV DT
TDI e’ velocity
Mitral e/e’
Vein S, D, and A wave velocity
Vein A wave duration
Vein S/D ratio
CW TR peak velocity
Color propagation m-mode
Valsalva (reverses E/A velocity)
Secondary measurements (color m-mode, propagation velocity, TE - e’)
Measure what for mitral inflow method
E wave, A wave, E/A ratio, Decel time, Duration of A wave, IVRT
CW or PW for mitral inflow velocities?
PW preferred; inflow will be ABOVE THE baseline at apical measurement… just a mental note - mitral stenosis will always be above the baseline then**
Using diastolic filling patterns to assess diastolic function is only appropriate when
no valvular obstruction is present such as mitral stenosis; arrhythmias also make evaluation limited
mitral inflow… normal diastolic dysfunction with older? what things change?
E and A wave become appx equal during the 6th and 7th decade of life
Common to see E to A reversal in patients after 70 years of age
DT and IVRT become longer with age
Atrial contraction contributes more to LV filling with age
What is a normal E to A in children and young adults
majority of filling occurs in early diastole so E wave is much more prominent than the A wave
Random question… increased after load would be increased with what issues… name a few
aortic stenosis, high blood pressure, sign of increased afterload is thickened ventricles as a result
what is after load (review)
the load or resistance against which the left ventricle must eject its volume of blood during contraction
in terms of diastolic dysfunction, what would be some results of increased preload
- increased E velocity
- Shortened IVRT (due to the quick increase in LA pressure)
- Steeper deceleration slope in early diastolic filling
- Small A velocity (LV pressure is higher so gradient between LA and LV is not as high
MR would be a good cause of increased preload
What does this image show
Shows an inflow pattern on a patient with severe MR. This is therefore a case where there is increased preload. Note the increased E velocity from increased volume across the valve. There will also be an increase in LA pressure with severe MR.
Reduced Preload (LA pressure) what results from this?
- reduced E velocity (chamber gradient is decreased)
- does not affect atrial contraction - a wave is the same or higher
- hypovolemia or ventilator (ex NTG) can cause decreased E velocity
Factors affecting late diastolic filling aka A wave (7)
- cardiac rhythm
- atrial contractile function
- ventricular end-diastolic pressure
- heart rate
- timing of atrial contraction (PR interval)
- ventricular diastolic function
- increases with age
higher heart rates: shorter diastole, A wave is closer to the E wave
A wave can be added or superimposed with E wave resulting in a single E/A velocity:
- Long PR interval
- Very high heart rates
- Complete heart block with intact atrial contraction
If you’re measuring waveforms, you need how many consistent beats for an irregular waveform? ex. arrhythmia
you measure 5 beats and let the machine average them
What is this image about
A-fib, no A velocity
What is this image about
Atrial arrhythmia, shorter diastolic interval
When do Mitral Valve L waves happen?
L waves happen when there is markedly delayed LV relaxation in the setting of elevated LV filling pressures that allows ongoing LV filling in mid diastole
waveform looks like blood pressure equalizing and not really sure where to go
Tracy calls it the “camel hump”
Really slow heart rate with really high atrial volume
What is the heart rate when mitral valve L waves are seen?
patient usu has very slow bradycardia (30-40 bpm), usually gonna see diastolic dysfunction with this
Where can you see L waveforms? (not super common finding)
Mitral inflow waveform and also on Tissue Doppler waveform (septal or lateral wall, doesn’t matter)
Use of Vasalva, when should that ALWAYS be done? what kind of assessment? what does it decrease? what wave velocities are affected? what will it indicate? Where should you put the sample gate? What will indicated increased LV filling pressures?
- should be done during diastolic function assessment
- it decreases preload or LA pressure
- Should see a decrease in the E and A wave velocity at maximal strain
- A decrease of the E/A ratio
- This will tell if patients are in a pseudonormalized pattern or if there is a significant increase in LV filling pressures
- Keep sample gate between mitral leaflet tips during maneuver as they hold breath…
- A decrease of the E/A ration of > or equal to 50% or an increase of A velocity during the maneuver (not from E to A fusion) indicates increased LV filling pressures
This decreases preload or LA pressure
Vasalva
Higher heart rates = shorter what
shorter diastole
most machines (default preset) is set to what for values
to average… your job is to assess and fix depending on what measurement you do (average, max, min) etc
When you ask a patient to vasalva… just ask them to stop breathing where they’re at and THEN bear down… 10 seconds is good.. otherwise what will happen?
otherwise they’ll take a deep breath and… womp womp… there goes your picture
What does this image show
Grade 2 diastolic dysfunction after Vasalva
Doppler tissue imaging can be evaluated in addition to recording E and A filling velocities… TRUE OR FALSE
TRUE
DTI allows for evaluation of regional wall motion in diastole with the pattern of diastolic wall velocities corresponding to E and A filling velocities
As LV fills in diastole, the myocardial walls expand outward and this motion is recorded with Doppler
Doppler is recording the velocity of movement of myocardium instead of intracavity blood flow velocities
Diastolic velocities of myocardium are less dependent on _________ than transmitral flow velocities and can be useful in evaluating _____________.
preload, diastolic fx
Compared to transmittal flow, myocardial doppler patterns are similar but ________ and have a _________ velocity.
inverted, lower
How to obtain DTI from a dinosaur machine…. 4 steps
- PW from an apical four chamber
- Sample volume is 5-10 mm
- Sweep speed at 50-100m sec at end expiration
- Sample volumes placed within 1 cm from mitral annulus in basal septum or basal lateral wall
What are the downsides with DTI septal wall vs lateral wall… main difference between the two
septum is more reproducible because it is parallel.. however there is RV influence
Lateral does not have RV influence but not as parallel to flow
The most valuable measurement when doing E prime is the
E’ to E’ ratio
When obtaining DTI waveform, make sure waveform are (image appearance)
sharp! without spikes, feathering, or ghosting
In DTI, E’ has several synonyms… also what is E’ a measurement of
E’ or EM
measures early systolic velocity peak away from transducer corresponding to early diastolic relaxation
Velocity between 0.10 to .14 cm/s
In DTI, A’ has several synonyms… also what is A’ a measurement of
A’ or AM
Second velocity peak away from the apex following atrial contraction
Normal ratio of EM/AM > 1.0
Ratio is a predictor of changes
Reduced ratio indicates impaired relaxation
Helps distinguish psuedonormalized patterns
What are standard DTI measurements for early diastolic filling velocity (E’ aka EM)? When averaging the septal and lateral wall aka E/e’ velocity ratio, what should it be less than?
Normal is > 7 cm/sec in septal wall and >10 cm/sec in lateral wall
E/e’ ratio should be less than 14
E/e’ ratio DTI measurement not as reliable in patients with what pathology
MAC
Mitral stenosis
Mitral prosthesis
Constrictive pericarditis
(Pulmonary wave doppler) Systolic predominance wave aka … what does it measure
S wave (for pulmonary vein doppler)
measures antegrade (forward) flow within the pulmonary vein during atrial diastole and ventricular systole
(pulmonary wave doppler) Diastolic velocity is the _____ wave. How is this wave created?
D wave (of S, D, A, waves in pulmonary doppler)
Early diastolic filling following the opening of the MV generates the MV inflow (E wave). THIS CREATES the D wave (or diastolic velocity) w/in the pulmonary veins
(Pulmonary wave doppler) Retrograde flow aka ______ wave. Created by _________ during _________.
A wave. Atrial contraction generates the mitral inflow A wave in late diastole AND THE RETROGRADE FLOW OR A WAVE OF THE PULMONARY VEIN.
Sometimes the S wave can be smaller than the D wave… so it’s important to always look at what for reference?
Look at the QRS complex… the S wave is the first wave to follow the QRS complex.
In pulmonary vein doppler, in patients younger than 40 years, the diastolic wave or D wave is usu
predominant
What does this picture show?
Relationship between mitral inflow filling (E-A wave) and pulmonary vein filling (SDA waves)
S wave always right after a QRS complex remember that
Can atrial pressures and filling curves also be used to evaluate diastolic function?
yes! AND ITS RELIABLE!
WHY are atrial pressures and filling curves reliable to evaluate diastolic function?
Because elevated ventricular diastolic pressures are also reflected in elevated atrial pressures
What is a normal LA pressure?
5-10 mmHg
Corresponds to normal LV-EDP
Slight increase in pressure occurs after atrial (a wave) and ventricular (v wave) contraction
what vein do you use for pulmonary vein doppler in the apical view?
we use the right superior pulmonary vein
With progressive diastolic dysfunction, increasing LA pressure leads to increased reliance on _________ to empty the LA. This shows up as increased _____ wave velocity in the pulmonary vein tracing.
atrial contraction, D wave
In progressive diastolic dysfunction, you can take the duration of the A wave from the pulmonary vein (AR wave) and subtract it from the ________________ wave. Values higher than _________ is an indicator of elevated ___________.
Mitral valve (MV) inflow A wave, >30msec, LVEDP
With respiratory variation, what is the difference between the left heart and the right heart? (4)
Lt is less prominent
Lt is directionally opposite
Diminishes during inspiration as blood “pools” in pulmonary veins not because of negative intrathoracic pressure
not usu respiratory variation in pulmonary veins… more hepatic veins
When doing Doppler for the pulmonary veins, you should do what on the US machine before you Doppler
lower your color scale
place your sample gate a few cm into the pulmonary vein flow otherwise you’ll be getting atrial flow waveform
What two other views (windows) can you utilize to Doppler pulmonary veins (although getting a good angle is hard)?
PSax @ base
Subcostal
Conditions that influence Systolic atrial filling and Diastolic atrial filling
Systolic atrial filling
- age
- LA size
- Changes in LA pressure
- Atrial contractile function
- LV and RV contractility
Diastolic atrial filling
- gradient from pulmonary veins to LV
- LV filling and compliance
- Changes in parallel with mitral E velocity
In LA filling patterns, a decrease in LA compliance and an increase in LAP is associated with
decrease in S velocity and increase in D velocity
A lot of things can affect your S and your D wave that have NOTHING TO DO WITH
diastolic dysfunction
CONDITIONS THAT ALTER LA FILLING PATTERNS (4)
- atrial contractile function
- LA compliance
- LV compliance
- Cardiac rhythm
Swan Ganz catheter detects
LAP (left atrial pressures) - indwelling rt heart catheter used in ICU
How can patients be managed using diastolic pressures alone
- LV-EDP
- Mean LAP
- In the absence of LV inflow tract obstruction the estimated LA pressure represents the LVEDP (Patient must have MR…
LAP = BPs - 4 x (VMaxMR2)
(simplified or modified is only for aortic stenosis)
Clinically, LAP is estimated using by
PCWP
(pulmonary catheter wedge pressure)
Surrogate is PA wedge pressure (this gives an average LA pressure during diastole)
Noninvasive estimates of LV Diastolic pressure: LA pressure is equivalent to _____________. This is a difficult value to obtain by US. Can use _____ jet to calculate.
LVEDP, AI jet
AI calculation of LVEDP
- Measure end diastolic AI regurgitant velocity
- Plug into Bernoulli equation (4v2)
- Take Bernoulli value and subtract diastolic blood pressure
(need to have recordable AI jet, must have accurate cuff diastolic measurement, small errors in either value can result in much larger errors in final value)
Right Atrial Filling: RA pressures usually what?
0-5 mmHg
Right Atrial Filling: characteristics? (4)
- Small reversal of flow following atrial contraction (a wave)
- Systolic phase (IVC and SVC fill atrium)
- Small reversal of flow at the end-systole (v wave)
- Diastolic filling phase - RA serves as a channel between the systemic venous return and the RV
What is this
Normal Hepatic Vein Waveform
What’s this
Normal RA inflow pattern / hepatic vein
A wave: follows atrial contraction
X-descent: corresponds to atrial systolic filling
V-wave: corresponds to ventricular contraction
Y-descent: corresponds to atrial diastolic filling
** A dz process should affect JVP and RA filling Doppler patterns in the same manner
RA filling pattern can also be recorded from these two windows, but it is a lot harder
Suprasternal notch (SVC)
Subcostal view (central hepatic vein)
- Both of these veins empty directly into the RA without interference from venous valves
RA filling pattern: Doppler recording
resembles jugular venous pressure curves
Is more reliable than jugular venous pressure curves
RA filling pattern: changes with respiration
inspiration (augmented RA inflow)
- creates negative intrathoracic pressure
- pressure gradient from extra thoracic to intrathoracic so great veins flow to RA
When measuring RAP you want to also measure the IVC and determine its collapsibility. How?
- Open IVC to its fullest
- Perpendicular to vessel
- 1-2 cm away from RA
- Inner to inner
- Abnormal > 2.1 cm
Collapsibility
Patient must sniff
M-mode preferred
Normal >50%
Abnormal <50%
If you can’t see the size of the IVC you can integrate other findings into your study that may justify normal or abnormal RAP such as
Dilated right atrium
Interatrial septum that bulges into the left atrium throughout cardiac cycle
Healthy young athletes may have dilated IVC’s in the presence of normal pressures TRUE or FALSE
TRUE; don’t measure IVC then to estimate RA pressure
The IVC is commonly dilated may not collapse in patients on ventilators TRUE or FALSE
TRUE; don’t measure IVC then to estimate RA pressure
Color Propagation M-mode: normal inflow where
along posterior lateral wall
Color Propagation M-mode: Lv systolic dysfunction where
lower velocity “puffs” of inflow
Color Propagation M-mode: prosthetic MV valves
flow directed along anteromedial wall
Color Propagation M-mode: records LV inflow from apical view… measures the what?
measures the propagation velocity as blood goes from annulus to apex
Color Propagation M-mode: cursor should be _____cm within LV chamber?
4cm
Color Propagation M-mode: Nyquist limit should be set that the highest velocity along the central jet appears
blue; shift color baseline in the direction of mitral valve inflow to lower velocity scale for red/yellow inflow velocity profile
Color Propagation M-mode: flow propagation velocity (Vp) is defined as _________. What rate is normal?
the slope of the first aliasing velocity during early LV filling
0.5 m/sec or greater is normal (this is decreased with restrictive ventricular filling (or decreased relaxation) and increased with constrictive pericarditis)
Myocardial Performance Index aka TEI index: What is the Tei index based on? What does it combine? What should you use to measure? A higher or lower index value correlates with dysfunction?
Doppler derived time intervals, combines systolic and diastolic cardiac performance, should use PW doppler or DTI to measure, a higher index correlates with dysfunction
What is this?
Color m-mode.. this is normal
What is this?
Color m-mode.. this is normal
What is this
Color m-mode
diastolic heart failure
advantages of Tei (4)
- noninvasive
- easy to obtain
- reproducible
- independent of arterial pressure, HR, AV vale regurg, ventricular geometry, after load and preload in supine pts
Tei index equation
(IVCT + IVRT) / ET
ejection time is ET (time the aortic valve is open)
Easy measurement to get
Impaired LV relaxation results in
Classic pattern of mild diastolic dysfunction
Impaired early diastolic filling
Increased atrial contribution to LV filling
LV compliance: abnormal compliance causes (7)
- rapid early diastolic filling following MV opening
- Short IVRT
- Rapid acceleration time
- High E velocity
- Steep deceleration slope (which leads to decrease deceleration time)
- Atrial contribution is small (not much of a gradient)
- Pull veins show D wave > S wave and a prominent A wave
Despite impaired LV relaxation, markedly elevated LA pressure causes: (2)
- high velocity of early diastolic filling
- stops abruptly because of abnormally rapid rise in ventricular pressure and atrial dysfunction
Reduced LV compliance: Pulmonary venous flow pattern (3)
- prominent diastolic inflow
- prominent atrial reversal
- high LV diastolic pressure reduces late LV filling so when atrial contraction occurs, reversed flow is seen in pulmonary veins
REVIEW CHARTS ON DIASTOLIC POWERPOINT
SLIDES 118-121
Diastolic stress testing indicated when echo does not explain symptoms of
heart failure or dyspnea, esp with exertion
diastolic stress testing most appropriate in patients with ________ and grade _____ diastolic dysfunction at rest
dyspnea and grade 1 diastolic dysfunction at rest
The only thing that SHOULDN’T be done during diastolic stress testing is
PHARMACOLOGIC STRESS TESTING. THAT SHOULD NOT BE DONE. Supine and treadmill stress is OK
For stress testing, what should be acquired?
Mitral E velocity
TDI annular e’ velocities
peak velocity TR jet from multiple windows
You have one to two minutes after patient exercises
Stress test interpretation… considered positive when what 3 conditions are met during exercise
average E/e’ > 14 or septal E/e’ ratio > 15
peak TR velocity > 2.8 m/sec
septal e’ velocity < 7 cm/sec
2 principle mechanisms are responsible for diastolic dysfunction
impaired active ventricular relaxation
increased passive myocardial stiffness (decreased compliance)
Diastolic dysfunction can be secondary to dz (4)
- secondary to LV hypertrophy and HTN
- coronary artery dz
- primary myocardial dz (DCM, HCM. RM)
- Extrinsic constraint: pericardial tamponade or pericardial constriction
whats the most common reason for development of diastolic dysfunction?
hypertension
a hypertensive patient with diastolic dysfunction… this is far in advance of what symptoms of what serious pathology that can occur later down the line
Heart failure
Chronic pressure overload from hypertension causes (7)
- cardiomyocyte hypertrophy
- enhanced collagen deposition
- reduction of microvascular density
- LVH
- Increased stiffness in systole and diastole
- Impaired relaxation
- Kidney is also affected and renal dysfunction worsens HTN
Examples of mechanisms leading to diastolic dysfunction secondary to LV hypertrophy are (3)
hypertension
aortic stenosis
congenital heart dz
In a patient with chronic CAD with ischemic segments, what is detectable?
diastolic dysfunction
_________ usually results in diastolic dysfunction before _______ dysfunction is seen.
(providing the patient has not had an MI)
ischemia
systolic
Post acute MI, what are some LV filling patterns? (3)
- successful repercussion and little myocardial damage (lv diastolic function returns to normal)
- MI w/ preserved LV function (impaired relaxation pattern persists
- Large MI and significant systolic dysfunction (pseudonormalized patterns from reduced compliance and high LVEDP)
Diabetic cardiomyopathy defined as
abnormal myocardial function in the absence of HTN, valvular dz, or coronary heart dz
Diabetic cardiomyopathy progresses through 3 stages….
early, middle, and late stage
early asymptomatic stage: myocardial damage at molecular level. Can manifest as LVH with abnormal diastolic function
middle stage: cardiomyocyte hypertrophy and fibrosis progress. Diastolic function worsens. Conventional echo techniques can detect MIDDLE STAGE.
Late stage: overt heart failure. micro/macrovascular CAD, HTN and cardiac autonomic neuropathy
Patients with diastolic dysfunction vs systolic dysfunction are more like to be what? (body habitus)
OBESE; it contributes by increasing the hemodynamic load on the heart.
Indirect effects of obesity can create a state of chronic inflammation which can cause dysfunction
HTN, CAD, Diabetes… all are _________ risk factors for _________________.
independent, diastolic dysfunction
Obstructive and central sleep _________ are common with obesity
sleep apnea; both implicate progression of diastolic dysfunction to heart failure
With what cardiomyopathy (not diabetic) is diastolic dysfunction prevalent… can be due to several mechanisms
Hypertrophic Cardiomyopathy (HOCM)
1. increased afterload
2. myocardial fibrosis
3. myocardial hypertrophy
With what hypertrophic cardiomyopathy is diastolic dysfunction the dominant pathophysiologic derangement
restrictive cardiomyopathy; while there are a number of different diseases with distinct histologic changes, diastolic dysfunction is a hallmark and is cause of myocardial fibrosis
- amyloidosis
- hemosiderosis
- sarcoidosis
- hyperesoinophilic syndrome
-systemic sclerosis
what’s the most common RCM?
amyloidosis; can affect both LV and RV; increases wall thickness and stiffness; affects heart in 90% of cases
Hemosiderosis is what ***can present as either _______ or __________.
iron overload… iron take up my macrophages. once macrophages are saturated, the excess iron spills into tissue of other organs which causes tissue damanage and fibrosis
can present as either restrictive diastolic dysfunction or dilated cardiomyopathy
sarcoidosis (cardiac) is what
only 5% of patients with sarcoidosis have cardiac involvement; granulomas deposit in walls (usu along LV free wall and basal ventricular septum). MRI better for diagnosing (echo findings nonspecific)
Hypereosinophilic syndrome
systemic dz affecting multiple organs; occurs from malignancies, vasculitides (inflammation of blood vessels), parasitic infections, idiopathic
- causes endomyocardial fibrosis
- thrombus along damaged endocardium is often seen
systemic sclerosis
scleroderma
an autoimmune dz that can cause severe dysfunction of any organ, including vasculature
HALLMARK IS EXTENSIVE FIBROSIS
Often has associated HTN
Pericardial dz (2)
pericardial tamponade - filling is impaired in early and late diastole
constrictive pericarditis - early diastolic filling is normal, marked impairment of filling in late diastole (pericardial encasement prevents heart from expanding)
PREGNANCY blood volume goes up what %
50% (majority in 1st trimester)
PREGNANCY CO up by what % due to
up 30-50% due to increased SV and a slight increase in HR (10bpm)
PREGNANCY ______ cell and ______volume increase
red cell and plasma volume; since plasma increases more it results in physiologic anemia
