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Ventricular Diastolic Filling and Function

Ventricular Diastolic Filling and Function. Stephen L. Rennyson M.D. Echocardiography Conference August 25, 2010. Objectives. Background of Diastolic Dysfunction Characteristics of Diastolic Dysfunction Echocardiographic Analysis Mitral inflow Pulmonary Venous Flow Tissue Doppler

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Ventricular Diastolic Filling and Function

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  1. Ventricular Diastolic Filling and Function • Stephen L. Rennyson M.D. • Echocardiography Conference • August 25, 2010

  2. Objectives • Background of Diastolic Dysfunction • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  3. Diastole • Diastole • Isovolumic relaxation • Early filling (E) • Diastasis • Late filling - atrial contraction (A)

  4. Background • Congestive Heart Failure (CHF) manifests as either systolic and/or diastolic dysfunction • Where is the dysfunction? • Systolic dysfunction -- manifest as a loss of ventricular function (decreased EF) • Diastolic dysfunction -- abnormal relaxation pattern manifest as increased filling pressures (Atrial and Ventricular)

  5. Diastolic Dysfunction • Diastolic Dysfunction is an echocardiographic / Cardiac Catheterization diagnosis based on: • Ventricular filling patterns • Velocity of myocardial motion • Atrial filling patterns • Based on these data, diastolic dysfunction can be determined and graded

  6. Diastolic Dysfunction • Early sign of cardiac disease • Preceding systolic dysfunction • Associated with increased mortality without the robust studies of treatment guidelines compared to systolic dysfunction • Exist as its own entity -- Diastolic Heart Failure • Studies of clinical heart failure admissions • 50% of those have only diastolic dysfunction • In systolic heart failure -- diastolic dysfunction can explain the differences in clinical presentation

  7. Etiology • Myocardial Disease • Dilated Cardiomyopathy • Restrictive Cardiomyopathy • Hypertrophic Cardiomyopahty • Secondary Ventricular Hypertrophy • Hypertension • AS • CAD -- Ischemia and infarction • Pericardial disease

  8. Overview • Background of Diastolic Dysfunction • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  9. Characteristics of Diastolic Dysfunction • LV hypertrophy • LA Volume • LA function • PA systolic and diastolic pressures

  10. LV hypertrophy • Majority of those with diastolic dysfunction: • Concentric hypertrophy (hypertensive heart disease) • Increased mass and wall thickness • Remodeling • Normal mass / increased wall thickness • Eccentric hypertrophy • Systolic dysfunction / depressed EF

  11. LA Volume • Easily measured and reliable in apical views • Significant relationship between LA remodeling and diastolic dysfunction • Consequence of longstanding elevated filling pressures • LA >34 mL/m2 predictor of death, heart failure, atrial fibrillation, ischemic stroke

  12. LA function • Reservoir / Conduit / Pump • Reservoir and conduit functions -- Early filling • Pump function -- Atrial contribution to LVEDV -- approximately 20%

  13. PA Systolic and Diastolic pressures • Symptomatic patients with diastolic dysfunction have increased pulmonary artery pressures • Correlate with elevated LV filling pressures • PA systolic -- Peak TR jet velocity + RA • PA diastolic -- End diastolic velocity + RA

  14. Overview • Background of Diastolic Dysfunction • Diastology • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  15. Mitral Inflow • Measurement • Inflow patterns • Clinical application

  16. Measurement • Pulse-wave doppler through mitral inflow: • Peak E (early diastole) • Peak A (late diastole) • E/A ratio • Deceleration time (DT) of Early filling

  17. E wave (Early Diastole) • LA-LV pressure gradient • Affected by: • Preload • LV relaxation

  18. A-Wave (late diastole) • A Wave • LA-LV pressure gradient • Affected by: • LV compliance • LA contraction

  19. E wave Deceleration Time (DT) • Influenced by LV relaxation • Values greater than 140 ms considered normal

  20. Inflow patterns • Normal • Impaired LV relaxation • Normal Atrial pressure • Pseudonormal filling pattern • Symptoms • Restrictive filling • Symptoms

  21. Normal inflow pattern

  22. Impaired LV relaxation

  23. Pseudonormal LV filling E/e’ = 17

  24. Restrictive LV filling

  25. Inflow patterns • Increasing Age -- Age related loss of compliance • E wave velocity and E/A ratio decrease • A wave velocity and Deceleration Time (DT) increase • By age 50 essentially equal E and A waves

  26. Systolic Dysfunction • Doppler mitral inflow patterns correlate symptoms better than ejection fraction: • Cardiac filling pressures • Functional class • Prognosis -- especially if patterns persist after reduction of preload

  27. Overview • Background of Diastolic Dysfunction • Diastology • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  28. Pulmonary Venous Flow • PW doppler of pulmonary venous flow • Not used as frequently • Can be difficult to obtain • Little additional information after use of Tissue Doppler

  29. Pulmonary Venous Flow • Measurements • Peak systolic • Peak anterograde diastolic • S/D ratio • Atrial reversal wave duration to A wave duration (mitral inflow)

  30. Overview • Background of Diastolic Dysfunction • Diastology • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  31. Tissue Doppler • Doppler Pulse Wave imaging of mitral annular velocity • Measure • Lateral and Medial/Septal mitral annulus • Medial more accurate than lateral or combination score • Early filling -- e’ wave • Late filling -- a’ wave

  32. Tissue Doppler • Mitral inflow E to tissue doppler e’ (LV filling pressure) • Calculation: • 81.9 / 8.7 = 9.4 • < 10 normal

  33. Overview • Background of Diastolic Dysfunction • Diastology • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  34. Diastolic Dysfunction Made Easy • Measurements • Mitral inflow patterns • E and A waves • E wave DT • Tissue Doppler of Mitral Annulus (medial) • E to e’

  35. Diastolic Dysfunction Analysis and Grading

  36. Symptoms from Diastolic Dysfunction • Symptoms driven by increased atrial pressures transmitted to pulmonary circulation • No symptoms likely from diastolic dysfunction: • Normal Diastolic Dysfunction • Impaired relaxation (normal atrial pressure) • Symptoms attributed to Diastolic Dysfunction: • Pseudonormal / Moderate diastolic dysfunction • Severe Diastolic Dysfunction

  37. InaccurateDiastolic Dysfunction • Mitral Valve Disease • MV replacement • Severe MR or MS • Atrial Fibrillation -- no A waves for analysis • Tachycardias as E and A waves fuse

  38. Objectives • Background of Diastolic Dysfunction • Characteristics of Diastolic Dysfunction • Echocardiographic Analysis • Mitral inflow • Pulmonary Venous Flow • Tissue Doppler • Analysis using Mitral inflow and Tissue Doppler • Cases

  39. Case # 1 • 57 year old male with presentation to the hospital for shortness of breath and exam consistent with CHF a exacerbation • Echo for shortness of breath ? heart failure

  40. TTE Apical

  41. Mitral inflow (E wave, A wave, Deceleration Time)

  42. Tissue Doppler

  43. Analysis • E wave greater than A wave • DT > 140 ms (190 ms) • e’ to a’ reversal • E/e’ = 31.9 • Pseudonormal Filling pattern / Moderate Diastolic Dysfunction

  44. Conclusion • Hypertensive patient with pseudonormal filling pattern consistent with moderate diastolic dysfunction. • Shortness of breath likely secondary to • Moderately reduced compliance • Impaired relaxation • Increased atrial pressure transmitted to pulmonary circulation • Episode driven by hypertensive urgency (medical noncompliance)

  45. Case # 2 • Patient with Cardiac Amyloidosis evaluation of cardiac structure and function

  46. PLAX

  47. Mitral inflow (E and,A waves, Deceleration Time)

  48. Tissue Doppler

  49. Mitral Inflow E wave greater than A wave • E wave > 2X A wave (3.1) • DT =140 ms (Criteria <140) • e’ to a’ reversal • E/e’ = 42.9 • Restrictive Filling Pattern

  50. Conclusion • Cardiac Amyloidosis • Severe Diastolic Dysfunction

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