1 / 62

Diastolic LV function and diastolic heart failure

Dr.Deepak Raju. Diastolic LV function and diastolic heart failure. Heart failure with normal ejection fraction-definition(2007 Eur Heart J). Symptoms and signs of heart failure Normal or mildly abnormal LV systolic function LVEF >50% in a non dilated LV(LVEDV <97ml/m2)

Télécharger la présentation

Diastolic LV function and diastolic heart failure

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Dr.DeepakRaju Diastolic LV function and diastolic heart failure

  2. Heart failure with normal ejection fraction-definition(2007 Eur Heart J) • Symptoms and signs of heart failure • Normal or mildly abnormal LV systolic function • LVEF >50% in a non dilated LV(LVEDV <97ml/m2) • Evidence of increased LV filling pressure • Tissue Doppler imaging(E/e’>15 or E/e’ 8-15 with other evidences of diastolic dysfunction) or • Invasive measurements(LVEDP>16 mmHg or mean PCWP>12 mmHg) or • Combination of natriuretic peptides or echo indices of LV diastolic dysfunction

  3. Treshold value to define normal Vs reduced EF is arbitrary;consensus is for using 50% as cut off

  4. Prevalence • Prevalence 50-55% of HF population • (Owan T ,NEJM 2006,Bhatia RS NEJM 2006) • Prevalence of HF nl EF among patients admitted for HF has increased over time • (Owen T ,NEJM 2006)

  5. Mortality • All cause mortality is similar in HF nl EF as compared to HF with reduced EF • Compared with patients with reduced EF ,pts with HF nl EF had more deaths from non CV causes(DIG study)

  6. Owan T nejm 2006

  7. Survival for HF with reduced EF have improved over time ,but not for HF nl EF

  8. Diastolic function • LV relaxation is an active energy dependent process • Begins during ejection phase of systole and continues through IVR and rapid filling phase • Calcium ion fluxes regulate contraction and relaxation phases • Depolarisation releases large amount of Ca into cytosol to initiate contraction • Decrease in cytosolic Ca initiates relaxation • Calmodulin mediated closure of L type Ca channels • SR reuptake of Ca by SERCA

  9. Calcium uptake by SERCA • Energy dependent process • Phosphorylation of phospholamban enhances uptake • Phospholamban respond to B adrenergic stimulation ,mediator is PKA • Impaired beta adrenergic signalling and inadequate ATP levels impair ventricular relaxation

  10. Major factors influencing relaxation • Cytosolic Ca level must fall- requires ATP & phosphorylation of phospholamban • Inherent viscoelastic properties of myocard – (hypertrophied heart -↑fibrosis, relaxation –slower) • ↑phosphorylation of troponin I • Influenced by systolic load- ↑the systolic load, the faster the rate of relaxation

  11. Phases of diastole • Isovolumic relaxation • Early rapid filling phase • 70 to 80 % of LV filling • Driven by LA LV pressure gradient • Dependent on • Myocardioal relaxation • LV elastic recoil • LA pressures • Mitral orifice area

  12. Diastasis • LA LV pressures almost equal • 5% of LV filling • Atrial systole • 15 to 25 % of LV filling • Depends on atrialpreload,afterload and inotropic state

  13. Pressure volume relationship

  14. Upward shift in diastolic pressure volume relation –increased LV diastolic stiffness-higher diastolic pressure required for filling • Downward shift-decreased stiffness

  15. HF nl EF • Upward and leftward shifted end-diastolic pressure–volume relationship • End-systolic pressure–volume relationship- unaltered or even steeper • Very small changes in LVEDV→ Marked ↑ in LVEDP & pulm venous P→ dyspnea during exercise, even pulm edema • Impaired LV filling and inability to use Frank-Starling mech→ Failure to ↑CO during exercise→ Exercise intolerance

  16. Indices of LV diastolic relaxation • Isovolumic pressure decay • Max rate of LV pressure decline after aortic valve closure in IVR phase measured(peak negdP/dt) • Affected by loading conditions • Time constant of relaxation • Load independent measure • Rate of LV pressure decay during isovolumic relaxation

  17. High fidelity manometer tipped LV catheters • Pressure and time data during period from end systole to LA-LV pressure crossover used • Weiss equation • P=P0*e-t/τ • τ=-(1/slope of Ln LVP Vs time) • Normal <40 ms • Relaxation is complete by 3.5 tau • Larger value of tau-more impaired relaxation

  18. Echocardiography • LV size –normal • LVH-Less than 50% • LA enlargement • Pulmonary HTN • Rule out valvular diseases causing symptoms of HF,pericardial d/s,congenital heart d/s

  19. Doppler echocardiography • Mitral inflow doppler velocities • TDI septal and lateral mitral annulus • Pulmonary vein Doppler • Color M mode of mitral inflow • Valsalva maneuver used to decrease venous return by increasing intrathoracic pressure

  20. Mitral inflow (left) and pulmonary venous flow (right)

  21. Normal diastolic filling pattern • Most LV filling occur in early diastole • Longitudinal mitral annular velocity mirrors normal mitral inflow • Normal E/e’ in rest and exercise • Parameters • E/A 0.9-1.5 • DT 160-240 ms • IVRT 70-90 ms • septal e’>10 cm/s • E/e’<8 • Vp>50 cm/s • LAVI-16 to 28 ml/m2

  22. Doppler parameters in different age groups

  23. Grade 1 diastolic dysfunction(mild) • LV relaxation impaired- • Slower LV pressure decay • Pressure crossover b/w LA and LV occurs late • IVRT,DT prolonged • Early transmitral gradient is reduced-reduced E vel • Adequate diastolic filling period is critical to maintain LV filling without increase in LA pressures

  24. Reduced LA emptying in early diastole increases atrial preload-A velocity increases • Pulmonary vein diastolic flow velocity parallels mitral E velocity-decreased.Compensatory increase in systolic velocity • Pul vein atrial flow reversal usually normal,can increase if atrial compliance decreases or LVEDP higher • Septal e’ < 7 cm/s • Vp< 50 cm /s • Grade 1a diastolic dysfunction • Filling pressure is increased (E/e’> 15) with grade 1 mitral inflow pattern

  25. Grade 2 –moderate diastolic dysfunction • LA pressures are elevated • LA-LV pressure gradient restored • Pseudonormalised mitral inflow pattern • E/A returns to normal,DT normal • Differentiation from true normal • Septal e’<7 cm/s • Valsalva decreases E/A by more than 0.5 • Pulmonary vein atrial flow reversal exceeds mitral A duration • Vp<45 cm/s

  26. Grade 3&4 LV diastolic dysfunction(severe) • Restrictive filling • Valsalva may reverse restrictive pattern to grade 1 or 2-reversible restrictive (grade 3) • Even if no change with valsalva reversibility cannot be excluded-filling pressure may be too high to be altered by valsalva • Grade 4 dysfunction not used in ASE rec.

  27. Early rapid diastolic filling into a less compliant LV cause a rapid increase in early diastolic LV pressure • Rapid equalisation produces a shortened DT • A velocity and duration shortened as atrial contraction produces rapid rise in LV pressure • Systolic forward flow in pulmonary vein reduced due to increased LA pressure • E/e’ > 15

  28. E/e’ ratio in rest and exercise • E/e’ ratio > 15 correspond to PCWP> 20 mmHg at rest and exercise • Normal-increase in E and e’ velocity with exercise to maintain ratio • In a subset of patients with diasolic dysfunction –increase in PCWP with exercise occur–increase in E not accompanied by increase in e’ to elevate the ratio • PCWP normal if E/e’< 8

  29. BNP and NT-pro BNP • BNP & NT-proBNP- • Elevated in HF nl EF but lower than levels in HF with reduced EF(wall stress is lower) • Less sensitive and specific

  30. BNP level 200 pg/ml or an NT-proBNP level 220 pg/ml to confirm the diagnosis of HFNEF in patients with symptoms of HF,LVEF 50%, and an ambiguous E/E value between 8 and 15 • Less reliable in elderly and in women • Exclusion of HF nl EF, with limits for exclusion of 100 and 120 pg/ml, respectively

  31. Demographic features • Aging • Diastolic function deteriorates with aging • Structural cardiac changes • Blunted beta adrenergic responsiveness • altered Ca handling proteins • Female gender • Higher ventricular systolic and diastolic stiffness • HF nl EF increases more sharply with age in women

  32. HTN • LVH which increases diastolic stiffness • Ischemia produces exaggerated increase in filling pressure • CAD • a/c ischemia causes diastolic dysfunction • Role of CAD in c/c diastolic dysfunction uncertain • Guidelines recommend revascularisation in pts in whom ischemia is felt to contribute to LV diastolic dysfunction • Reduced coronary microvascular density-impaired coronary flow reserve-diastolic dysfunction in stress

More Related