Post on 13-Jan-2016
description
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
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Diastole• Diastole
• Isovolumic relaxation
• Early filling (E)
• Diastasis
• Late filling - atrial contraction (A)
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)
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
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
• Myocardial Disease
• Dilated Cardiomyopathy
• Restrictive Cardiomyopathy
• Hypertrophic Cardiomyopahty
• Secondary Ventricular Hypertrophy
• Hypertension
• AS
• CAD -- Ischemia and infarction
• Pericardial disease
Etiology
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
Characteristics of Diastolic
Dysfunction• LV hypertrophy
• LA Volume
• LA function
• PA systolic and diastolic pressures
LV hypertrophy• Majority of those with diastolic
dysfunction:
1.Concentric hypertrophy (hypertensive heart disease)
• Increased mass and wall thickness
2.Remodeling
• Normal mass / increased wall thickness
3.Eccentric hypertrophy
• Systolic dysfunction / depressed EF
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
LA function
• Reservoir / Conduit / Pump
• Reservoir and conduit functions -- Early filling
• Pump function -- Atrial contribution to LVEDV -- approximately 20%
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
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
Mitral Inflow
• Measurement
• Inflow patterns
• Clinical application
• Pulse-wave doppler through mitral inflow:
• Peak E (early diastole)• Peak A (late diastole)
• E/A ratio
• Deceleration time (DT) of Early filling
Measurement
E wave (Early Diastole)
• LA-LV pressure gradient
• Affected by:
• Preload
• LV relaxation
A-Wave (late diastole)
• A Wave
• LA-LV pressure gradient
• Affected by:
• LV compliance
• LA contraction
E wave Deceleration Time (DT)
• Influenced by LV relaxation
• Values greater than 140 ms considered normal
Inflow patterns• Normal
• Impaired LV relaxation
• Normal Atrial pressure
• Pseudonormal filling pattern
• Symptoms
• Restrictive filling
• Symptoms
Normal inflow pattern
Impaired LV relaxation
Pseudonormal LV filling
E/e’ = 17
Restrictive LV filling
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
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
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
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
Pulmonary Venous Flow
• Measurements
• Peak systolic
• Peak anterograde diastolic
• S/D ratio
• Atrial reversal wave duration to A wave duration (mitral inflow)
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
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
Tissue Doppler
• Mitral inflow E to tissue doppler e’ (LV filling pressure)
• Calculation:
• 81.9 / 8.7 = 9.4
• < 10 normal
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
Diastolic Dysfunction Made
Easy• Measurements
• Mitral inflow patterns
• E and A waves
• E wave DT
• Tissue Doppler of Mitral Annulus (medial)
• E to e’
Diastolic Dysfunction Analysis and Grading
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
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
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
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
TTE Apical
Mitral inflow (E wave, A wave, Deceleration Time)
Tissue Doppler
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
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)
Case # 2
• Patient with Cardiac Amyloidosis evaluation of cardiac structure and function
PLAX
Mitral inflow (E and,A waves, Deceleration Time)
Tissue Doppler
• 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
Conclusion
• Cardiac Amyloidosis
• Severe Diastolic Dysfunction
Changes to the Protocol?
• Should we report all diastolic dysfunction -- even normal diastolic dysfunction?
• Can pulmonary venous inflow pulse wave doppler be omitted?
• Can we rely on medial mitral tissue doppler alone?