Diastology and Plenty of it! · Diastology and Plenty of it! Jeffrey C. Hill, BSBA, ACS, FASE...
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Diastology and Plenty of it! Jeffrey C. Hill, BSBA, ACS, FASE Chair, Joint Review Commission on Education in CVT Program Director, Clinical Coordinator, School of CVT The Hoffman Heart & Vascular Institute of CT Saint Francis Hospital, Hartford, CT
Transcript of Diastology and Plenty of it! · Diastology and Plenty of it! Jeffrey C. Hill, BSBA, ACS, FASE...
Diastology and Plenty of it!Jeffrey C. Hill, BSBA, ACS, FASE
Chair, Joint Review Commission on Education in CVT
Program Director, Clinical Coordinator, School of CVT
The Hoffman Heart & Vascular Institute of CT
Saint Francis Hospital, Hartford, CT
Disclosures
• Philips Healthcare: Consultant
Must Read!
The Role of PASP in Left Heart Filling Pressures
Bouchard et al. Am J Cardiol 2008;101:1673–1676
Mitral A wave
Strain phaseRest
Dumesnil JG, et al. Am J Cardiol. 1991;68:515–519
Strain phaseEarly phase
Dumesnil JG, et al. Am J Cardiol. 1991;68:515–519
Release phase
Systolic waveforms (S1,S2)Diastolic waveform
Atrial reversal waveform
E/e’ Ratio for Estimation of Filling Pressures
Peak mitral E velocity
Peak DTI e’ velocity
Nagueh et al, JACC 1997, Ommen et al, Circ. 2000
Invention of Tissue Doppler
Isaaz et al. Am J Cardiol. 1989 Jul 1;64:66-75.
Image adapted and modified from: Oki T, et al. Am JCardiol April 1997;79:921– 8
• Tau is time constant of isovolumic relaxation
• Tau > 48 ms = abnormal relaxation
• e’ velocity showed significant correlation with Tau
• Longer Tau = slower relaxation = lower e’ velocity
r = - 0.78, p <0.0001
N =50
Tissue Doppler e’ Velocity Validation
E/e’ Ratio Validation
Images obtained and modified from: Nagueh et al. J Am Coll Cardiol, November 1997;30:1527–33
Open Circles= PN
“E/e’>10 = PCWP >15”
Lateral DTI E’ only
Role of DTI in Fused E/A
Sohn DW. J Am Soc Echocardiogr. 1999 Mar;12(3):203-8.
LA End-Systolic Volume Index (LA-ESV): What to Avoid
4-chamber 2-chamber
Aurigemma et al. Circ Cardiovasc Imaging 2009;2:282-289Abhayaratna , et al. J Am Coll Cardiol 2006;47:2357-63
IAS
Pulm Vein
Tenting Vol
Pulm Vein
LA Discrepancy
Image obtained and modified from: Jansen et al. JACC: CV Imaging 2014;7:529-33.
Left Atrial Volumes: Should We Reset the Reference Standard?
Current Published Reference Value(LAVI 22 +/- 6 mL/m2)
Mean LAVI in 285 Healthy Pts(LAVI 30 +/- 6 mL/m2)
Lang et al, ASE 2005 Guidelines
Lang et al, ASE 2015 Guidelines
Chahal, et al. European Journal of Echocardiography. 2010 11, 51–56.
EAE A
Where’s the Decel?
Where’s the Peak e’ Velocity?
Hill, Palma. J Am Soc Echocardiogr 2005;18:80–90
Bierig, Hill. J Diagn Med Sonography 2011;27:65–78.
Effects of SV Positioning on DTI
Effects of Gain on DTI Waveforms
Spectral broadening: e’ = 16 cm/s
Optimized: e’ = 12 cm/s
Faint waveforms: e’ = 8 cm/s
Waggoner AD, Bierig SM. J Am Soc Echocardiogr 2001;14:1143-52.
MAC Influences the E/e’ Ratio
Soeki, et al, Jpn Circ J 2001
e’ = 5 cm/s: E/e’ = 11 e’ = 9 cm/s: E/e’ = 5
MACBelow MAC
Effects of Respiration on DTI
Hill, Palma, JASE 2005
Normal RespirationAve e’ = 10
End-apneaAve e’ 7
• 93 y/o female
• Lower extremity edema
• No significant valvular dz
• PASP = 40 mmHg
• Severe LAE
• EKG demonstrates…
Case courtesy of Daniel Bourque, MS, RCS
S D
• 84 y/o female
• H/O HTN, CAD, CHF
• Dyspnea, new pedal edema
• Multiple WMAs
• PASP = 45 mmHg
• Severe LAE
e’
a’
E/e’ = 8
e’
a’
E/e’ = 8
Significant “Down Time”: MPI
a’
e’
IVRT
s’
IVCT
E/e’ Unreliable 2° MAC
*Table adapted and modified from Redfield et al
Perfect Picture
Image modified from Redfield et al, JAMA. 2003;289:194-202
Discrepant Diastology
“Real World” Diastology
Variable Measurable
(%)
E/A 71
DT 73
E/e’ 75
Pulm vein
S/D56
P/A duration 25
Narayanan A,. Circulation 2008 (Abstract);118(18):787
N =100
29 y/o male
CP, mild DOE
No valvular dz
EF = 60-65%
NL LA size
PASP = 25 mmHg
This Patient Has…
Not measured
Image modified from Redfield et al, JAMA. 2003;289:194-202
• 68 y/o male
• CHF
• Inferior WMA’s
• BPEF = 44%
• No significant valvular dz
• PASP = 19 mmHg
• Mild LAE
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
Not measured
• 82 y/o female
• H/O Diastolic CHF
• DOE
• PASP = 45-50 mmHg
• Severe LAE
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
• 64 y/o male
• Fresh STEMI
• Borderline tachycardia
• EF = 25-30%
• Multiple WMAs
• No significant valvular DZ
• PASP = 50 mmHg
• Severe LAE
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
• 60 y/o male
• CAD, Dyspnea
• Dynamic EF
• No significant valvular DZ
• PASP = 30-35 mmHg
• Severe LAE
Ave = 14
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
14
Discrepancy!
• 82 y/o female
• HHD/CHF
• Multiple WMA’s
• PASP = 48 mmHg
• EF = 35-40%
•Moderate/severe LAE
• Severe MAC
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
Discrepancy!
• 53 y/o female
• S/P arrest
• HR = 78 BPM
• New LBBB
• ICD Placement
• No valvular dz
• PASP = 19 mmHg
• NL LA ESV
• EF = 50 ish %
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
Not measured
• 30 y/o female
• Edema
• Borderline tachycardia
• Evaluate RV/LV fx
• PASP = 17 mmHg
• No significant valvular dz
• NL LA size
Image modified from Redfield et al, JAMA. 2003;289:194-202
This Patient Has…
Not measured
Take-Home
Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2016
Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2016
