5/11/2014
STATE OF THE ART ECHOCARDIOGRAPHY 2014
22-24 April, 2014
How Can Echo Stratify Diastolic
Function Of The Heart
Hanan Albackr
Cardiology Consultant KFCC , Assistant
Professor King Saud University
Outlines
•
•
•
•
Why it is important to study diastology.
Cases
Physiology
Different stages of diastolic dysfunction and its
mechanism
• Diastolic dysfunction doppler and 2-D indices
• Parameters of increased LV filling pressure
• conclusion
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Diastolic dysfunction etiologies
Increase LV afterload
Ischemia
LVH
Myocardial fibrosis
Pericardial constraints
 Decreased relaxation
 Increased stiffness
 May or may not have LV systolic
dysfunction.
Diastolic dysfunction progression

Impaired relaxation

Increase LVEDP and LAP

Increase LV stiffness

Impaired PV filling

Severe increase LVEDP
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Evaluation of diastolic dysfunction
Left ventricular inflow (LVI)
Pulmonary vein inflow (PVI)
LA size
LV systolic function
Effect of valsalva maneuver
STATE OF THE ART ECHOCARDIOGRAPHY 2014
22-24 April, 2014
• CASE1:
– 62 yo F with HTN & Parpxysmal AFIB
– Previous NYHA I SOB
– Echo showed normal LV. systolic function
– Now progressive dyspnea with exertion
– ER: AFIB at 120 bpm, Pulmonary Edema
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Echocardiogram
E/A=2
DT=169
D>S
E/e’=16
Case 2
E/A=1.5
DT=229
D>S
E/e’=17
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E/A=1
DT=218
S>D
E/e’=15
RVSP=44
Case 3
Stages of DHF
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Diastolic Heart Failure - physiology
1) Isometric Relaxation
2) Ventricular Filling
3) Atrial Contraction
1
2
3
ENSURE ATRIAL
RHYTHM
Diastolic function-echo evaluation
normal conditions
LV
pressure
LV
E/A 1.7+-0.6
LA
pressure
LA
79+-26 cm/sec
Early
ECHO
trium mitral inflow
48+-22 cm/sec
A
0
E deceleration time
184+-24 msec
A pulmonary
Pulmonary vein inflow
19+-4 cm/sec
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Diastolic dysfunction-Echo diagnostic
Impaired relaxation
LV
pressure
E/A < 0.8
E/A 1.7+-0.6
LA
pressure
A increased
79+-26 cm/sec
Early
E deceleration time
184+-24 msec
48+-22 cm/sec
Atrium
E reduced
mitral inflow
0 Pulmonary
A pulmonary vein inflow
19+-4 cm/sec
E deceleration time
prolonged
A pulmonary
deeper
Echo-diagnosed diastolic dysfunction
Pseudonormalized
elevated atrial pressure
LV
pressure
E/A normal
E/A 1.7+-0.6
LA
pressure
0 mmHg
A normal.
79+-26 cm/sec
Early
E deceleration time
184+-24 msec
48+-22 cm/sec
Atrium
E normalised
mitral inflow
0 cm/sec
Pulmonary
A pulmonary vein inflow
19+-4 cm/sec
A pulmonary
E deceleration time
shortened
deeper
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Echo-diagnosed diastolic dysfunction
E/A > 2.0
LV
pressure
Restrictive pattern
E/A 1.7+-0.6
LA
pressure
E increased
0 mmHg
A small
79+-26 cm/sec
Early
E deceleration time
184+-24 msec
48+-22 cm/sec
Atrium
mitral inflow
0 Pulmonary
A pulmonary vein inflow
19+-4 cm/sec
E deceleration time
<<<150 msec
A pulmonary
deeper
Evaluation of Diastolic Dysfunction
What Do We Want to Know
• Is relaxation impaired
• What are the filling pressures
• Etiology of diastolic dysfunction
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DD INDICES





MITRAL B BUMP
IVRT
MITRAL INFLOW – E, A
MITRAL ANNULAR VELOCITIESPulmonary Venous Doppler Flow into LA –
 SYSTOLIC (S), DIASTOLIC (D) , ATRIAL REVERSAL (Ar),
-Mitral inflow propagation velocity -VP
• Two-Dimensional Echocardiography
• The combination of
 Thickened left ventricular walls,
 Left atrial dilation,
 Absence of mitral valve disease
Strong evidence of diastolic dysfunction and
elevated left ventricular diastolic
pressure.
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• M-Mode Echocardiography
HFnEF-CONCEPTS AND
MANAGEMENT
Transmitral Doppler
Inflow
E velocity,
A velocity,
E/A
deceleration time (DT)
IVRT.
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Valsalva Maneuver
• Valsalva maneuver decreases preload during
the strain phase, pseudonormal mitral
inflow changes to a pattern of impaired
relaxation.
• Mitral E velocity decreases with a
prolongation of DT, whereas the A velocity
is unchanged or increases, such that the
E/A ratio decreases.
• A decrease of 50% in the E/A ratio is highly
specific for increased LV filling pressures.
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IVRT
Normal – 70-90 ms.
Pulmonary Venous Doppler Flow
•
•
•
•
•
right upper pul vein
> 0.5 cm into the pul vein
End-expiration
Sweep speed of 50 to 100
mm/s
Average of 3 values
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S wave -54.3 cm/sec
D = 74.2cm/sec
S/D<1
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Ar vel = 36cm/s
Ar=130ms
Ar-A=130-106=24ms
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• An Ar velocity >35 cm/sec & a difference in duration ( Ar – A )
>30 msec, is higly predictive of a LVEDP > 15 mm Hg.
• Major limitation is difficult to obtain and influence by
rhythm distrubances
Tissue Doppler
•
An important limitation of Doppler echocardiography is that
altered left ventricular preload affects transmitral flow indices.
•
An alternative approach is tissue Doppler imaging, which
permits direct measurement of myocardial velocity in real time
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Measuring e' on the medial annulus tissue doppler trace
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TISSUE DOPPLER ANNULAR DIASTOLIC VELOCITIES
E/e’
<8
LVEDP
No
N
8 –15
Normal LV F
Mitral valve diease
IVRT/ TE-e’ < 2
> 15
LVEDP > 12
Yes
Estimation of LV filling pressures.
Markers of elevated LV filling pressure:

E/A > 2

Dct < 160ms

E/e' (medial) >15

E/e' (lateral) >10

PFV S/D <40%

PFV AR amplitude >35 cm/sec

PFV AR duration > 21 ms more than A wave

LA enlargement

LV hypertrophy
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Summary-Echo Doppler Evaluation of
Diastolic Function
• Diastolic dysfunction is an important cause of symptoms
in many cardiac diseases
• CHF often is due to diastolic dysfunction alone or
complicating systolic dysfunction.
• Assessing diastolic function requires an integrated
approach of MV, PV, Tissue Doppler
• Echo-Doppler studies can accurately evaluate
impairment of relaxation and filling pressures but
requires an understanding of uses and limitations
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Microlife BP A150 AFIB