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ECHOCARDIOGRAPHIC EVALUATION of LEFT VENTRICULAR DIASTOLIC FUNCTION toufiqur rahman NICVD
1. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com
2. One decade and a half back, diastole of the heart thought to
be wholly passive. Though it occupies the greater part of
cardiac cycle. We thought that this period is meant for the
passive filling of the ventricle and subsequent systole does
the job of left ventricular function. In the course of different
observations there was a puzzle in that, there was good
contraction but yet there is feature of ‘heart failure’. We have
now solved the puzzle and identify that functions of the left
ventricle depend on either systolic or diastolic- sometimes on
both.
3. Defining diastole
Methods to assess diastole
Patterns of diastolic disease
Age-related changes
7. Ventricular function
AV valve function
Rate of relaxation
Ventricular compliance
Atrial systolic function
Preload
Heart rate and rhythm
8. Ventricles receive blood at a regular fashion
in diastole which encompasses the isovolumic
relaxation and filling phases of the cardiac
cycle and has active and passive components.
9.
10. Active myocardial relaxation
-mediated by intracellular calcium and ATP
Passive Pressure-Volume relationship of left ventricle
-Elastic nature of the myocardium
-Chamber size and shape
-Wall thickness
-Right & left ventricular pressure-volume
interaction
-Intrathoracic pressure
-Pericardial restraint
- Incomplete active myocardial relaxation
Left atrial function
11. It implies impaired filling of ventricle at its
usual low filling pressure
Ventricular filling is slow, delayed or
incomplete, with a normal atrial pressure
13. c) Both compliance and relaxation
abnormality
Hypertensive heart disease
Hypertrophic obstructive cardiomyopathy
IHD
Aortic valvular disease
d)Co-existent with systolic
dysfunction
IHD
Cardiomyopathy
14. a) Clinical parameters:
Features of underlying aetiology
Absence of other causes of dyspnoea
Features of LV dysfunction
b) ECG:
LVH, LA enlargement, IHD
c) CXR:
Normal heart size
15. c) Doppler Echocardiographic Evaluation
Mitral valve inflow pattern
Pulmonary venous flow pattern
Mitral inflow at peak valsalva maneuver
Colour M-mode ( CMM) –propagation study
Doppler tissue imaging (DTI) of the mitral
annulus
d) Cardiac catheterization
e) Radionuclide techniques
16. LV filling patterns are assessed using pulsed
wave Doppler mitral flow velocity
recordings.
4 useful variables are-
E-peak early diastolic transmitral flow
velocity
A-peak late diastolic transmitral flow velocity
DT-early filling decelerayion time
A dur-A wave duration
17. Peak E wave velocity: 53-105 cm/sec
Peak A wave velocity: 26-70 cm/sec
E/A ratio: >0.75 & < 1.5
DT: 160-220 m sec
18. MITRAL INFLOW IN STAGE I – DIASTOLIC
DYSFUNCTION
( ABNORMAL RELAXATION)
E/A ratio: ≤ 0.75
DT > 240 m sec
MITRAL INFLOW IN STAGE I I– DIASTOLIC
DYSFUNCTION (PSEUDONORMALIZATION)
E/A ratio: > 0.75, < 1.5
DT : > 140 m sec
19. MITRAL INFLOW IN STAGE III– DASTOLIC
DYSFUNCTION(REVERSIBLE RESTRICTIVE)
E/A ratio : > 1.5
DT : < 140 m sec
MITRAL INFLOW IN STAGE IV– DASTOLIC
DYSFUNCTION(FIXED RESTRICTIVE)
E/A ratio : > 1.5
DT : < 140 m sec
20.
21. In pseudo normal ( stage II ) LV diastolic
dysfunction Valsalva strain unmasks
underlying impaired LV relaxation and causes
E/A ratio < 1
Stage III pattern at Valsalva maneuver may
turn into stage II or even Stage I pattern. But
if unchanged, it indicates fixed restrictive
abnormality .
22. Apical 4-chamber
view
Align Doppler beam
to be parallel to
mitral inflow
Pulsed-wave
sampling at tips of
MV leaflets
◦ Decreased velocity if
sampled within LA
23. Peak E and A velocities, ratio E/A
Mitral A-wave duration (to compare with PV AR
duration)
Mitral deceleration time(from peak of E-wave
to base)
Mitral Doppler VTI (and valve area)
24. In a 5 chamber view
◦ Continuous-wave
across tips of MV
through LVOT
◦ Obtain mitral inflow &
LV outflow
◦ Measure Isovolumetric
Relaxation Time (IVRT)
25. Measures displacement of myocardium while
avoiding blood flow detection throughout the
cardiac cycle
For our purposes:
◦ Mitral valve annular junction
◦ Septal annular junction
◦ Tricuspid annular junction
Mitral and tricuspid data is relatively volume
load independent, including respiratory cycle
26. Using Doppler
pulsed cursor, 3-5
mm
Set Nyquist limits to
15-30 cm/s
Using lowest wall
filter
Set dynamic range
to 30-35db
Sweep speed of
100-150 mm/s
27. Ea ( or E´), Aa ( or A´), Sa ( or S´) waves
IVRT and Isovolumetric Contraction Time
(IVCT)
Important to maintain a parallel line of
annular motion with the imaging beam
28. Estimate of ventricular filling to correlate with
LV relaxation, even at increased LA pressures
Not affected by preload
Varies with changes of lusitropic conditions
Correlates in ischemic heart disease
29. In apical 4 chamber
view
Align M-mode cursor
through LV apex and
orifice of MV
Apply Color Doppler
Switch to M-mode
acquisition
Decrease Nyquist
limit until color
inflow shows line of
aliasing
30. Demonstrated by Garcia et al., JACC 1999, that in both
dogs with occluded IVC and in adults undergoing CABG,
under partial CPB, measures were not affected
◦ Although, MV E waves and associated measures were impacted
by each scenario
◦ In dogs, under various doses of dobutamine and esmolol,
there were expected changes of Vp correlating to measured
changes of LVEDp
32. Gonzalez-Vilchez, JACC 1999
Adults in ICU w Swan’s
20 test, 34 study patients
Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-9
Simplified to:
◦ 103/[2•IVRT]+FPV
◦ Value ≥5.5, correlates to PCWP > 15mmHg (r=0.89)
33.
34.
35. Study by Larrazet et al, Pediatric Critical Care
Medicine, 2005
Studied infants 3-8 months of age,
immediately post-operatively for VSD/AVCD
repair w LA line in place
For LA pressure > 10mmHg
◦ E/Ea > 15 – Sensitivity 94%, Specificity 72%
◦ E/Vp >2.0 – Sensitivity 83%, Specificity 89%
36. Place Apical 4 w PW in Distal PV
Apical 4-chamber
view
Identify RUPV or
LUPV inflow parallel
to beam
Pulsed-wave
sampling
◦ 1-2 cm distal to
orifice
Alternatives views:
◦ Parasternal
◦ Suprasternal
◦ Subcostals
37. Identify peak S and D velocities
Measure atrial reversal (AR) duration
◦ AR presence is variable. It is indicative of abnormal
elevated LA pressure in a neonate, but may be normal in a
child with more compliant pulmonary veins. The duration
of flow reversal is more helpful in relation to atrial systole
38. Note: S-wave may be biphasic owing to
differences of atrial relaxation and mitral
valve annular displacement
Should take the highest of the peaks
39. It is an additional source of information to evaluate
diastolic dysfunction.
Obtained by 3 to 4 mm pulsed Doppler sample volume in
the right paraseptal vein from the apical 4-chamber view.
4 useful variables are of pulmonary venous
flow-
S wave: Peak systolic PV flow velocity (normal value- 40 to 90
cm/sec)
D wave: Peak diastolic PV flow velocity (normal value- 30 to 70
cm/sec; S/D ratio: > 1)
AR velocity: Peak PV atrial reversal flow velocity (normal- < 25
cm/sec)
AR dur: AR duration ( normal- A dur/AR dur >1 )
40. Peak systolic ( S ) and diastolic PV flow velocity
waves do not add any incremental value in
assessment of the diastolic dysfunction as they
are also volume dependent and follow a
parabolic pattern.
AR dur > A dur + 30 m sec and AR value> 35
cm/sec is associated with moderate and severe
diastolic dysfunction.
41.
42.
43. A recent work in NICVD, Dhaka, on diastolic
dysfunction (MD thesis, 2003) showed a negative
correlation of Doppler estimated left atrial pressure
wave transit time ( A- Ar interval) with left
ventricular passive elasticity and end diastolic
pressure.
Sample volume of pulsed Doppler is placed at
about 1 cm distal to aortic valve in LV outflow tract
to detect A-Ar interval
Normal value of A-Ar interval is 25 to 80 m sec.
Shorter the interval, more likely to have severe LV
diastolic dysfunction.
44.
45. Left ventricular end diastolic pressure
( LVEDP ) & Pulmonary capillary wedge
pressure are two important determinants of
LV diastolic dysfunction.
46. In adults, atrial dilation has correlated as a risk for first
CV event (a-fib, stroke, CHF)
Defined as: women ≥ 30cm2/m2, men ≥ 33cm2/m2
Not routinely measured in children,
but recent norms established
8/3π[(A1)(A2)/(L)] obtained from Apical 2 & 4 chamber views
47. Data collected by 3D Echo and separated by
BSA
◦ 0.5-0.75m2 : 19.6 mL/m2
◦ 0.75-1.0m2 : 21.7 mL/m2
◦ 1.0-1.25m2 : 22.0 mL/m2
◦ 1.25-1.5m2 : 24.5 mL/m2
◦ >1.5m2 : 27.4 mL/m2
No normative values for RA established in
kids
48. Usual measures performed on MV, are
influenced by variable preload through the
respiratory cycle.
With inspiration amongst children
◦ Peak E may increase by 26%
◦ Peak A may increase by 20%
49. SVC inflow invariably does not have AR
amongst healthy children
AR-wave usually seen with:
◦ Right atrial hypertension
◦ Tricuspid stenosis
Reversal with ventricular systole
◦ Significant tricuspid regurgitation
◦ Loss of AV-synchrony
◦ Restrictive physiology
Decreased flow of systemic veins or TV
inflow with Exhalation seen with
Tamponade
◦ MV E-wave decreases by >25% during onset of
INhalation
50. In a restrictive, non-compliant RV, which acts
essentially as a conduit for the PA
◦ Forward flow may be seen in PA with atrial systole
◦ Only in settings with low PVR or absence of distal
stenoses
◦ May be seen in those with history of Tetralogy or
Pulmonary valve abnormalities
51.
52.
53. The ability of the LV myocardial filaments to
actively uncouple after systole, is delayed
Ventricular compliance is unaffected
IVRT is prolonged, as time needed to
decrease LV pressure < LA pressure is
extended
54. LA-LV pressure
difference in early
diastole narrowed –
max E-wave velocity
decreased
LV relaxation is slower,
so E-wave is prolonged
A-wave increased as a
compensatory to
complete LV filling
Insert fig
8.14
Insert
fig 8.15
55. Infamous “L-wave” seen in MV inflow
pattern
◦ Described by Keren in 1986
◦ Presence of LA-LV pressure gradient in diastasis
◦ Occurs with MARKEDLY delayed LV relaxation
56. Also called “Pseudonormalization”
Result of worsened ventricular compliance
with transmitted increase of atrial pressure
Ultimately, relative pressure difference
between LA-LV is similar to normal, just at
higher pressure
Pulmonary vein inflow pattern helpful to
distinguish this from normal
57. TDI has been shown to be relatively
independent of preload
◦ Abali et al, JASE 2005, studied 100+ adult males
after 500mL blood donation, found no differences
in TDI measures or Color M-mode, Vp
◦ Eidem et al, JASE 2005, found that children with
chronic LV preload (VSD’s) and preserved systolic
and diastolic function, did not have changes in TDI
Those with chronic afterload (AS) demonstrated
decreases of TDI measures
58. Nagueh et al, JACC 1997
125 adults, 60 cathed for PCWP, separated
Normal from Impaired Relaxation from
Pseudnormalized (EF low in this group)
Found E/Ea >10 correlated to PCWP of
>12mmHg
◦ Sensitivity 91%, Specificity 81%
60. Helpful to differentiate normal MV inflow
patterns from ‘pseudonormalization’
Decreased rate of flow propagation (Vp)
correlate with delayed relaxation, even with
elevated LA pressure
Measures are preload independent
Measure of MV peak E velocity to rate of flow
propagation, E/ Vp > 2.0 predicts LVEDp
>15mmHg (sensitivity 100%, specificity 77%)
61. Ventricle is significantly stiff, non-compliant, that
with small increases of volume, pressures increase
disproportionately
On MV inflow, the E-wave is accelerated with short
deceleration time due to rapid rise of ventricular
pressure and the end of inflow
A-wave is remarkably small, if not absent all
together, as atrial systole minimally generates a
pressure gradient across the AV valve
◦ Instead prolonged reflux in PV observed
62. IVRT shortened due to atrial hypertension
with early opening of MV and ventricular
filling
63. Infants
◦ Very limited early diastolic flow
◦ Significant contribution from atrial systole
◦ Limited tolerance to changes in preload
◦ Improved compliance around 2 months
Childhood
◦ Limited variability of measures (Inflow/TDI) through
childhood and adolescence
◦ Noted changes with increasing IVRT likely
associated with age-related decreased HR
64.
65.
66. Doppler Echocardiography has emerged as a
highly versatile tool for evaluation of diastolic
function.
Anatomic and functional evaluation of heart
along with interrogation of mitral valve inflow &
PV flow parameters may accurately disclose LV
diastolic dysfunction.
Valsalva maneuver, CMM & DTI are useful
adjuncts for complete evaluation of diastolic
dysfunction.