ECHO 2 (Diastolic Dysfunction)

what are the phases of diastole?**

1. isovolumetric relaxation

2. early rapid diastolic filling

3. diastasis

4. late diastolic filling by atrial contraction

what happens during isovolumetric relaxation? (valves and pressure)**

• aortic and mitral valves closed but mitral will open soon

• rapid decline in LV pressure

what happens during isovolumetric contraction?*** know on waveform

LV filled up and mitral and aortic valve closed but aortic will open soon

where you do see early rapid diastolic filling in EKG?

latter part of the T wave

what factors influence rate of blood flow from LA to LV?

pressure difference, ventricular relaxation, relative compliance of two chambers 

what occurs during diastasis? (valves and pressure)

• LV and LA pressures equalize → causing little flow from the LA to LV

• MVLs remain in a semi open position 

diastasis is indicated by what on the PW doppler of the mitral valve?

slope after E deceleration and before A wave

duration of diastasis dependens on

heart rate

• slow heart rate = longer diastasis

• fast heart rate = shorter diastasis/ absent

what happens during late diastolic filling by atrial contraction? (pressure and valves)

• LA pressures exceed LV pressure

• MVL opens and causes a second pulse of LV filling 

atrial contribution is - of total ventricular filling

20%

review images

what are the clinically relevant parameters in diastolic function?

ventricular relaxation

myocardial/chamber compliance

filling pressures

when does ventricular relaxation occur?

during isovolumetric relaxation and early diastollic filling

what factors will indicate impaired LV relaxation?

prolonged IVRT
slower rate of decline in ventricular pressure (reduced dP/dt)

what doppler signs indicate impaired LV relaxation?

prolonged IVRT

reduced E velocity

increased A velocity

how is ventricular compliance measured?

ratio of change in volume to change in pressure (dV/dP)

ventricular compliance is affected by

size, shape, myocardium characteristics, extrinsice factors

what doppler characteristics will you see with decreased ventricular compliance?

decreased IVRT

steep deceleration slope

reduced a velocity

what are the causes of diastolic dysfunction?**

anything that causes heart to thicken**

primary myocardial disease

• restrictive cardiomyopathy

• hypertrophic cardiomyopathy

secondary LV hypertrophy (thick heart → non compliant)

• hypertension 

coronary artery disease

• fibrotic/stiff bc of infarcted tissue and less ability to relax

• both systolic and diastolic

extrinsic constraint

what are examples of primary myocardial disease?

dilated cardiomyopathy (mainly systolic)

restrictive cardiomyopathy 

hypertrophic cardiomyopathy 

what are examples of secondary hypertrophy?

hypertension 

aortic stenosis

congenital heart disease

what are examples of coronary artery disease?

ischemia

infarction 

what are examples of extrinsic constraint?

pericardial tamponade

pericardial constriction 

what measures evaluation of LV diastolic function?

trans mitral inflow (valsalva)**

tissue doppler**

pulmonary venous flow 

left atrium volume index 

tricuspid regurgitation velocity 

why do we measure LA volume index to evaluate LV diastolic function?

because if LV does not accept blood, it will back up into the LA and cause dilation

diastolic filling patterns for assessing diastolic function is valid only

in the absence of obstruction (mitral stenosis)

KNOW WIGGINS

what does the E and A wave represent in mitral inflow?

E = rapid diastolic filling

A = atrial systole/kick 

how is mitral inflow measured? (view, doppler)

• apical 4CH

• PW at opening of mitral valve leaflets

what is normal E/A ratio is healthy young adults?**

1.5

the E and A wave fuse when

pt is tachycardic (hihg heart rate)

what happens to A wave in Afib?

absent because there is not atrial kick

describe normal diastolic function

• E/A ratio

• LV relaxation

• Atrial pressure

• atrial contraction 

• E/A ratio : E>A

• LV relaxation : normal 

• Atrial pressure : normal 

• atrial contraction : normal 

describe mild diastolic dysfunction (grade 1) 

• E/A ratio

• LV relaxation

• Atrial pressure

• atrial contraction 

• E/A ratio : E<A

• LV relaxation : impaired

• Atrial pressure : normal 

• atrial contraction : normal 

describe moderate diastolic dysfunction (grade 2) 

• E/A ratio

• LV relaxation

• Atrial pressure

• atrial contraction 

• E/A ratio : E>A

• LV relaxation : impaired

• Atrial pressure : elevated 

• atrial contraction : normal 

pseudonormal is considered

moderate diastolic dysfunction

how can you differentiate normal vs moderate diastolic dysfunction

in moderate/pseudonormal : elevated atrial pressure and impaired LV relaxation

describe severe diastolic dysfunction (grade 3)

• E/A ratio : E»A

• LV relaxation : impaired

• Atrial pressure : very elevated

• atrial contraction : impaired 

what is this

normal diastolic function OR moderate (pseudonormal) 

can not tell with wave alone 

why does normal diastolic and pseudonormal look the same? 

• elevated LAP so when valves open it pushes all the blood into LV making it appear normal 

what is this

mild diastolic (E<A) 

• E : decreased pull from LV due to impaired relaxation

• A : atrial kick pushes in excess blood flow

what is this

severe diastolic dysfunction

• E : VERY high because of very elevated LAP 

• A : small 

what occurs is moderate dysfunction that causes the wave to appear the way it does?

E : increased PUSH from LA due to increased LAP

A : most blood pushed in during early diastole (smaller A wave) 

what are the E/A ratios for normal, mild, moderate and severe diastolic functions?**

normal : E/A ≥ .8

mild : E/A < .8

moderate : E/A ≥ .8

severe : E/A ≥ 2

why would the mitral inflow be assessed with valsalva maneuver? explain

to unmask pseudonormal diastolic dysfunction;

valsalva decreases preload and causes E/A ratio to be less than 1

what is the deceleration time of mitral inflow and what does it indicate?

time interval from E peak to projected baseline

indicates duration of time it takes to equalize pressure difference between LA and LV

what is normal e wave deceleration time?

150-200 ms

a deceleration time <150 indicates?

a deceleration time >200?

severe diastolic dysfucntion 

mild diastolic dysfunction 

what is the deceleration time in moderate dysfunction?

150-200

what does a shorter/longer deceleration time indicate?

shorter : moderate to severe diastolic function

• this is because there is a large initial LA/LV pressure difference due to stiff ventricle → causes steep tall and steep E wave → quick filling and pressure equalizes faster 

longer : mild diastolic function 

what is the IVRT?

time interval between aortic closure and mitral opening

what does prolonged vs shortened IVRT indicate?

prolonged : impaired relaxation

shortened : decreased compliance 

what does tissue doppler measure in regards to evaluating for diastolic dysfunction?

diastolic excursion of the atrioventricular annuli AWAY from the probe during diastole (measures velocity of tissue)

in TDI what is shown above and below the baseline?

above : how far annulus moves away from apex (diastole) 

below : how far annulus moves towarsd apex (systole) 

what measurements are taken on the TDI?

S’ (systolic above baseline)
E’ : diastolic below baseline

A’ : diastolic below baseline 

if e’ is less than a’ on TDI what is indicated?

diastolic dysfunction

what do S’, E’ and A’ represent?

S’ : ventricular ejection

E’ : ventricular filling

A’ : atrial kick 

how do you obtain pulmonary venous flow? (view, doppler, cursor) 

• in 4CH view you can see paralel alignment with right superior pulmonary vein 

• pulsed wave doppler 

• 1-2cm from orifice 

what clinical measurements are done with pulmonary venous flow?

peak systolic velocity (PVs)

peak diastolic velocity (PVd) 

peak atrial reversal velocity (Pva) 

duration of pulm vein atrial reversal (a-dur) 

how is LA index measured?

use biplane method to measure LA in end diastole (right before MV valves open) in apical 2CH and 4CH 

what LA index is considered abnormal?**

LA index ≥ 34ml/m2

how is TR systolic jet velocity measured?

obtain highest CW doppler from PLAX/apical view

meaure peak velocity during systole

what TR jet velocity is considered abnormal?

> 2.8 m/s

what are indications of elevated LV filling pressures?

• e/e’ ratio

• Pva

• pulm a-dur vs mitral valve a-dur

• pulm venous systolic flow vs pulm venous diastolic flow

• e/e’ ratio >15

• Pva >.35 m/s

• pulm adur 20ms > than mitral a-dur

• pulm venous syst flow < pulm venous diastolic flow 

study this

study this

based on what variables is diastolic dysfunction diagnosed?

1. average e/e’ ratio

2. annular e’ velocity (Septal e’ velocity or lateral e’ velocity) 

3. LA max volume index

4. Peak TR velocity 

how do the variable indicate diastolic function vs dysfunction?

if less than 2 of the variables are positive → normal diastolic function 

2 variables positive → indeterminate

more than 2 variables positive → diastolic dysfunction 

what are the normal values for normal LV EF? **

1. annular e’ velocity

2. average e/e’ ratio

3. LA max volume index

4. Peak TR velocity 

1. annular e’ velocity : >14

2. avg e/e’ ratio :

   1. septal e’ : <7 cm/s

   2. lateral e’ : <10 cm/s

3. LA max volume index : >34 ml/m²

4. Peak TR velocity : >2.8 m/s

study this

study this

review qs

what are the phases of diastole?

isovolumetric relaxation

early rapid filling

diastasis

atrial filling

review qs

what is the purpose of the valsalva maneuver with E/A mitral flow?

unmask psuedonormal (grade 2 diastolic dysfunction)

review qs

when are diastolic inflow patterns no longer valid? 

mitral stenosis 

review qs

what is assess to grade diastolic dysfunction?

E/A mitral inflow, pulmonary venous flow, tissue dopple (mitral annulus → septal and lateral), LA volume, TR jet 

what is the cutoff for tricuspid regurg jet velocity for diastolic dysfunction?

for LA volume? 

TR jet regurg : 2.8 m/s

LA volume : 34 ml/m²

what is measured

pulmonary vein (PW) 

how would you characterize this pts diastolic function?

normal bc E’> A’ 

how would you characterize this patient?

mild dysfunction (grade1) because E is lower than A 

if a pt has E/A ratio of >2 what is their diastolic function?

severe

what is the normal range for deceleration time?*

150-200

A patient's pulsed wave Doppler of the mitral valve had an E/A ratio of 1.5. The patients tissue Doppler had a decreased e' velocity and E/e' ratio >14. What is the most likely diagnosis?

moderate dysfunction

what diastolic pattern is shown here?

severe

• deceleraion less than 150

• E/A ratio : 2.78