ECHO 2 exam 4

normal diastolic function

This process depends on creating and maintaining a pressuregradient between the two chambers. The magnitude of which determines rate of flow

Blood can be either pulled through the mitral valve, by rapidly lowering LV pressure below LA pressure (suction) or

pushed through the valve during atrial contraction. The concept of pulling verses pushing blood through the mitral

valve is fundamental to understanding some of the pathophysiologic principles of diastolic function

Normal Diastolic function:

has two characteristics

1. active relaxation

2. passive compliance/stiffness

active relaxation in normal diastole

when the myocardium recoils back to its normal presystolic state.

passive compliance/stiffness in normal diastole

the filling period during mid to late diastole, where there is a volume exchange into the LV increasing pressure

myocardial relaxation in patients with diastolic dysfunction

abnormal

myocardial stiffness results in

increased filling pressure

when does left ventricular diastole begin

when the aortic valves closes

left ventricular diastole includes

1. Isovolumic relaxation

2.Rapid (passive) early ventricular filling (suction)

3.Diastasis

3.Left atrial contraction (pushing)

Isovolumic relaxation

Determined by cessation of excitation-contraction coupling

Loading conditions preload or LA pressure

Age (relaxation lengthens with advanced age)

Rapid (passive) early ventricular filling (suction)

80% of filling, LV pressure falls below LA pressure

Influenced by rate of LV relaxation, elastic recoil(suction), chamber compliance and LA pressure

Diastasis

Mid-diastolic period with little or no LA/LV gradient

Little change in LV volume

Duration of phase dependent on heart rate

Left atrial contraction (pushing)

Results in second filing gradient at end-diastole

20% of filling

Absent in atrial fibrillation

causes of diastolic dysfunction

Regardless of LV or RV Diastolic Dysfunction there will be stiffening of

the ventricle

When this happens then this may occur:

Hypertrophy

Hypertension

Pulmonary edema

the ejaction fraction during diastolic dysfunction

normal

Hypertrophy in diastolic dysfunction

due to the increased pressure and stiffness

Hypertension in diastolic dysfunction

Non-essential (secondary) due to long standing elevated pressures

Pulmonary edema in diastolic dysfunction

due to the difficultly for blood to flow into the LA

what does Valsalva Maneuver do

Increases intrathoracic pressure and thus

reduces venous return to the atrium.

This "unloads" the ventricle and causes a drop in filling pressure.

-unmasks diastolic dysfunction and alters

pseudonormal filling into impaired relaxation.

how to perform valsalva maneuver

let the patient press while he is in

mid-breathing level. Observe the mitral inflow signal. The maneuver

is effective once you see a rise in heart rate. Usually you will also see

a decrease in overall inflow velocity.

normal diastolic function

transmitral inflow

E peak greater than A peak

normal diastolic function

during valsalva maneuver

E peak greater than A peak

normal diastolic function

during tissue doppler

e' greater than a'

normal diastolic function

pulmonary venous flow

S larger than D

Side note- in young patients (less

than 40 yrs old) the S may be

smaller than D due to enhanced LV

suction and filling

normal diastolic function

LV relaxation

normal

normal diastolic function

LV compliance

normal

normal diastolic function

LA pressure

normal

Diastolic dysfunction occurs when

there is an abnormal

increase in atrial pressure in order to sustain ventricular filling

Diastolic Dysfunction grade system

Grade I Impaired (abnormal) relaxation

Grade II Pseudonormalization

Grade III Restrictive (reversible)

Grade IV Restrictive (irreversible)

Impaired Relaxation, Grade I

transmitral flow

E peak smaller than A peak

Impaired Relaxation, Grade I

during valsalva maneuver

E peak smaller than A peak

Impaired Relaxation, Grade I

tissue doppler

e' smaller than a'

Impaired Relaxation, Grade I

pulmonary venous flow

S larger than D

Impaired Relaxation, Grade I

LV relaxation

impaired (takes a longer time than usual)

Impaired Relaxation, Grade I

LV compliance

normal to decrease

Impaired Relaxation, Grade I

LA pressure

normal, normal dimension/dilated (may behypercontractile)

Pseudonormalization,Grade II

transmitral flow

E peak greater than A peak

Pseudonormalization,Grade II

during valsalva maneuver

reverses E peak smaller than A peak

Pseudonormalization,Grade II

tissue doppler

e' smaller tha a'

Pseudonormalization,Grade II

pulmonary venous flow

S smaller than D

Pseudonormalization,Grade II

LV relaxation

impaired, ( slower than usual)

Pseudonormalization,Grade II

LV compliance

decreased

Pseudonormalization,Grade II

LA pressure

increased, dilated LA

the difference between grade III and grade IV is

grade III is reversible, could get better with medical attention, grade IV is irreversible, heart is failing

Restrictive Filling, Grades III,IV

transmitral flow

E peak greater than A peak

Restrictive Filling, Grades III,IV

during valsalva maneuver

E and A peak can possibly reverse in grade III, will not reverse in IV

Restrictive Filling, Grades III,IV

tissue doppler

very low myocardial e' and a' velocities

Restrictive Filling, Grades III,IV

pulmonary venous flow

small S larger D

Restrictive Filling, Grades III,IV

LV relaxation

significantly impaired

Restrictive Filling, Grades III,IV

LV compliance

significantly impaired

Restrictive Filling, Grades III, IV

LA pressures

significantly increased, LA dilated

Impaired Relaxation, Grade I

The initial or earliest abnormality

This results from the loss of elastic recoil of the left ventricle in early diastole leading to a reduction in the force by which blood is sucked through the mitral valve

Pseudonormalization Grade II

With further deterioration of diastolic function, a decrease in chamber compliance (increased stiffness) adds to the continued delay in relaxation

Transmitral flow is increasingly dependent on maintaining a high left atrial pressure rather than active relaxation (i.e., pushing as opposed to pulling blood into the left ventricle)

*The important concept here is that the mitral inflow velocity pattern resembles the normal state due to the combined effects of high filling pressure and impaired relaxation*

Restrictive Filling (reversible) grade III

left ventricularchamber compliance becomes increasingly abnormal To maintain forward flow , left atrial filling pressure must continue to increase

There is a rapid rise in LV pressure with rapid equalization of LV/ LA pressure, this results in significant shortening of Deceleration time

*In some patients this stage may be reversible with diuresis ( or other forms of preload reduction)and may revert back to one of the earlier stages*

Restrictive filling (irreversible) GradeIV

In later stages of restrictive filling stage, the pattern may become irreversible

This most severe form of diastolic dysfunction (grade 4)

differs from grade 3 only by the fact that a Valsalva

maneuver is unable to reverse the pattern to a

pseudonormal one

These patients commonly have advanced forms of heart failure and are usually symptomatic.

Right Ventricular Diastolic Dysfunction

can be assessed in a similar manner as for the Left

Ventricle

can be evaluated via interrogation of RV and RA filling profiles and myocardial velocities of the lateral tricuspid annulus (Tissue Doppler)

Important differences between LV and RV filling

-RV inflow velocities vary with respiration

-RV inflow velocities are lower

-SV is derived from the CSA and VTI therefore, as the

Tricuspid annulus is larger than the Mitral annulus the

VTI (and velocities) must be lower

-RV diastolic filling time is longer

-The TV opens before and closes after the MV

Stress echo

noninvasive diagnostic method which combines

baseline echo imaging with a peak / post exercise in order to detect ischemia and assess known or suspected CAD.

why do stress echos?

because if a patient with significant CAD exercise's, ischemia will be induced in the region by a narrowed coronary artery. This will be demonstrated as an abnormality of contractility (thickening and /or

motion)

stress echo equipment

-2-D and Doppler Echocardiogram

-Treadmill or bicycle ergometer

-Continuous 12-lead EKG

-Acquisition system

-Imaging Bed

-Resuscitation equipment and medication

( crash cart and defibrillators are checked every day in the department or office, which ever they are

performing stress tests)

stress echo patient instructions

-NPO after midnight / 3-4 hours prior

-Last meal light no coffee, tea, alcohol

-No smoking for at least 4 hours

-Dress comfortably

-Lightweight shoes

-No bath oils or body creams in chest area

stress echo patient preparation

-Explain procedure to patient

-Sign consent form

-Screen for indications and contraindications

-Place on electrodes for resting EKG(depending on facilitysome will have an EKG tech monitoring that aspect)Obtain resting EKG

-Obtain resting blood pressure reading

-Take resting 4 Echocardiographic views patient in LLD (left lateral decubitus)

Proper Electrode Placement stress test

-LA and RA placed by clavicle

-V1 and V2 placed higher

-V3-V6 placed lower

-LL and RL placed on the torso

Stress Echocardiography Treadmill

views

PSLA

PSSA

PAP

APICAL 4

APICAL 2

possible A3

acquire images at systole

Stress Echocardiography Treadmill

EKG

"R" intervals (systolic beat is captured)

Stress Echocardiography Treadmill

images before and after stress images

-rest

-peak

-post/final

-quad screen layout

stress echo types of stressors

-treadmill

-bicycle ergometer

-pharmacologic (dobutamine)

stress echo personnel needed

-physician

-cardiac sonographer

-EKG technician

-nurse if pharmacologic

stress echo

what are you testing for

-coronary artery disease

when plaque builds up in the coronary arteries it can obstruct blood flow

must meet myocardial oxygen demand

-wall motion abnormalities

stress echo

normal response

-LV contractility increases

-Decrease in LV chambervolume size

-Thickening in all wall segments

stress echo

abnormal response

-New wall motion abnormality of a wall segment

-No change in wall motion after exercise - can represent myocardial scar or hibernating myocardium

-LV chamber dilatation with hypokinesis

Descriptors of Wall Motion Abnormalities

Hyperkinetic/ Hyperdynamic

Hypokinetic

Akinetic

Dyskinetic

wall motion scoring

1 normal

Normal endocardial inward motion

and wall thickening in systole

wall motion scoring

2 hypokinesis

Reduced endocardial motion and wall

thickening in systole

wall motion scoring

3 Akinesis

Absence of inward endocardial motion or wall thickening in systole

wall motion scoring

4 Dyskinesis

Outward motion or "bulging" of the

segment in systole, usually associated with a thin, scarred myocardium

wall motion scoring

5 Aneurysmal

Diastolic deformation with associated

outward systolic expansion

Bruce Protocol

Most commonly used protocol

Increases speed and grade every 3 minutes

bruce protocol 7 stages

Stage 1 = 1.7 mph at 10% Grade

Stage 2 = 2.5 mph at 12% Grade

Stage 3 = 3.4 mph at 14% Grade

Stage 4 = 4.2 mph at 16% Grade

Stage 5 = 5.0 mph at 18% Grade

Stage 6 = 5.5 mph at 20% Grade

Stage 7 = 6.0 mph at 22% Grade

Naughton Protocol

Workloads increased in each stage every 2 minutes

Naughton protocol

two speeds

3.4 mph healthier patients

3.0 mph in between stage

2.0 mph older or coronary patients

Predicted Maximum Heart Rate

MHR=

220- Patients Age

Target Heart Rate

THR=

MHR x 0.90

Treadmill Technique

Completion of exercise patient is immediately returned

to the bed for the peak exercise echocardiographic

views

PEAK images are obtained within one minute from the

completion of exercise use same window!

Take blood pressure

Compare rest, peak and recovery images

Supine Bicycle Stress Echo Technique

Difference is images can be performed before, during,

and after the exercise

United States uses this technique less often

Resistance is increased every 2-3 minutes by 25-50

watts per stage

Supine Bicycle Stress Echo Technique

image taken

PSLA, PSSA PAP, A4, A2

REST

PEAK (85-90% of MHR) (within 60 seconds)

FINAL (recovery)

Pharmacologic Stress Echo Technique

Utilized when a patient cannot perform a treadmill test

Dobutamine

Adenosine

EKG Changes

ST depressions

The more changes visualized in the ST

segment the more severe the ischemic

area

A depression of 1 mm or more has clinical

significance

EKG changes

ST elevation

Indicated more severe ischemia than ST

depression

Echo Bubble Study

an injection of saline after agitation with air to

create micro-bubbles that are ultrasound reflective into a vein in order to

reach and opacify the right heart chambers, the coronary sinus in cases of

persistent left superior vena cava (PLSVC), or the pericardium during

pericardiocentesis.

Normally performed on patient who have experienced a stroke; but who do

not have any risk factors for strokes; such as HTN or atrial fibrillation

Bubbles are seen traveling through a tiny, flaplike tunnel between the right

and left atria.

Echo Bubble Study

equipment necessart

2 syringes, saline and

a 3 way stop cock then agitate and inject

Stress Echocardiography with Contrast Agents

are microbubbles

that are injected into the

patient (they are smaller

than erythrocytes and pass

through capillaries safely)

When endocardial borders

are not well visualized

Contrast should be used when

two or more segments are not

well visualized.

Nuclear Imaging

Utilized to correlate with stress ehcocardiography

Myocardial imaging to evaluate for CAD

Assess the vascular distribution and severity of CAD and to detect

viable myocardium

When the stress echocardiograms are deemed unreliable or

non-diagnostic

Strain / Speckle Tracking

a fundamental

role in the evaluation of the systolic function of the left ventricle, with several advantages

over the Doppler method, including angle independence, greater reproducibility, and

rapidity of image acquisition. Speckle tracking finds application in various pathologies,

tissue doppler imagining measures

movement

tissue doppler imaging strain measures

deformation

movement is defined as

the act of changing position

Deformation is defined as

an object changing shape

Speckle Tracking (STE)

is a method in which the

ultrasound speckles (i.e., motion of the kernel) are tracked over time.

Speckles are contained within the gray scale image and are created by the

interference patterns that are generated by the reflection ultrasound.

the region of speckles being tracked in a single fram is called

the kernel

The scientific definition of strain(S)

refers to the deformation to the size

and shape of an object as a result of applied stress.