0508-1015-Oh-Echocardiographic Evaluation of Diastolic ......Luis Caballero et al. EHJ 2015 20-40...

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©2018 MFMER | 3712003-1

Assessment of Diastolic FunctionChallenging, but Can be Simple

ASE Echo Board Review CourseMay 8th, 2018

Jae K. Oh, MDSamsung Professor of CV Diseases

©2018 MFMER | 3712003-2

Learning Objectives for DiastologyAfter this talk, you will be able to

• Understand physiology and hemodynamics of diastole

• Know correlation between Echo diastolic parameters and underlying hemodynamics

• Classify and grade diastolic function

• Estimate filling pressure reliably in most patients at rest and with exercise

• Understand pitfalls of Echo diastolic function assessment

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Diastolic Filling with Relaxation

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Myocardial relaxation is one of the earliest manifestations of mechanical dysfunction of the human LV. The time constant tau

(Ƭ) is higher in the elderly and patients with HCM, CAD, and cardiomyopathies.

Circulation 1980

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Echo evaluation of diastolic functionTrans-mitral inflow velocity

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Diastolic Function GradingMitral Inflow (U curve)

40

0

NormalNormalAbnormalrelaxationAbnormalrelaxation

Pseudo-normalization

Pseudo-normalization

RestrictiveRestrictive

LAP NL (< 15) Normal

TAU NL (< 45)

Grade 1 2 3

LAP NL (< 15) Normal

TAU NL (< 45)

Grade 1 2 3

CP1254003-13Concept from Appleton and Hatle, 1985

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Mitral Inflow and Pulmonary Vein Flow Diastolic Function Assessment

Grade 1 Grade 2 Grade 3

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Firstenberg et al: J Appl Physiol 90:299, 2001, Nagueh et al: JACC 1997Oki et al: AJC 1997 , Sohn et al:JACC 1997, Ommen et al: Circ 2000 Opdahl et al: Circulation 119:2578, 2009, and more

LV Relaxation by Cath and Echo (tau) vs e’ (mitral annulus velocity)

0

20

40

60

80

100

120

0 2 4 6 8 10 12e’ (cm/sec)

Tau

(m

sec) y=-6.80x + 85.68

r=0.70P<0.001

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Assessment of LV Relaxation by Echoe’ velocity reflects LV relaxation

CP1254003-8Myocardial Relaxation is the Key for Diastole

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Myocardial Relaxation (e’)

e’= 12 cm/s e’ = 4 cm/se’= 7 cm/s

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Mitral flow

Mitral annulusvelocity

Evaluation of Diastolic FunctionMitral Inflow and Annulus Velocity

Sohn et al: JACC, 1997Sohn et al: JACC, 1997

Normal Ab Relax Pseudo RestrictiveGrade 1 Grade 2 Grade 3

CP1254003-30

Preload dependent

Preload independent

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Nagueh et al: JACC, 1997Ommen et al: Circ, 2000 Nagueh et al: JACC, 1997Ommen et al: Circ, 2000

45

40

35

30

25

20

15

105

0 105 15 20 25 30 35E/E

PCWP (mm Hg)

y=1.9 + 1.24xr=0.87n=60

Annulus E

Mitral E

E/E

As LV fillingpressure As LV fillingpressure

CP1254003-31

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Estimation of LV Filling PressuresE/e’ (Medial MV annulus)

0

5

10

15

20

25

30

35

40

Ommen SR et al: Circulation 102:1788, 2000

LV f

illin

g p

ress

ure

EF >50%EF <50%

E/E <8 E/E 8-15 E/E >15

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What are normal values for e’ and E/e’ ?

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Septal e’ based on Age Groups Septal E/e’ based on Age Groups

20-40 40-60 >60 20-40 40-60 >60

Luis Caballero et al. EHJ 2015

20-40 40-60 >60

©2018 MFMER | 3712003-16Ritzema et al JACC Imaging 2011

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LA Volume Index vsDiastolic Dysfunction

CP1041500-8

Inde

xed

LA v

olum

eIn

dexe

d LA

vol

ume

Diastolic function gradeDiastolic function grade

Normal I II IIINormal I II III

r=0.78n=147 ptr=0.78n=147 pt

70

60

50

20

30

40

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©2011 MFMER | slide-18

0.0 0.2 0.4 0.6 0.8 1.00.0

0.2

0.4

0.6

0.8

1.0

Line of no information

Left atrial volume indexE/e' ratio

Left ventricular mass indexRelative wall thickness

PASP

1-Specificity

Sen

sitiv

ity

p<0.01*vs line of no information;†vs PASP

*†*†

*††

*

Hypertensive Heart Disease vs HFpEFImportance of PASP and E/e’

Lam C et al, JACC, 2009

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Four Major Parameters in DiastologyNormal values

1. E’ velocity ≥ 7(med), 10 (lat) cm/s

2. E/e’ ≤ 14 (Av), 15(Med)

3. TR velocity ≤ 2.8 m/sec

4. LAVI ≤ 34 mL/m2

Four Major Diagnostic ParametersNormal Values

JASE and EJ CV Imaging April 2016

©2018 MFMER | 3712003-20

New Criteria for Diastolic Function Assessment

Criteria for diagnosis of LV diastolic dysfunction in patients with normal LVEF in JASE 2016

In pts with normal LVEF≥ 50%

1 – Septal e’ velocity ≥7 cm/s orlateral e′ velocity ≥10 cm/s

2 – Average E/e′ ≤14 , 15 (Med)3 – TR velocity ≤2.8 m/s4 – LA volume index ≤34 mL/m2

≥ 3 Normal 2 and 2 ≥ 3 Abnormal

Normal diastolic function Indeterminate Diastolic dysfunction

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Normal Diastolic Function

Medial e’ 12 cm/s Lateral e’ 16 cm/s

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True Normal Diastolic Function

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71 year old woman with LAVI = 39 mL/m2

Lateral e’ = 10 cm/sec Medial e’ = 9 cm/sec

E/e’ = 9 E/e’ = 10

E/e’ NL < 14e’ NL > 7

LAVI EnlargedTR NL < 2.8

©2018 MFMER | 3712003-24

71 year old woman with LAVI = 39 mL/m2

Lateral e’ = 10 cm/sec

E/e’ = 9

E/e’ NL < 14e’ NL > 7

LAVI EnlargedTR NL < 2.8

LVOT TVI = 26 cm

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Reasons for LA enlargement

• Diastolic dysfunction

• Increased filling pressure

• Increased volume

• Athlete’s heart

• Measurement error

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Normal or Grade 1 Diastolic Dysfunction ?LAVI 28 mL/m2

E = 50 A= 100 E/A =0.5

e’ = 6 cm/secE/e’ = 8

E/e’ NL < 14e’ ABNL < 7LAVI NormalTR NL < 2.8

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Criteria for diagnosis of LV diastolic dysfunction in patients with normal LVEF






Normal Diastolic Filling Pressure

Increased Diastolic Filling Pressure

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Diastolic Function?

e’ = 4 cm/secE/e’ = 30

TR = 4 m/sec

E= 120 cm/s

e’ ABNL < 7E/e’ ABNL > 14LAVI ??TR NL > 2.8

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Criteria for diagnosis of LV diastolic dysfunction in patients with normal LVEF






Normal Diastolic Filling Pressure

Increased Diastolic Filling Pressure

©2018 MFMER | 3712003-30

Diastolic Function AssessmentTake Home Point #1

• LV myocardial relaxation is reduced in all stages of diastolic dysfunction

• Mitral annulus e’ velocity reflects myocardial relaxation

• Normal e’ = Normal diastolic function

• Algorithm #1 separates normal filling from elevated filling pressure

• Initial assessment of diastolic functon is based on• E’, E/e’, TR velocity, and LAVI

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Diastolic Function?

e’ = 4 cm/secE/e’ = 30

TR = 4 m/sec

E= 120 cm/s A= 20 cm/sE/A = 6


©2018 MFMER | 3712003-32

In patients with depressed LVEF or normal EF with diastolic dysfunction

Mitral inflow

E/A ≤0.8 + E <50 cm/s

E/A ≤0.8 + E >50 cm/sor

E/A >0.8-<2

E/A ≥2

Normal LAPGrade I diastolic

dysfunction

3 criteria to be evaluated*

1 – Average E/e′ >142 – TR velocity >2.8 m/s3 – LA volume index >34 mL/m2

2 of 3 negative

2 of 3 or3 of 3

positive

2 negative2 negative 1 positive and1 negative

1 positive and1 negative 2 positive2 positive

When only 2 criteria are availableWhen only 2 criteria are available

Cannot determine LAP and diastolic dysfunction

grade*

LAPGrade II diastolic

dysfunction

LAPGrade III diastolic

dysfunction

If symptomatic consider CAD or proceed to diastolic stress test

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67 yo man with ischemic CM and HFGr. 1 dysfunction with normal filling pressure

E= 45 cm/sec A= 90 cm/secE/A = 0.5

Grade 1 Dysfunction

E/A ≤ 0.8E <50 cm/sec

©2018 MFMER | 3712003-34

67 yo man with ischemic CM and HFGr. 1 dysfunction with normal filling pressure


Grade 1 Dysfunction

E/A ≤ 0.8E <50 cm/sec

Medial e’ = 4 cm/sE/e’ = 11

E/e’ NL < 14e’ ABNL < 7LAVI ABNLTR NL < 2.8

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Grade 1 Diastolic Dysfunction


Grade 1 DysfunctionE/A ≤ 0.8

E <50 cm/sec

Medial e’ = 4 cm/sE/e’ = 11

E = 50 A= 100 E/A =0.5e’ = 6 cm/sec

E/e’ = 8

©2018 MFMER | 3712003-36

67 year old man with ischemic CM and HF

2 months before

E= 120 cm/sec E/A =0.9E/e’ = 30

TR Vel = 3 m/sec

E= 45 cm/s E/A = 0.5E/e’= 12

Medial e’ = 4 cm/s

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67 yo man with ischemic CM and HFGr. 2 dysfunction with increased filling pressure

E= 120 cm/sec E/A =0.9E/e’ = 30

TR Vel = 3 m/sec

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Ischemic Cardiomyopathy Echo PredictorSTICH Trial (N=1511)

Lin et al. 2014 AHA

Best survival with E/A 0.6-0.8

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Grade 3 DysfunctionL wave

e’ = 4 cm/secE/e’ = 30

TR = 4 m/sec

E= 120 cm/s A= 20 cm/sE/A = 6


©2018 MFMER | 3712003-40

CP1100934-2Frommelt et al: J Am Soc Echocardiogr 16:176, 2003

Mid-diastolic mitral flow (L)Delayed relaxation

A. Fib

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Distribution of 2D and Doppler Variables

Elevated filling pressure (n=165)

Normal fillingpressure (n=155)

Mitral E/A ratio 0.8 + E 50 cm/s 0 23

Mitral E/A ratio 2 53 5

None of the cutoff values met for the 3 variables in patients with diastolic dysfunction

15 70

3 abnormal LAV >34 ML/m2, E/e>14, and TRV >2.8 m/s

25 0

2 abnormal (2 of 3 listed) LAV >34 mL/m2, E/e>14, TRV <2.8 m/s

35 7

LAV >34 mL/m2, E/e<14, TRV >2.8 m/s

11 8

LAV <34 mL/m2, E/e>14, TRV >2.8 m/s

8 1

1 abnormal LAV >34 mL/m2 6 32

E/e >14 8 4

TR >2.8 m/s 4 5

• Normal Filling Pressure• 3 normal parameters• LAVI >34 mL/m2

• E/A ≤ 0.8 + E ≤ 50 cm/s

• Increased Filing pressure• E/A ≥2• E/e’ > 14 + LAVI >34 mL/m2

• 3 abnormal• 2 abnormal

Andersen et al: J Am Coll Cardiol 2017;69:1937-48

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23 YO with HCM1. Grade 1

2. Grade 2

3. Grade 3

4. Possibly normal

E = 70 cm/s A= 30 cm/s E/A = 2.3

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23 yo with HCM

Medial e’ = 8 cm/sec Lateral e’ = 10 cm/sec

E = 70 cm/s

E/e’ = 9 E/e’ = 7

Can he have a normal diastolic function ?

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23 yo man with HCMLAVI 29 mL/m2

TR = 2 m/sec IVRT = 120 msec

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Valsalva in 23 yo HCMNormal filling pressure

E/A= 2.3 E/A = 2.0

IVRT 100 msec

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Mitral A duration is shorter than PV ARIncreased LVEDP

©2011 MFMER | slide-46

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Rossvoll and Hatle:JACC, 1993Rossvoll and Hatle:JACC, 1993

PVad-Ad (ms)PVad-Ad (ms)

EDP(mm Hg)EDP(mm Hg)

r=0.68r=0.68P<0.001P<0.001

05

1015202530354045

-100 -50 0 50 100

Ma=100 msPVa=165 ms

0.5

0.5

Mitral flow velocity LV pressure

Pulmonary vein

25 mm Hg

DopplerDeterminationof LVEDP

DopplerDeterminationof LVEDP

CP1057136-18

LVEDP can be increased with normal mean LV diastolic pressure

©2018 MFMER | 3712003-48

Diastolic Function AssessmentTake Home Message #2

• Grade 1 diastolic dysfunction is the best pattern for the patients with Heart Failure

• Evidence for diastolic dysfunction needs an objective evidence

• Hypertension• Hypertrophic CM• Old age

The best evidence is reduced relaxationReduced e’

L waveProlonged IVRT

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©2018 MFMER | 3712003-49

Difficult Situations• Assess diastolic function or filling pressure in

• 2 normal and 2 abnormal• HCM• LBBB• MAC• Atrial Fibrillation

• Additional supportive parameters• Pulmonary vein• Valsalva• IVRT and timing intervals• Strain

©2018 MFMER | 3712003-50

67 year old woman with HPT and SOBLAVI = 54 and TR= 2.8 m/s

1. E’ +/-

2. E/e’ NL

3. TR ≤ 2.8

4. LAVI ++

Med e’ = 7E/e’ =13

Lat e’ =8E/e’ = 12

E= 90 A= 40 E/A=2.3

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Indeterminate ?

• E’ +/-

• E/e’ < 15

• LA > 34

• TR > 2.8 m/sec

TR = 2.83 m/s

©2018 MFMER | 3712003-52

Normal Impairedrelaxation

compliance LAP

compliance LAP

PVsPVd

PVa

Pulmonary Vein VelocityPVs decreases as filling pressure increases

Pulmonary Vein VelocityPVs decreases as filling pressure increases

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©2018 MFMER | 3712003-53

Valsalva Maneuver : E/A reduced > 0.5Grade 2 Dysfunction

E= 90 A= 40 E/A=2.3 E= 60 A= 60 E/A=1.0

©2018 MFMER | 3712003-54

Conclusions—In 100 symptomatic patients with HCM, Doppler echo estimates of LV filling pressure correlate modestly with direct measurement of LAP. Given the complex nature of diastolic

dysfunction in HCM, precise characterization of LV filling pressure in an individual patient cannot be determined with the use of these noninvasive parameters. (Circulation. 2007;116:2702-2708.)

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©2018 MFMER | 3712003-55

0

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60

0 5 10 15 20 25 30 35 40 45

Medial E/e’ Ratio Versus Mean LAPM

edia

l E-e

’ rat

io

Mean LAP (mmHg)

Geske et al: Circulation; 116:2702, 2007

All studiesAll = 0.45x + 11.5r=0.44P<0.001

Simultaneous studiesy=0.28x + 13.8r=0.28P=0.07

Simultaneous studies<48 hours between studies

©2018 MFMER | 3712003-56

0

5

10

15

20

25

30

35

40

45

<8 8-15 >15

Mean LAP vs Medial E-e’ ratioHypertrophic CM

Mea

n LA

P (

mm

Hg)

Mean E-e’ Ratio

Geske et al: Circulation; 116:2702, 2007

Simultaneous studies<48 hours between studies

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©2018 MFMER | 3712003-57

Diastolic Function Evaluation in HCM

• E’ velocity is reduced in almost all patients

• E/e’ predicts clinical outcome

• Use following parameters (ASE 2016 Guideline)• E/e’ >15• LAVI >34 mL/m2

• TR velocity > 2.8 m/sec• PV Ar-A duration ≥ 30 msec

• The majority rules

©2018 MFMER | 3712003-58

72 yo woman with HCM

E=80 A=95 E/A = 0.85

Med e’ = 2 E/e’ = 40

Lat e’ = 5 E/e’ =15

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©2018 MFMER | 3712003-59

72 yo woman with apical HCMGrade 2 dysfunction with LAVI 37 mL/m2

TR = 3 m/sec

©2018 MFMER | 3712003-60

Mitral annulus e’ velocity

• ASE/EACVI recommends average value

• E’ from one location is acceptable

• We need a caution in using e’• Primary pulmonary hypertension• Pacemaker• LBBB• Wall motion abnormality• Mitral annulus calcification• Hypertrophic CM

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©2018 MFMER | 3712003-61

67 yo woman with LBBB

E= 60 A= 80 E/A = 0.7

Medial e’ = 3 cm/s E/e’= 23

Lat e’ = 9 cm/s E/e’= 8

©2018 MFMER | 3712003-62

67 yo with LBBB

TR = 2.4 m/sec

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Mitral annulus calcification and TAVR

E= 100 cm/sec

Lat e’= 4 cm/s Med e’ = 3 cm/s

©2018 MFMER | 3712003-64

Mitral annulus calcification and TAVR

E= 100 cm/sec

Lat e’= 4 cm/s Med e’ = 3 cm/s

TR = 2.4 m/sec

E= 100 cm/s Pulmonary Vein

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©2018 MFMER | 3712003-65

Mitral annulus e’ velocity vs MACMean age 73 years

Variable

Group 1n=79

no MAC

Group 2n=38

mild MAC

Group 3n=38

mod-severe MAC P for trend

Agatston Score 0 1-119 >119

Septal e’ 5.96±1.82 5.15±1.56 5.05±1.93 0.01

Lateral e’ 7.37±2.44 6.89±2.71 6.28±1.81 0.01

Average e’ 6.63±2 6.02±1.79 5.67±1.69 0.01

E/avg e’ ratio 13±4.93 15±8.95 18±8.26 <0.001

Codolosa et al: Am J Cardiol 2016;117:847-852

LV diastolic parameters are altered in the presence of MAC. This could be due to direct effects of MAC or might reflect truly reduced diastolic function. Interpretation

of diastolic parameters in patients with MAC should be performedwith caution.

©2018 MFMER | 3712003-66

Abudiab et al: Am Coll Cardiol Img, 2017

Mild Moderate Severe

Representative Images of Patients With Mitral Annular Calcification

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Correlation of Selected Doppler Variables With Left Ventricular Filling Pressure


0

1

2

3

4

0 20 40 60LVFP (mm Hg)

Mit

ral E

/A

0

50

100

150

0 20 40 60LVFP (mm Hg)

IVR

T

0

10

20

30

40

50

0 20 40 60LVFP (mm Hg)

E/e(

avg

)

r=0.66, P<0.001 r=-0.50, P<0.001

r=0.42, P=0.003

©2018 MFMER | 3712003-68

Proposed Clinical Algorithm for Estimationof Left Ventricular Filling Pressure inSubjects With Mitral Annular Calcification


High LVFP

Normal LVFP High LVFP

Initial Cohort (n=50):Sensitivity: 81%Specificity: 100%PPV: 100%NPV: 67%

Total Cohort (n=71):Sensitivity: 85%Specificity: 95%PPV: 97%NPV: 78%

Initial: 8/9 (89%)Total 12/13 (92%)

10/10 (100%)11/11 (100%)

4/9 (44%)9/14 (64%)

16/16 (100%)23/24 (96%)

Mitral E/A

IVRTNormal LVFP

<0.8 0.8-1.8 >1.8

80 ms <80 ms

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©2018 MFMER | 3712003-69

Diastolic Function in A. Fib

• DT < 160 msec (with reduced EF)

• DT < 130 msec poor survival (Hurley, Oh)

• Other measurements• E acceleration > 1900 cm/sec2

• IVRT ≤ 65 msec• E/e’ ≥ 11• IVRT/ T E-e’• TR velocity

©2018 MFMER | 3712003-70

E/e’ =20

L waveE=120

E’= 6

JASE 1999

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©2018 MFMER | 3712003-71

Atrial FibrillationVariation in E velocities : NL Pressure

DT = 100 msecDT= 210 msec

©2018 MFMER | 3712003-72

Atrial FibrillationVariation in E velocities and E/e’ <11

E/e’ = 9

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©2018 MFMER | 3712003-73

66 yo woman with dyspnea and EF 20%

E-A = 105 cm/sec

Lat e’ = 5 cm/secE/e’= 21

Medial e’= 7 cm/secE/e’= 15

©2018 MFMER | 3712003-74

66 yo woman with HF and severe MRLVEF 20%

TR= 2.9 m/s

IVRT = 75 msec

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©2018 MFMER | 3712003-75

Nagueh et al Circulation 1998

©2018 MFMER | 3712003-76

My Recommendations

• For patients with reduced EF (<35%) or with preserved EF with known diastolic dysfunction, evaluate diastolic function based on E/A ratio

• For all other patients, based on the 4 parameters• Normal : ≥ 3 normal (for patient’s age)• Abnormal : ≥ 3 abnormal (grade 2 or 3 based on E/A)• Indeterminate : Need help from PV, IVRT, Valsalva, Time interval,

Exercise, Strain Imaging

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©2018 MFMER | 3712003-77

My recommendation based on e’ velocityLV relaxation is the key for normal diastole

• True Normal• Medial e’ >10 cm/sec or Lateral e’ > 15 cm/sec

• Age-related Normal• Medial e’ 7-10 cm/s or Lateral e’ 10-15 with normal TR

• Abnormal • Medial e’ < 7 cm/s or lateral e’<10 cm/s• Grade 1, 2, and 3 based on E/e’, TR, and LAVI

©2018 MFMER | 3712003-78

Thank [email protected]

0508-1015-Oh-Echocardiographic Evaluation of Diastolic ......Luis Caballero et al. EHJ 2015 20-40...

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