Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography

LAM-1965AO (07/13) For Broker/Dealer Use Only

Diastole and Systole

• Diastole: The normal rhythmically occurring relaxation and dilatation of the heart chambers, especially the ventricles, during which they fill with blood.

• Systole: The contraction, or period of contraction, of the heart, especially of the ventricles, during which blood is forced into the aorta and pulmonary artery.

Cardiac Cycle

What is Diastolic Dysfunction?

• Changes in the ventricle which may result in impaired relaxation, reduced compliance and elevated pressures

• Diastolic Dysfunction ≠ Diastolic Heart Failure

What is Diastolic Dysfunction?• Who is more likely to develop DD? Elderly* Women Obese• What diseases are more likely to produce DD? HTN LVH CAD VHD (AS)• Text book Example: Older lady overweight with long history of

hypertension with exercise intolerance

What is Diastolic Dysfunction?• 3 Stages to Diastolic Dysfunction

I) Impaired Relaxation II) Pseudonormal III) Restrictive

• Primary measurements include peak E & A transmitral velocities, E/A ratio, DT (Deceleration Time) and IVRT (Isovolumetric Relaxation Time)

• Additional measurements E/e’, LA volume index, Pulmonary Vein Flow ( S/D & AR) and

Vp (Propagation Velocity)

What is Diastolic Dysfunction?

Figure 2 Doppler echocardiogram shows normal pattern of diastolic filling. Opening of the mitral value produces increased flow velocity through the valve annulus, which is represented as a large E wave (E). During late diastolic filling, the transmitral pressure gradient increases once again, with atrial contraction producing a smaller A wave (A).

(3)

What is Diastolic Dysfunction?

What is Diastolic Dysfunction?

What is Diastolic Dysfunction?

I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance), ECG: electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocity of flow progression, LA: left atrium, PASP: pulmonary artery systolic pressure.

What is Diastolic Dysfunction?

• 1st use E/A, DT, and IVRT• 2nd use E/e’ (<8,8-15,>15) and LA vol index (< 28 ml/M2

WNL and > 34 ml/M2 increased mortality)

• 3rd use Pulmonary Vein Flow ( S/D & AR) and Vp (Propagation Velocity)

What is Diastolic Dysfunction? Normal E/A Ratio (>1)• Good: < 60 yo, no risk factors, no evidence of increased filling

pressures ( E/e’ > 15, S<D, inc AR, dec Vp )• Not Good: > 70 yo with risk factors (HTN/LVH, CAD, ), evidence ♀

of increased filling pressures E/A < 1 ( Grade I DD, Impaired Relaxation)• NBD: > 70 yo and no HTN/LVH or CAD • BD: < 50 yo with HTN/LVH or CAD Grade II DD, Pseudonormal and LA vol index (> 34 ml/M2)• BAD ( until proven otherwise) Grade III or IV, Restrictive • BAD BAD BAD

Diastolic Dysfunction Case Study

• 74 yo male applying for $5 mil , no h/o HTN, heart disease , diabetes or cancer

• 6’ 0” , 185 lbs, 125/82 mmHg , 62 reg• Labs and EKG WNL• APS: 2012 echo….LV size and function WNL , EF 65%,

LVPWd 1.1 cm, R & L atrium WNL, Grade I DD, no significant valvular disease….GXT: exercised 13 min to 14 METS, no ischemic changes

• Offer?

Diastolic Dysfunction Case Study

• 72 yo female applying for $5 mil , long h/o HTN, no heart disease , diabetes or cancer

• 5’2” , 220 lbs, 154/92 mmHg , 92 reg• Labs WNL except NTproBNP 320 pg/ml and EKG LAD,

LVH & LAE• APS: 2012 echo….LV size and function WNL , EF 65%,

LVPWd 1.6 cm, L atrium 5.2 cm, E:A 2.2, E/e’ 20, no significant valvular disease….GXT: exercised 3 min to 4 METS, no ischemic changes

• Offer?