2016 recommendations for the evaluation of left ventricular diastolic function samir rafla
Diastolic Dysfunction. Normal diastolic function : Adequate ventricular filling without abnormal...
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Transcript of Diastolic Dysfunction. Normal diastolic function : Adequate ventricular filling without abnormal...
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Diastolic DysfunctionDiastolic Dysfunction
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Normal diastolic function : Adequate ventricular filling without abnormal elevation in diastolic pressures. Ensures normal stroke volume based on Frank Starling mechanism.
Diastole
IVRT EFP AFP
IVRT : Isovolumic relaxation. Energy dependent..
Doppler : Evaluates transmitral velocities resulting from pressure gradients.
EFP : Predominant force = LV elastic recoil (rate LV relaxation) with subsequent vaccum. 80% LVEDV
AFP : Atrial contraction. 20% LVEDV
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Variables : 1- Peak E velocity 2- Peak A velocity ( E at A velocity) 3- E/A ratio 4- IVRT (Parallels DT) 5- DT. 6- A duration. ( Compared with AR in PVF tracing) Normally A-AR >0
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Pulmonary vein flow
L Atrial relaxation
RV systoleEFP
L Atrial contraction
1- PS1 not seen in 70% cases.2- AF PVS1 lost and PVS2 always smaller than PD3- Peak velocity and duration of PVar increase with increased EDP
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Normal Patterns
LV relaxation becomes slower : a) lower initial and peak trasmitral gradient with age resulting in b) Longer IVRT and DT c) Less contribution of early filling d) More of an A component with increased vel. e) E/A ratio close or below one by age 70 d) Increased PVs and decreased PVd with increased PVar velocity.
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Abnormal diastolic function Abnormal relaxation pattern
Caused by impaired = slower relaxation. Maintained mean LA and LVEDP.MIT : a) Decreased E velocity + Increased A velocity = E/A ratio < 1 b) Prolonged IVRT and DTPVF : a) Predominant PVs flow with blunting of PVd velocity. b) PVar remains normal or slightly faster. c) A-Pvar >1
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Increased A waveIncreased LVEDP base on increased A componentNormal mean LA pressure.Ma < PVar
Transition
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Abnormal diastolic function Pseudo-normalization
DT 200 msE/A >1
DT 200 msE/A >1
PVs > PVdMa > PVar
PVs < PVdMa < PVar
Moderate increase in LA atrial pressure superimposed on relaxation abnormality.Clues to pseudonormal pattern : a) Abnormal 2D findings where increased LA pressure is expected. b) LA enlargement without MR/MS. c) Reduction in preload with Valsalva/NTG (LA pressure) can unmask the pseudonormal pattern and bring out the abn. Relaxation = reversal of E/A ratio to <1.
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Abnormal diastolic function Restrictive Pattern
Results from marked increase in LAPressure/ Decreased LV compliance/Relaxation abnormality.
MVI1- Increased E velocity2- Short DT (< 160 ms ) & IVRT (< 60 ms)2- E/A ratio > 2. Decreasing with Valsalva
PVF1- Decresed PVs with increased PVd2- Longer/faster Pvar3- Ma << Pvar4- Increased PVar velocity (>0.35 m/s)
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Abnormal diastolic function Restrictive Pattern Cont…
Tachycardia can mask PVF reversal due to occurrence of Atrial contraction during forward pulmonary vein flow (mid diast)
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LVFP MITRAL INFLOW PULM. VEIN FLOW
Grade Relax Comp. WP LVEDP E/A DT IVRT PVS/PVD PVS % ARV Ma-Pvar Sympt LA Size (msec) (msec) (cm/sec) (msec)
Mild(Abnormal Imp NL NL NL <1 >200 >100 > 1 >50% <35 <20 None NLRelaxation)
Abnormal Imp. NL or NL Inc. <1 >200 >100 >1 >50% >35 and/or >20 None or at NLRelaxation. mildly exerciseLikely elev. Imp.LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exerciseNormalized 200 100Pattern)
Severe(Restrictive) Imp Imp Very Very >2 <150 <60 <0.5 <50% >35 >20 Rest or L Inc. Inc. excersice
LVFP MITRAL INFLOW PULM. VEIN FLOW
Grade Relax Comp. WP LVEDP E/A DT IVRT PVS/PVD PVS % ARV Ma-Pvar Sympt LA Size (msec) (msec) (cm/sec) (msec)
Mild(Abnormal Imp NL NL NL <1 >200 >100 > 1 >50% <35 <20 None NLRelaxation)
Abnormal Imp. NL or NL Inc. <1 >200 >100 >1 >50% >35 and/or >20 None or at NLRelaxation. mildly exerciseLikely elev. Imp.LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exerciseNormalized 200 100Pattern)
Severe(Restrictive) Imp Imp Very Very >2 <150 <60 <0.5 <50% >35 >20 Rest or L Inc. Inc. excersice
LVFP MITRAL INFLOW PULM. VEIN FLOW
Grade Relax Comp. WP LVEDP E/A DT IVRT PVS/PVD PVS % ARV Ma-Pvar Sympt LA Size (msec) (msec) (cm/sec) (msec)
Mild(Abnormal Imp NL NL NL <1 >200 >100 > 1 >50% <35 <20 None NLRelaxation)
Abnormal Imp. NL or NL Inc. <1 >200 >100 >1 >50% >35 and/or >20 None or at NLRelaxation. mildly exerciseLikely elev. Imp.LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exerciseNormalized 200 100Pattern)
Severe(Restrictive) Imp Imp Very Very >2 <150 <60 <0.5 <50% >35 >20 Rest or L Inc. Inc. excersice
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Estimation of LV filling pressures
Similar mitral inflow patterns might reflect completely different processes. General guidelines for estimating filling pressures ( High or normal…)
1- Abn. Relaxation Pattern = Normal filling pressures unless IVRT and DT are normalized or shorter. (<60 / < 160)2- Expected impaired relax. = Elevated pressures (pseudonormal) and E>>A
3- E/A higher and DT shorter = Elevated pressures. than expected.
4- Restrictive filling pattern = Elevated pressures.
5- PVS flow < 40% of all = Elevated pressures (mean LV diast) forward flow. - PVar vel > 0.35 m/s
6- PVar > Ma by 30 msec = LVEDP > 15 mm ( Very reliable indicator)
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Not all is black and white in diastolic dysfunction
Severe LVH
Early diastolicRestrictivephysiology
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Short PR
Tachycardia
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Advanced Amiloidosis
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HOCM
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