Ventricular Diastolic Filling and Function Stephen L. Rennyson M.D. Echocardiography Conference...
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Transcript of Ventricular Diastolic Filling and Function Stephen L. Rennyson M.D. Echocardiography Conference...
Ventricular Diastolic Filling and
Function
Stephen L. Rennyson M.D.Echocardiography Conference
August 25, 2010
Objectives• Background of Diastolic Dysfunction
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Diastole• Diastole
• Isovolumic relaxation
• Early filling (E)
• Diastasis
• Late filling - atrial contraction (A)
Background• Congestive Heart Failure (CHF)
manifests as either systolic and/or diastolic dysfunction
• Where is the dysfunction?
• Systolic dysfunction -- manifest as a loss of ventricular function (decreased EF)
• Diastolic dysfunction -- abnormal relaxation pattern manifest as increased filling pressures (Atrial and Ventricular)
Diastolic Dysfunction
• Diastolic Dysfunction is an echocardiographic / Cardiac Catheterization diagnosis based on:
• Ventricular filling patterns
• Velocity of myocardial motion
• Atrial filling patterns
• Based on these data, diastolic dysfunction can be determined and graded
Diastolic Dysfunction
• Early sign of cardiac disease
• Preceding systolic dysfunction
• Associated with increased mortality without the robust studies of treatment guidelines compared to systolic dysfunction
• Exist as its own entity -- Diastolic Heart Failure
• Studies of clinical heart failure admissions
• 50% of those have only diastolic dysfunction
• In systolic heart failure -- diastolic dysfunction can explain the differences in clinical presentation
• Myocardial Disease
• Dilated Cardiomyopathy
• Restrictive Cardiomyopathy
• Hypertrophic Cardiomyopahty
• Secondary Ventricular Hypertrophy
• Hypertension
• AS
• CAD -- Ischemia and infarction
• Pericardial disease
Etiology
Overview• Background of Diastolic Dysfunction
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Characteristics of Diastolic
Dysfunction• LV hypertrophy
• LA Volume
• LA function
• PA systolic and diastolic pressures
LV hypertrophy• Majority of those with diastolic
dysfunction:
1.Concentric hypertrophy (hypertensive heart disease)
• Increased mass and wall thickness
2.Remodeling
• Normal mass / increased wall thickness
3.Eccentric hypertrophy
• Systolic dysfunction / depressed EF
LA Volume• Easily measured and reliable in apical
views
• Significant relationship between LA remodeling and diastolic dysfunction
• Consequence of longstanding elevated filling pressures
• LA >34 mL/m2 predictor of death, heart failure, atrial fibrillation, ischemic stroke
LA function
• Reservoir / Conduit / Pump
• Reservoir and conduit functions -- Early filling
• Pump function -- Atrial contribution to LVEDV -- approximately 20%
PA Systolic and Diastolic pressures• Symptomatic patients with diastolic
dysfunction have increased pulmonary artery pressures
• Correlate with elevated LV filling pressures
• PA systolic -- Peak TR jet velocity + RA
• PA diastolic -- End diastolic velocity + RA
Overview• Background of Diastolic Dysfunction
• Diastology
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Mitral Inflow
• Measurement
• Inflow patterns
• Clinical application
• Pulse-wave doppler through mitral inflow:
• Peak E (early diastole)• Peak A (late diastole)
• E/A ratio
• Deceleration time (DT) of Early filling
Measurement
E wave (Early Diastole)
• LA-LV pressure gradient
• Affected by:
• Preload
• LV relaxation
A-Wave (late diastole)
• A Wave
• LA-LV pressure gradient
• Affected by:
• LV compliance
• LA contraction
E wave Deceleration Time (DT)
• Influenced by LV relaxation
• Values greater than 140 ms considered normal
Inflow patterns• Normal
• Impaired LV relaxation
• Normal Atrial pressure
• Pseudonormal filling pattern
• Symptoms
• Restrictive filling
• Symptoms
Normal inflow pattern
Impaired LV relaxation
Pseudonormal LV filling
E/e’ = 17
Restrictive LV filling
Inflow patterns• Increasing Age -- Age related loss
of compliance
• E wave velocity and E/A ratio decrease
• A wave velocity and Deceleration Time (DT) increase
• By age 50 essentially equal E and A waves
Systolic Dysfunction
• Doppler mitral inflow patterns correlate symptoms better than ejection fraction:
• Cardiac filling pressures
• Functional class
• Prognosis -- especially if patterns persist after reduction of preload
Overview• Background of Diastolic Dysfunction
• Diastology
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Pulmonary Venous Flow
• PW doppler of pulmonary venous flow
• Not used as frequently
• Can be difficult to obtain
• Little additional information after use of Tissue Doppler
Pulmonary Venous Flow
• Measurements
• Peak systolic
• Peak anterograde diastolic
• S/D ratio
• Atrial reversal wave duration to A wave duration (mitral inflow)
Overview• Background of Diastolic Dysfunction
• Diastology
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Tissue Doppler• Doppler Pulse Wave imaging
of mitral annular velocity
• Measure
• Lateral and Medial/Septal mitral annulus
• Medial more accurate than lateral or combination score
• Early filling -- e’ wave
• Late filling -- a’ wave
Tissue Doppler
• Mitral inflow E to tissue doppler e’ (LV filling pressure)
• Calculation:
• 81.9 / 8.7 = 9.4
• < 10 normal
Overview• Background of Diastolic Dysfunction
• Diastology
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Diastolic Dysfunction Made
Easy• Measurements
• Mitral inflow patterns
• E and A waves
• E wave DT
• Tissue Doppler of Mitral Annulus (medial)
• E to e’
Diastolic Dysfunction Analysis and Grading
Symptoms from Diastolic
Dysfunction• Symptoms driven by increased atrial pressures
transmitted to pulmonary circulation
• No symptoms likely from diastolic dysfunction:
• Normal Diastolic Dysfunction
• Impaired relaxation (normal atrial pressure)
• Symptoms attributed to Diastolic Dysfunction:
• Pseudonormal / Moderate diastolic dysfunction
• Severe Diastolic Dysfunction
InaccurateDiastolic
Dysfunction• Mitral Valve Disease
• MV replacement
• Severe MR or MS
• Atrial Fibrillation -- no A waves for analysis
• Tachycardias as E and A waves fuse
Objectives• Background of Diastolic Dysfunction
• Characteristics of Diastolic Dysfunction
• Echocardiographic Analysis
• Mitral inflow
• Pulmonary Venous Flow
• Tissue Doppler
• Analysis using Mitral inflow and Tissue Doppler
• Cases
Case # 1
• 57 year old male with presentation to the hospital for shortness of breath and exam consistent with CHF a exacerbation
• Echo for shortness of breath ? heart failure
TTE Apical
Mitral inflow (E wave, A wave, Deceleration Time)
Tissue Doppler
Analysis
• E wave greater than A wave
• DT > 140 ms (190 ms)
• e’ to a’ reversal
• E/e’ = 31.9
• Pseudonormal Filling pattern / Moderate Diastolic Dysfunction
Conclusion• Hypertensive patient with pseudonormal filling pattern
consistent with moderate diastolic dysfunction.
• Shortness of breath likely secondary to
• Moderately reduced compliance
• Impaired relaxation
• Increased atrial pressure transmitted to pulmonary circulation
• Episode driven by hypertensive urgency (medical noncompliance)
Case # 2
• Patient with Cardiac Amyloidosis evaluation of cardiac structure and function
PLAX
Mitral inflow (E and,A waves, Deceleration Time)
Tissue Doppler
• Mitral Inflow E wave greater than A wave
• E wave > 2X A wave (3.1)
• DT =140 ms (Criteria <140)
• e’ to a’ reversal
• E/e’ = 42.9
• Restrictive Filling Pattern
Conclusion
• Cardiac Amyloidosis
• Severe Diastolic Dysfunction
Changes to the Protocol?
• Should we report all diastolic dysfunction -- even normal diastolic dysfunction?
• Can pulmonary venous inflow pulse wave doppler be omitted?
• Can we rely on medial mitral tissue doppler alone?