1. Ventricular Diastolic Filling and Function
Stephen L. Rennyson M.D.
Echocardiography Conference
August 25, 2010

2. 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

3. Diastole Diastole Isovolumic relaxation Early filling (E) Diastasis
Late filling - atrial contraction (A)

4. 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)

5. 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

6. 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

7. Etiology Myocardial Disease Dilated Cardiomyopathy
Restrictive Cardiomyopathy
Hypertrophic Cardiomyopahty
Secondary Ventricular Hypertrophy
Hypertension AS
CAD -- Ischemia and infarction
Pericardial disease

8. 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

9. Characteristics of Diastolic Dysfunction
LV hypertrophy
LA Volume
LA function
PA systolic and diastolic pressures

10. LV hypertrophy Majority of those with diastolic dysfunction:
Concentric hypertrophy (hypertensive heart disease)
Increased mass and wall thickness
Remodeling
Normal mass / increased wall thickness
Eccentric hypertrophy
Systolic dysfunction / depressed EF

11. 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

12. LA function Reservoir / Conduit / Pump
Reservoir and conduit functions -- Early filling
Pump function -- Atrial contribution to LVEDV -- approximately 20%

13. 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

14. 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

15. Mitral Inflow
Measurement
Inflow patterns
Clinical application

16. Measurement Pulse-wave doppler through mitral inflow:
Peak E (early diastole)
Peak A (late diastole)
E/A ratio
Deceleration time (DT) of Early filling

17. E wave (Early Diastole)
LA-LV pressure gradient
Affected by:
Preload
LV relaxation

18. A-Wave (late diastole)
LA-LV pressure gradient
Affected by:
LV compliance
LA contraction

19. E wave Deceleration Time (DT)
Influenced by LV relaxation
Values greater than ms considered normal

20. Inflow patterns Normal Impaired LV relaxation Normal Atrial pressure
Pseudonormal filling pattern
Symptoms
Restrictive filling

21. Normal inflow pattern

22. Impaired LV relaxation

23. Pseudonormal LV filling
E/e’ = 17

24. Restrictive LV filling

25. 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

26. 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

27. 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

28. 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

29. Pulmonary Venous Flow Measurements Peak systolic
Peak anterograde diastolic
S/D ratio
Atrial reversal wave duration to A wave duration (mitral inflow)

30. 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

31. 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

32. Tissue Doppler
Mitral inflow E to tissue doppler e’ (LV filling pressure)
Calculation:
81.9 / 8.7 = 9.4
< 10 normal

33. 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

34. Diastolic Dysfunction Made Easy
Measurements
Mitral inflow patterns
E and A waves
E wave DT
Tissue Doppler of Mitral Annulus (medial)
E to e’

35. Diastolic Dysfunction Analysis and Grading

36. 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

37. Inaccurate Diastolic Dysfunction
Mitral Valve Disease
MV replacement
Severe MR or MS
Atrial Fibrillation -- no A waves for analysis
Tachycardias as E and A waves fuse

38. 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

39. 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

40. TTE Apical

41. Mitral inflow (E wave, A wave, Deceleration Time)

42. Tissue Doppler

43. 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

44. 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)

45. Case # 2
Patient with Cardiac Amyloidosis evaluation of cardiac structure and function

46. PLAX

47. Mitral inflow (E and,A waves, Deceleration Time)

48. Tissue Doppler

49. 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

50. Conclusion
Cardiac Amyloidosis
Severe Diastolic Dysfunction

51. 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?