Presentation is loading. Please wait.

Presentation is loading. Please wait.

Ventricular Diastolic Filling and Function

Similar presentations


Presentation on theme: "Ventricular Diastolic Filling and Function"— Presentation transcript:

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?


Download ppt "Ventricular Diastolic Filling and Function"

Similar presentations


Ads by Google