1. Diastolic Dysfunction

2. Normal diastolic function : Adequate ventricular filling without abnormal elevation in diastolic pressures. Ensures normal stroke volume based on Frank Starling mechanism. Diastole IVRT EFPAFP 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

3. 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

4. Pulmonary vein flow L Atrial relaxation RV systole EFP L Atrial contraction 1- PS1 not seen in 70% cases. 2- AF PVS1 lost and PVS2 always smaller than PD 3- Peak velocity and duration of PVar increase with increased EDP

5. 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.

6. 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 DT PVF : a) Predominant PVs flow with blunting of PVd velocity. b) PVar remains normal or slightly faster. c) A-Pvar >1

7. Increased A wave Increased LVEDP base on increased A component Normal mean LA pressure. Ma < PVar Transition

8. Abnormal diastolic function Pseudo-normalization DT 200 ms E/A >1 DT 200 ms E/A >1 PVs > PVd Ma > PVar PVs < PVd Ma < 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.

10. Abnormal diastolic function Restrictive Pattern Results from marked increase in LA Pressure/ Decreased LV compliance/ Relaxation abnormality. MVI 1- Increased E velocity 2- Short DT (< 160 ms ) & IVRT (< 60 ms) 2- E/A ratio > 2. Decreasing with Valsalva PVF 1- Decresed PVs with increased PVd 2- Longer/faster Pvar 3- Ma << Pvar 4- Increased PVar velocity (>0.35 m/s)

11. Abnormal diastolic function Restrictive Pattern Cont… Tachycardia can mask PVF reversal due to occurrence of Atrial contraction during forward pulmonary vein flow (mid diast)

12. 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 200 >100 > 1 >50% <35 <20 None NL Relaxation) Abnormal Imp. NL or NL Inc. 200 >100 >1 >50% >35 and/or >20 None or at NL Relaxation. mildly exercise Likely elev. Imp. LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exercise Normalized 200 100 Pattern) Severe (Restrictive) Imp Imp Very Very >2 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 200 >100 > 1 >50% <35 <20 None NL Relaxation) Abnormal Imp. NL or NL Inc. 200 >100 >1 >50% >35 and/or >20 None or at NL Relaxation. mildly exercise Likely elev. Imp. LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exercise Normalized 200 100 Pattern) Severe (Restrictive) Imp Imp Very Very >2 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 200 >100 > 1 >50% <35 <20 None NL Relaxation) Abnormal Imp. NL or NL Inc. 200 >100 >1 >50% >35 and/or >20 None or at NL Relaxation. mildly exercise Likely elev. Imp. LVEDP) Moderate Imp. Imp. Inc Inc 1-2 150 60 0.5-1 ~50% >35 >20 Rest or Inc. (Pseudo- to to exercise Normalized 200 100 Pattern) Severe (Restrictive) Imp Imp Very Very >2 35 >20 Rest or L Inc. Inc. excersice

13. 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)

14. Not all is black and white in diastolic dysfunction Severe LVH Early diastolic Restrictive physiology

15. Short PR Tachycardia

16. Advanced Amiloidosis

18. HOCM