diastolic dysfunction 2016

ASSESMENT OF DIASTOLIC DYSFUNCTION- NEWER

GUIDELINES (ASE/EACVI 2016)

Presenter- Dr. Abhishek Rathore

Moderator – Prof Dr.B C Srinivas Dr. Yeriswamy M C

INTRODUCTION Diastolic dysfunction is a important cause of

left heart failure and also predicts cardiovascular events.

DD is Present in > 25% of adults >40 yrs of age.

A primary cause of > 50% of heart failure cases.

So, diastolic function assessment should be included in every adult echocardiographic examination.

DEFINITIONS Traditional definition of diastole (in ancient Greek

language the term διαστολε means expansion): includes the part of the cardiac cycle starting at the AoV closure - when LV pressure falls below aortic pressure - and finishing at the mitral valve (MV) closure.

Normal LV diastolic function may be clinically defined as the capacity of the LV to receive a LV filling volume able in its turn to guarantee an adequate stroke volume, operating at a low pressure regimen.

EAE Textbook of Echocardiography 2013

CAUSES OF DIASTOLIC DYSFUNCTIONStructural Abnormalities:

Hypertrophy

Fibrosis

Constriction

Functional Abnormalities:Ischemia

Calcium overload

ATP depletion

FACTORS AFFECTING DIASTOLE Ventricular function AV valve function Rate of relaxation Ventricular compliance Atrial systolic function Preload Heart rate and rhythm

NORMAL DIASTOLIC FUNCTION

Rapid early filling (E wave) - Result of elastic recoil and active relaxation of the chamber.

Also associated with a similar brisk motion of the mitral annulus as the chamber expands to accommodate the inflow of blood. This process quantified using tissue Doppler as the e′.

Diastasis- Little filling occurs in mid diastole, the duration of which is heart rate dependent.

Atrial systole (A wave) – contributes small amount of additional filling.

As blood enters the ventricle through the mitral valve, it propagates rapidly toward the apex - evaluated using color Doppler M-mode, and termed the propagation velocity or Vp.

Normal pulmonary venous flow consists of a systolic and diastolic component followed by a brief reversal of flow during atrial systole .

Finally, normal diastolic function is associated with a normal left atrial volume.

STAGES OF DIASTOLIC DYSFUNCTIONGrade Stage Dominant Pathophysiology1 Impaired relaxation Delayed LV early diastolic active relaxation

Normal LA pressureLow opening LA-LV pressure gradientReduced LV suction force

2 Pseudonormalization Delayed LV early diastolic active relaxationMildly elevated LA pressureLow opening LA-LV pressure gradientReduced LV suction force

3 Restrictive filling (Reversible)

Noncompliant LV chamber (increased stiffness)Diminished LV suction forceHigh opening LA-LV pressure gradientElevated LA pressure (inflow by “pushing” blood)Failing LA contractilityResponds positively to preload reduction

4 Restrictive filling (Irreversible)

Same as Stage 3 No improvement with preload reduction.

Feigenbaum's Echocardiography, 7th edition, 2011.

LV relaxation, filling pressures and 2D and Dopplerfindings according to LV diastolic function

Normal Grade I Grade II Grade IIILV Relaxation N Impaired Impaired ImpairedLAP N Low or N Elevated ElevatedMitral E/A Ratio ≥0.8 ≤ 0.8 >0.8 to <2 >2Average E/e’ ratio

<10 <10 10-14 >14

Peak TR velocity(m/sec)

<2.8 <2.8 >2.8 >2.8

LA volume index

N N or Increased

Increased Increased

ASE/EACVI Guidelines And Standards, J Am Soc Echocardiogr 2016;29:277-314

BASIC DIASTOLIC FUNCTION INDICES

IVRT

Mitral Inflow--- E/A DT

Mitral Annular e’---- E/e’

Pulmonary vein doppler--- Ar-A duration

Propagation Velocity (Vp)

LA size

ISOVOLUMIC RELAXATION TIME

Duration of relaxation prior to MV opening.

When relaxation is prolonged, mitral valve opening is delayed and IVRT is increased.

Conversely, when left atrial pressure is elevated, mitral valve opening will occur earlier and IVRT will be shortened.

It is derived using pulsed Doppler from a modified apical 4C view. Simultaneous visualization of left ventricular inflow and outflow. Sample volume is placed midway between the inflow and outflow areas so that mitral and

aortic flows are captured simultaneously. relatively large sample volume is best. Time from middle of the aortic closure click to the onset of the E wave. fast sweep speed is used and performed at end-expiration. at least three measurements of IVRT should be obtained and averaged.

Furthermore, IVRT increases with age and is sensitive to changes in both heart rate and systolic function.

So, never be used in isolation as a predictor of diastolic function.


MITRAL INFLOW Apical 4C view.

at the tips of the mitral leaflets. Small sample volume, ~2 mm. End-expiration.

E wave and A wave velocity E/A ratio E wave deceleration time A wave duration

Deceleration time is defined as the time interval from early peak inflow velocity (the E wave) to the cessation of the rapid early filling phase. It is inversely proportional to chamber stiffness. N= 140 – 240 ms

MITRAL INFLOW PATTERNS

Factors that affect the mitral inflow pattern include sinus tachycardia and first-degree atrioventricular (AV) block,

which tend to fuse the E and A waves, atrial fibrillation, which eliminates the A wave, and mitral valve disease, which independently alters the velocity

pattern.


COLOR M-MODE FLOW PROPAGATION VELOCITY (VP)

4 C view : M-mode cursor in the center of the column of mitral inflow, as parallel as possible to flow direction.

Slope of the early diastolic valve-to-apex contour is used most often.

Impaired relaxation will slow the propagation of blood and thereby reduce the slope of the line.

N= ≥ 50 cm/sFeigenbaum's Echocardiography, 7th edition, 2011.

factors affect include : ventricular geometry,

chamber volume, regional dyssynchrony, systolic function, and

Assessed in dilated left ventricle with reduced systolic function.

Normal

Diastolic dysfunction

E/Vp Ratio

Correlates with LAP

E/Vp ≥ 2.5 predicts PCWP >15 mm Hg with reasonable accuracy in patients with depressed EFs.

TISSUE DOPPLER MITRAL ANNULAR VELOCITY

4C view, the sample volume is positioned on the annulus, near the insertion site of the mitral valve. Both the septal (medial) and lateral annulus. Sweep speed between 50 and 100 cm/sec. Measurement of ≥ 3 consecutive cycles should be obtained at end-

expiration.

Peak annular velocity in early diastole (e′) - primarily depends on LV relaxation. When diastolic function is abnormal, e′ is relatively independent of

preload. However, when diastolic function is normal, e′ increases with higher

filling pressure.

E/e′ ratio usually measured rather than e´.

e′ should be made from both septal and lateral locations. In most patients, lateral e′ will be higher

than the septal value.

E/e′ ratio is to predict filling pressure in the setting of abnormal diastolic function.

Normal E/e’ = < 10

Limitations – E and e′, are obtained from different cardiac

cycles and at different times. Age, preload, and systolic function can

affect these parameters. prosthetic mitral valves, annular rings, and

significant annular calcification can create technical problems in measuring e′.

PULMONARY VENOUS FLOW PATTERNS Apical 4-C view, recorded at the junction of the veins and left

atrium. Sample volume ~ 5 mm within the vein.

Normal Pattern

Both time velocity integral and peak velocity of each component is measured.

Systolic fraction is defined as the ratio of systolic to the diastolic time velocity integral.

S/D ratio Most commonly reported value is the ratio of the peak antegrade velocities in systole and diastole.

Normally- S ≥ D

Ar– A duration Ar – A < 0 ms ( > 30ms is abnormal)

Duration of the retrograde atrial wave (Ar), increases with increased filling pressure.

Ar – A duration - shown to correlate with LVEDP.

As left atrial pressure rises, Ar duration lengthens and Ar - A difference increases.

most sensitive and earliest indicator of elevated LAP. >30 ms indicates elevated LVEDP and will be present before mean

LAP becomes abnormal. This may be useful in patients with abnormal relaxation to separate

those with normal from those with elevated filling pressures.

Abnormal pulmonary venous flow patterns

Diastolic predominance (D > S)

Absent systolic wave and forward flowoccur exclusively in diastole


S/D ratio Affected by several factors. Young normal subjects have a predominant diastolic wave. With increasing age, the S/D ratio increases. As left atrial compliance decreases and pressure rises, the S/D

ratio decreases and the systolic fraction is usually less than 40%.

Technical challenges in obtaining the recordings, age, heart rate, PR interval, mitral regurgitation, and systolic function.


LEFT ATRIAL VOLUME

An increase in left atrial size is the morphologic expression of chronic diastolic dysfunction. Reflects both duration and severity of disease.

Measured at end-systole, just prior to mitral valve opening.

Approaches to volume calculation : Simpson's Method Area-length method

Normal LA vol index- 16-28ml/m2

Both diagnostic and prognostic value in the assessment of diastolic function.

Mitral annulus is used as inferior border

Exclude pulmonary veins

LA volume should be corrected for BSA (ml/m2 )

VALSALVA MANEUVER

Normal subjects: Reduction in velocity, affecting E and A wave to a similar degree. so E/A ratio is unchanged.

Pseudonormal stage , the Valsalva maneuver will change the pattern to one resembling impaired relaxation. because pseudonormalization causes a moderate increase in filling pressure

superimposed on delayed relaxation. By lowering preload, the delayed relaxation pattern is unmasked.

During Valsalva strain phrase, a decrease in the E/A ratio of >50% is a useful indicator of elevated filling

pressure. In the setting of irreversibly elevated filling pressure (the restrictive filling

pattern), this decrease in E/A may not occur.

Valsalva maneuver in a patient with grade II diastolic dysfunction. At baseline, E/A ratio is 1.3 (left) and decreases to 0.6 (impaired relaxation pattern) with Valsalva.

LESS AGE DEPENDENT PARAMETERS E/e’ ratio

Change in mitral inflow velocities with valsalva

Ar – A duration

IMPAIRED RELAXATION – GRADE I

Initial or earliest abnormality.

loss of elastic recoil of the LV in early diastole.

Prolongation of the isovolumic relaxation time (IVRT).

With the decrease in suction during early diastole, the left atrial to left ventricular (LA-LV) pressure gradient also decreased.

Prolonged DT

Mitral flow velocity during atrial systole is increased. through a combination of increased atrial preload and a more

forceful atrial contraction, a compensatory mechanism.

Pulmonary venous flow and the E/e′ ratio usually are normal, consistent with normal filling pressures at rest.

PSEUDONORMALIZATION – GRADE II

Decrease in chamber compliance (increased stiffness) adds to the continued delay in relaxation.

Transmitral flow is increasingly dependent on maintaining a high left atrial pressure rather than active relaxation.

Increase in mean left atrial pressure has two subsequent effects: First, it contributes to a shortening of IVRT. Second, in contrast to impaired relaxation, the early mitral inflow

velocity is restored back to the normal range, due to larger LA-LV pressure gradient .

Thus, this phase is often referred to pseudonormalization.

Pulmonary venous flow will usually show : diastolic predominance. A very small systolic wave (less than 50% of the diastolic wave) -

suggests elevated filling pressures.

Mitral inflow velocity pattern resembles the normal state due to the combined effects of high filling pressure and impaired relaxation.

RESTRICTIVE FILLING (REVERSIBLE),GRADE III

Left ventricular chamber compliance becomes increasingly abnormal.

To maintain forward flow, left atrial filling pressure must continue to increase. This results in – further shortening of the IVRT and marked increase in the early diastolic mitral inflow velocity.

The rate of deceleration of flow is marked, result of a noncompliant left ventricular chamber leading to a rapid equilibration of the LA-LV pressure gradient early in diastole.

Filling velocity during atrial contraction is also reduced through a combination of elevated left ventricular pressure and failing left atrial

contractility.

Pulmonary venous flow during systole is greatly reduced relative to diastolic flow . prominent flow reversal during atrial systole. retrograde pulmonary venous Awave duration (Ar) is typically longer

than the mitral A-wave duration (Ar - A > 30 ms), indicating high filling pressures.

In some patients, this stage may be reversible. with diuresis (or other forms of preload reduction)

RESTRICTIVE FILLING (IRREVERSIBLE), GRADE IV

In later stages of the restrictive filling stage, the pattern may become irreversible.

No improvement in the filling pattern or the clinical status with preload reduction.

Marked intolerance to volume manipulation.

DIASTOLIC DYSFUNCTION GRADESLV relaxation, filling pressures and 2D and Dopplerfindings according to LV diastolic function

Normal Grade I Grade II Grade IIILV Relaxation N Impaired Impaired ImpairedLAP N Low or N Elevated ElevatedMitral E/A Ratio ≥0.8 ≤ 0.8 >0.8 to <2 >2Average E/e’ ratio

<10 <10 10-14 >14

Peak TR velocity(m/sec)

<2.8 <2.8 >2.8 >2.8

LA volume index

N N or Increased

Increased Increased


POLLING QUESTION Which finding is consistent with normal mean

LAP in patients with LV diastolic dysfunction?

A. E/A ratio = 2 B. LA maximum Vol index= 46ml/m2 C. Pulmonary vein S/D ratio = 0.3 D. Septal E/e’ ratio = 18 E. Peak TR velocity = 2.5m/s

Ans-E

ASE 2009 VS ASE/EACVI 2016 It incorporates a new algorithm that is based on only four

variables to diagnose the presence or absence of diastolic dysfunction, and it also offers a new algorithm to estimate LV filling pressures with fewer variables than the 2009 guidelines.

The society noted that the approach is similar for patients with both depressed and normal ejection fractions.

The grading of diastolic dysfunction is linked to estimation of LV filling pressures, and a single algorithm is used for both, according to ASE.

Primary goal with this update was to simplify the approach and hopefully increase the usefulness of the guidelines in daily practice.”

ALGORITHM FOR DIAGNOSIS OF LV DIASTOLIC DYSFUNCTION IN NORMAL LVEF

ALGORITHM FOR ESTIMATION OF LV FILLING PRESSURES AND GRADING LV DIASTOLIC FUNCTION IN DEPRESSED LVEF AND NORMAL LVEF

ALGORITHM COMPARING CONSTRICTIVE PERICARDITIS AND RESTRICTIVE CARDIOMYOPATHY


CASE 66 year old woman H/o previous MI presents with recurrent

episodes of dyspnea with daily activities. Onset of dyspnea 6 months ago with a

progressive course.

H/o HTN, DM and Dyslipidemia

No H/o pulmonary disease.

MITRAL AND PULMONARY VENOUS FLOW

CASE SUMMARY Clinical data consistant with cardiac disease LVEF depressed E/A ratio > 2 Pulmonary vein S/D ratio < 1 LA enlarged >34ml/m2

ALGORITHM FOR ESTIMATION OF LV FILLING PRESSURES AND GRADING LV DIASTOLIC FUNCTION IN DEPRESSED LVEF AND NORMAL LVEF

DIASTOLIC DYSFUNCTION IN SPECIFIC PATIENT GROUPS Atrial Fibrillation Peak acceleration rate of mitral E velocity (≥1,900 cm/sec2) IVRT (≤ 65 msec) DT of pulmonary venous diastolic velocity (≤ 220 msec) E/Vp ratio (≥ 1.4) Septal E/e’ ratio (≥ 11)

Sinus Tachycardia Mitral inflow pattern with predominant early LV filling in EFs <50% IVRT ≤ 70 msec is specific (79%) Pulmonary vein systolic filling fraction ≤ 40% is specific (88%) Average E/e’ >14 (highest specificity but low sensitivity) When E and A velocities are partially or completely fused, the presence

of a compensatory period after premature beats often leads to separation of E and A velocities which can be used for assessment of diastolic function


DIASTOLIC DYSFUNCTION IN SPECIFIC PATIENT GROUPS CONT… Noncardiac pulmonary hypertension If cardiac etiology is present, lateral E/e’ >13 Noncardiac

etiology, lateral E/e’ is <8

HCM Average E/e’ (>14) Ar-A (≥ 30 msec) TR peak velocity (>2.8 m/sec) LA volume (>34 mL/m2).

RCM DT (<140 msec) Mitral E/A (>2.5) IVRT (<50 msec has high specificity) Average E/e’ (>14)


DIASTOLIC DYSFUNCTION IN SPECIFIC PATIENT GROUPS CONT… Mitral stenosis IVRT (<60 msec has high specificity) IVRT/TE-e’ (<4.2) Mitral A velocity (>1.5 m/sec) MR Ar-A (≥ 30 msec) IVRT (<60 msec has high specificity) IVRT/TE-e’ (<5.6) may be applied for the prediction of

LV filling pressures in patients with MR and normal EFs Average E/e’ (>14) may be considered only in patients

with depressed EFsASE/EACVI Guidelines And Standards, J Am Soc Echocardiogr 2016;29:277-314

DIASTOLIC DYSFUNCTION IN SPECIFIC PATIENT GROUPS CONT… After Heart Transplantation Restrictive filling pattern in patients with preserved EFs. No single diastolic parameter appears reliable enough to predict

graft rejection. PASP estimation using the TR jet can be helpful as a surrogate

measurement of mean LAP in the absence of pulmonary disease.

AV block and Pacing In first degree AV block, the variables used to evaluate diastolic

function and filling pressures likely remain valid as long as there is no fusion of mitral E and A velocities.

Accuracy of mitral annular velocities and E/e’ ratio is less in the presence of LBBB, RV pacing, and in patients who have received CRT.

If only mitral A velocity is present, only TR peak velocity (>2.8 m/sec) can be used as an indicator of LV filling pressures.

POLLING QUESTION Which of the following parameter can be

applied to estimate LV filling pressure in HCM, Aortic stenosis, Atrial fibrillation and Cardiac transplants?

A. Mitral E/A ratio B. LA maximum volume index C.Pulmonary vein S/D ratio D.Peak TR velocity Mitral anuular e’ velocity

Ans- D

DIASTOLIC STRESS TEST Indication: When resting echo does not explain the symptoms of heart failure or

dyspnea, especially with exertion..

It is performed using supine bike or treadmill stress testing.

Helpful to evaluate filling pressures in patients with known diastolic dysfunction with no or mild symptoms.

At rest, mitral E and annular e’ velocities should be recorded, along with the peak velocity of TR jet.

The same parameters are recorded during exercise or 1 to 2 min after termination of exercise when E and A velocities are not merged.

The test is considered positive when all of the following three conditions are met during exercise:

Average E/e’ > 14 or septal E/e’ ratio > 15 Peak TR velocity > 2.8 m/sec and Septal e’ velocity < 7 cm/sec.

PROGNOSIS IN PATIENTS WITH DIASTOLIC DYSFUNCTION Acute myocardial infarction, a mitral deceleration time <140 ms

predicts a poor short- and intermediate-term prognosis.

E/e′ ratio has been studied in a variety of conditions and appears to provide prognostic data.

Mitral inflow pattern - restrictive filling pattern conveys a poor prognosis in heart failure.

Increasing left atrial volume is generally associated with increasing risk.

Abnormal untwisting, or torsion, derived from the speckle tracking technique may prove useful for predicting risk

CONCLUSION Factors that affect diastolic function

parameters should be taken into account.

Diastolic dysfunction parameters should not be used in isolation.

Diastolic dysfunction is an important prognostic tool for future CV outcomes.

Diastolic function assesment should be a routine part of comprehensive adult echocardiographic examination.

The four recommended variables and their abnormal cutoff values are annular e’ velocity (septal e’< 7 cm/sec, lateral e’ < 10 cm/sec), average E/e’ ratio > 14, LA maximum volume index > 34 mL/m2, and peak TR velocity > 2.8 m/sec.

LV diastolic function is normal if more than half of the available variables do not meet the cutoff values for identifying abnormal function. LV diastolic dysfunction is present if more than half of the available parameters meet these cutoff values. The study is inconclusive if half of the parameters do not meet the cutoff values.

diastolic dysfunction 2016

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