echocardiographic evaluation of left ventricular diastolic function toufiqur rahman nicvd
TRANSCRIPT
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ECHOCARDIOGRAPHIC EVALUATION of LEFT VENTRICULAR DIASTOLIC FUNCTION
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of CardiologyNational Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi [email protected]
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One decade and a half back, diastole of the heart thought
to be wholly passive. Though it occupies the greater part
of cardiac cycle. We thought that this period is meant for
the passive filling of the ventricle and subsequent systole
does the job of left ventricular function. In the course of
different observations there was a puzzle in that, there was
good contraction but yet there is feature of ‘heart failure’.
We have now solved the puzzle and identify that functions
of the left ventricle depend on either systolic or diastolic-
sometimes on both.
INTRODUCTION
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Assessment of Diastolic Ventricular Function
Defining diastole
Methods to assess diastole
Patterns of diastolic disease
Age-related changes
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When does diastole occur?Required for every heart beat
Systole
Diastole
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Isovolumic relaxation Early rapid filling Diastasis ( slow diastolic filling phase) Atrial contraction
4 Phases of diastole
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Phases of Diastole
Isovolumetric relaxation
Rapid filling◦ E-wave
2/3 LV filling Diastasis
Atrial contraction◦ A-wave
1/3 LV filling
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Factors Affecting Diastole Ventricular function AV valve function Rate of relaxation Ventricular compliance Atrial systolic function Preload Heart rate and rhythm
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Ventricles receive blood at a regular fashion in diastole which encompasses the isovolumic relaxation and filling phases of the cardiac cycle and has active and passive components.
Diastolic function of the heart:
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Active myocardial relaxation -mediated by intracellular calcium and ATP Passive Pressure-Volume relationship of left
ventricle -Elastic nature of the myocardium -Chamber size and shape -Wall thickness -Right & left ventricular pressure-volume
interaction -Intrathoracic pressure -Pericardial restraint - Incomplete active myocardial relaxation Left atrial function
DETERMINANTS OF DIASTOLIC FUNCTION
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It implies impaired filling of ventricle at its usual low filling pressure
Ventricular filling is slow, delayed or incomplete, with a normal atrial pressure
DIASTOLIC DYSFUNCTION
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a) Impaired Relaxation Myocardial infarction
b)Decreased compliance of LV Restrictive cardiomyopathy Endomyocardial fibrosis Elderly people, particularly ladies Diabetes mellitus
Aetiology of diastolic dysfunction
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c) Both compliance and relaxation abnormality
Hypertensive heart disease Hypertrophic obstructive cardiomyopathy IHD Aortic valvular disease
d)Co-existent with systolic dysfunction
IHD Cardiomyopathy
Aetiology of diastolic dysfunction
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a) Clinical parameters:Features of underlying aetiologyAbsence of other causes of dyspnoeaFeatures of LV dysfunction
b) ECG: LVH, LA enlargement, IHD
c) CXR: Normal heart size
Assessment Of LV diastolic dysfunction
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c) Doppler Echocardiographic Evaluation
Mitral valve inflow pattern Pulmonary venous flow pattern Mitral inflow at peak valsalva maneuver Colour M-mode ( CMM) –propagation study Doppler tissue imaging (DTI) of the mitral
annulus
d) Cardiac catheterization
e) Radionuclide techniques
Assessment Of LV diastolic dysfunction
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LV filling patterns are assessed using pulsed wave Doppler mitral flow velocity recordings.
4 useful variables are- E-peak early diastolic transmitral flow velocity A-peak late diastolic transmitral flow velocity DT-early filling decelerayion time A dur-A wave duration
MITRAL VALVE INFLOW PATTERN
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Peak E wave velocity: 53-105 cm/sec Peak A wave velocity: 26-70 cm/sec E/A ratio: >0.75 & < 1.5 DT: 160-220 m sec
NORMAL MITRAL INFLOW PATTERN
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MITRAL INFLOW IN STAGE I – DIASTOLIC DYSFUNCTION
( ABNORMAL RELAXATION)E/A ratio: ≤ 0.75DT > 240 m sec
MITRAL INFLOW IN STAGE I I– DIASTOLIC DYSFUNCTION (PSEUDONORMALIZATION)
E/A ratio: > 0.75, < 1.5 DT : > 140 m sec
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MITRAL INFLOW IN STAGE III– DASTOLIC DYSFUNCTION(REVERSIBLE RESTRICTIVE)
E/A ratio : > 1.5 DT : < 140 m sec
MITRAL INFLOW IN STAGE IV– DASTOLIC DYSFUNCTION(FIXED RESTRICTIVE)
E/A ratio : > 1.5 DT : < 140 m sec
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EVALUATION OF DIASTOLIC DYSFUNCTION
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In pseudo normal ( stage II ) LV diastolic dysfunction Valsalva strain unmasks underlying impaired LV relaxation and causes E/A ratio < 1
Stage III pattern at Valsalva maneuver may turn into stage II or even Stage I pattern. But if unchanged, it indicates fixed restrictive abnormality .
MITRAL INFLOW AT PEAK VALSALVA MANEUVER
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Mitral Inflow
Apical 4-chamber view
Align Doppler beam to be parallel to mitral inflow
Pulsed-wave sampling at tips of MV leaflets◦ Decreased velocity if
sampled within LA
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Pulsed-wave Mitral Valve Inflow
Peak E and A velocities, ratio E/A Mitral A-wave duration (to compare with PV AR
duration) Mitral deceleration time(from peak of E-wave to base) Mitral Doppler VTI (and valve area)
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Mitral Valve Doppler Evaluation
In a 5 chamber view◦ Continuous-wave
across tips of MV through LVOT
◦ Obtain mitral inflow & LV outflow
◦ Measure Isovolumetric Relaxation Time (IVRT)
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Tissue Doppler Measures displacement of myocardium
while avoiding blood flow detection throughout the cardiac cycle
For our purposes:◦ Mitral valve annular junction◦ Septal annular junction◦ Tricuspid annular junction
Mitral and tricuspid data is relatively volume load independent, including respiratory cycle
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TDI Methodology
Using Doppler pulsed cursor, 3-5 mm
Set Nyquist limits to 15-30 cm/s
Using lowest wall filter
Set dynamic range to 30-35db
Sweep speed of 100-150 mm/s
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TDI Pulsed-wave
Ea ( or E´), Aa ( or A´), Sa ( or S´) waves IVRT and Isovolumetric Contraction Time
(IVCT) Important to maintain a parallel line of
annular motion with the imaging beam
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Color M-mode Flow Propagation
Estimate of ventricular filling to correlate with LV relaxation, even at increased LA pressures
Not affected by preload Varies with changes of lusitropic conditions Correlates in ischemic heart disease
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Color M-mode Flow Propagation
In apical 4 chamber view
Align M-mode cursor through LV apex and orifice of MV
Apply Color Doppler Switch to M-mode
acquisition Decrease Nyquist
limit until color inflow shows line of aliasing
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Color M-mode Flow Propagation
Demonstrated by Garcia et al., JACC 1999, that in both dogs with occluded IVC and in adults undergoing CABG, under partial CPB, measures were not affected◦ Although, MV E waves and associated measures were impacted by
each scenario◦ In dogs, under various doses of dobutamine and esmolol, there
were expected changes of Vp correlating to measured changes of LVEDp
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Calculations using Vp
Border et al, JASE 2003 20 pts age 6.6yrs ± 6yrs Indicated L heart cath w/o MV
stenosis/arrhythmia Found E/ Vp > 2.0,
◦ LVEDp >15mmHg◦ Sensitivity 100%◦ Specificity 77%◦ PPV: 70%◦ NPV: 100%
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Calculations using Vp(FPV)
Gonzalez-Vilchez, JACC 1999 Adults in ICU w Swan’s 20 test, 34 study patients Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-9 Simplified to:
◦ 103/[2•IVRT]+FPV◦ Value ≥5.5, correlates to PCWP > 15mmHg (r=0.89)
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Calculations using Vp
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Use of TDI and Color M-mode in Infants
Study by Larrazet et al, Pediatric Critical Care Medicine, 2005
Studied infants 3-8 months of age, immediately post-operatively for VSD/AVCD repair w LA line in place
For LA pressure > 10mmHg◦ E/Ea > 15 – Sensitivity 94%, Specificity 72%◦ E/Vp >2.0 – Sensitivity 83%, Specificity 89%
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Place Apical 4 w PW in Distal PV
Pulmonary Venous Inflow
Apical 4-chamber view
Identify RUPV or LUPV inflow parallel to beam
Pulsed-wave sampling ◦ 1-2 cm distal to
orifice Alternatives views:
◦ Parasternal◦ Suprasternal◦ Subcostals
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Pulsed-wave Pulmonary Vein Inflow
Identify peak S and D velocities Measure atrial reversal (AR) duration
◦ AR presence is variable. It is indicative of abnormal elevated LA pressure in a neonate, but may be normal in a child with more compliant pulmonary veins. The duration of flow reversal is more helpful in relation to atrial systole
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Note: S-wave may be biphasic owing to differences of atrial relaxation and mitral valve annular displacement
Should take the highest of the peaks
Pulsed-wave Pulmonary Vein Inflow
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It is an additional source of information to evaluate diastolic dysfunction.
Obtained by 3 to 4 mm pulsed Doppler sample volume in the right paraseptal vein from the apical 4-chamber view.
4 useful variables are of pulmonary venous flow-
S wave: Peak systolic PV flow velocity (normal value- 40 to 90 cm/sec)
D wave: Peak diastolic PV flow velocity (normal value- 30 to 70 cm/sec; S/D ratio: > 1)
AR velocity: Peak PV atrial reversal flow velocity (normal- < 25 cm/sec)
AR dur: AR duration ( normal- A dur/AR dur >1 )
PULMONARY VENOUS FLOW PATTERN
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Peak systolic ( S ) and diastolic PV flow velocity waves do not add any incremental value in assessment of the diastolic dysfunction as they are also volume dependent and follow a parabolic pattern.
AR dur > A dur + 30 m sec and AR value> 35 cm/sec is associated with moderate and severe diastolic dysfunction.
PULMONARY VENOUS FLOW PATTERN
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EVALUATION OF DIASTOLIC DYSFUNCTION
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A recent work in NICVD, Dhaka, on diastolic dysfunction (MD thesis, 2003) showed a negative correlation of Doppler estimated left atrial pressure wave transit time ( A- Ar interval) with left ventricular passive elasticity and end diastolic pressure.
Sample volume of pulsed Doppler is placed at about 1 cm distal to aortic valve in LV outflow tract to detect A-Ar interval
Normal value of A-Ar interval is 25 to 80 m sec. Shorter the interval, more likely to have severe LV diastolic dysfunction.
OTHER DOPPLER PARAMETERS
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EVALUATION BY A-Ar INTERVAL
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Left ventricular end diastolic pressure ( LVEDP ) & Pulmonary capillary wedge pressure are two important determinants of LV diastolic dysfunction.
CARDIAC CATHETERISATION
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LA Volume
In adults, atrial dilation has correlated as a risk for first CV event (a-fib, stroke, CHF)
Defined as: women ≥ 30cm2/m2, men ≥ 33cm2/m2 Not routinely measured in children, but recent norms established
8/3π[(A1)(A2)/(L)] obtained from Apical 2 & 4 chamber views
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LA Volume in Children Data collected by 3D Echo and separated by
BSA◦ 0.5-0.75m2 : 19.6 mL/m2 ◦ 0.75-1.0m2 : 21.7 mL/m2 ◦ 1.0-1.25m2 : 22.0 mL/m2 ◦ 1.25-1.5m2 : 24.5 mL/m2 ◦ >1.5m2 : 27.4 mL/m2
No normative values for RA established in kids
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Tricuspid and Right Heart Evaluation
Usual measures performed on MV, are influenced by variable preload through the respiratory cycle.
With inspiration amongst children◦ Peak E may increase by 26%◦ Peak A may increase by 20%
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Tricuspid and Right Heart Evaluation
SVC inflow invariably does not have AR amongst healthy children
AR-wave usually seen with:◦ Right atrial hypertension◦ Tricuspid stenosis
Reversal with ventricular systole◦ Significant tricuspid regurgitation◦ Loss of AV-synchrony◦ Restrictive physiology
Decreased flow of systemic veins or TV inflow with Exhalation seen with Tamponade◦ MV E-wave decreases by >25% during onset of
INhalation
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Tricuspid and Right Heart Evaluation
In a restrictive, non-compliant RV, which acts essentially as a conduit for the PA◦ Forward flow may be seen in PA with atrial systole◦ Only in settings with low PVR or absence of distal
stenoses◦ May be seen in those with history of Tetralogy or
Pulmonary valve abnormalities
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Classification of Diastolic Dysfunction
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Classification of Diastolic Dysfunction
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Abnormal LV Relaxation The ability of the LV myocardial filaments to
actively uncouple after systole, is delayed
Ventricular compliance is unaffected
IVRT is prolonged, as time needed to decrease LV pressure < LA pressure is extended
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Abnormal LV Relaxation
LA-LV pressure difference in early diastole narrowed – max E-wave velocity decreased
LV relaxation is slower, so E-wave is prolonged
A-wave increased as a compensatory to complete LV filling
Insert fig 8.14
Insert fig 8.15
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Abnormal LV Relaxation
Infamous “L-wave” seen in MV inflow pattern◦ Described by Keren in 1986◦ Presence of LA-LV pressure gradient in diastasis◦ Occurs with MARKEDLY delayed LV relaxation
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Abnormal LV Relaxation … and LA Hypertension
Also called “Pseudonormalization” Result of worsened ventricular compliance
with transmitted increase of atrial pressure Ultimately, relative pressure difference
between LA-LV is similar to normal, just at higher pressure
Pulmonary vein inflow pattern helpful to distinguish this from normal
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Abnormal LV Relaxation … and LA Hypertension
TDI has been shown to be relatively independent of preload◦ Abali et al, JASE 2005, studied 100+ adult males
after 500mL blood donation, found no differences in TDI measures or Color M-mode, Vp
◦ Eidem et al, JASE 2005, found that children with chronic LV preload (VSD’s) and preserved systolic and diastolic function, did not have changes in TDI Those with chronic afterload (AS) demonstrated
decreases of TDI measures
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Abnormal LV Relaxation … and LA Hypertension
Nagueh et al, JACC 1997 125 adults, 60 cathed for PCWP, separated
Normal from Impaired Relaxation from Pseudnormalized (EF low in this group)
Found E/Ea >10 correlated to PCWP of >12mmHg◦ Sensitivity 91%, Specificity 81%
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TDI in Pseudonormalization
Nagueh et al, JACC 1997, 30; 1527-33
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Color M-mode in Pseudonormalization
Helpful to differentiate normal MV inflow patterns from ‘pseudonormalization’
Decreased rate of flow propagation (Vp) correlate with delayed relaxation, even with elevated LA pressure
Measures are preload independent Measure of MV peak E velocity to rate of
flow propagation, E/ Vp > 2.0 predicts LVEDp >15mmHg (sensitivity 100%, specificity 77%)
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Restrictive Physiology/Decreased Ventricular Compliance
Ventricle is significantly stiff, non-compliant, that with small increases of volume, pressures increase disproportionately
On MV inflow, the E-wave is accelerated with short deceleration time due to rapid rise of ventricular pressure and the end of inflow
A-wave is remarkably small, if not absent all together, as atrial systole minimally generates a pressure gradient across the AV valve◦ Instead prolonged reflux in PV observed
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Restrictive Physiology/Decreased Ventricular Compliance
IVRT shortened due to atrial hypertension with early opening of MV and ventricular filling
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Measures through childhood
Infants◦ Very limited early diastolic flow◦ Significant contribution from atrial systole◦ Limited tolerance to changes in preload◦ Improved compliance around 2 months
Childhood◦ Limited variability of measures (Inflow/TDI)
through childhood and adolescence◦ Noted changes with increasing IVRT likely
associated with age-related decreased HR
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Tables of normative values for children are available
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Tables of normative values for children are available
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Doppler Echocardiography has emerged as a highly versatile tool for evaluation of diastolic function.
Anatomic and functional evaluation of heart along with interrogation of mitral valve inflow & PV flow parameters may accurately disclose LV diastolic dysfunction.
Valsalva maneuver, CMM & DTI are useful adjuncts for complete evaluation of diastolic dysfunction.
CONCLUSION
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Thank [email protected]
Asia Pacific Congress of Hypertension, 2014, February
Cebu city, Phillipines
Seminar on Management of Hypertension, Gulshan, Dhaka