Ventricular Diastolic Filling and

Function

Stephen L. Rennyson M.D.Echocardiography Conference

August 25, 2010

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

Diastole• Diastole

• Isovolumic relaxation

• Early filling (E)

• Diastasis

• Late filling - atrial contraction (A)

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)

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

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

• Myocardial Disease

• Dilated Cardiomyopathy

• Restrictive Cardiomyopathy

• Hypertrophic Cardiomyopahty

• Secondary Ventricular Hypertrophy

• Hypertension

• AS

• CAD -- Ischemia and infarction

• Pericardial disease

Etiology

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

Characteristics of Diastolic

Dysfunction• LV hypertrophy

• LA Volume

• LA function

• PA systolic and diastolic pressures

LV hypertrophy• Majority of those with diastolic

dysfunction:

1.Concentric hypertrophy (hypertensive heart disease)

• Increased mass and wall thickness

2.Remodeling

• Normal mass / increased wall thickness

3.Eccentric hypertrophy

• Systolic dysfunction / depressed EF

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

LA function

• Reservoir / Conduit / Pump

• Reservoir and conduit functions -- Early filling

• Pump function -- Atrial contribution to LVEDV -- approximately 20%

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

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

Mitral Inflow

• Measurement

• Inflow patterns

• Clinical application

• Pulse-wave doppler through mitral inflow:

• Peak E (early diastole)• Peak A (late diastole)

• E/A ratio

• Deceleration time (DT) of Early filling

Measurement

E wave (Early Diastole)

• LA-LV pressure gradient

• Affected by:

• Preload

• LV relaxation

A-Wave (late diastole)

• A Wave

• LA-LV pressure gradient

• Affected by:

• LV compliance

• LA contraction

E wave Deceleration Time (DT)

• Influenced by LV relaxation

• Values greater than 140 ms considered normal

Inflow patterns• Normal

• Impaired LV relaxation

• Normal Atrial pressure

• Pseudonormal filling pattern

• Symptoms

• Restrictive filling

• Symptoms

Normal inflow pattern

Impaired LV relaxation

Pseudonormal LV filling

E/e’ = 17

Restrictive LV filling

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

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

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

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

Pulmonary Venous Flow

• Measurements

• Peak systolic

• Peak anterograde diastolic

• S/D ratio

• Atrial reversal wave duration to A wave duration (mitral inflow)

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

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

Tissue Doppler

• Mitral inflow E to tissue doppler e’ (LV filling pressure)

• Calculation:

• 81.9 / 8.7 = 9.4

• < 10 normal

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

Diastolic Dysfunction Made

Easy• Measurements

• Mitral inflow patterns

• E and A waves

• E wave DT

• Tissue Doppler of Mitral Annulus (medial)

• E to e’

Diastolic Dysfunction Analysis and Grading

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

InaccurateDiastolic

Dysfunction• Mitral Valve Disease

• MV replacement

• Severe MR or MS

• Atrial Fibrillation -- no A waves for analysis

• Tachycardias as E and A waves fuse

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

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

TTE Apical

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

Tissue Doppler

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

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)

Case # 2

• Patient with Cardiac Amyloidosis evaluation of cardiac structure and function

PLAX

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

Tissue Doppler

• 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

Conclusion

• Cardiac Amyloidosis

• Severe Diastolic Dysfunction

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?