How to Assess Diastolic Dysfunction?
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1 How to Assess Diastolic Dysfunction? Fausto J Pinto, MD, PhD, FESC, FACC, FASE Lisbon University
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4 Dyastolic Dysfunction Impaired relaxation Elevated filling pressures Ischemic heart disease Cardiomyopathies Systemic disease Hypertension Valvular heart disease
5 Extracellular matrix and cardiomyocytes determine myocardial stiffness and interact via matricellular proteins. Borlaug B A, Paulus W J Eur Heart J 2010;eurheartj.ehq426
6 How to Assess Diastolic Function and LV filling pressures M-Mode (b bump) 2D Echo Doppler MV flow Pulmonary venous flow Color M Mode Altered loading conditions Tissue Doppler imaging
7 Diastolic Filling
8 How to assess diastolic function: What to Measure?
9 MV velocities and time intervals
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11 Filling Patterns
12 PW Doppler of mitral inflow velocities from predominant relaxation abnormality (left), normal or pseudonormal (center), and restrictive (right) filling patterns Oh, J. K. et al. J Am Coll Cardiol 2006;47:
13 Prognostic value of mitral inflow restrictive pattern Bruch, C. et al. J Am Coll Cardiol 2005;45:
14 Limitations Heart rate PR interval Arrhythmias AV conduction abnl Technical problems in recording
15 Influence of heart rate
16 Where to put the sample?
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18 Load dependence of the LV filling pattern. (A) Restrictive filling associated with increased preload in a patient with renal failure. (B) Following dialysis, removal of intravascular volume has reduced LV filling pressure and unmasked the underlying impaired relaxation pattern. The presence of "reversibility" of the restrictive filling pattern indicates less severe LV stiffening and is associated with a better prognosis. Mottram, P. M et al. Heart 2005;91:
19 MV flow dependent factors Rate and extent of ventricular relaxation Suction Atrial and ventricular compliance Mitral valve inertance LA pressure
20 Diastolic function curve Garcia et al. JACC 1998
21 Pseudonormalization pattern Dilated cardiomyopathy LAP 32 mm Hg Tau 68 ms Nishimura, Tajik JACC 1997;30:8
22 Valsalva Maneuver Change in E/A ratio with a reduction >0.5
23 Pulmonary Venous flow Velocities Oh J et al. Jam Soc Echocardiogr 1997;10:246
24 Normal Pseudonormal
25 Relaxation/Compliance abnl
26 Impact of Age
27 Color M Mode Flow propagation
28 Color M Mode Flow propagation
29 Longitudinal velocity Systole Diastole IVC Peak Systole Diastasis IVR E Diastolic Filling Phase A IVC IVR Isovolumic contraction time Isovumic relaxation time
30 Normal vs pseudonormal patterns
31 Restriction vs Constriction
32 Restriction vs Constriction Ha JW et al. Am J Cardiol 2004;94:316
33 Estimation of LV filling pressures Ommen SR et al Circulation 2000;102:1788
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35 Estimation of LV filling pressures How to do it practically? E/E <8 Normal E/E > 15 Elevated 15<E/E >8 look at Pva 30 ms longer than Mva E/A reduction >0.5 with Valsalva LA size (LAV index>26 mm 2 )
36 Assessing Filling Pressure Post-AMI Hillis GS JACC 2004
37 Assessing Filling Pressure Post-AMI Hillis GS JACC 2004
38 Assessing Filling Pressure Post-AMI Hillis GS JACC 2004
39 Hemodynamic and Doppler traces of a patient with normal left ventricular diastolic pressure (LVDP) at rest (A) and an increase in LVDP with exercise (B) Burgess, M. I. et al. J Am Coll Cardiol 2006;47:
40 (A) Changes in the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/E') between rest and exercise in patients with normal mean left ventricular diastolic pressure (LVDP) at both rest and exercise Burgess, M. I. et al. J Am Coll Cardiol 2006;47:
41 Relation between mitral E/Ea ratio and PCWP at baseline (top) and relation between changes (baseline to follow-up) in mitral E/Ea ratio and changes (baseline to follow-up) in PCWP (bottom) Mullens, W. et al. Circulation 2009;119:62-70
42 Limitations of e/e Tachycardia Hyperventilation Fusion of early and late trans mitral velocities Acute decompensated systolic heart failure (HFrEF)
43 Relationships between severity of diastolic dysfunction (DD) (left) and left atrial (LA) volume index (right) and survival Pritchett, A. M. et al. J Am Coll Cardiol 2005;45:87-92
44 LA volume and diastolic dysfunction Pritchett, A. M. et al. J Am Coll Cardiol 2005;45:87-92
45 Predictors of all cause mortality Pritchett, A. M. et al. J Am Coll Cardiol 2005;45:87-92
46
47 Diagnostic flowchart on How to diagnose HFNEF' in a patient suspected of HFNEF Paulus, W. J. et al. Eur Heart J 2007
48 Assessing Diastolic Function Extensive study (no magic numbers...) Evaluate relaxation/filling pressures Determine etiology/staging/prognosis Evaluate therapy
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