Echo-Doppler evaluation of left ventricular diastolic function. Michel Slama Amiens France
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1 Echo-Doppler evaluation of left ventricular diastolic function Michel Slama Amiens France
2 Left ventricular pressure Pressure A wave [ LVEDP LVEDP préa
3 Congestive cardiac failure with preserved systolic function 50% of patients with congestive heart failure Increased prevalence with - Age - Hypertension
4 Pathophysiology Pressure Normal Diastolic dysfunction Normal Volume
5 MC OC AO MO AO LV LA Systole Contraction IVRT RR Relaxation Filling SR AC
6 Diastolic cardiac dysfunction Impaired LV relaxation Impaired LV compliance - Hypertrophy - infiltration - Collagen
7 Tools Mitral flow Pulmonary venous flow Vp : left ventricular inflow propagation velocity using M-mode color Doppler imaging Ea : annulus displacement analysed using doppler tissue imaging (DTI)
8 I Mitral Flow
9 Early filling LAP LVP Vitesses Velocies Late filling
10 Mitral flow : how to record? Pulsed Doppler Correct Alignement Small window At the tip of mitral valve Visible opening sound Settings et filters 100 mm/s Average of 3 measurements
11 Mitral Flow : which measurement? E A IVRT DTE Am
12 Mitral Flow : normal values (Appleton et al, J Am Coll Cardiol 1988 ; 12 : ) - Isovolumic relaxation time avant 40 ans : 69 ± 12ms après 40 ans : 76 ± 13ms - Maximal velocity of E : 86 ± 13 cm/s - Maximal velocity of A : 56 ± 13 cm/s - E/A : 1.6 ± Deceleration time of E : 199 ± 32 ms Normales: E/A = 1-2 TDE = ms TRIV = ms
13 Factors influencing mitral flow - Age - Heart rate - LV relaxation+++ - LV compliance+++ - Load conditions+++ - Mitral regurgitation or stenosis
14 Mitral flow and age Young subject E, A, E/A TDE E/A < 1 in 85% of subjects > 70 ans ( Sagie et al. JASE 1993) Middle age subject E A Aged subject
15 Heart Rate
16 Decreased preload BASE TNT SOHN, JACC 1997
17 Mitral Flow Effect of preload modification Basal Fluid challenge Flux mitral Mitral flow
18 LVDP
19 Correlation DTE and LVEDP (Yamamoto et al. JACC 1997;30: ) EF < 50% : r = - 0,85 EF > 50% : r = - 0,15 DTE 150 ms et LV dysfunction : PTDVG mmhg
20 Type I of Appleton relaxation impairement Early diastole LAP LVP LAP Velocities Vitesses Late diastole
21 HCM with normal EF
22 Flux Mitral Type II de Appleton Early diastole LAP LVP Vitesses Velocities Remplissage Late tardif diastole
23 Compliance impairement (restrictive profile) Anterior infarction - FE = 30% E/A = 2 ; DTE = 100 ms SPAP = 80 mmhg
24 Ejection fraction = 30% Patient A Patient B
25 Heart Rate Age Preload
26 II Pulmonary venous flow
27 Pulmonary venous flow : how to record? VG OG TTE: RSPV 4C apical view Small window 1-2cm into PV minimum settings minimum filters 100mm/s faisability by TTE: - S et D : 70 à 95% - Ap : 40 à 90% reproductibility Ap (Yamamoto 97) 10 8ms (inter) TEE: LSPV
28 Pulmonary venous flow : how to record?
29
30 Pulmonary veinous flow : what to mesure? S S2 D S1 Ap A Am
31 Normal values for pulmonary venous flow S : 65 ± 15 cm/s Normal values : S/D > 1 Ap < 35 cm/s durée Ap Am FS > 55% D : 45 ± 14 cm/s A : -18 ± 7 cm/s Duration A : 140 ± 35 ms (60 à 230 ms) < duration A (mitral) Systolic fraction : VTIS VTI S + VTI D = 66 ± 10%
32 Effect of age on pulmonary venous flow E Young : E A E/A DTE Aged : E A E/A DTE E A A E/A < 1 in 85% of > 70 ans ( Sagie et al. JASE 1993) S/D <1 S/D > 1 S D S D
33 LV diastolic pressure and systolic fraction ETT (Rossvoll JACC 1993) ETO (Kuecherer Circulation 1990) r = - 0,70 r = - 0,88 30 PCP (mmhg) PDVG pré A (mmhg) Fraction systolique (%) SF< 40% Fraction systolique (%) LVDP préa> 15mmHg SF < 55% PWP 15 mmhg
34 Corrélation Ap - Am et LVEDP (Yamamoto et al. JACC 1997;30: ) EF< 50% r=0,80 EF >50% r = 0,69 Ap > Am : LVEDP > 15mmHg (Se : 85%, Sp: 79%, Rossvoll) Ap - Am >20ms : LVEDP > 12mmHg (Se : 74%, Sp: 95%,Appleton)
35 Ap - Am Am = 120 ms SF=40%, Ap = 220 ms Anterior MI - EF 40% LVEDP = 20mmHg
36 Type I Mitral flow Type II E A PV flow S D A Appleton et al Type III
37 III Mitral flow propagation velocity (Color M-Mode)
38 Mitral flow propagation velocity (Vp) (Color M-Mode)
39 Mitral flow propagation velocity (Color M-Mode) Vp Vp = slope of isovelocities = LV relaxation index Vp
40 Mitral flow propagation velocity (Color M-Mode) : how to measure? 4C apical view Color Doppler M-mode 100 mm/s Aliasing limit : 50% to 75% E velocity Mesure of Vp : - Slope of isovelocity first aliasing (interface between orange and blue) - Mitral annulus to 4 cm into LV - Average of 3 measurements Vp > 45 cm/s
41 Vp : measurement Zero E A E A
42 Anterior MI - EF = 40% - LVEDP = 20mmHg Vp = 24 cm / s
43 Mitral flow propagation velocity (Color M-Mode) Relaxation index Preload independant To distinguish normal and pseudo normal MF Recordable in 80% of patients Limits : influence of age
44 Vp : influence of age Normal values( Mego et al. JASE 1998; 11: 20-5 ) Age (years) Vp (cm/s) >
45 IV Mitral annulus movement (DTI)
46 Normal values Ea > 8 cm/s et Ea / Aa > 1 Aa Ea DTI Mitral annulus Minimum settings Ea = 15 ± 4 cm/s Aa = 10 ± 3 cm/s
47 Mitral annulus movement normal Ea = 18cm/s Ea > Aa Relaxation impairement (HT) Ea = 7,5cm/s et Ea < Aa Aa Ea Ea Aa
48 Nagueh, JACC 1997
49 Preload effect on mitral annulus DTI Basal Trinitrine Mitral flow DTI Sohn et al. JACC 1997; 30:
50 Preload effect on mitral annulus DTI Basal Fluid Mitral flow DTI (Annulus) Sohn et al. JACC 1997; 30:
51 Mitral annulus movement (DTI ) Normal Impaired relaxation Pseudo-normal Restriction SOHN, JACC 1997
52
53 Conclusion In ICU many factors influence mitral flow and pulmonary venous flow (age, HR, LVDP, compliance, relaxation) These indice may not be used to assess LV diastolic function (compliance and relaxation) To assess relaxation : Vp and Ea/Aa
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