Diastology State of The Art Assessment

Transcription

1 Diastology State of The Art Assessment Dr. Mohammad AlGhamdi Assistant professor, KSAU-HS Consultant Cardiologist King AbdulAziz Cardiac Center Ministry of National Guard Health Affairs

2 Diagnostic Clinical implications of diastolic assessment o identify the underlying disease process o Differentiate pathophysiologic etiologies Therapeutic o HFrEF vs HFpEF o Restriction vs constriction Prognostic o Prediction of mortality o Prediction of response to treatment

3 Cardiac function Physiology Filling Pumping Pathology Impaired diastolic function Impaired systolic function Clinical HFpEF HFrEF Echo Diastolic function assessment Systolic function assessment

4 Normal diastolic filling Early diastolic filling 75 80% of LV filling Passive flow (needs LV relaxation) Late diastolic filling 20 25% of LV filling Due to atrial systole (needs compliant LV) Early filling Diastasis Late filling Diastasis State of equilibrium No flow or minimal flow

5 Determinants of LV filling

6 Normal mitral inflow

7 LV filling is load dependent Before dialysis After dialysis

8 Pathophysiology of diastolic dysfunction Caused by structural abnormalities that lead to adverse hemodynamic consequences Common predisposing conditions include: o Hypertension o Renal failure o Coronary artery disease o Dilated CM o Hypertrophic CM o Restrictive CM Myocardial ischemia LV hypertrophy LV fibrosis or infiltration Impaired LV relaxation Increased LV stiffness Inability of the heart to fill optimally under normal loading conditions

9 Spectrum of diastolic dysfunction Mitral flow Tissue Doppler

10 Essentials Technical o o o o o o o Competent sonographer Adequate study time Comprehensive assessment Accurate measurements Up-to-date technology Good quality images Cooperative patient Interpretation o o o o Well trained cardiologist Comprehensive Integrated Conclusive

11 Latest guidelines (J Am Soc Echocardiogr 2016;29: )

12 Assessment tools 2D and M mode Flow Doppler Tissue Doppler

13 Common substrates Dilated CM Restrictive CM IHD Scar tissue Hypertrophic CM Aortic stenosis

14 Hemodynamic effects B bump Dilated LA High PAP

15 Diastolic parameters Flow Doppler Mitral inflow: E velocity A velocity & duration E/A ratio Valsalva maneuver DT L velocity Pulmonary vein flow: S wave D wave S/D ratio A reversal (V & dur) Shared: E/e ratio Ar-A duration Tissue Doppler Mitral annulus: Lat. Velocity (e ) Sept. Velocity (e ) Others LA volume index TR velocity Secondary: IVRT C. M-mode Vp T E-e E/Vp ratio

16 Doppler assessment

17 Normal flow patterns

18 Spectrum of mitral inflow patterns

19 Pulmonary vein flow

20 We need to answer the following questions Is there diastolic dysfunction or not? o Yes o No o Indeterminate How severe is the diastolic dysfunction? o Mild o Moderate o Severe Is the left atrial pressure normal or high? o Low (normal) o High

21 Cut off values for diastolic dysfunction

22 Major criteria for presence of diastolic dysfunction

23 Grading of LAP and diastolic dysfunction

24 A young healthy male Para. Value Normal E vel A vel DT ms E/A e vel Sep 12 S 7 L 10 E/e 7 < 10 LAVI 29 < 34 TR vel 1.5 < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

25 65 y old male with IHD Para. Value Normal E vel A vel DT ms E/A e vel NA S 7 L 10 E/e NA < 10 LAVI NA < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A 90 < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

26 93 y old male with severe AS Para. Value Normal E vel A vel DT ms E/A e vel Sept 4 S 7 L 10 E/e 14 < 10 LAVI 31 < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D NA > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

27 58 y old male with HTN Para. Value Normal E vel A vel DT ms E/A e vel Sep 6 S 7 L 10 E/e 9 < 10 LAVI 34 < 34 TR vel 2 < 2.8 E/A NA < 0.50 S/D NA > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

28 85 y old female with HTN Para. Value Normal E vel A vel DT ms E/A e vel S 7 4 & 7 L 10 E/e 13 < 10 LAVI 38 < 34 TR vel 2.5 < 2.8 E/A NA < 0.50 S/D >1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

29 66 y old female with HTN Para. Value Normal E vel A vel DT ms E/A e vel S 7 7 & 4 L 10 E/e 13 < 10 LAVI NA < 34 TR vel 2.7 < 2.8 E/A NA < 0.50 S/D >1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

30 75 y old female with HTN Para. Value Normal E vel A vel DT ms E/A e vel Sep 6 S 7 L 10 E/e 14 < 10 LAVI < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D NA > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

31 47 y old female with ESRD Para. Value Normal E vel A vel DT ms E/A e vel Sept 8 S 7 L 10 E/e 12.5 < 10 LAVI < 34 TR vel 3.6 < 2.8 E/A 57% < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

32 68 y old male with DCM Para. Value Normal E vel 92/ A vel 34/ DT ms E/A 2.7/ e vel Lat 4 S 7 L 10 E/e 23 < 10 LAVI < 34 TR vel NA < 2.8 E/A 63% < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

33 56 y old female with ACS/NSTEMI Para. Value Normal E vel A vel DT ms E/A e vel Sept 3 S 7 L 10 E/e 32 < 10 LAVI 44 < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

34 66 y old male with DCM Para. Value Normal E vel A vel DT ms E/A e vel S 7 4 & 5 L 10 E/e 31 < 10 LAVI NA < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

35 50 y old male with DCM Para. Value Normal E vel A vel DT ms E/A e vel sept 4 S 7 L 10 E/e 33 < 10 LAVI 47 < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A <0 < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

36 60 y old female with high BP Para. Value Normal E vel A vel DT ms E/A e vel Sept 5 S 7 L 10 E/e 23 < 10 LAVI 31 < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

37 37 y old male with BP of 209/120 mmhg Para. Value Normal E vel A vel DT ms E/A e vel Lat 8 S 7 L 10 E/e 16 < 10 LAVI 45 < 34 TR vel NA < 2.8 E/A NA < 0.50 S/D <1 > 1 Ar A NA < 0 ms Vel. (m/s), e vel (cm/s), LAVI (ml/m 2 ), NA (not available)

38 Peak acceleration rate of mitral E velocity (1,900 cm/s2). Atrial fibrillation (Normal values) IVRT (65 ms). DT of pulmonary venous diastolic velocity (< 220 ms). E/Vp ratio (1.4). septal E/e= ratio (>11)

39 Atrial fibrillation

40 Conclusions Diastolic assessment is an essential component of echocardiographic study Mitral inflow Doppler, Tissue Doppler, LA volume and TR velocity are the most important components of diastolic assessment New criteria-based algorithms makes interpretation easier, consistent and more clinically oriented

41 Thank you