Choose the grading of diastolic function in 82 yo woman
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- Buddy McDowell
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1 Question #1 Choose the grading of diastolic function in 82 yo woman E= 80 cm/s A= 70 cm/s LAVI < 34 ml/m 2 1= Grade 1 2= Grade 2 3= Grade 3 4= Normal 5= Indeterminate 2018 MFMER Choose the grading of diastolic function in 82 yo woman E= 80 cm/s A= 70 cm/s LAVI < 34 ml/m 2 E/e = 10 Medial e = 8 cm/s TR =2.7 m/sec 1= Grade 1 2= Grade 2 3= Grade 3 4= Normal 5= Indeterminate 2018 MFMER
2 82 year old woman with normal diastolic function TR = 3.2 m/sec TR =2.7 m/sec 2018 MFMER Question #2 Grade diastolic function in 80 YO man with dyspnea TR = 3.5 m/sec E= 60 cm/s A= 80 cm/s E/A = 0.75 Medial e = 2 cm/s E/e =30 Lat e = 6 cm/s E/e = Grade 1 2. Grade 2 3. Grade 3 4. Normal 5. Indeterminate 2018 MFMER
3 80 YO man with dyspnea Septal e is reduced due to PHT 1. e is reduced 2. E/e +/- 3. LAVI normal 4. TR is high 2018 MFMER year old man with dyspnea and PHT Cardiac Cath Data RA pressure 2 mmhg RVSP 50 mmhg Mean PASP 28 mmhg PCWP 4 mmhg LVEDP 13 mmhg Cardiac Index 1.5 L/min/m MFMER
4 Question #3 Diastolic Function in 65 yo man with hypertension? LAVI = 20 ml/m 2 & TR = 3 m/s E=127 cm/s A= 135 cm/s Medial e = 5 cm/sec E/e = Grade 1 2. Grade 2 3. Grade 3 4. Normal Filling Pressure 5. Indeterminate Lat e = 8 cm/sec E/e = MFMER LV volume measurement 2018 MFMER
5 65 yo man with hypertension E/A = 1.0 E/A = MFMER Good Quality in Measurements is the Key! No data is better than wrong data! 2018 MFMER
6 78 yo woman with 21 mm CE AVR 2010 for severe AS Referred for Valve in Valve with high gradient and dyspnea Aorta 3 cm 2018 MFMER yo female with 21 mm CE AV prosthesis and SOB How do you grade her diastolic function? E =45 A= 140 E/A = 3 4 m/sec i EOA < 0.65 AT 75 msec 1. Grade 1 2. Grade 2 3. Grade 3 4. Normal Filling Pressure 5. Indeterminate 2018 MFMER
7 78 yo female with 21 mm CE AV prosthesis and SOB What is you next diagnostic step? E =45 A= 140 E/A = 3 4 m/sec i EOA < 0.65 AT 75 msec 1. Aortic valve replacement 2. Refer to pulmonary 3. Exercise test 4. TEE 5. Old age and Observe 2018 MFMER Pericardial Aortic Prosthesis AT >100 ms AT 100 ms ieoa <0.65 cm 2 /m 2 ieoa <0.65 cm 2 /m 2 ieoa 0.85 cm 2 /m 2 MG >20 mmhg MG 20 mmhg Aortic root diameter 3 cm Aortic root diameter <3 cm MG >20 mmhg MG 20 mmhg Pathologic Obstruction (normal flow) Pathologic Obstruction (low flow) Severe PPM Severe PPM ± Pressure Recovery High flow Pathologic Regurgitation Norma l 2018 MFMER
8 Exercise Cardiac Catheterization PPM + Pressure Recovery Rest LVEDP 12, PAWP 8 CO 2.8, CI 1.5, MG 17 mmhg AVA 1.1 cm 2 Exercise PAWP 41, LVEDP 44, mean PA 46 Aortic pressure 220 CO 5.7, CI 3.1, gradient 10, AVA 2.0 cm MFMER Mitral inflow E/A E <50 cm/s E/A E >50 cm/s or E/A >0.8-<2 E/A 2 3 criteria to be evaluated* 2 of 3 negative 1 Average E/e >14 2 TR velocity >2.8 m/s 3 LA volume index >34 ml/m 2 2 of 3 or 3 of 3 positive When only 2 criteria are available 2 negative 1 positive and 1 negative 2 positive Normal LAP Grade I diastolic dysfunction Cannot determine LAP and diastolic dysfunction grade* LAP Grade II diastolic dysfunction LAP Grade III diastolic dysfunction If symptomatic consider CAD or proceed to diastolic stress test 2018 MFMER
9 73 yo woman with Hypertension and Exertional Dyspnea No ischemia E/e = 7 E = 50 cm/s DT = 250 ms This patient has delayed myocardial relaxation, but filling pressure is not increased at rest e = 7 cm/s CP /8/ MFMER Change in CI and PCWP with Exercise Normal and Abnormal Diastolic Function 8 6 Normal Cardiac index (L/min/m 2 ) 4 2 Diastolic dysfunction PCWP (mm Hg) CP /8/ MFMER
10 Dynamic Diastology Filling Pressure (E/e ) with Exercise E e E/e Normal Abnormal LV filling pressure (E/e ) does not increase much with exercise in normal heart, but increases in symptomatic patients with diastolic dysfunction. CP /8/ MFMER Diastolic Stress Test Baseline and Peak (or Post) Exercise Supine bike or Treadmill 25 watts (3 min) increments Assess LVEF, size, and wall motion Mitral inflow (E, A, and DT) Mitral annulus velocity E/e ratio TR velocity 5/8/ MFMER
11 E (cm/s) E/e septal e septal (cm/s) 5/8/2018 Diastology Exercise Test Normal Values Baseline Exercise E (cm/s) 73±19 90±25 A (cm/s) 69±17 87±22 DT (ms) 192±40 176±42 e (cm/s) 12±4 15±5 E/e 6.7± ±2.5 Mean age 59±14 yrs Ha J et al: AJC, 2003 CP /8/ MFMER LV Diastolic Function at Rest and With Stress Diastolic Stress Echocardiography in the Young: Endurance-Trained (ET) Healthy Subjects Rest Exercise 12 ET NA * Nonathletic (NA) and Rest Exercise Mean age 29 yrs 2 0 Rest Bruengger et al: JASE, 2014 Exercise 2018 MFMER
12 Exertional Dyspnea E = 50 DT = 250 E = 85 DT = 140 e = 7 E/e = 7 TR = 2.4 e = 7 E/e = 12 TR = 3.8 Baseline Supine Bike CP /8/ MFMER Echo-Cath Correlation E/e = 16 E/e = 25 Ha et al. JASE MFMER
13 E/e medial E/e medial 5/8/ Mean LVDP vs E/e Rest and Exercise Rest: y=0.44x r=0.67, P< Exercise: y=0.46x r=0.59, P<0.01 E/e Mean LVDP (mm Hg) Burgess et al: JACC 47:1891, 2006 CP /8/ MFMER Echocardiographic Hemodynamic and Ventricular Function Indices During Exercise Submaximal (20W) Peak A 50 P< % Not measurable B 50 P< % Non measurable NCD HFpEF 0 NCD HFpEF Obokata M et al: Circ 135: , MFMER
14 Exercise Echo for Dyspnea E= 50 cm/s E= 100 cm/s e = 5 cm/s e = 6 cm/s 5/8/ MFMER Exercise Echo for Dyspnea E= 100 cm/s E= 150 cm/s e = 5 cm/sec 5/8/ MFMER
15 Question #4 Which of following clinical situation is best suited for using E/A ratio as the initial diastolic assessment parameter? 1. Age > 80 years 2. Uncontrolled hypertension 3. LVEF 45% 4. AL Cardiac Amyloidosis 5. Hypertrophic cardiomyopathy 6. Marked mitral annulus calcification 2018 MFMER Question #5 79 year old with bigemini E= 60 A=70 E/A= 0.8 Med e = 7 E/e = 8 1. Grade 1 2. Grade 2 3. Grade 3 4. Normal Filling Pressure 5. Indeterminate 2018 MFMER
16 79 yo with bigemini TR 2.4 m/sec Valsalva E=40 A= 60 E/A= MFMER year old man with dyspnea PFO velocity LAP- RAP = 36 mmhg 2018 MFMER
17 PFO Velocity for estimating LA pressure Baseline After Diuresis Peak V = 3.2 m/s Peak V = 1.6 m/s From Chandra, MD & Will Miranda, MD 2018 MFMER Atrial Fib. And Mitral Regurgitation Medial e = 8 cm/s E= 90 cm/s E/e =11 TR = 2.5 m/sec 2018 MFMER
18 Atrial Fib. And Mitral Regurgitation with exercise E= 90 cm/s E= 130 cm/s and DT 120 msec Medial e = 8 cm/s Medial e = 9 cm/s TR = 2.5 m/sec TR = 3.2 m/sec 2018 MFMER Mitral E, e and Pulmonary Vein Normal Grade 1 Grade MFMER
19 Questions & Discussion 2018 MFMER Pericardial Diseases Questions Jae K. Oh, MD 2018 MFMER
20 Question #6 Who from following patients has the highest medial e velocity expected? year old woman with CP after radiation treatment year old woman with CP after viral illness year old man with CP after CABG year old man with cardiac Fabry s year old woman with HFPEF 2018 MFMER VBaseline Primary CP Secondary CP Primary CP Secondary CP Baseline Post Pericardiectomy Medial e 14.6 ± ± ± ± 2.0 Lateral e 12.8 ± ± ± ± 2.0 e 15 cm/s e 10cm/s Veress et al. Circulation CV Imaging July MFMER
21 Tissue Doppler in Constriction vs Restriction E normal to high in constriction, low in myocardial disease 2018 MFMER Normal vs RCM vs CP Medial Mitral e velocity (LV Relaxation) Normal RCM CP Medial e 13 cm/s Medial e 3 cm/s Medial e 14 cm/s Usually > Lateral e (Annulus Reversus) 2018 MFMER
22 Question #7 A 26 year old woman with a previous pericardiectomy, for tbc CP presenting with edema Doppler demonstrates? 1. Recurrent CP 2. Normal 3. Restriction 4. Respiratory distress Lateral e = 10 cm/s Medial e = 15 cm/s 2018 MFMER A 26 year old woman with a previous pericardiectomy, presenting with edema 2018 MFMER
23 41 pts MFMER Cho and Schaff et al. Annal Thorac Surgery MFMER Question #8 Which of following statements is correct regarding Kussmaul sign? 1. Expiratory increase in JVP 2. Cannot be correct since opposite to Hepatic Vein 3. Due to increased IVC flow 2018 MFMER
24 T Meyer AJC MFMER Question #9 42 year old man with dyspnea Gradual onset of chest tightness and dyspnea Physical Examination HR 90 BPM JVP mildly elevated Increased S2 intensity GR 1/6 systolic murmur Mild pitting edema 2018 MFMER
25 42 year old man with dyspnea What is his diastolic function? E= 120 A= 30 cm/sec E/A =4 Lat e = 12 cm/sec E/e = 10 Med e = 9 cm/sec E/e = 13 1= Grade 1 2= Grade 2 3= Grade 3 4= Normal 5= Constriction 2018 MFMER year old man with dyspnea and high output LVOT D = 2.3 m/sec LVOT TVI = 26cm SV= (2.3) 2 x x 26 = 108 ml CO = SV x HR = 108 x 80 = 8.6 L CI = CO/BSA = 8.6 /1.93 = 4.48 L/m MFMER
26 What is the most common cause of HF seen in this 42 year old man? SV= (2.3) 2 x x 26 = 108 ml CO = SV x HR = 108 x 80 = 8.6 L CI = CO/BSA = 8.6 /1.93 = 4.48 L/m 2 1. Shunt 2. Obesity 3. Liver Disease 4. Pheochromocytoma 2018 MFMER year old man with high output HF Before and after treatment (Thyrotoxicosis) 2018 MFMER
27 Etiologies of High Output Failure Cardiac Index > 4.0 L/m 2 Obesity (31%) Liver Disease (23%%) Shunt (22%) Diastolic function can be normal Reddy et al JACC MFMER year old man with chest pain What is your next step? Question #10 1. Cardiac Cath 2. TEE 3. CT 4. Stress Echo 2018 MFMER
28 Congenital Absence of the Pericardium Snoopy Sign 2018 MFMER Pericardial Cyst 2018 MFMER
29 A large pericardial cyst 2011 MFMER slide MFMER Cardiac Tamponade RV collapse Mitral inflow variation HV expiratory reversal 2018 MFMER
30 Hemo-pericardium 2018 MFMER Intramural Hematoma 2018 MFMER
31 66 year old woman with dyspnea Pneumo-pericardium PneGastro-pericardial fistulau 2018 MFMER year old woman from Middle East with ascites several month after acute pericarditis and pericardial effusion Medial e = 14 cm/s Lateral e = 11 cm/s 2018 MFMER
32 23 year old woman from Middle East with ascites several month after acute pericarditis and pericardial effusion (Thrombotic CP) Medial e = 14 cm/s Courtesy of H. Schaff, MD 2018 MFMER yo man presents with dyspnea and fever BP 80/40 mmhg Hepatic vein 2018 MFMER
33 35 yo man with tamponade and fever TEE after pericardiocentesis 2018 MFMER Final Pericardial Disease Case 45 yo male with chest pain x 4 days Pain preceded by heavy lifting while camping. No relationship to exercise. MVA with pelvic and rib fractures. Chest tube and IVC filter placement 6 yrs ago. Many CV risk factors 2012 MFMER MFMER
34 Echocardiographic images in 45 yo with chest pain 2018 MFMER MFMER Chest and Cardiac CT 2012 MFMER MFMER
35 CT scans now and 8 years ago 2012 MFMER MFMER Embolic strut from IVC Filter 2012 MFMER MFMER
36 2012 MFMER MFMER Constriction or Myocardial Disease? Diagnostic Algorithm Medial e 12 cm/s Medial e 5 cm/s Syed, Schaff, Oh Nature Review Sep MFMER
37 Thank You! MFMER Echo-Guided Pericardiocentesis Welles mov Chest wall 79% 3% 18% Subcostal Location 2018 MFMER
38 Questions & Discussion 2018 MFMER
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