The Patient with Atrial Fibrilation

Assessment of Diastolic Function The Patient with Atrial Fibrilation Assoc. Prof. Adriana Ilieşiu, FESC University of Medicine Carol Davila Bucharest, Romania

Associated Conditions with Atrial Fibrillation (AF) Age Hypertension CAD 20 Symptomatic Heart Failure 30% Diabetes mellitus 20% Valvular Heart Disease 30% Sleep apneea, thyroid dysfunction CMP 10% Congenital Heart Defects (ASD) 10-15% Lone AF ( electrical CMP) Obesity 25% COPD 10-15% Chronic renal disease 10-15% Guidelines for the management of AF, EHJ 2010

Hemodynamic Effects of AF Loss of Atrial Contraction Irregular ventricular rhythm Loss of mechanical A-V synchrony Beat to beat variation in loading conditions Increase in mean LA diastolic pressure reduction in LVEDP + If LV compliance is affected Pulmonary edema Impact on LV filling and CO Rapid ventricular rate

Algorhytms for the Estimation of LV Filling Pressures (LVFPs) In patients with depressed EF In patients with normal EF E/A (+Valsalva) Ar-A IVRT/TE e LA volume Variability in RR cycle lengths Nagueh SF et al, JASE and Eur JL Echocard 2009

Doppler Evaluation of LVFPs in AF - Papers -

Doppler Evaluation for LVFPs Assessment in AF TDI e and E/e ratio Transmitral flow and isovolumic relaxation time (IVRT) Pulmonary venous flow Color M- mode intraventricular flow velocity propagation (Vp) and E/Vp ratio

Mitral Annulus Velocity e and LV Relaxation Sinus Rhythm cm/s 12 y = 14,70 0,15x r = - 0,56 p = 0.01 e 10 8 6 4 2 30 40 50 60 70 80 tau Sohn DW, et al. J Am Coll Cardiol 1997

Mitral Annulus Velocity e and LV Relaxation Atrial Fibrillation 0.20 0.15 y = 0.0014x + 0.1556 r = 0.509 p = 0.007 e (m/s) 0.10 0.05 0.00 30 40 50 60 70 80 Tau e < 8 cm/s could predict prolonged tau ( 50 ms) Sn -73%, Sp - 100% Sohn DW, et al J Am Soc Echocardiogr 1999

e (cm/s) Mitral Annulus Velocity e and LV Filling Pressures Tau 50 Tau > 50 Maximal transmitral pressure gradient (mmhg) In patients with cardiac diasease e can be used as non-invasive index of LV relaxation Nagueh SF, et all, J Am Coll Cardiol 2001

PWCP mmhg E/e Ratio and the Estimation of LVFPs 45 40 35 Y = 1.9 + 1.24 x R = 0.87 N=60 30 25 20 15 10 Sinus Rhythm 5 0 5 10 15 20 25 30 35 E/e Solid circles impaired relaxation Open circles pseudonormal/restrictive filling Nagueh SF et al. J Am Coll Cardiol 1997

E/e Ratio and Estimation of LVFPs Atrial Fibrillation 30 y = 0.8211x + 6.489 r = 0.786 p < 0.001 LVFP 20 (mmhg) 10 0 0 5 10 15 20 25 E/e E/e 11 could predict LVEDP 15 mm Hg Sn - 75%, Sp - 93% Sohn DW, et al J Am Soc Echocardiogr 1999

Mitral Inflow and IVRT 60 patients 30 in training population ( mean age, 69 y) and 30 in test population (mean age, 65y) LV ejection fraction 20% to 75% ( 48±17%) Invasively determined LVFPs were compared with several Doppler variables: Isovolumic relaxation time (IVRT) Max Velocity (E) Acceleration time (AT) Peak Acceleration rate ( PkAcc rate) Deceleration time (DT)

Peak Acceleration Rate of the Mitral Flow ( PkAcc rate) Physical and Physiological determinants of E wave acceleration Thomas JD, Weyman AE, Circ. 1991 Method of PkAcc rate calculation: Acceleration time/ 20 equal intervals and Highest change in velocity per unit of time was selected (computer algorithm) Nagueh SF, et al Circulation1996

Relationship of IVRT and Mitral Doppler Variables to LVFPs Correlation Coefficient ( r ) p PkAcc rate.84 <.0001 IVRT -.76 <.0001 E velocity.42.02 Deceleration time -.42.02 Acceleration time -.37.04 Velocity time integral.35.05 Nagueh SF, et al Circulation1996

E Wave Deceleration Time and LVFPs Patients with reduced and preserved EF Number of patients r p Study 35-0.50 0.007 Chirillo F JACC 1997 30-0.42 0.02 Nagueh S Circ 1996 37-0.65 0.0001 Matsukida K JASE 2001 27 ns ns Sohn DW JASE 1999 Patients with depressed EF EF % r p Study < 45-0.78 < 0.0001 Nagueh S Circ 1996 22 ± 5-0.95 0.0001 Temporelli PL AmJCardiol 1999

Relationship Between the Level of LVFPs and the Variability in Transmitral Velocity in AF Hypothesis : the beat-to-beat variability in transmitral velocity is greater when the mean left atrial pressure is normal and less when the pressure is elevated Coefficient of variation (ratio of SD to mean) of Doppler parameters LVFP 15 mmhg (n=17) LVFP > 15 mmhg (n=43) P Cycle length 0.14 ± 0.08 0.15 ± 0.06 NS PkAcc rate 0.35 ± 0.17 0.23 ± 0.1.015 Deceleration time 0.28 ± 0.14 0.19 ± 0.06.02 Peak E velocity 0.23 ± 0.24 0.06 ± 0.02.05 Velocity time integral 0.18 ± 0.16 0.14 ± 0.06 NS Nagueh SF, et al Circulation1996

Relationship Between the Level of LVFPs and the Variability in Transmitral Velocity in AF Mitral inflow in a patient with DCMP, AF Mitral inflow in a patient with lone AF and increased LVFPs and normal LVFPs

Effect of AF on PulmonaryVenous Flow Patterns S1 S2 S D D Av TEE Doppler Echocardiographic Study Peak systolic velocity (cm.s -1 ) Peak diastolic velocity (cm.s -1 ) Time velocity integral of systolic flow (cm) Time velocity integral of diastolic flow (cm) Systolic fraction of time-velocity integral (%) SR (n=21) AF (n=14) 54 ± 17 31 ± 13* 43 ± 18 42 ± 15 13 ± 6 5 ± 2* 7 ± 3 8 ± 3 61 ± 15 36 ± 8* SR = sinus rhythm; AF = atrial fibrillation; * = P < 0.05 Modified from Ren WD et al, European Heart Journal (1993)

Relation of Pulmonary Venous Flow Variables to LVFPs in AF Pulmonary vein velocity Correlation Coefficient ( r ) p Diastolic velocity.50.007 Systolic/diastolic velocity -.50.007 Diastolic TVI.43.02 Systolic TVI/diastolic TVI -.38.04 Nagueh SF, et al Circulation1996

Deceleration Time of Pulmonary Venous Diastolic Velocity and LVFPs Sinus Rhythm Atrial Fibrillation Kinnaid et al, J Am Coll Cardiol 2001 Kinnaid et al, J Am Coll Cardiol 2001 Chirillo F, et al. J Am Coll Cardiol 1997;30:19 26. Matsukida KM et al, J Am Soc Echocardiogr 2001 ;14:1080-7.

Deceleration Time of Pulmonary Venous Diastolic Velocity and LVFPs Measurement of the initial deceleration slope time BUT, - With faster heart rates, it would be difficult to separate the first and second components. - In AF the value would vary depending on the selected beats.

Doppler Evaluation for LVFPs Assessment in AF TDI e and E/e ratio Transmitral flow and isovolumic relaxation time (IVRT) Pulmonary venous flow Intraventricular colour M-mode flow propagation velocity (Vp) and E/Vp ratio

Intraventricular Colour M-mode Flow Propagation Velocity in Early Diastole -Vp Tau (msec) 180 160 140 120 100 80 R = -0.78 Y = 592.21x p < 0.001-0.6838 Vp < 50 cm/sec impaired relaxation 60 40 20 0 20 40 60 80 Vp Hemodynamic determinants: - Ventricular suction (intraventricular pressure gradient) - LV geometry - LV function - Contractile dyssynchrony Garcia MJ, et al. J Am Coll Cardiol 2000

E/Vp (cm/sec) E/Vp Ratio and PCWP 2.5 2.0 1.5 1.0 0.5 0.0 Sinus Rythm y = 0.039x + 1.02 r = 0.81 p < 0.001 0 5 10 15 20 25 PCWP E/Vp > 2.5 predict elevated LVFPs Atrial Fibrillation Correlation coeficient ( r ) E velocity/vp.65.0005 E/Vp > 1.4 predict elevated LVFPs P Rivas-Gotz C, et al. Am J Cardiol 2003 Nagueh SF, et al Circulation1996

Reproducibility of Doppler Measurements Inter- and Intraobserver Variability Interobserver Intraobserver Parameter Mean Difference Mean % Error Mean Difference Mean % Error PkAcc, cm/s 2-98±581 (7.5-1039) 18±17 215±749 (100-1386) 22±12 IVRT, ms 4.5±9 (0-20) 13±15 1.4±8.4 (1-15) 10±9 Dec time, ms 5.4±7.8 (0-30) 13±15 1±4 (2-25) 8±10 E velocity, cm/s 2.5±6 (0-10) 6±3-0.16±6 (0-10) 5±4 Prop velocity, cm/s -1.6±18 (0-32) 18±18 2.7±10 (0-18) 20±9 E/Prop velocity 0.13±0.4 (0-0.35) 24±20 0.2±0.4 (0.12-0.6) 18±16 Values are mean±sd (range). Nagueh SF, et al Circulation1996

Values of Doppler Variables Indicative for Increased LVFPs in AF TD E < 150 msec - in patients with depressed EF ( < 45 %) IVRT < 65 msec Less beat-to-beat variability of mitral inflow with the RR cycle length with increased LVFPs Septal e < 8 cm/sec - impaired LV relaxation (tau > 50 msec) Septal E/ e ratio 11 DT of pulmonary venous diastolic velocity < 220 ms E/Vp ratio 1.4 PkAcc rate of mitral flow velocity 1900 cm/sec²

Practical Issues for the Evaluation of LVFPs in AF Patients with AF should have a controlled heart rate (60-100 bpm) How many cycles should be measured? Correlation Coeficient r 95% confidence limits 10 beats.88 ± 7 mmhg 3 nonconsecutive beats (heart rate within 10% to 20% of the average heart rate) 1 cardiac cycle (equivalent with a HR of 70-80 bpm).82 ± 9 mmhg.74 ± 11 mmhg DT should be measured only when E velocity ends before the onset of QRS Nagueh SF, et al Circulation1996

Practical Issues for the Evaluation of LVFPs in AF DT - 115 ms DT - 69 ms DT of E wave is underestimated when E velocity ends after the onset of QRS

Conclusions 1. Doppler assessment of LV diastolic function and filling pressures is limited in patients with AF due to beat to-beat variability in cycle length, absence of organized atrial contraction and frequent enlargement of the left atrium. 2. A comprehensive echocardiographic evaluation of the patients with AF should include an integrated approach of two dimensional and Doppler data. 3. In accordance to the presence of cardiac disease and LV systolic function, the assessment of multiple Doppler variables is recommended. 4. Averaging Doppler measurements from ten cardiac cycles is more accurate; however measurements from three non-consecutive cardiac cycles or from one cardiac cycle are still useful.