Evalua&on)of)Le-)Ventricular)Diastolic) Dysfunc&on)by)Echocardiography:) Role)of)Ejec&on)Frac&on) N.Koutsogiannis) Department)of)Cardiology) University)Hospital)of)Patras)!
I have no conflicts of interest to declare
For)normal)cardiac)performance) the)le-)ventricle)must)be)able) to):) Eject)an)adequate)stroke)volume)at)arterial) pressure)(systolic)func&on)) Fill)without)requiring)an)elevated)le-)atrial) pressure)(diastolic)func&on)) ) These))func&ons)must)be)adequate)to)meet)the) needs)of)the)body)both)at)rest)and)during)stress)
Mechanisms)of)Diastolic)Dysfunc&on) Resistance to filling by : Impaired)relaxa&on)(early!diastole)!!!!!! energy!dependent!mechanism!of!ac5ve!filling!and!first! func5on!to!slow!down! ) Reduced)compliance)(mid:!to!late!diastole)! passive!lv!proper5es!(myocardial!s5ffness,!chamber! geometry,!wall!thickness)! Pericardial!restraint,!ventricular!interac5on!
The!main!physiologic!consequence!of!!diastolic!dysfunc5on! is!elevated!lv!filling!pressures,!which!represent!the!common! feature!for!heart!failure!regardless!underlying!ae5ology! Assessment of LV filling pressures provides important information for: Diagnosis Prognosis Monitoring therapy Mean LA pressure (PCWP) >12 mmhg LVEDP > 16mmHg
Determinants)of)diastolic)func&on) Active elements Actin-myosine crossbrige inactivation Passive elements Elasticity (diastolic recoil) Lengthening load (Filling pressures,geometry) Pressure-volume relation intrinsic factors: myocardial stiffness, wall thikness and chamber geometry extrinsic factors : pericardial restraint, ventriular interaction Early diastole Relaxation Restoring forces Filling load Mid-late diastole Compliance
Early!diastole! Diastolic recoil (Restoring forces) (+) Residual crossbridge interaction (impaired relaxation) (-) The relative importance of these forces depends on the remodeling process and systolic function Lengthening load (filling pressures and geometry) (+)
Laplace law T = P x r / 2h Concentric remodeling (small LV cavity size and thick LV walls) Eccentrc remodeling (large LV cavity size and thin LV walls) Lengthening load is low Lenghening load is high
Early!diastole!!Concrentric!Remodeling! Diastolic recoil (Restoring forces) (+) Residual crossbridge interaction (impaired relaxation) (-) Doppler findings of early diastole are mainly determined from relaxation kinetics Lengthening load (filling pressures and geometry) (+)
Early!diastole!!Eccentric!Remodeling! Diastolic recoil (Restoring forces) (+) Residual crossbridge interaction (impaired relaxation) (-) Doppler findings of early diastole are mainly determined from filling pressures Lengthening load (filling pressures and geometry) (+)
Late diastole Pressure Reduced compliance Hypertension Hypertrophy Diadetes Obesity Fibrosis Myocardial stiffness c b Compliance is load depended a Diuretics Volume
Systolic!func5on! EF = SV /EDV Simple evidence based prognostic
How!to!assess!Diastolic!func5on!by!echo!!Step!by!step!Approach! Are!there!morphologic!and!func5onal!correlates! for!diastolic!dysfunc5on!?! Does!mitral!inflow!velocity!paNern!indicates! diastolic!dysfunc5on!/elevated!filling!pressures!?! How!abnormal!is!myocardial!relaxa5on! (especially!when!ef!is!preserved)!?! Is!filling!pressures!elevated!at!rest!and/or!with! exer5on!?!
2-D findings and diastolic dysfunction LVEF <50% slowed relaxation interpretation of Doppler findings LA volume Cumulative effects of diastolic dysfunction and filling pressures over time (especially when EF>50%) LA volume > 34ml/m2 (diagnostic and prognostic implications) LV Hypertrophy slowed relaxation Exclude : Atrial fibrillation Mitral valve disease Volume overload Athletes heart
Pulmonary artery pressures and diastolic dysfunction PA systolic pressure 4 (V)² peak TR + RA pressure PA diastolic pressure 4 (V)² end diast PR + RA pressure Significant correlation between PAS and LV filling pressures in the absence of pulmonary disease Correlates well with invasively measured PCWP in patients without mean PA pressure > 40mmHg
Mitral inflow and Hemodynamics E LA pressure LV impaired relaxation DT LV stiffness (LVDP) LV impaired relaxation A LV stiffness (LVEDP) LA contractility Age Heart rate and rhythm P-R interval Cardiac output Mitral annular size LA function
E / A ratio Filling pressure Compliance Relaxation EF < 50% (dilated cardiomyopathies, after MI) Mitral inflow pattern correlate with filling pressures, functional class and prognosis better than EF. As E/A ratio increases and DT shortens filling normal pressures increases, functional class is worse and prognosis is poor Therapeutic goal EF > 50% Gray zone EF > 50% restrictive and morfologic correlates of diastolic dysfunction pseudonormal (LA enlargment, severe hypertrorhy, HCM,amyolidosis) Restrictive pattern indicates elevated Impaired relaxation filling pressures and poor prognosis Disease severity
Biphasic)response)of)tradi&onal) indices)to)diastolic)dysfunc&on) Diastolic normal mild severe Parameter function dysfunction dysfunction Systolic IVTR dysfuction E/A ratio EF < 50% DT S/D pulm veins + age dependence
Pulmonary venous flow pattern and filling pressures Mitral flow velocity LV pressure 0.5 0.5 25 mm Hg Ma=100 ms PVa=165 ms Pulmonary vein EF <50% S/D <1 Systolic fraction < 40% Increased PCWP Any EF Ar duration > 30msec from A duration Increased LVEDP
Asymptomatic NYHA III Recurrent Hospitalizations NYHA II
?
The Valsalva Maneuver Baseline Strain Pseudonormalization impaired relaxation Normal normal A decrease of >50% in the E/A ratio is highly specfic for increased fillinig pressures A decrease of 20cm/sec in mitral peak E velocity is considered an adequate effort
Tissue Doppler Annular velocities Color M-mode flow propagation velocity How abnormal is myocardial relaxation? Time interval between E and e Global longitudinal SR IVRT
Tissue Doppler longitudinal Annular Velocities and Hemodynamics Recoil (systolic force) (+) Residual crossbridge interaction (Impaired Relaxation) (-) LA contraction(+) e is reduced and delayed LVEDP (-) Lengthening load (+) (filling pressures and geometry) When relaxation is impaired especially with normal EF
e vs Maximal Instantaneous Transmitral Pressure Gradient Divided According to Tau e cm/ sec 14 12 10 8 4 Mitral flow Mitral annulus 6 velocity Tau <50 2 0 Tau >50 0 2 4 6 8 10 Maximal transmitral pressure gradient (mmhg) Nagueh et al: JACC 37(1): 226-85, 2001
Clinical Application in patients with cardiac disease Most patients with e (lateral) < 10cm/sec or e (septal) < 8cm/sec have impaired myocardial relaxation Transmitral E velocity depends on LA pressure, relaxation kinetics and age Mitral annular e velocity depends on relaxation kinetics and age. The E/e ratio eliminates the effect of relaxation and age e as a surrogate of LV relaxation E/e ratio as predictor of LV filling pressures
E/e ratio for the prediction of LV filling pressures E/e < 8 associated with normal filling pressures E/e > 15 associated with increased filling pressures Omen et al Circ 2000 E/e between 8 15 other echo indices should be used When using lateral or average values lower cutoff (12 for lateral and 13 for average) should de used for increased filling pressures
E/e = 7 E/e = 20 E/e = 16?
E/e!and!diastolic!func5on! E/e E/e is unreliable in Normal health people (e preload dependent) MItral stenosis/regurg/calcification/prosthetic valves Hypertrophic cardiomyopathy Severe LV systolic dysfunction ( e load dependent) Constictive pericarditis (annulus paradoxus) E/e works were we need it most, in patients with Heart Failure and normal EF
After Acute MI Hillis JACC 2004 Cardiomyopathies (Ishaemic, Dilated) Troughton AJC 2005, Yamamoto JASE 2003 Wang JACC 2005, Dokainish JACC 2005 Atrial fibrillation Okura Heart 2006 E /e and prognosis Secondary MR Bruch AJC 2007 Hypertensive heart disease Wang J Hypertens 2005 Sharp AS Eur Heart J 2010 End stage Renal disease Sharma JASE 2006
Color M-Mode flow propagation Velocity (Vp) Slope of the first aliasing velocity during early filling Normaly Vp > 50cm/sec Index of relaxation (inverse relation to τ) and load independent but only in patients with depressed EF Patients with normal LV volumes and EF but elevated filling pressures can have misleadingly normal Vp (dependency of load, geometry,contractile function) E / Vp 2,5 Predicts elevated filling pressures in patients with depressed EF when other indices appear inconclusive
Time interval between onset of the E and onset of the e When myocardial relaxation in normal both E and e coincided with the crossover of the LA-LV pressure. When relaxation is abnormal the e is reduced and delayed and occurs after LA-LV pressure crossover (asymmetrical longitudinal LV expansion) T E-e is an index of impaired relaxation (directly related to τ) IVRT / T E-e ratio < 2 Rivas-Gotz JACC 2003 Predicts increased filling pressures Useful when: - E/e is inconclusive - In mitral valve diseases
Global longitudinal SR IVRT by 2D speckle tracking Index strongly dependent on LV relaxation E/ SR IVRT > 236 Predicts increased filling pressures Useful when : -E/e is inconclusive, -EF is normal -In patients with regional dysfunction Wang J Circulation 2007
Heart failure symptoms with normal EF restrictive filling pattern, IVC dilatation Abnormal Pericardium Constrictive Restrictive 1.Increased thickness yes no 2.Septal fluttening yes no 3.Mitral inflow respiratory yes no variation 4.Hepatic vein expiratory yes no diastolic flow reversal Normal Myocardium 1.Ventricular septal Strain normal reduced 2. Septal annular e > 7cm/sec yes no 3. E/E normal Increased
Special populations
Conclusions) Tradi5onal!doppler!indices!are!usually! adequate!for!the!evalua5on!of!filling! pressures!in!pa5ents!with!low!ef.! A!relaxa5on!index!(usually!e )!mast!be!added! in!pa5ents!with!normal!ef! Diastolic!func5on!assessment!should!always! consider!all!available!echo!parameters!and! clinical!informa5on.!