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
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
Cardiac function Physiology Filling Pumping Pathology Impaired diastolic function Impaired systolic function Clinical HFpEF HFrEF Echo Diastolic function assessment Systolic function assessment
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
Determinants of LV filling
Normal mitral inflow
LV filling is load dependent Before dialysis After dialysis
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
Spectrum of diastolic dysfunction Mitral flow Tissue Doppler
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
Latest guidelines (J Am Soc Echocardiogr 2016;29:277 314.)
Assessment tools 2D and M mode Flow Doppler Tissue Doppler
Common substrates Dilated CM Restrictive CM IHD Scar tissue Hypertrophic CM Aortic stenosis
Hemodynamic effects B bump Dilated LA High PAP
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
Doppler assessment
Normal flow patterns
Spectrum of mitral inflow patterns
Pulmonary vein flow
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
Cut off values for diastolic dysfunction
Major criteria for presence of diastolic dysfunction
Grading of LAP and diastolic dysfunction
A young healthy male Para. Value Normal E vel 83 0.7 1 A vel 29 0.4 0.7 DT ms 180 160 240 E/A 2.8 0.8 2 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)
65 y old male with IHD Para. Value Normal E vel 136 0.7 1 A vel 33 0.4 0.7 DT ms 140 160 240 E/A 4 0.8 2 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)
93 y old male with severe AS Para. Value Normal E vel 56 0.7 1 A vel 115 0.4 0.7 DT ms 243 160 240 E/A 0.5 0.8 2 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)
58 y old male with HTN Para. Value Normal E vel 56 0.7 1 A vel 99 0.4 0.7 DT ms 310 160 240 E/A 0.6 0.8 2 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)
85 y old female with HTN Para. Value Normal E vel 66 0.7 1 A vel 111 0.4 0.7 DT ms 292 160 240 E/A 0.6 0.8 2 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)
66 y old female with HTN Para. Value Normal E vel 64 0.7 1 A vel 92 0.4 0.7 DT ms 238 160 240 E/A 0.7 0.8 2 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)
75 y old female with HTN Para. Value Normal E vel 86 0.7 1 A vel 70 0.4 0.7 DT ms 143 160 240 E/A 1.2 0.8 2 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)
47 y old female with ESRD Para. Value Normal E vel 100 0.7 1 A vel 72 0.4 0.7 DT ms 193 160 240 E/A 1.4 0.8 2 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)
68 y old male with DCM Para. Value Normal E vel 92/40 0.7 1 A vel 34/40 0.4 0.7 DT ms 211 160 240 E/A 2.7/1 0.8 2 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)
56 y old female with ACS/NSTEMI Para. Value Normal E vel 95 0.7 1 A vel 46 0.4 0.7 DT ms 141 160 240 E/A 2 0.8 2 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)
66 y old male with DCM Para. Value Normal E vel 123 0.7 1 A vel 45 0.4 0.7 DT ms 108 160 240 E/A 2.7 0.8 2 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)
50 y old male with DCM Para. Value Normal E vel 130 0.7 1 A vel 30 0.4 0.7 DT ms 165 160 240 E/A 4.3 0.8 2 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)
60 y old female with high BP Para. Value Normal E vel 113 0.7 1 A vel 97 0.4 0.7 DT ms 218 160 240 E/A 1.2 0.8 2 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 y old male with BP of 209/120 mmhg Para. Value Normal E vel 128 0.7 1 A vel 45 0.4 0.7 DT ms 108 160 240 E/A 2.9 0.8 2 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)
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)
Atrial fibrillation
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
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