Diastolic Function Overview

Diastolic Function Overview Richard Palma BS, RDCS, RCS, APS, FASE Director and Clinical Coordinator The Hoffman Heart and Vascular Institute School of Cardiac Ultrasound

None Disclosures

Learning Objectives Review the ASE/EAE Guidelines & Standards for the assessment of DF Discuss normal and abnormal filling pressures List measurements Discuss technical tips Discuss caveats, pitfalls, limitations of Doppler measurements Review key points on what and how to measure DF

Why Assess Diastolic Function? Treatment Purpose Stage 1: Abnormal relaxation (low E velocity, but no evidenced increase pressures) - ß-Blockers Heart rate control during exercise - Calcium channel blockers - ACE inhibitors Regression of LVH, afterload reduction Stage 2: Pseudonormal (low E velocity, with evidenced of increased pressures) - Above + diuretics/nitrates Achieve preload & afterload reduction Stage 3: Restrictive filling (low E velocity, with evidenced of highly elevated pressures) - Diuretics Preload reduction - ACE inhibitors Preload & afterload reduction, survival benefit - Nitrates Preload reduction - ß-Blockers LV remodeling, survival benefit - Digoxin (-CCBs? ß-B) Symptomatic improvement Information modified from: Naqvi TZ. Reviews in CV Medicine 2003;4:81-99.

Filling Pressures are Considered Elevated When Mean PCWP > 12 mmhg/lvedp > 16 mmhg Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

ASE/EAE Guidelines Nagueh et al, J Am Soc Echocardiogr. 2009 Feb;22(2):107-33. Eur J Echocardiogr. 2009 Mar;10(2):165-93 Table 1 reference values from: De Sutter J et al. Am J Cardiol 2005;95:1020-3

Diastolic Function Work-up

Transmitral Characteristics Mitral E wave Mitral A wave E wave deceleration

Key Points Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Pulmonary Vein Characteristics Systolic waveforms (S1,S2) Diastolic waveform Atrial reversal waveform

Key Points Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations Far-field resolution issues Velocity motion artifacts Arrhythmias Feasibility

Valsalva Maneuver Early phase Strain phase Release phase Dumesnil JG, et al. Am J Cardiol. 1991;68:515 519

Key Points Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations Challenging to perform correctly Not standardized DTI stole the show!

Doppler Tissue Imaging (DTI) Characteristics s velocity e velocity a velocity Isaaz et al. Am J Cardiol. 1989;64:66-75

Key Points Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations Multiple peaks MAC WMAs

E/e Ratio for Estimation of Filling Pressures Peak mitral E velocity Peak DTI e velocity Nagueh et al, JACC 1997, Ommen et al, Circ. 2000

Color M-mode Velocity Propagation (CMM-Vp) Characteristics Garcia et al, J Am Coll Cardiol 1997;29:448-54, Moller et al. (J Am Coll Cardiol 2000;35:363 70

Abnormal Relaxation: CMM Vp

Key Points Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations Slopes can be difficult to measure Load and EF dependant Vp can be increased in patients with normal LV volumes and EFs, despite impaired relaxation

LA End-Systolic Volume Index (LA-ESV): What to Avoid 4-chamber 2-chamber Tenting Vol Pulm Vein IAS Pulm Vein Aurigemma et al. Circ Cardiovasc Imaging 2009;2:282-289 Abhayaratna, et al. J Am Coll Cardiol 2006;47:2357-63

Estimation of PASP Included in the DF Work-up Bouchard et al. Am J Cardiol 2008;101:1673 1676

Tissue Doppler e Velocity Validation (posterior wall) Tau is time constant of isovolumic relaxation Tau > 48 ms = abnormal relaxation e velocity showed significant correlation with Tau Longer Tau = slower relaxation = lower e velocity r = - 0.78, p <0.0001 N =50 Isaaz et al. Am J Cardiol. 1989 Jul 1;64:66-75. Image adapted and modified from: Oki T, et al. Am JCardiol April 1997;79:921 8

Further e Validation (septal annulus) Septal DTI E only Sohn et al. J Am Coll Cardiol, August 1997;30:474 80

E/e Ratio Validation (lateral annulus) Lateral DTI E only Open Circles= PN E/e >10 = PCWP >15 Nagueh et al. J Am Coll Cardiol, November 1997;30:1527 33

Where s the Peak e Velocity?

Where s the Peak e Velocity?

IVRT Duration & Velocity in Abnl Relaxation Normal Relaxation Abnormal Relaxation Normal IVRT Prolonged IVRT Peak IVRT velocity Peak E velocity Peak IVRT velocity Peak E velocity

Factors That May Influence Doppler Tracings Sample volume positioning Doppler gain Annular restriction (MAC) Respiration

Effects of SV Positioning Too far into cavity A B C D E F Too close to annulus Leaflet tips Appleton et al. J Am Soc Echocardiogr 1997;10:271-91

Effects of SV Positioning on DTI Hill, Palma. J Am Soc Echocardiogr 2005;18:80 90 Bierig, Hill. J Diagn Med Sonography 2011;27:65 78.

Effects of Gain on DTI Waveforms Faint waveforms: e = 8 cm/s Spectral broadening: e = 16 cm/s Optimized: e = 12 cm/s Waggoner AD, Bierig SM. J Am Soc Echocardiogr 2001;14:1143-52.

MAC Influences the E/e Ratio e = 5 cm/s: E/e = 11 e = 9 cm/s: E/e = 5 MAC Below MAC Soeki, et al, Jpn Circ J 2001

Effects of Respiration on DTI Normal Respiration Ave e = 10 End-apnea Ave e 7 Hill, Palma, JASE 2005

E/e Ratio Validation in AFIB (septal & lateral annulus) N = 27 Sohn DW, et al. J Am Soc Echocardiogr 1999;12:927-31 E/e >11 = Elevated pressures Kusunose K, et al: JACC Cardiovasc Imaging 2009;2:1147 1156

AFib With & Without Suspected Elevated Filling Pressures RVSP 25 mmhg: E/e = 10 RVSP 35 mmhg: E/e = 20 Bierig, Hill. J Diagn Med Sonography 2011;27:65 78.

Classification of Diastolic Function *Table adapted and modified from Redfield et al Images modified from Redfield et al, JAMA. 2003;289:194-202

Prevalence of Unclassifiable Diastolic Function: Real World Diastology E/A, DT and E/E were measurable in approximately 3/4 of pts Variable N =100 Measurable (%) The most common reasons for inability to record data were (1) absence of apical view (2) fusion of these waves Pulmonary vein flow and A dur were only measurable in 1/2 and 1/4 of pts E/A 71 DT 73 E/e 75 Pulm vein S/D 56 12% unclassifiable P/A duration 25 Narayanan A,. Circulation 2008 (Abstract);118(18):787

Case Studies

60 y/o male DM, HTN, CAD 5ft 6in / 270 lbs Unable to assess PASP No significant valvular dz Moderate LAE

68 y/o male CHF CAD/RCA territory Inferior WMA s BPEF = 44% PASP = 19 mmhg No significant valvular dz Mild LAE

This Patient Has Not measured E/e = 9 *Table adapted and modified from Redfield et al

30 y/o female Edema Borderline tachycardia Evaluate RV/LV fx PASP = 17 mmhg No significant valvular dz NL LA size

e a e a

This Patient Has Not measured Not measured Not measured Normal E velocity

64 y/o male CAD, Dyspnea Borderline tachycardia EF = 25-30% Multiple WMAs PASP = 50 mmhg No significant valvular DZ Moderate LAE

Vp = 61

This Patient Has Discrepancy! E/e = 17

82 y/o female HHD/CHF Multiple WMA s PASP = 48 mmhg EF = 35-40% Moderate/severe LAE Severe MAC

This Patient Has Not measured Discrepancy!

29 y/o male CP, mild DOE PASP = 25 mmhg No valvular dz NL LA size EF = 60-65% No WMA s

This Patient Has Not measured Not measured E/E = 7

84 y/o female H/O HTN, CAD, CHF Dyspnea, new pedal edema Multiple WMAs PASP = 45 mmhg Severe LAE

BP EF = 33%

Significant Down Time : MPI s IVRT IVCT e a

E/e Unreliable 2 MAC

Elevated CVP = Pedal Edema

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

At the End of the Day