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What is Diastolic Dysfunction?
the inability of the heart maintaining normal diastolic pressures during left ventricular filling.
What will increase the diastolic dysfunction?
An increase in LV pressure.
B/C of the reduced filling.
What shows up first...
Diastolic dysfunction or systolic dysfunction?
Why is echocardiography great for the use of diastolic dysfunction? (4)
- 1.) single most important test
- 2.) non-invasive
- 3.) portable
- 4.) cost effective
What are 7 causes of diastolic dysfunction?
- 1. abnormalities in relaxation
- 2. increased stiffness
- 3. constrictive pericarditis
- 4. restrictive cardiomyopathy
- 5. coronary artery disease
- 6. hypertension
- 7. diabetes
What makes it harder to evaluate for diastolic dysfunction?
patients with good systolic function.
What are 4-5 ways that diastolic dysfunction is evaluated?
- 1.) mitral inflow pattern in 4 Chamber
- 2.) mitral inflow pattern with valsalva
- 3.) TDI (tissue doppler) looking at the mitral annular motion and the structure of the MV
- 4.) pulmonary venous flow
- 5.) LA volume/pressure
Mitral inflow facts: (3)
- 1.) PW above MV in 4 chamber
- 2.) Influenced by the rate of filling and LA pressure.
- 3.) Need to be parallel
What are the normal phases of diastole? (4)
- 1. IVRT: Isovolumetric Relaxation Time
- 2. Early Diastolic Filling
- 3. Diastasis
- 4. Atrial contraction
E wave: (5)
- 1. Early Diastolic Filling
- 2. Energy dependent
- 3. Elastic recoil of LV
- 4. Normally less dependent on atrial pressures
- 5. 80% of LV filling
F wave: (3)
- 1. Diastasis
- 2. Equalization of LA/LV pressure
- 3. Little forward flow
A wave: (3)
- 1. Atrial contraction
- 2. 10-15% or 15-20% of LV filling
- 3. A wave lines up with QRS
Determinants of E and A wave (4)
- 1.) Elastic recoil of LV (change in shape and its ability to revert back to normal)
- 2.) Rate of myocardial relaxation (how slow/fast the myocardium can relax after systole)
- 3.) Chamber compliance
- 4.) LA pressure
What Factors can influence diastolic function data? (but do not cause it)
- 1. loading conditions
- 2. heart rate
- 3. atrial function (ex: atria dilated)
- 4. myocardial stiffness
- 5. mitral valve function (ex: MV stenosis)
- 6. pericardial constraint
- 7. right ventricular size and function
Normal = 160-240 ms
Impaired = > 240 ms
Restrictive = < 160 ms
Some facts about TBI when evaluating Diastolic dysfunction: (5)
- 1. Looks at structural mechanics, not flow dynamics
- 2. Flow will be below the baseline
- 3. Signal will have low velocities but high amplitude
- 4. Velocities are less dependent on loading conditions
- 5. Will get "a prime" and "e prime" which "e prime is used to get the E/e prime ratio.
A patient with Aortic Stenosis will have what when using TDI?
Velocities are going to be lower than normal.
What is the differences between Constrictive Pericarditis and Restrictive Cardiomyopathy diseases (disease wise)?
Constrictive Pericarditis = disease when the pericardium causes restriction on the heart.
Restrictive cardiomyopathy = filling muscle disease
What is one way to differeniate between constrictive pericarditis and restrictive cardiomyopathy using evaluation?
CP = TDI velocities will be normal or higher, 20 cm/sec (velocities may not be affected)
Restrictive CMP = TDI velocities will be lower, 8 cm/sec
Besides differentiate between Constrictive Pericarditis and Restrictive Cardiomyopathy, what other two conditions can TDI be used to differentiate between?
Physiologic hypertrophy and hypertrophic cardiomyopathy.
Hypertrophic cardiomyopathy will have lower velocities.
Some facts about Pulmonary Vein PW Doppler when evaluating diastolic dysfunction? (7)
- 1. waveforms called S, D, A
- 2. may have two S waveforms (s1 & s2) if the PR interval is longer than normal
- 3. Normal blood flow in the pulmonary vein into the LA is Red. Abnormal is blue.
- 4. A small A wave is normal, larger is abnormal.
- 5. The "s wave" and "D wave" should be close to the same size.
- 6. If "D wave" is larger than "S wave" its abnormal.
- 7. Normal pulmonary vein reversal of flow should no greater than 0.4 m/sec or 40 cm/sec.
Important number to remember regarding pulmonary vein reversal of flow?
should not be greater than 0.4 m/sec or 40 cm/sec.
When does the LA contract?
During ventricular diastole.
4 physiologic roles of the LA
- 1. Acts as a contractile pump/atrial contraction 15-30% of LV filling
- 2. Reservoir that collects pulmonary venous return during systole.
- 3. Channel for the passage of blood from LA to LV in diastole.
- 4. It determines the filling pressure of the LV
Facts about E/e prime Ratio (4)
- 1. includes MV inflow and TDI
- 2. used to determine if there is an elevation in LA pressure.
- 3. At septum considered elevated if > 8
- 4. At lateral wall considered elevated if > 12
Increased LA size has a correlation with: (5)
- 1. A-fib
- 2. CVA
- 3. Risk of death and hospitalization in patients with dilated cardiomyopathy
- 4. Risk of death after MI
- 5. Marker for severity and chronicity of diastolic dysfunction and LA pressure elevation.
Technical Tips for LA volume measurement
- 1. Measure at end-ventricular systole when LA is the greatest. (MV Closed still)
- 2.Measure volume in both 4 CH and 2 CH.
- 3. Avoid foreshortening of the LA
- 4. LA volume more accurate than linear LA measurement
- 5. Exclude the pulmonary veins and LAA
- 6. Know calculation for finding LA volume
What are the LA volume units?
What are the LA volume limits for:
Mildly abnormal =
Moderately abnormal =
Severely abnormal =
Normal = 22 +/- 6
Mildly Abnormal = 29-33
Moderately abnormal = 34-39
Severely abnormal = >/= 40
Patients who have pulmonary hypertension will have....
RSVP correlation with diastolic dysfunction:
Normal - Grade I=
Stage II =
Stage III-IV =
Normal - Stage 1 = RVSP 27 +/- 7 mmHg
Stage II = RVSP 38+/- 7 mmHg
Stage III-IV = RVSP 64 +/- 15 mmHg
3 Conclusion Facts to Remember
- 1. Diastolic dysfunction surfaces before the systolic dysfunction
- 2. 40-50% of patients with CHF have normal LVEF
- 3. Mitral inflow pattern alone is not a reliable measurement of diastolic dysfunction.
Review formula for LA volume
Review Chart of diastolic dysfunction including:
1. MV inflow
3. pulmonary venous
4. LA volume