Ventricular Diastolic
Filling and Function
Stephen L. Rennyson M.D.
Echocardiography Conference
August 25, 2010
Objectives
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Background of Diastolic Dysfunction
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
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Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Diastole
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Diastole
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Isovolumic
relaxation
Early filling (E)
Diastasis
Late filling - atrial
contraction (A)
Background
• Congestive Heart Failure (CHF)
manifests as either systolic and/or
diastolic dysfunction
• Where is the dysfunction?
• Systolic dysfunction -- manifest as a loss
of ventricular function (decreased EF)
• Diastolic dysfunction -- abnormal
relaxation pattern manifest as increased
filling pressures (Atrial and Ventricular)
Diastolic Dysfunction
• Diastolic Dysfunction is an
echocardiographic / Cardiac
Catheterization diagnosis based on:
• Ventricular filling patterns
• Velocity of myocardial motion
• Atrial filling patterns
• Based on these data, diastolic dysfunction
can be determined and graded
Diastolic Dysfunction
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Early sign of cardiac disease
Preceding systolic dysfunction
Associated with increased mortality without the robust
studies of treatment guidelines compared to systolic
dysfunction
Exist as its own entity -- Diastolic Heart Failure
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Studies of clinical heart failure admissions
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50% of those have only diastolic dysfunction
In systolic heart failure -- diastolic dysfunction can
explain the differences in clinical presentation
Etiology
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Myocardial Disease
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Dilated Cardiomyopathy
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Restrictive Cardiomyopathy
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Hypertrophic Cardiomyopahty
Secondary Ventricular Hypertrophy
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Hypertension
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AS
CAD -- Ischemia and infarction
Overview
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Background of Diastolic Dysfunction
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
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Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Characteristics of
Diastolic Dysfunction
• LV hypertrophy
• LA Volume
• LA function
• PA systolic and diastolic pressures
LV hypertrophy
• Majority of those with diastolic dysfunction:
1. Concentric hypertrophy (hypertensive heart
disease)
• Increased mass and wall thickness
2. Remodeling
• Normal mass / increased wall thickness
3. Eccentric hypertrophy
• Systolic dysfunction / depressed EF
LA Volume
• Easily measured and reliable in apical
views
• Significant relationship between LA
remodeling and diastolic dysfunction
• Consequence of longstanding elevated
filling pressures
• LA >34
2
mL/m
predictor of death, heart
failure, atrial fibrillation, ischemic stroke
LA function
• Reservoir / Conduit / Pump
• Reservoir and conduit functions -Early filling
• Pump function -- Atrial contribution to
LVEDV -- approximately 20%
PA Systolic and
Diastolic pressures
• Symptomatic patients with diastolic
dysfunction have increased pulmonary
artery pressures
• Correlate with elevated LV filling
pressures
• PA systolic -- Peak TR jet velocity + RA
• PA diastolic -- End diastolic velocity +
RA
Overview
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Background of Diastolic Dysfunction
Diastology
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
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•
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Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Mitral Inflow
• Measurement
• Inflow patterns
• Clinical application
Measurement
• Pulse-wave doppler through mitral
inflow:
• Peak E (early diastole)
• Peak A (late diastole)
• E/A ratio
• Deceleration time (DT) of Early filling
E wave (Early
Diastole)
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LA-LV pressure
gradient
Affected by:
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Preload
LV relaxation
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A-Wave (late
diastole)
A Wave
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LA-LV pressure
gradient
Affected by:
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LV
compliance
LA
contraction
E wave Deceleration
Time
(DT)
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Influenced by LV
relaxation
Values greater than
140 ms considered
normal
Inflow patterns
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Normal
Impaired LV relaxation
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Normal Atrial pressure
Pseudonormal filling pattern
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Symptoms
Restrictive filling
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Symptoms
Normal inflow pattern
Impaired LV
relaxation
Pseudonormal LV
filling
E/e’ = 17
Restrictive LV filling
Inflow patterns
• Increasing Age -- Age related loss of
compliance
• E wave velocity and E/A ratio
decrease
• A wave velocity and Deceleration
Time (DT) increase
• By age 50 essentially equal E and A
waves
Systolic Dysfunction
• Doppler mitral inflow patterns correlate
symptoms better than ejection fraction:
• Cardiac filling pressures
• Functional class
• Prognosis -- especially if patterns
persist after reduction of preload
Overview
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•
•
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Background of Diastolic Dysfunction
Diastology
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
•
•
•
Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Pulmonary Venous
Flow
• PW doppler of pulmonary venous flow
• Not used as frequently
• Can be difficult to obtain
• Little additional information after use
of Tissue Doppler
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Pulmonary Venous
Flow
Measurements
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Peak systolic
Peak anterograde
diastolic
S/D ratio
Atrial reversal wave
duration to A wave
duration (mitral
inflow)
Overview
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Background of Diastolic Dysfunction
Diastology
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
•
•
•
Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Tissue Doppler
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Doppler Pulse Wave imaging of
mitral annular velocity
Measure
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Lateral and Medial/Septal
mitral annulus
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Medial more accurate
than lateral or
combination score
Early filling -- e’ wave
Late filling -- a’ wave
Tissue Doppler
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Mitral inflow E to
tissue doppler e’ (LV
filling pressure)
Calculation:
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81.9 / 8.7 = 9.4
< 10 normal
Overview
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•
•
•
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Background of Diastolic Dysfunction
Diastology
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
•
•
•
Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Diastolic Dysfunction
Made Easy
• Measurements
• Mitral inflow patterns
• E and A waves
• E wave DT
• Tissue Doppler of Mitral Annulus
(medial)
• E to e’
Diastolic Dysfunction
Analysis and Grading
Symptoms from
Diastolic Dysfunction
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Symptoms driven by increased atrial pressures
transmitted to pulmonary circulation
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No symptoms likely from diastolic dysfunction:
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Normal Diastolic Dysfunction
Impaired relaxation (normal atrial pressure)
Symptoms attributed to Diastolic Dysfunction:
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Pseudonormal / Moderate diastolic
dysfunction
Severe Diastolic Dysfunction
Inaccurate
Diastolic Dysfunction
• Mitral Valve Disease
• MV replacement
• Severe MR or MS
• Atrial Fibrillation -- no A waves for
analysis
• Tachycardias as E and A waves fuse
Objectives
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•
•
•
•
Background of Diastolic Dysfunction
Characteristics of Diastolic Dysfunction
Echocardiographic Analysis
•
•
•
Mitral inflow
Pulmonary Venous Flow
Tissue Doppler
Analysis using Mitral inflow and Tissue Doppler
Cases
Case # 1
• 57 year old male with presentation to
the hospital for shortness of breath and
exam consistent with CHF a
exacerbation
• Echo for shortness of breath ? heart
failure
TTE Apical
Mitral inflow (E wave, A wave,
Deceleration Time)
Tissue Doppler
Analysis
• E wave greater than A wave
• DT > 140 ms (190 ms)
• e’ to a’ reversal
• E/e’ = 31.9
• Pseudonormal Filling pattern /
Moderate Diastolic Dysfunction
Conclusion
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Hypertensive patient with pseudonormal filling pattern
consistent with moderate diastolic dysfunction.
Shortness of breath likely secondary to
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Moderately reduced compliance
Impaired relaxation
Increased atrial pressure transmitted to pulmonary
circulation
Episode driven by hypertensive urgency (medical
noncompliance)
Case # 2
• Patient with Cardiac Amyloidosis
evaluation of cardiac structure and
function
PLAX
Mitral inflow (E and,A waves,
Deceleration Time)
Tissue Doppler
• Mitral Inflow E wave greater than A
wave
• E wave > 2X A wave (3.1)
• DT =140 ms (Criteria <140)
• e’ to a’ reversal
• E/e’ = 42.9
• Restrictive Filling Pattern
Conclusion
• Cardiac Amyloidosis
• Severe Diastolic Dysfunction
Changes to the
Protocol?
• Should we report all diastolic
dysfunction -- even normal diastolic
dysfunction?
• Can pulmonary venous inflow pulse
wave doppler be omitted?
• Can we rely on medial mitral tissue
doppler alone?