Download ASSESSMENT OF LV DIASTOLIC FUNCTION BY DOPPLER

10/16/2011
ASSESSMENT OF
LV DIASTOLIC FUNCTION
BY DOPPLER
ECHOCARDIOGRAPHY
S Bakhoum,
Bakhoum, MD
Assistant Professor of Cardiology
Cairo University
PHYSIOLOGY OF DIASTOLE
Normal diastolic function is defined as
the ability of the LV to accommodate an
adequate filling volume to maintain CO
while operating at low pressure.

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AVC
IVRT
Rapid
Early
Filling
LV
Diastasis
Atrial
Systole
MVO
S2
MVC
LA
D
S1
A wave
E wave
AR
PV Flow
MV Flow
Doppler Indices of
Diastolic Function
 Isovolumic
relaxation time.
 Transmitral
 Pulmonary
flow.
vein flow.
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Isovolumic Relaxation Time
LV
LVOT
MV
LA
Isovolumic Relaxation Time
IVRT
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Isovolumic Relaxation Time
Clinical Applications
 Normal value:
value: 65 + 20 msec
msec..
 Prolonged in various
ario s diseases (>
(>90
90 msec)
that result in impairment of myocardial
relaxation..
relaxation
 Non invasive predictor of:
of:
– Doxorubicin
Doxorubicin--induced cardiomyopathy
cardiomyopathy..
– Early cardiac transplant rejection
 Shortened in stages 2(<
(<90
90 msec), 3 & 4
(<70
(<
70 msec) diastolic dysfunction.
dysfunction.
Isovolumic Relaxation Time
Limitations

It measures the time taken by isovolumic
relaxation
l
i andd not the
h rate off relaxation.
l
i

It is age dependent.

It is sensitive to changes in HR and systolic
function.

It does not give information on LV filling.
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Doppler Indices of
Diastolic Function
 Isovolumic
relaxation time.
 Transmitral
 Pulmonary
flow.
vein flow.
Transmitral Flow

Transmitral
blood
flow
velocities
representative
t ti off volumetric
l
t i flow.
fl
are

The measured peak velocity is indicative of the
relative instantaneous change in pressure between
the LA and LV after the opening of the MV.
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Technical Considerations
for optimal recording of TM flow

Sample size should be relatively small, at the leaflet tips to
yield higher flow velocities.

Use color flow Doppler echocardiography to line up the
sample volume parallel to flow in the 44-CH view .

PW Doppler has superior temporal and range resolution
than CW Doppler.

Use the lowest filter settings possible.

Ask patient to hold normal expiration, avoiding straining
and average at least three beats.
Normal Transmitral Flow
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Doppler Transmitral Flow

Peak E wave velocity: 70 – 100 cm/sec.

Peak A wave velocity: 45 – 70 cm/sec.

E/A ratio: 1.0 – 2.0

E deceleration time (DT): 160 – 240 msec.
Abnormal Transmitral Flow

Stage I: Impaired Relaxation

Stage II: Pseudo
Pseudo--normalization

Stage III: Restrictive Filling (Reversible)

Stage IV: Restrictive Filling(Irreversible)
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Impaired LV Relaxation
A
E
E/A <1
DT >240msec
IVRT >90msec
Impaired LV Relaxation
Clinical Applications

This pattern has been described in:
in:
– Patients
i
with
i h LVH due
d
to HTN, AS,
hypertrophic cardiomyopathy & obesity
heart syndrome.
syndrome.
– Patients with
syndromes..
syndromes
myocardial
y
ischemic
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Pseudonormalization
E/A :1 -1.5
DT: 160-240msec
IVRT<90msec
Pseudonormal Pattern

The diagnosis can often be suspected by LA
enlargement
enlargement.
l
.

Confirmation of the diagnosis can be made
on the basis of abnormal PV flow, abnormal
TD annular motion or an abnormal response
to the Valsalva maneuver.
maneuver.
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Pseudonormalization
Restrictive Pattern
E
A
E/A >2
DT <160 msec
IVRT<70msec
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Restrictive Pattern
Clinical Applications

This ppattern has been described in patients
p
with advanced heart failure & in patients
with restrictive cardiomyopathy.
cardiomyopathy.

Heart failure patients with this pattern have:
– poor treadmill performance.
– higher mortality.
Transmitral Flow
Limitations

A large number of factors can affect the
transmitral
i l flow
fl
i l di age, heart
including
h
rate,
heart rhythm, loading conditions, LV
systolic function, atrial function, and mitral
valve disease
disease..

TM flow cannot be used in isolation to
assess diastolic function.
function.
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Doppler Indices of
Diastolic Function
 Isovolumic
relaxation time.
 Transmitral
 Pulmonary
flow.
vein flow.
Normal Pulmonary Venous Flow
S2
S1
D
Pulm. V.
Flow
e l
Ar
Transmitral
Flow
Tra
IVRT
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Normal Pulmonary Venous Flow
S
D
Ar
Normal Pulmonary Venous Flow
Peak S wave velocity: 60 + 15 cm/sec.
 Peak D wave velocity: 40 + 15 cm/sec.
 Peak S / Peak D ratio: 1.3 – 1.5 ( + 0.3).
 Systolic fraction= STVI/DTVI x 100= 60 - 68
+10%
 Peak Ar wave velocity: -32 + 10 cm/sec.
 Ar duration: 137 + 31 msec.

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Impaired LV Relaxation
Higher S1 and S2
peak velocity.
p
y
Lower D peak
velocity.
Higher systolic
fraction.
S
D
A
Variable Ar.
Pseudormalisation Pattern
Lower S1 and
S2 peak velocity.
 Higher D peak
velocity.
S
Lower Systolic
fraction.
D
A
 Higher Ar
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Pulmonary Venous Flow
Estimation of LA Pressure
LAP = 35 – 0.39
0 39 x ( systolic
t li fraction)
f ti )
Systolic Fraction < 55% was
91% sensitive & 87% specific
for predicting
a mean LA pressure >15 mmHg
Kuecherer et al., Circulation 1990; 82: 1127
Pulmonary Venous Flow
Estimation of LVEDP
 An
A
Ar velocity
A
l i >35
3 cm/sec
/
& a difference in duration
( Ar – A ) >30 msec, is higly
predictive of a LVEDP > 15 mm Hg.
p
g
Rossvol et al. JACC 1993; 21: 1687
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Other Markers of Diastolic Function
 Non
Invasive Assessment of Tau.
 Color
MM-mode Propagation Velocity.
 Tissue
Doppler Mitral Annular
Velocity.
 LA
Volume
Other Markers of Diastolic Function
 Non
Invasive Assessment of Tau.
 Color
MM-mode Propagation Velocity.
 Tissue
Doppler Mitral Annular
Velocity.
 LA
Volume
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Non Invasive Measurement of Tau τ
Measurement of “Tau τ (TL)”
 Normal values:
values: 25 – 40 msec
msec..
 Higher
i h
values
l
represent reduced
d d early
l
diastolic distensibility due to slow
relaxation..
relaxation
 It does not however describe events during
phases of ventricular filling
filling..
 It is only applicable in patients with a
complete MR envelope.
envelope.
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Other Markers of Diastolic Function
 Non
Invasive Assessment of Tau.
 Color
MM-mode Propagation Velocity.
 Tissue
Doppler Mitral Annular
Velocity.
 LA
Volume
Color MM-mode
Flow Propagation Velocity
E
Vp
A
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Color MM-mode
Flow Propagation Velocity

The slope of the early filling wave front
“Vp
V ” is
Vp”
i a useful
f l non invasive
i
i index
i d off LV
relaxation..
relaxation

“Vp
Vp”” < 55 cm/sec in the young or < 45
cm/sec in older individuals identifies
impaired LV relaxation.
relaxation.

It is less affected by preload than TM or PV
flow..
flow
Color MM-mode
Flow Propagation Velocity

E/Vp
E/
Vp ratio can be used to estimate PCWP
PCWP..

PCWP = [5.27 x E/
E/Vp
Vp]] + 4.6 (in mmHg)
Garcia et al. JACC 1997;29: 448

Positive and negative predictive values for
E/Vp
E/
Vp > 1.5 to predict PCWP >12 mm Hg
were 93%
93% and 70%
70% respectively.
respectively.
Garcia et al. JACC 2000; 35: 201
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Other Markers of Diastolic Function
 Non
Invasive Assessment of Tau.
 Color
MM-mode Propagation Velocity.
 Tissue
Doppler Mitral Annular
Velocity.
 LA
Volume
Tissue Doppler Mitral Annular Velocity
S
a’
e’
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TD Mitral Annular Velocity
Impaired LV Relaxation
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TD Mitral Annular e’ Velocity
Is related to LV relaxation.
relaxation.
 Reduced and delayed in impaired LV
relaxation, relates inversely with the time
constant of LV relaxation.
relaxation.
 It is relatively load independent.
independent.
 Patients with pseudonormal LV filling are
separated from normal by an e’ < 8.5
cm/sec and an e’ /a’ ratio < 1.

E/e’ Ratio

E/e’ > 15 identifies patients with LVEDP
>12 mm Hg .

E/e’ < 8 identifies patients with normal
LVEDP.

PCWP (mm Hg) = 1.24 (E/e’) + 1.9
Nagueh et al., JACC 1997; 30: 1527
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E/e’ Ratio

E/e’ should not be used to estimate LV
filling in :
–
–
–
–
–
–
–
Normal subjects.
Significant annular calcification.
Surgical rings.
Mitral stenosis.
stenosis.
Prosthetic mitral valves.
Moderate to severe mitral regurge.
regurge.
Constrictive pericarditis.
pericarditis.
Recommendations for the Evaluation of LV Diastolic Function by Echocardiography.
European Journal of Echocardiography 2009: 10; 165–193
TE-e´ Interval
The time interval between the QRS
complex and the onset of mitral E velocity
is subtracted from the time interval between
the QRS complex and e´ onset to derive (TEe´).
 It is advantageous to use:

– subjects with normal cardiac function
– those with mitral valve disease
– when the E/e´
E/e´ ratio is 8 to 15
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TE-e´ Interval

An IVRT/TE-e´ ratio < 2 has reasonable
accuracy in identifying patients with
increased LV filling pressures.
pressures.
 Tau
τ (msec) = 32 + 0.7 x (TE-e’)
Rivas-Gotz et al. J Am Coll Cardiol 2003; 42:1463–70.
Other Markers of Diastolic Function
 Non
Invasive Assessment of Tau.
 Color
MM-mode Propagation Velocity.
 Tissue
Doppler Mitral Annular
Velocity.
 LA
Volume
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LA Volume

An increase in LA size is a morphologic
expression
i off chronic
h i diastolic
di
li dysfunction
d f
dysfunction.
i .

Although non specific, it reflects both the
duration and severity of the disease.
disease.

LA volume indexed to BSA has both
diagnostic and prognostic value
value..
Novel markers of diastolic function
Global diastolic strain
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Novel markers of diastolic function

Global diastolic myocardial strain rate:
– SRIVR has a strong correlation with time constant of
LV pressure decay.
– SRE is significantly related to LVEDP.
– E/ SRIVR is most useful in patients with E/e’ ratio: 8
to 15 and is more accurate than E/e’ in patients with
normal EF and regional dysfunction
Wang, et al. Circulation. 2007;115:1376-1383
Novel markers of diastolic
function

Regional diastolic myocardial strain rate:
– to evaluate diastolic stiffness during stunning &
infarction..
infarction
– correlates with the degree of interstitial
fibrosis..
fibrosis

LV twist:
twist:
– Both rate and extent of untwisting can be
quantified..
quantified
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Recommendations for the Evaluation of LV Diastolic Function by Echocardiography. European
Journal of Echocardiography (2009) 10, 165–193
CONCLUSION

LV filling is the result of a variety of
complex forces
forces..

No single parameter can be derived that
will adequately
describe
diastolic
function..
function

Diastolic filling patterns do not remain
static in either health or disease
disease..
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