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Suzanne "Shine" Tobias Admin Coordinator [email protected] Tel: 966-1-4647272 x 32018 Color M-mode flow propagation velocity. Color M-mode propagation velocities in a patient with normal (left) and abnormal (right) diastolic function. Vp, color M-mode color flow propagation velocity (normal Vp [cm/s] > 45; diastolic dysfunction < 45). ===================================================================== Diastolic Function Assessment Algorithm 1. Assess overall LV and RV systolic function from two-dimensional images. “Yes” answers increase the likelihood of diastolic dysfunction. a. Are chamber sizes normal? i. Is LA enlargement seen? ii. Is LVH present? iii. Is LV systolic function abnormal? b. Standard Doppler interrogation of mitral inflow and PV flow. i. If mitral inflow appears normal, integrate the above information and assess the PV flow pattern to differentiate from a pseudonormal pattern. c. DTI to measure Ea. d. Color M-mode of mitral inflow with qualitative assessment of Vp. e. If further investigation is required, consider: i. Assessment of mitral filling patterns in response to alterations in loading conditions (administration of sublingual nitroglycerin to decrease preload or passive leg raising to increase preload). ii. Response to exercise. iii. Estimation of LV filling pressures using E/Ea. iv. Measurement of IVRT. Dilated cardiomyopathy: Mitral regurgitation. Mitral annular dilatation, lateral papillary muscle displacement, and apical tethering prevent normal leaflet coaptation. The result is typically mitral regurgitation (MR) with a centrally directed jet. Worsening MR heralds a worse prognosis. Color M-mode Doppler across the mitral valve (apical four-chamber view) during diastole provides a spatio-temporal display of blood velocities across the vertical interrogation line. This parameter may be less affected by loading conditions. The slope of this flow signal—flow propagation velocity (Vp)—is the slope of the first aliasing velocity measured on the E wave. Normal Vp is > 55 cm/s. Vp < 45cm/s may indicate impaired relaxation . Mechanism of septal “bounce”/diastolic “checking”/ “shuddering” in constrictive pericarditis. Signs of ventricular interdependence are manifest in constrictive pericarditis. During inspiration, right heart filling proceeds at the expense of left ventricular filling (seen on spectral Doppler pattern)—shifting the interventricular septum to the left. This is followed by an abrupt cessation of diastolic filling (diastolic “checking”) corresponding to a third heart sound or pericardial “knock.” During expiration, increased left heart filling occurs at the expense of the right ventricle with reciprocal movement in the interventricular septum. Constrictive pericarditis. Sketch depicting exaggerated patterns of ventricular filling in inspiration and expiration in constrictive pericarditis. In inspiration, an exaggerated increase in right ventricular (tricuspid valve [TV]) inflow velocities occurs at the expense of left ventricular (mitral valve [MV]) inflow as manifest on pulsed Doppler tracings. During expiration, reciprocal changes occur. Similar respirophasic variations on pulsed Doppler can be seen in pulmonary embolism, right ventricular infarction, and COPD . A more specific sign of cardiac tamponade is the echocardiographic finding of RV diastolic collapse, compression, or inversion. These patterns are visualized as persistent posterior or inward motion of the RV free wall during diastole, representing elevation of intrapericardial pressure above RV diastolic pressure . The parasternal or subcostal long-axis views are best for visualizing this effect. The sensitivity of this finding is less than that of right atrial collapse (approx 60–80%), but the specificity is high (between 90 and 100%).