Download How to Perform a First Rate Diastology Exam Disclosure Objectives

How to Perform a First Rate
Diastology Exam
Jill A Odabashian RDCS, FASE
Cardiovascular Imaging Core
Clinical/Research Sonographer
Heart and Vascular Institute
Cleveland Clinic
Disclosure
• Speaker Bureau for GE Healthcare
Objectives
• Components and technique for performing a
diastolic exam
• Including right sided diastology exam
• Proper Doppler display
• Respiratory variation
• Incorporate maneuvers
• TDI
• Recognize diastolic abnormalities
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Great Reference
Publication date: 2008
How Do We get Diastolic Dysfunction?
• Happens with aging
• LVH
• Most cardiac diseases
• Pericardial Constriction
• Results in increased filling pressures
Who Should Have a Diastolic Assessment?
• CAD
• Conduction system disorder
• Hypertensive Heart disease
• Heart transplant rejection
• Diabetes
• Constrictive pericarditis
• Obesity/Metabolic syndrome
• Drug related cardiac toxicity
• Chronic renal failure
• Diabetes
• Cardiomyopathies
(HCM, DCM, ICM)
• Chronic renal failure
• Valvular heart disease
• Infiltrative Disorder
(amyloid)
amyloid)
• Sleep Apnea
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Diastology is part of the echo exam
• Includes left heart evaluation
• Essential for all CHF pts
• HTN
• Nearly 50% of pts with HF have normal or near
normal global systolic function
• Almost half of the pts presenting to ED with
acute HF have diastolic dysfunction
• Diastolic dysfunction is often overlooked
Sonographers Diastolic Assessment
• Establish a routine
• Starts when meeting the pt and asking questions
• Note HT, WT (BSA), HR, BP, rhythm,
hemodynamics
• Hx of HTN, HF
• Dyspnea (walking down the echo hallway)
• Patient in wheelchair
• SOB (lying flat on the echo table)
• Requires O2 (during echo exam)
Sonographers
Diastolic Assessment cont.
• Get the facts
• Pt history
• Previous echo or other
imaging exams
• Indication for
echocardiogram
QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
• Explain procedure…
procedure…echo
exam may take a few
minutes longer
3
Back to Basics
• Clean ECG signal (tap electrodes to confirm)
• Good voltage, big R wave (change lead),
no artifact
• Place electrode over diaphragm and others close
to heart (in case respirometer is needed)
Look For Doppler Clues
Quality PW Doppler Exam
• SemiSemi-transparent spectral
• Decrease Doppler gains
• Clean/sharp edges for
reproducibility
• Optimize scale
E A
• Sample volume (SV) will vary
• Use respirometer if E/A
velocities vary beat to beat
or effusion is present (a fib
exception)
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LV/MV Inflow Measurements
• Peak E and A velocities
• E wave Decel Time (DT)
• E/A ratio
• LV/MV IF and atrial duration
E A
AD
100 sweep speeds for measuring
Observe and acquire at 50 sweep speed
SV Placement and Size
Affects Peak E/A Velocity
E
E
A
A
E wave at MV tips 1.0m/sec
A wave close to MV 0.2m/sec
PERFECT!
E wave close to MV 0.5m/sec
A wave close to MV 0.2m/sec
SV Placement and Size
Affects Peak E/A Velocity
SV too far away from
MV tips
SV too close to
MV annulus
E
E
E
A
PERFECT!
A
A
70 cm/sec
50 cm/sec
60 cm/sec
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Atrial Fibrillation
• No A wave present
• Capture / acquire / measure 33-6 beats
Respirometer Tips
•
•
•
•
•
Practice breathing technique with pt
If needed optimize respirometer gain to observe peaks and valleys
Deeper breathing
Keep ECG and respirometer close together for timing
Sweep speed (25(25-50) slower to better assess respiratory variation
Observe septal motion during deep inspiration and expiration
QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
SV placement at MV leaflet tips
SV size 11-2cm
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Valsalva Maneuver
• If E wave > A wave perform valsalva maneuver
• Valsalva maneuver on average should be held for
at least 12 seconds to help differentiate between
stages
• Temporarily alters hemodynamics
During valsalva maintain cursor and SV placement (use 2D update)
Annotate on screen
An adequate valsalva maneuver should have 20% decrease in E wave velocity
Color MM-mode LV Filling Flow
Propagation Velocity (Vp
(Vp))
Early
Filling
Measure along first aliasing velocity
Late
Filling
4cm
• Two components are present: early and late diastolic filling velocities
velocities
within the LV
• Slope represents the speed of ventricular inflow
• Not affected by loading conditions
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Color MM-mode A4C
Early
Filling
Measure along first aliasing velocity
Late
Filling
4cm
Normal > 45cm/sec
• Optimize image depth (14(14-16cm)
• Shift color Doppler baseline shift upwards 3030-40cm for best aliasing
• Size color sector (annulus to annulus) to cover entire LV chamber
chamber (MV to apex)
including 1/3 of LA
• Maximize color frame rate
• Adjust color gain to just below saturation
• Cursor parallel to inflow (red/yellow diastolic inflow)
• 100 sweep speed for measuring
• Vp slope of 1st aliasing velocity from MV opening to 4cm into LV
Pulmonary Vein
• A5C, A2C, A3C
• RUPV most common
• Color guided (decrease color scale to 30
if not seen)
• SV size 33-4mm
• Placement 0.50.5-1cm into vein (avoid
junction of LA/PV)
S
D
• Sweep speed 50 assessment
• Measure 100 sweep speed
• Atrial fibrillation (collect 3 - 6 beats)
A
Avoid junction of LA/PV
PV with contrast enhancement, try holding breath
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Tissue Doppler Imaging (TDI)
• Newer diastolic indexes for
assessing filling pressures
regardless of loading
conditions
• Optimize depth 16cm
• Sweep speed 5050-100
• Evaluate filling pressures E/e’
E/e’
TDI Limitations
• Irregular rhythm
• Translational and rotational motion
• Angle dependent
SV size 5mm
Activate color TDI, reduce 2D gain
s’
e’
a’
PW SV placement on septal/medial
septal/medial and lateral MV annulus add TV annulus
(practice with ROI with translation)
Ventricular systolic evaluation (S wave)
Optimize scale 1010-15cm/s (increase scale will be noisy)
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Using E/e΄
E/e΄ to Estimate LV Filling Pressures
Ratio
<8
8 – 15
>15
Formula
LVIF 100
Average TDI 8
100/8 = 12.5
LVEDP
Low/NL
Mod
High
LVIF 100 cm/sec
Formula
Average TDI 8 cm/sec
If LA pressures are elevated, then MV inflow pattern is affected
Formula
Velocity Ratios
LVIF 100
Average TDI 8
Normal LA pressures
E/e’ <8mmHg
100/8 = 12.5
High LA pressures
E/e’ >15mmHg
LVIF 100 cm/sec
Formula
Average TDI 8 cm/sec
e'
Who Should Have a Right Heart Diastolic Exam?
Right heart evaluation must be included:
• Constrictive disease
• Right heart failure
• Differentiate COPD from constrictive disease
Add:
• IVRT
• RV inflow
• Respirometer
• Hepatic vein flow
• SVC vein flow
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(IVRT) Isovolumic Relaxation Time
• Between A4C and A5C view
• Measuring time between AV
closure and MV opening
• Cursor between AV and MV
• CW (increase filter)
• PW (SV 33-4/low filter) 1 cm
above AV in LVOT
• Achieve AV closure click and
MV opening click
• Sweep speed 50 measure 100
sweep speed
IVRT
TV/RV Inflow
• Repeat same measures as MV/LV inflow
• Assess TR velocity in all views
• Prepare for best Doppler alignment by
moving RV image to center of sector
• Optimize Doppler scale
• 50 sweep speed for assessment
• 100 sweep for measuring
• Up to 35% respiratory variation is
normal.
• Use respirometer if E/A velocities vary
beat to beat or effusion is present (a fib
exception)
E
A
TV/RV Inflow
Observe septal motion during deep inspiration (does it bow to the left?)
QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
SV placement at TV leaflet tips (try not crossover LV)
SV size 11-2cm
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IVC
• Subcostal view
• Proximal diameter of IVC (normal 2.1cm)
• Optimize depth
• IVC should collapse 50% with inspiration
QuickTime™ and a
Microsoft Video 1 decompressor
are needed to see this picture.
Collect and capture sniff test by 2D
QuickTime™ and a
Microsoft Video 1 decompressor
are needed to see this picture.
QuickTime™ and a
Microsoft Video 1 decompressor
are needed to see this picture.
Practice (check respirometer)
respirometer)
Utilize mm-mode
Hepatic Vein Doppler
• Subcostal SAX
• Index 12 o’
o’clock
• PW SV size 33-4mm
• Color guided SV
placement 22-3cm into HV
from IVC junction
• Normal HV are
sometimes difficult to
obtain
VR
AR
S D
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Hepatic Vein Doppler Cont.
~15% respiratory variation is normal
PW SV size 33-4mm
Assess at 50 sweep speed
Measure 100 sweep speed
Superior Vena Cava Doppler
• Pt supine, no pillow,
chin up, head tilt to left
• Right supraclavicular
fossa
• Index marker 10 o’
o’clock
Superior Vena Cava Doppler
• Color guided PW placement 5cm into SVC
• Check respirometer
• SV size 33-4mm
• Sweep speed 50 (shows ~5 beats)
• Measure 100 sweep speed
QuickTime™ and a
Microsoft Video 1 decompressor
are needed to see this picture.
AR VR
D
S
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Other Helpful Maneuvers
• Unmask the A wave
• Change preload
• Sitting
• Standing
• Raise legs
• Isometrics
• Maintain SV placement by using 2D update
Use 2D update and annotate position on screen
LV, LA, RA Volumes
• Optimize depth and zoom on each chamber separately
• A4C, A2C obtain biplane measurements
• LV EDV/ESV
• Planimeter atria at endend-systole (just before MV/TV opens
• Extra attention to LA size
• Largest LA / RA size
• LAVI = LA Volume / BSA
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Why Volumes to Assess Diastolic
Dysfunction?
• Assess the ability of the LV to fill to a normal EDV
without abnormal increase of the EDP at rest and
with exercise
• Failure to increase LV EDV and maintain CO2
with exercise
2009 ASE/EAE Guidelines
and Standards
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Great Reference
Publication date: 2008
Thank You
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