diastolic dysfunction

ECHOCARDIOGRAPHIC ASSESSMENT OF

DIASTOLIC DYSFUNCTION

Dr Mahendra Maske

Assessment of diastolic function should be an integral part of an evaluation of cardiac function because about 50% of patients with heart failure have preserved LVEF.

Diastolic dysfunction has a major impact on symptom status, functional capacity, medical treatment, and prognosis in both systolic and diastolic heart failure (HF), irrespective of the cause.

Most imp determinant is age & should be taken into account while evaluating diastolic dysfunction {DD}.

Objectives

• To determine how to identify the presence of diastolic dysfunction and its assessment with respect to different parameters.

• To determine the grade of diastolic dysfunction.• Practical approach to DD according to 2016

ASE/EACI guidelines.• To determine DD in special situations like HCM,

A fib.

Parameters1} IVRT – Isovolumic relaxation time2} Mitral inflow velocity patterns

Peak E- wave velocity Peak A-wave velocity E/A ratio DT With valsalva

3} TDI mitral annular velocity4} Pulmonary venous flow waveform

-PV S wave, D wave & Ar wave5} LA volume index6} Propogation velocity- Vp

Normal values:• E/A > 0.9-1.5• With valsalva -- E↓ & A↑• DT --- 140-240 mSec.• IVRT -- 70-90 mSec

Normal values:Brisk motion of mitral annulus as chamber expand to accommodate inflow of blood.• e’ septal > 7 cm/sec• e’ lateral > 10 cm/sec• E/e’ <14.. Sp- 92% & Sn- 83%

{Kasner M et all.. Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation 2007;116:637-47}

Normal values:• Vp-- >50cm/sec• S/D – systolic to diastolic time velocity

integral( areas under velocity curves)• Normally S≥D• LA volume index- <34 ml/m2.

ASE/EACVI GUIDELINES AND STANDARDS

• Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography:

• An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

• Sherif F. Nagueh et al --J Am Soc Echocardiogr 2016

Special situations

HCM• variability in muscle mass, phenotype, fibre disarray• Comprehensive approach with muktiple parameters are taken

into account. Recommended are average E/e’ ratio (>14), LA volume index (>34 mL/m2), pulmonary vein atrial reversal velocity (Ar-A duration > 30 msec), peak velocity of TR jet by CW Doppler (>2.8 m/sec). • The parameters can be applied irrespective of the presence or

absence of dynamic obstruction and MR, except for patients with more than moderate MR, in whom only Ar-A duration and peak velocity of TR jet are still valid.

Mitral stenosis• Typically, patients with mitral stenosis have

normal or reduced LV diastolic pressures.other LV inflow obstruction- prosthetic mitral valve large LA tumor cor triatriatum sinustrum Congenital MS

o IVRTo IVRT/ T (E-e’) -- <3 increase PCWP & LAP

MR

• With normal EFT Ar-A IVRT/ T E-e’ <3 increase PCWP & LAP

• With low EFE/e’

AS/AR• Similar approach

A Fib• Absent A wave & beat to beat variability

E/e‘ > 11 Peak TR velocity > 2.8 m/sec is suggestive of elevated LAP. depressed LVEFs - mitral DT <160 msec

other Doppler measurements • IVRT < 65 msec• DT of pulmonary venous diastolic velocity < 220 msec• E/Vp ratio >1.4,

Blocks• Routine parameters remain valid as long as there is

no fusion of mitral E and A velocities.• 1st degree AV block 200-280msec -- routine paramters>280 msec fusion of E & A wave occurs– TR velocity• RBBB, LAFB,LPFB-- routine parameters.• LBBB – associated with organic heart disease and

associated diastolic dysfunction.

Novel indices

• LV global longitudinal diastolic strain rate LVGLS by STE have a significant association with the time constant of LV relaxation-tau.

• LV untwisting rate• LA systolic strain & its inverse relationship with

mean wedge pressure.

• Thank you…!!!