diastolic dysfunction: nuts, bolts & who cares ? kunjan bhatt md austin heart

Diastolic Diastolic Dysfunction: Dysfunction: Nuts, bolts & Nuts, bolts & who cares ?who cares ?

Kunjan Bhatt MDKunjan Bhatt MDAustin HeartAustin Heart

BackgroundBackground

• For patients > 65 years old, CHF is For patients > 65 years old, CHF is the most common diagnosis at the most common diagnosis at discharge.discharge.

• The population is agingThe population is aging– In the early 1900s, ~ 4% population was In the early 1900s, ~ 4% population was

> 65. > 65. – By 2010, 1/3 population will be > 65.By 2010, 1/3 population will be > 65.


• Among the elderly, cardiovascular Among the elderly, cardiovascular disease is the MOST common cause disease is the MOST common cause of mortality and morbidity.of mortality and morbidity.

• In the US, 5 million people have CHF. In the US, 5 million people have CHF. ½ these cases are from CHF with ½ these cases are from CHF with preserved LV function.preserved LV function.


• Classically, we’ve sought out causes Classically, we’ve sought out causes of CHF as a result of systolic of CHF as a result of systolic dysfunction.dysfunction.

• Now we are discovering that ½ cases Now we are discovering that ½ cases of CHF is being caused by diastolic of CHF is being caused by diastolic dysfunction, where LV systolic dysfunction, where LV systolic function is preserved.function is preserved.

Let’s Clarify some Let’s Clarify some misconceptions…misconceptions…

Misconception #1Misconception #1

Diastolic dysfunction is uncommon as is Diastolic Diastolic dysfunction is uncommon as is Diastolic congestive heart failure.congestive heart failure.

•Fact #1Fact #1– Everyone and their mother over the age of 40-Everyone and their mother over the age of 40-

50 has E/A reversal, during resting 2D echo. The 50 has E/A reversal, during resting 2D echo. The actual incidence is ~25-30% in individuals > 45 actual incidence is ~25-30% in individuals > 45 years.years.

– Over the past 10 years, incidence of Diastolic Over the past 10 years, incidence of Diastolic CHF has increased.CHF has increased.

•70 y.o pts’ incidence of CHF: SHF = DHF70 y.o pts’ incidence of CHF: SHF = DHF

•80 y.o pts’ incidence of CHF: DHF > SHF80 y.o pts’ incidence of CHF: DHF > SHF


• Discussions of Diastolic dysfunction Discussions of Diastolic dysfunction cause people to vasovagal, fall cause people to vasovagal, fall asleep, and bore them ½ to death. asleep, and bore them ½ to death. Diastolic dysfunction is simple, SEE?Diastolic dysfunction is simple, SEE?– E/A normal E/A normal great! Normal Diastolic great! Normal Diastolic

function! Stop pestering me!function! Stop pestering me!– E/A reversed E/A reversed whoop-dee-do. Abnormal whoop-dee-do. Abnormal

diastolic dysfunction. Can we stop talking diastolic dysfunction. Can we stop talking about this now?about this now?

FACT #2FACT #2

• This is actually ½ true – this subject is This is actually ½ true – this subject is great to put most people to sleep.great to put most people to sleep.

• HOWEVER, Diastolic dysfunction HOWEVER, Diastolic dysfunction classification should not be normal or classification should not be normal or abnormal. It’s patronizing to patient’s abnormal. It’s patronizing to patient’s who have rip-roaring CHF with who have rip-roaring CHF with preserved LV function.preserved LV function.

• Spectrum of disease. LOAD Spectrum of disease. LOAD DEPENDENT!!DEPENDENT!!

• This is why I’m giving the talk!This is why I’m giving the talk!


• Diastolic dysfunction = Diastolic CHFDiastolic dysfunction = Diastolic CHF

• Not quite!Not quite!

• Fact #3Fact #3– Diastolic dysfunction characterizes Diastolic dysfunction characterizes

abnormal relaxation of the LV, and for the abnormal relaxation of the LV, and for the purposes of this talk, an echo finding.purposes of this talk, an echo finding.

– Diastolic CHF describes a clinical syndrome Diastolic CHF describes a clinical syndrome of CHF in patient with preserved LV of CHF in patient with preserved LV function.function.

Causes of Diastolic Causes of Diastolic dysfunction dysfunction Heart Failure Heart Failure

• HypertensionHypertension







Other CausesOther Causes of abnormal of abnormal Diastolic fillingDiastolic filling

• CardiomyopathyCardiomyopathy– HypertrophicHypertrophic– RestrictiveRestrictive– InfiltrativeInfiltrative

• CADCAD

• Valvular heart diseaseValvular heart disease

• DiabetesDiabetes

• ObesityObesity

• Sleep ApneaSleep Apnea

• *** Constrictive Pericarditis*** Constrictive Pericarditis

Determinants of Diastolic Determinants of Diastolic fillingfilling

Quinones ASE Review 2007

Topics for DiscussionTopics for Discussion

1.1. Brief Review of Diastolic physiologyBrief Review of Diastolic physiology

2.2. MV inflow patternsMV inflow patterns

3.3. IVRT – Isovolumic Relaxation timeIVRT – Isovolumic Relaxation time

4.4. DT – Deceleration timeDT – Deceleration time

5.5. Velocity of propagationVelocity of propagation

6.6. Tissue Doppler of the MV annulus Tissue Doppler of the MV annulus

7.7. E/E’E/E’

8.8. Atrial Fib and Sinus TachycardiaAtrial Fib and Sinus Tachycardia

9.9. Diseases of the PericardiumDiseases of the Pericardium

10.10.The “who cares factor”The “who cares factor”

Normal Diastolic functionNormal Diastolic function

• Occupies about 2/3 of the cardiac Occupies about 2/3 of the cardiac cycle. Takes longer than systolecycle. Takes longer than systole

• Active process, requires energyActive process, requires energy

• Abnormalities of diastolic function Abnormalities of diastolic function ALWAYS precede those of systolic ALWAYS precede those of systolic function.function.– Ex: Acute MIEx: Acute MI

Normal Diastolic fillingNormal Diastolic filling

1. Isovolumic 1. Isovolumic RelaxationRelaxation

2. Early rapid 2. Early rapid diastolic filling diastolic filling phasephase

3. Diastasis3. Diastasis

4. Late diastolic 4. Late diastolic filling due to atrial filling due to atrial contractioncontraction

Quinones, ASE Review 2007


• When LV pressure When LV pressure becomes less than LA becomes less than LA pressure, MV openspressure, MV opens

• Rapid early diastolic Rapid early diastolic filling begins.filling begins.

• Driving force is Driving force is predominantly elastic predominantly elastic recoil and normal recoil and normal relaxation.relaxation.

• ~80% LV filling during ~80% LV filling during this phasethis phase


• As a result of rapid As a result of rapid filling, LV pressure filling, LV pressure rapidly equilibrates rapidly equilibrates with and may exceed with and may exceed LA pressure.LA pressure.

• Results in deceleration Results in deceleration of MV inflow.of MV inflow.

• Late diastolic filling is Late diastolic filling is from atrial contraction. from atrial contraction. It’s ~ 20% LV filling.It’s ~ 20% LV filling.

MV Inflow PatternsMV Inflow Patterns

MV inflow PatternsMV inflow Patterns

• 5 stages – Normal and Stages I – IV 5 stages – Normal and Stages I – IV diastolic dysfunctiondiastolic dysfunction

• Stage I – Impaired relaxationStage I – Impaired relaxation

• Stage II – Pseudo-normalStage II – Pseudo-normal

• Stage III – Restrictive Filling, reversibleStage III – Restrictive Filling, reversible

• Stage IV – Restrictive Filling, Stage IV – Restrictive Filling, irreversibleirreversible

MV PW inflow patternsMV PW inflow patterns

MV inflow pattern MV inflow pattern limitationslimitations

Advantages Disadvantages

DT and IVRTDT and IVRT

IVRT – Isovolumic relaxation IVRT – Isovolumic relaxation timetime

• Time interval Time interval between aortic between aortic valve closure and valve closure and mitral valve mitral valve opening. Usually opening. Usually obtained from obtained from Apical view with Apical view with Doppler sample Doppler sample between AV and MVbetween AV and MV

• It will lengthen with It will lengthen with impaired LV impaired LV relaxation and relaxation and decrease with with decrease with with increase in LV increase in LV filling pressures.filling pressures.

• Normal = 70 – 90 Normal = 70 – 90 ms.ms.

DT and IVRTDT and IVRT

• DT - Peak of the E DT - Peak of the E wave – time wave – time interval for the E interval for the E wave velocity to wave velocity to reach 0.reach 0.

• PHT = 0.29 * DTPHT = 0.29 * DT

• IVRT – time interval IVRT – time interval of AV closure to MV of AV closure to MV opening.opening.

Deceleration timeDeceleration time

• Nl = 160 – 220 msNl = 160 – 220 ms

• Deceleration time increases, if there is abnormal Deceleration time increases, if there is abnormal relaxation. It decreases in elevated LV filling relaxation. It decreases in elevated LV filling pressurespressures

• The LV can also relax vigorously from tremendous The LV can also relax vigorously from tremendous elastic recoil such as young healthy people (short elastic recoil such as young healthy people (short DT but normal)DT but normal)

• Conversely, if there is a decrease in LV compliance Conversely, if there is a decrease in LV compliance or a significant increase in LA pressure or a significant increase in LA pressure DT DT decreases (pathologic – suggests elevated filling decreases (pathologic – suggests elevated filling pressures)pressures)

IVRT + DT: Strengths and IVRT + DT: Strengths and WeaknessesWeaknesses

Strengths Weaknesses

Lester et al, JACC 2008; 51; 679 - 689

Velocity of Velocity of PropogationPropogation

(color M-mode of MV inflow)(color M-mode of MV inflow)

Velocity of propagation of Velocity of propagation of mitral inflowmitral inflow

• Normally, there is a Normally, there is a intraventricular pressure intraventricular pressure gradient.gradient.– Apical < BaseApical < Base

• This gradient decreases This gradient decreases with a decrease in with a decrease in myocardial relaxationmyocardial relaxation

• Color M mode displays Color M mode displays color coded mean color coded mean velocities from the velocities from the annulus to the apex over annulus to the apex over time.time.


• Color flow baseline needs Color flow baseline needs to be shifted to lower the to be shifted to lower the nyquist limit.nyquist limit.

• The central highest The central highest velocity jet should be blue. velocity jet should be blue.

• Trace the slope of the first Trace the slope of the first aliasing line.aliasing line.

• > 50 cm/s normal> 50 cm/s normal

• < 50cm/s abnormal< 50cm/s abnormal

• Load dependent. Load dependent.

• Hard to do accuratelyHard to do accurately


• Vp has been used to estimate filling Vp has been used to estimate filling pressures (PCWP)pressures (PCWP)1. E/Vp > 1.5 1. E/Vp > 1.5 PCWP > 15 mmHg PCWP > 15 mmHg

2. PCWP = 4.5 [1000/(2 x IVRT) + Vp] – 92. PCWP = 4.5 [1000/(2 x IVRT) + Vp] – 9

3. PCWP = (5.27 x E/Vp) + 4.63. PCWP = (5.27 x E/Vp) + 4.6

• Falsely high in restrictive Falsely high in restrictive Cardiomyopathy and HOCM.Cardiomyopathy and HOCM.

MV inflow propagation MV inflow propagation velocity: Strengths and velocity: Strengths and

WeaknessesWeaknesses Strengths Weaknesses

Lester et al, JACC 2008; 51; 679 - 689

LA VolumeLA Volume

LA Volume IndexLA Volume Index

• EASY TO DO!!EASY TO DO!!

• The new echo GOLD The new echo GOLD STANDARD for LA size.STANDARD for LA size.

• LA 2D dimension LA 2D dimension extrapolates that LA extrapolates that LA enlarges in an AP enlarges in an AP diameter. Erroneous diameter. Erroneous assumption. assumption.

• Correlates much better Correlates much better with the true gold standard with the true gold standard which is MRI.which is MRI.

• Has been called the HbAIC Has been called the HbAIC of cardiac disease. Robust of cardiac disease. Robust marker of clinical marker of clinical outcomesoutcomes

• WHAT DO YOU NEED:WHAT DO YOU NEED:– BSA (remember, it’s an BSA (remember, it’s an

index)index)– A4C and A2C traced A4C and A2C traced

LA’sLA’s– Shortest lengthShortest length

LA volumeLA volume

• Divide the LA volume Divide the LA volume by BSA!!by BSA!!

• A-L method is used A-L method is used most commonly most commonly (we don’t like (we don’t like

calculus)calculus)

• 22 +/- 6 ml / m2 22 +/- 6 ml / m2 (normal)(normal)– 28-34 - mild28-34 - mild– 34-40 - moderate34-40 - moderate– >40 - severe>40 - severe

LA volume: Strengths and LA volume: Strengths and WeaknessesWeaknesses


Lester et al, JACC 2008; 51; 679 - 689

Pulmonary Vein Pulmonary Vein ProfileProfile

Pulmonary venous flowPulmonary venous flow

• Normally 4 Normally 4 different waves different waves seen – S1/S2/D/Aseen – S1/S2/D/A

• Normal S – Normal S – dominance.dominance.

• Young people Young people can have a D can have a D dom normallydom normally

Pulmonary Vein ProfilePulmonary Vein Profile

• PVs1 – early in systole and PVs1 – early in systole and relates to atrial relaxation. relates to atrial relaxation. A decrease in LA pressure A decrease in LA pressure promotes forward flow.promotes forward flow.

• PVs2 – mid systole. PVs2 – mid systole. Represents the increase in Represents the increase in pulmonary venous pulmonary venous pressure.pressure.– Normally the S2>S1Normally the S2>S1

• Distinction only Distinction only identifiable in about 30% identifiable in about 30% people, normally.people, normally.


• PVd – occurs after PVd – occurs after opening of the MV and opening of the MV and in conjunction with in conjunction with decrease in LA pressuredecrease in LA pressure

• Pva – increase with Pva – increase with atrial contraction. May atrial contraction. May result in a flow reversal result in a flow reversal into the PV. Depends into the PV. Depends upon upon – LV diastolic pressureLV diastolic pressure– LA complianceLA compliance– HRHR


• Think of PVd and Pva as Think of PVd and Pva as extensions of MV inflow E and extensions of MV inflow E and A.A.

• The peak velocity and DT The peak velocity and DT correlate well with those of correlate well with those of mitral E velocity because the mitral E velocity because the LA acts as a passive conduit LA acts as a passive conduit for flow during early diastole.for flow during early diastole.

• DT becomes shorter as PCWP DT becomes shorter as PCWP increases.increases.

• Both Pva velocity and Both Pva velocity and duration increase with higher duration increase with higher LVEDP.LVEDP.

PV profiles in diastolic PV profiles in diastolic dysfunction.dysfunction.

Pulmonary Vein flow: Pulmonary Vein flow: Strengths and WeaknessesStrengths and Weaknesses


Lester et al, JACC 2008; 51; 679 - 689

Tissue DopplerTissue Doppler(here’s where it gets ugly)(here’s where it gets ugly)

Tissue dopplerTissue doppler

• Measuring Measuring tissue velocity tissue velocity and and NOTNOT blood flowblood flow

• Speed of tissue is ~ 1/10 of arterial Speed of tissue is ~ 1/10 of arterial blood.blood.– Arterial blood velocity ~ 150 cm/sArterial blood velocity ~ 150 cm/s– Venous Blood velocity ~ 10 cm/sVenous Blood velocity ~ 10 cm/s– Myocardial Tissue velocity ~ 1 – 20 cm/sMyocardial Tissue velocity ~ 1 – 20 cm/s

• Speed usually expressed in cm/sSpeed usually expressed in cm/s

Tissue Doppler – What we Tissue Doppler – What we change on echo Machineschange on echo Machines

• Doppler instruments are altered to Doppler instruments are altered to reject the high velocity of bloodreject the high velocity of blood

• Requires a high frame rateRequires a high frame rate

• DECREASE GAIN!DECREASE GAIN!

• Lower aliasing velocitiesLower aliasing velocities

QUESTION QUESTION

WHAT ARE THE 3 profiles seen WHAT ARE THE 3 profiles seen on Tissue Doppler?on Tissue Doppler?

Tissue dopplerTissue doppler

• 3 velocity profiles are seen – systolic (3 velocity profiles are seen – systolic (S’S’), Early Diastolic (), Early Diastolic (E’E’) )

and late diastolic (and late diastolic (A’A’))

• S’ S’ – systolic velocity of the MV annulus.– systolic velocity of the MV annulus.– Normally should be > 6 cm/sNormally should be > 6 cm/s– Can perform segmental or regional functional assessmentCan perform segmental or regional functional assessment

• E’ E’ – Early Diastolic velocity– Early Diastolic velocity– 2 sites are typically measured – medial and lateral – 2 sites are typically measured – medial and lateral – Normal RangeNormal Range……– E’m – > 10 cm/sE’m – > 10 cm/s– E’l > 15 cm/sE’l > 15 cm/s

• A’ A’ - Late diastolic velocity.- Late diastolic velocity.– Atrial contractionAtrial contraction– Correlates with LA functionCorrelates with LA function– Increases in early diastolic dysfunction Increases in early diastolic dysfunction – decreases with LA dysfunction (later diastolic dysfunction)decreases with LA dysfunction (later diastolic dysfunction)

TDI - applicationsTDI - applications

• Beyond E’ and E/E’, mostly in Beyond E’ and E/E’, mostly in research…research…

• Evaluation of Thick WallsEvaluation of Thick Walls– LVH, HCM, Infiltrative CM, Restrictive CM, & LVH, HCM, Infiltrative CM, Restrictive CM, &

Athlete's Heart Athlete's Heart – Normal TDI and strain vs abnormal TDI and strainNormal TDI and strain vs abnormal TDI and strain

• Assessment of viability (akinetic vs Assessment of viability (akinetic vs scar).scar).– Relates to Tissue velocity gradientsRelates to Tissue velocity gradients

Tissue Doppler – Normal Tissue Doppler – Normal ProfilesProfiles

Lateral > 15 cm/s

Medial > 10 cm/s

Tissue DopplerTissue Doppler

• E’ velocity is essential for classifying the E’ velocity is essential for classifying the diastolic filling pattern and estimating filling diastolic filling pattern and estimating filling pressures.pressures.

• Helpful to differentiate myocardial disease Helpful to differentiate myocardial disease from pericardial diseasefrom pericardial disease

• Normally E’ increases with an increase in the Normally E’ increases with an increase in the transmitral gradient (exertion or increase transmitral gradient (exertion or increase preload) preload)

• In Diastolic Dysfunction – it’s low & doesn’t In Diastolic Dysfunction – it’s low & doesn’t increase as much with exertion or inc. preloadincrease as much with exertion or inc. preload


• E’ decreases with aging (precedes even E’ decreases with aging (precedes even E/A reversal)E/A reversal)

• Load independent! ReproducibleLoad independent! Reproducible

• One of the earliest markers for diastolic One of the earliest markers for diastolic dysfunctiondysfunction

• Correlates with filling pressures, especially Correlates with filling pressures, especially when used as a ratiowhen used as a ratio– E/E’E/E’


STRENGTHSSTRENGTHS1. Can be obtained in 1. Can be obtained in

most patientsmost patients

2. Early marker of 2. Early marker of diastolic dysfunctiondiastolic dysfunction

3. Not influenced by 3. Not influenced by changes in heart ratechanges in heart rate

4. Primarily load 4. Primarily load independent in independent in disease statesdisease states

WEAKNESSESWEAKNESSES1. Influenced by local 1. Influenced by local

changes in wall changes in wall motion (infarction)motion (infarction)

2. Not accurate in 2. Not accurate in significant MV disease significant MV disease – –

- MAC- MAC

- MVR - MVR

Who cares about Tissue Who cares about Tissue Doppler? Doppler? (beyond the Echo Nerd Herd)(beyond the Echo Nerd Herd)

• E/E’ can guesstimate E/E’ can guesstimate PCWPPCWP– >15 >15 wedge > 20 wedge > 20– < 8 – normal< 8 – normal– 8 - 15 ??8 - 15 ??

• E/E’ has been E/E’ has been validated in clinical validated in clinical studies as a marker of studies as a marker of elevated PCWP (> 15).elevated PCWP (> 15).

• Elevated E/E’ is Elevated E/E’ is predictive of poor predictive of poor outcomes in MIoutcomes in MI

• Significantly Significantly decreased E’ decreased E’ associated with higher associated with higher mortality.mortality.

E/E’ is a robust clinical E/E’ is a robust clinical markermarker

What the ratio What the ratio means?means?

> 15 > 15 elevated elevated filling pressuresfilling pressures

< 8 < 8 Nl Nl

8 – 15 8 – 15 ??? ???

Nagueh et al, JACC 1997; 30: 1527 - 1533

Assessment of Diastolic Assessment of Diastolic filling in A-fib and Sinus filling in A-fib and Sinus

TachycardiaTachycardia• A fib:A fib:

– No A wave from Mv inflow and blunted No A wave from Mv inflow and blunted PVs wavePVs wave

– DT time measurement is tricky, variableDT time measurement is tricky, variable– Can use E/E’Can use E/E’– Can use DT of the PVd waveCan use DT of the PVd wave

• Sinus TachycardiaSinus Tachycardia– E and A waves may fuse.E and A waves may fuse.– Use E/E’Use E/E’

Let’s ReviewLet’s Review

Normal MV inflowNormal MV inflow

• E/A = 0.9-1.5E/A = 0.9-1.5

• DT = 160-240 DT = 160-240 msms

• IVRT 70-90 msIVRT 70-90 ms

• Vp > 50 cm/sVp > 50 cm/s

• S – dominant S – dominant PV patternPV pattern

Stage IStage I• DT > 240 msDT > 240 ms

• E/A < 0.9E/A < 0.9

• IVRT - > 90 msIVRT - > 90 ms

• LAVI>28 ml/m2LAVI>28 ml/m2

• E’<10E’<10

• Vp < 50 cm/sVp < 50 cm/s

• S – dominant S – dominant PV patternPV pattern

Stage IIStage II

• Looks the same like Looks the same like normal – hence the normal – hence the name name “pseudonormal”“pseudonormal”

• Many of the Many of the parameters are the parameters are the same as Normal LV same as Normal LV inflow.inflow.

• PV – S blunting or D PV – S blunting or D dominant PVdominant PV

How do I differentiate How do I differentiate between Stage II and between Stage II and

normal?normal?• Valsalva – Valsalva – shouldn’t change normal but pseudonormal should look shouldn’t change normal but pseudonormal should look

like Stage I. Also Stage III should look like stage Ilike Stage I. Also Stage III should look like stage I

• E’ (Tissue Doppler) – E’ (Tissue Doppler) – Normal is normal. Lower velocities Normal is normal. Lower velocities with diastolic dysfunction (E’m <10, E’l < 15).with diastolic dysfunction (E’m <10, E’l < 15).

• Left atrial volume – Left atrial volume – With elevated filling pressures, the With elevated filling pressures, the left atrium will remodel and enlarge (LA Volume Index > 28 ml / m2)left atrium will remodel and enlarge (LA Volume Index > 28 ml / m2)

• Velocity of propagation - Velocity of propagation - > 50 cm/s (normal) or < > 50 cm/s (normal) or < 50 cm/s (abnormal)50 cm/s (abnormal)

• D – dominant pulmonary veinsD – dominant pulmonary veins

Stage IIStage II

ValsalvaValsalva

The 4 Phased Valsalva The 4 Phased Valsalva ManeuverManeuver

PHASES PHASES

• I - AO pressure I - AO pressure increases (increase in increases (increase in IT pres.)IT pres.)

• II – AO and PP II – AO and PP decrease because decrease because dec. in preload. Reflex dec. in preload. Reflex tachycardia.tachycardia.

• III – AO pressure III – AO pressure decreases more in decreases more in response to release of response to release of IT pressureIT pressure

• IV – recovery period. IV – recovery period. Preload, AO, PP + Preload, AO, PP + increase.increase.

Nishimura et al. Mayo clinic proceedings. 2004;79: 577-578.

Stage III – Stage III – Restrictive,reversibleRestrictive,reversible

• DT < 160 msDT < 160 ms

• IVRT < 70 msIVRT < 70 ms

• E/A > 2:1E/A > 2:1

• E’ < 5cm/sE’ < 5cm/s

• Vp < 50 cm/sVp < 50 cm/s

• LAVI > 35 ml / m2LAVI > 35 ml / m2

• D>>S (PV Pattern)D>>S (PV Pattern)

Stage III – Restrictive, Stage III – Restrictive, reversiblereversible

ValsalvaValsalva

Stage IV – restrictive Stage IV – restrictive irreversibleirreversible

• DT < 130msDT < 130ms

• E/A > 2.5E/A > 2.5

• E’ < 5 cm/sE’ < 5 cm/s

• Vp < 50 cm/sVp < 50 cm/s

• IVRT < 70msIVRT < 70ms

• LAVI > 40LAVI > 40

• No valsalva changeNo valsalva change

• D>>S (PV pattern)D>>S (PV pattern)

What about other causes of What about other causes of CHF with preserved LV CHF with preserved LV functionfunction

TEE 5C viewTEE 5C view

Causes of pericardial Causes of pericardial constrictionconstriction

• Prior Cardiac surgeryPrior Cardiac surgery

• IdiopathicIdiopathic

• PericarditisPericarditis

• Prior RadiationPrior Radiation

• Collagen VascularCollagen Vascular

• Infection (TB)Infection (TB)

Constrictive PericarditisConstrictive Pericarditis

• Everything we’ve spoken about for Everything we’ve spoken about for diastolic dysfunction DOES NOT APPLY diastolic dysfunction DOES NOT APPLY HERE.HERE.

• Not uncommonNot uncommon

• Escapes clinical and echo detectionEscapes clinical and echo detection

• Pericardial Thickness may be normal in Pericardial Thickness may be normal in 1/51/5thth of cases of cases

• Calcification of the pericardium may only Calcification of the pericardium may only occur in ~ 20% pts on CXRoccur in ~ 20% pts on CXR

Constrictive Pericarditis – Constrictive Pericarditis – some Echo findingssome Echo findings

• Thickened pericardium (~ 80%)Thickened pericardium (~ 80%)

• Abnormal ventricular septal motionAbnormal ventricular septal motion

• Flattening of the posterior wall during Flattening of the posterior wall during diastolediastole

• Respirophasic variation of Ventricular Respirophasic variation of Ventricular cavity size cavity size

• Dilated IVCDilated IVC

Echo criteria to diagnose Echo criteria to diagnose Pericardial ConstrictionPericardial Constriction

1)Disassociation between 1)Disassociation between intrathoracic and intra-pericardial intrathoracic and intra-pericardial pressures. (normally they’re related)pressures. (normally they’re related)

2)Exaggerated ventricular 2)Exaggerated ventricular interdependence (i.e. the filling of interdependence (i.e. the filling of one, significantly impacts the filling one, significantly impacts the filling of the other)of the other)

Doppler Findings in Doppler Findings in Constrictive PericarditisConstrictive Pericarditis

Respiratory variation of >25% in mitral E velocity Respiratory variation of >25% in mitral E velocity

Doppler Findings in Doppler Findings in Constrictive PericarditisConstrictive Pericarditis

• Increased DFR with expiration in the Increased DFR with expiration in the hepatic vein.hepatic vein.

• OH Figure 17-29OH Figure 17-29

Other features of Other features of constrictionconstriction• Tissue doppler that is > 7 cm/s (annulus Tissue doppler that is > 7 cm/s (annulus

paradoxus)paradoxus)– Unless the myocardium is involved, myocardial Unless the myocardium is involved, myocardial

relaxation is intact.relaxation is intact.– Septal annular velocities are normal or even increased Septal annular velocities are normal or even increased

(not close to the pericardium like the lateral annulus)(not close to the pericardium like the lateral annulus)

• PW MV inflow that looks like restrictive PW MV inflow that looks like restrictive filling pattern filling pattern – E/A > 1.5 and DT < 160 ms.E/A > 1.5 and DT < 160 ms.

• E/E’ is E/E’ is inverselyinversely proportional to the PCWP proportional to the PCWP (as opposed to myocardial diseases).(as opposed to myocardial diseases).

WHO CARES?WHO CARES?

Who cares about diastolic Who cares about diastolic dysfunction?dysfunction?

• Steady rise in prevalence of CHF with preserved Steady rise in prevalence of CHF with preserved LV function.LV function.

• By the 7By the 7thth decade, incidence of diastolic CHF = decade, incidence of diastolic CHF = systolic CHFsystolic CHF

• By the 8By the 8thth decade, incidence of diastolic CHF > decade, incidence of diastolic CHF > systolic CHFsystolic CHF

• The survival of patients with the clinical The survival of patients with the clinical syndrome of heart failure is similar in those syndrome of heart failure is similar in those with persevered versus those with a with persevered versus those with a reduced LV ejection fractionreduced LV ejection fraction

SummarySummary

• Diastolic Dysfunction is a real, dynamic Diastolic Dysfunction is a real, dynamic process. process.

• Much information can be gained on LV filling Much information can be gained on LV filling pressures without a drop of blood (no cath)pressures without a drop of blood (no cath)

• Prognostic information and therapeutic options Prognostic information and therapeutic options stem from the results (myocardial, pericardial).stem from the results (myocardial, pericardial).

• You are in the front line to look for this stuff. You are in the front line to look for this stuff. Keep a sharp look out, you’ll favorably alter Keep a sharp look out, you’ll favorably alter patient care. That’s the bottom line.patient care. That’s the bottom line.

Thank you !Thank you !(for not falling asleep)(for not falling asleep)

diastolic dysfunction: nuts, bolts & who cares ? kunjan bhatt md austin heart

Documents