diastolic function assessment...normal values jase and ej cv imaging april 2016 ©2018 mfmer |...
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©2018 MFMER | 3712003-1
Diastolic Function Assessment Practical Ways to Incorporate into Every Echo
Jae K. Oh, MDEcho Hawaii 2018
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Learning ObjectivesMy presentation will help you to • Appreciate the importance of myocardial relaxation for satisfactory
diastolic function
• Assess and Grade diastolic function
• Estimate LV filling pressure noninvasively
• Incorporate Diastolic Function assessment into every Echo
• Apply Diastolic Function Assessment in• Diagnosis of HFpEF• Exercise Diastolic Test• Restrictive CM vs Constriction
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Cardiac FunctionSystole and Diastole (διαστολή)
Normal diastolic function allows adequate filling of the heart without excessive increase in diastolic filling pressure at rest and
with stress
Filling Pumping
διαστολή: Greek word for dilation
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Diastolic Filling with Relaxation
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Diastolic Filling PatternsTransmitral Gradient vs Mitral Inflow
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Firstenberg et al: J Appl Physiol 90:299, 2001, Nagueh et al: JACC 1997Oki et al: AJC 1997 , Sohn et al:JACC 1997, Ommen et al: Circ 2000
LV Relaxation by Cath and Echo (tau) vs e’ (mitral annulus velocity)
0
20
40
60
80
100
120
0 2 4 6 8 10 12e’ (cm/sec)
tau
(m
sec) y=-6.80x + 85.68
r=0.70P<0.001
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Which of following patients has the most advanced diastolic dysfunction (or impaired relaxation)?
1 2 3
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Myocardial Relaxation (e’)
e’ = 12 cm/sec e’ = 7 cm/sec e’= 3 cm/sec
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Mitral flow
Mitral annulusvelocity
Evaluation of Diastolic FunctionMitral Inflow and Annulus Velocity
Sohn et al: JACC, 1997
Normal Ab Relax Pseudo RestrictiveGrade 1 Grade 2 Grade 3
CP1254003-30
Preload dependent
Preload independent
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Estimation of LV Filling PressuresE/e’ (Medial MV annulus)
0
5
10
15
20
25
30
35
40
Ommen SR et al: Circulation 102:1788, 2000
LV f
illin
g p
ress
ure
EF >50%EF <50%
E/E <8 E/E 8-15 E/E >15
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Four Major Parameters in DiastologyNormal values
1. E’ velocity ≥ 7(med), 10 (lat) cm/s
2. E/e’ ≤ 14 (Ave), 15(Med)
3. TR velocity ≤ 2.8 m/sec
4. LAVI ≤ 34 mL/m2
Four Major Diagnostic ParametersNormal Values
JASE and EJ CV Imaging April 2016
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New Criteria for Diastolic Function Assessment
In pts with normal LVEF≥ 50%
1 – Septal e’ velocity ≥7 cm/s orlateral e′ velocity ≥10 cm/s
2 – Average E/e′ ≤14 , 15 (Med)3 – TR velocity ≤2.8 m/s4 – LA volume index ≤34 mL/m2
≥ 3 Normal 2 and 2 ≥ 3 Abnormal
Normal diastolic function Indeterminate Diastolic dysfunction
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71 year old woman with HR 45 BPM & LAVI = 39 mL/m2
Lateral e’ = 10 cm/sec Medial e’ = 9 cm/sec
E/e’ = 9 E/e’ = 10
E/e’ NL < 14E’ NL > 7
LAVI EnlargedTR NL < 2.8
LVOT TVI = 30 cm
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67 year old man with HF
E= 100 A = 30 cm/secE/A = 3.3
e’ = 5 cm/secE/e’ = 20
ӿ E’ӿ E/e’ӿ LAVIӿ TR vel.
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In patients with depressed LVEF or normal EF with diastolic dysfunction
Mitral inflow
E/A ≤0.8 + E <50 cm/s
E/A ≤0.8 + E >50 cm/sor
E/A >0.8-<2
E/A ≥2
Normal LAPGrade I diastolic
dysfunction
3 criteria to be evaluated*
1 – Average E/e′ >142 – TR velocity >2.8 m/s3 – LA volume index >34 mL/m2
2 of 3 negative
2 of 3 or3 of 3
positive
2 negative2 negative 1 positive and1 negative
1 positive and1 negative 2 positive2 positive
When only 2 criteria are availableWhen only 2 criteria are available
Cannot determine LAP and diastolic dysfunction
grade*
LAPGrade II diastolic
dysfunction
LAPGrade III diastolic
dysfunction
If symptomatic consider CAD or proceed to diastolic stress test
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67 year old man with HFGR 3 Diastolic Dysfunction with Severe Increase in Filling Pressure
E= 100 A = 30 cm/secE/A = 3.3
e’ = 5 cm/secE/e’ = 20
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67 yo man with ischemic CM and HFGr. 1 dysfunction = normal filling pressure
E= 45 cm/sec A= 90 cm/secE/A = 0.5
Grade 1 DysfunctionE/A ≤ 0.8
E <50 cm/sec
E=45 cm/s A= 90 cm/sE/A = 0.5
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67 year old man with ischemic CM and HF
2 months before
E= 120 cm/sec E/A =1.0E/e’ = 30
TR Vel = 3 m/sec
E= 45 cm/s E/A = 0.5E/e’= 12
Medial e’ = 4 cm/s
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Ischemic Cardiomyopathy Echo PredictorSTICH Trial (N=1511)
Best survival with E/A 0.5-0.8
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Grade the diastolic function of23 YO male with HCM
1. Grade 1
2. Grade 2
3. Grade 3
4. Possibly normal
E = 70 cm/s A= 30 cm/s E/A = 2.3
Case # 2 ARS
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23 yo with HCM
Medial e’ = 8 cm/sec Lateral e’ = 10 cm/sec
E = 70 cm/s
E/e’ = 9 E/e’ = 7
Can he have a normal diastolic function ?
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23 yo man with HCMLAVI 29 mL/m2
TR = 2 m/sec IVRT = 120 msec
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Valsalva in 23 yo HCMNormal filling pressure
E/A= 2.3 E/A = 2.0
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When LVEF is reduced or Diastolic Function is abnormal
Mitral inflow
E/A ≤0.8 + E <50 cm/s
E/A ≤0.8 + E >50 cm/sor
E/A >0.8-<2
E/A ≥2
Normal LAPGrade I diastolic
dysfunction
3 criteria to be evaluated*
1 – Average E/e′ >142 – TR velocity >2.8 m/s3 – LA volume index >34 mL/m2
2 of 3 negative
2 of 3 or3 of 3
positive
2 negative 1 positive and1 negative 2 positive
When only 2 criteria are available
Cannot determine LAP and diastolic dysfunction
grade*
LAPGrade II diastolic
dysfunction
LAPGrade III diastolic
dysfunction
If symptomatic consider CAD or proceed to diastolic stress test
e’ < 7 cm/s
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Prognosis of a patient after AMI
E’ = 8 cm/s
TR = 2 m/sec
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Anterior Wall Myocardial Infarction
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An elderly man with exertional dyspnea
E= 80 A=80
E’ = 5 cm/sec E/e’ = 16
TR = 2.9 cm/s
HFpEF
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Diastolic function assessment in patients with mitral annulus calcification
E= 100 cm/sec
Lat e’= 4 cm/s Med e’ = 3 cm/s
TR = 2.4 m/sec
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Mitral annulus e’ velocity vs MACMean age 73 years
Variable
Group 1n=79
no MAC
Group 2n=38
mild MAC
Group 3n=38
mod-severe MAC P for trend
Agatston Score 0 1-119 >119
Septal e’ 5.96±1.82 5.15±1.56 5.05±1.93 0.01
Lateral e’ 7.37±2.44 6.89±2.71 6.28±1.81 0.01
Average e’ 6.63±2 6.02±1.79 5.67±1.69 0.01
E/avg e’ ratio 13±4.93 15±8.95 18±8.26 <0.001
Codolosa et al: Am J Cardiol 2016;117:847-852
LV diastolic parameters are altered in the presence of MAC. This could be due to direct effects of MAC or might reflect truly reduced diastolic function. Interpretation
of diastolic parameters in patients with MAC should be performedwith caution.
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Proposed Clinical Algorithm for Estimationof Left Ventricular Filling Pressure in
Subjects With Mitral Annular Calcification
Abudiab et al: Am Coll Cardiol Img, 2017
High LVFP
Normal LVFP High LVFP
Initial Cohort (n=50):Sensitivity: 81%Specificity: 100%
Total Cohort (n=71):Sensitivity: 85%Specificity: 95%
Initial: 8/9 (89%)Total 12/13 (92%)
10/10 (100%)11/11 (100%)
4/9 (44%)9/14 (64%)
16/16 (100%)23/24 (96%)
Mitral E/A
IVRTNormal LVFP
<0.8 0.8-1.8 >1.8
80 ms <80 ms
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Atrial Fib. And Mitral Regurgitation
Medial e’ = 8 cm/s E= 90 cm/s E/e’=11
TR = 2.5 m/sec
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Atrial Fib. And Mitral Regurgitation with exercise
Medial e’ = 8 cm/s
E= 90 cm/s
TR = 2.5 m/sec
E= 130 cm/s and DT 120 msec
Medial e’ = 9 cm/s
TR = 3.2 m/sec
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Diastolic Function in A. Fib
• DT < 160 msec (with reduced EF)
• DT < 130 msec poor survival (Hurley, Oh)
• Other measurements• E acceleration > 1900 cm/sec2
• IVRT ≤ 65 msec• E/e’ ≥ 11• IVRT/ T E-e’• TR velocity
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E/e’ =20
E=120
E’= 6
JASE 1999
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An elderly patient with worsening dyspnea
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Take-home message Part 1
• Abnormal LV relaxation is one of the first manifestation of diastolic dysfunction
• Mitral annulus e’ velocity is a clinically reliable parameter for LV relaxation
• Diastolic function and filling pressure can be assessed by simple Echo-Doppler parameters at rest and with exercise
• E/e’ ≥ 15 is specific for increased filling pressure
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Thanks for [email protected]
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Mitral Regurgitation and Diastolic Function
E= 80 cm/s
E’ = 6 cm/sE/e’ = 13
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Mitral Regurgitation and Diastolic Function
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Assessment of Diastolic FillingBefore and after TAVR
Baseline Normal Filling Pressure Post TAVR with PVARIncrease in FP
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89 year old with TAVR4 year follow-up
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Stages of Heart Failure2013/14 HF Guideline
A B C D
At high risk for HF W/O SHD or symptoms
Structural Heart Disease W/O symptoms or signs
Structural Heart Disease W/ symptoms or signs
Refractory Heart Failure
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Distribution of Values of LV Moprhofunctional Parametersfor Stage B Heart Failure Categorization
Kosmala W et al: JACC 65:257-266, 2015
Strain > -18% (n=13)
Strain -18% (n=58)
Strain > -49% (n=13)
Strain -18% (n=267)
Strain > -18% (n=11)
Strain -18% (n=29)
Strain > -18% (n=11)
Strain -18% (n=60)
E/eʹ <13n=83
E/eʹ >13n=40
E/eʹ >13n=71
E/eʹ <13n=316
Moderate-to-severe LVHn=123
No or mild LVHn=387
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Mitral A duration is shorter than PV ARIncreased LVEDP
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Rossvoll and Hatle:JACC, 1993Rossvoll and Hatle:JACC, 1993
PVad-Ad (ms)PVad-Ad (ms)
EDP(mm Hg)EDP(mm Hg)
r=0.68r=0.68P<0.001P<0.001
05
1015202530354045
-100 -50 0 50 100
Ma=100 msPVa=165 ms
0.5
0.5
Mitral flow velocity LV pressure
Pulmonary vein
25 mm Hg
DopplerDeterminationof LVEDP
DopplerDeterminationof LVEDP
CP1057136-18
LVEDP can be increased with normal mean LV diastolic pressure
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LEVDP Elevation with normal filling pressure
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“L” WaveDelayed Relaxation + Increased Filling Pressure
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CP1100934-2
0.15
m/s
0.15
m/s
0.80
Frommelt et al: JASE 16:176, 2003
Mid-diastolic mitral flow (L)Delayed relaxation
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95 year old woman
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95 year old woman
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Normal “L” wave