Diastolic Function Overview - Indonesian Echo Function Overview.pdf · Diastolic Function Overview...

Diastolic Function Overview

Richard Palma BS, RDCS, RCS, APS, FASE

Director and Clinical Coordinator

The Hoffman Heart and Vascular Institute

School of Cardiac Ultrasound

Disclosures

• None

Learning Objectives

•Review the ASE/EAE Guidelines & Standards for the

assessment of DF

•Discuss normal and abnormal filling pressures

•List measurements

•Discuss technical tips

•Discuss caveats, pitfalls, limitations of Doppler measurements

•Review key points on what and how to measure DF

Why Assess Diastolic Function? Treatment Purpose

Stage 1: Abnormal relaxation (low E’ velocity, but no evidenced increase pressures)

- ß-Blockers Heart rate control during exercise

- Calcium channel blockers

- ACE inhibitors Regression of LVH, afterload reduction

Stage 2: Pseudonormal (low E’ velocity, with evidenced of increased pressures)

- Above + diuretics/nitrates Achieve preload & afterload reduction

Stage 3: Restrictive filling (low E’ velocity, with evidenced of highly elevated pressures)

- Diuretics Preload reduction

- ACE inhibitors Preload & afterload reduction, survival benefit

- Nitrates Preload reduction

- ß-Blockers LV remodeling, survival benefit

- Digoxin (-CCBs ? ß-B) Symptomatic improvement

Information modified from: Naqvi TZ. Reviews in CV Medicine 2003;4:81-99.

Filling Pressures are Considered

Elevated When…

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Mean PCWP > 12 mmHg/LVEDP > 16 mmHg

ASE/EAE Guidelines

Nagueh et al, J Am Soc Echocardiogr. 2009 Feb;22(2):107-33. Eur J Echocardiogr. 2009 Mar;10(2):165-93

Table 1 reference values from: De Sutter J et al. Am J Cardiol 2005;95:1020-3

Diastolic Function Work-up

Mitral A wave

Mitral E wave

E wave deceleration

Transmitral Characteristics

Key Points

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Systolic waveforms (S1,S2) Diastolic waveform

Atrial reversal waveform

Pulmonary Vein Characteristics

Key Points

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations

• Far-field resolution issues

• Velocity motion artifacts

• Arrhythmias

• Feasibility

Valsalva Maneuver

Strain phase Early phase

Dumesnil JG, et al. Am J Cardiol. 1991;68:515–519

Release phase

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Key Points

Limitations

• Challenging to perform correctly

• Not standardized

• DTI stole the show!

e’ velocity

a’ velocity

Doppler Tissue Imaging (DTI) Characteristics

s’ velocity

Isaaz et al. Am J Cardiol. 1989;64:66-75

Key Points

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations

• Multiple peaks

• MAC

• WMAs

E/e’ Ratio for Estimation of

Filling Pressures

Peak mitral E velocity

Peak DTI e’ velocity

Nagueh et al, JACC 1997, Ommen et al, Circ. 2000

Color M-mode Velocity Propagation

(CMM-Vp) Characteristics

Garcia et al, J Am Coll Cardiol 1997;29:448-54, Moller et al. (J Am Coll Cardiol 2000;35:363–70

Abnormal Relaxation: CMM Vp

Key Points

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Limitations

• “Slopes” can be difficult to measure

• Load and EF dependant

• Vp can be increased in patients with

normal LV volumes and EFs, despite

impaired relaxation

LA End-Systolic Volume Index

(LA-ESV): What to Avoid

4-chamber 2-chamber

Aurigemma et al. Circ Cardiovasc Imaging 2009;2:282-289

Abhayaratna , et al. J Am Coll Cardiol 2006;47:2357-63

IAS

Pulm Vein

Tenting Vol

Pulm Vein

Estimation of PASP Included in the

DF Work-up

Bouchard et al. Am J Cardiol 2008;101:1673–1676

Image adapted and modified from: Oki T, et al. Am JCardiol April 1997;79:921– 8

• Tau is time constant of

isovolumic relaxation

• Tau > 48 ms = abnormal

relaxation

• e’ velocity showed significant

correlation with Tau

• Longer Tau = slower

relaxation = lower e’ velocity

r = - 0.78, p <0.0001

N =50

Tissue Doppler e’ Velocity Validation

(posterior wall)

Isaaz et al. Am J Cardiol. 1989 Jul 1;64:66-75.

Sohn et al. J Am Coll Cardiol, August 1997;30:474–80

Further e’ Validation

(septal annulus)

Septal DTI E’ only

E/e’ Ratio Validation

(lateral annulus)

Nagueh et al. J Am Coll Cardiol, November 1997;30:1527–33

Open Circles= PN

“E/e’>10 = PCWP >15”

Lateral DTI E’ only

Where’s the Peak e’ Velocity?

Where’s the Peak e’ Velocity?

IVRT Duration & Velocity in

Abnl Relaxation

Normal Relaxation

Prolonged

IVRT

Peak E’ velocity Peak IVRT velocity

Abnormal Relaxation

Normal IVRT

Peak E’ velocity Peak IVRT velocity

Factors That May Influence

Doppler Tracings

Sample volume positioning

Doppler gain

Annular restriction (MAC)

Respiration

Effects of SV Positioning Too far into cavity

Too close to annulus Leaflet tips

Appleton et al. J Am Soc Echocardiogr 1997;10:271-91

A D E F B C

Hill, Palma. J Am Soc Echocardiogr 2005;18:80–90

Bierig, Hill. J Diagn Med Sonography 2011;27:65–78.

Effects of SV Positioning on DTI

Effects of Gain on DTI Waveforms

Spectral broadening: e’ = 16 cm/s

Optimized: e’ = 12 cm/s

Faint waveforms: e’ = 8 cm/s

Waggoner AD, Bierig SM. J Am Soc Echocardiogr 2001;14:1143-52.

MAC Influences the E/e’ Ratio

Soeki, et al, Jpn Circ J 2001

e’ = 5 cm/s: E/e’ = 11 e’ = 9 cm/s: E/e’ = 5

MAC Below MAC

Effects of Respiration on DTI

Hill, Palma, JASE 2005

Normal Respiration

Ave e’ = 10

End-apnea

Ave e’ 7

E/e’ Ratio Validation in AFIB

(septal & lateral annulus)

N = 27

Kusunose K, et al: JACC Cardiovasc Imaging 2009;2:1147–1156

“E/e’>11 = Elevated pressures”

Sohn DW, et al. J Am Soc Echocardiogr 1999;12:927-31

AFib With & Without Suspected

Elevated Filling Pressures

RVSP 25 mmHg: E/e’ = 10 RVSP 35 mmHg: E/e’ = 20

Bierig, Hill. J Diagn Med Sonography 2011;27:65–78.

*Table adapted and modified from Redfield et al

Classification of Diastolic Function

Images modified from Redfield et al, JAMA. 2003;289:194-202

• E/A, DT and E/E’ were measurable in approximately 3/4 of pts

• The most common reasons for inability to record data were

(1) absence of apical view

(2) fusion of these waves

• Pulmonary vein flow and A dur were only measurable in 1/2 and 1/4 of pts

• 12% “unclassifiable”

Prevalence of Unclassifiable Diastolic Function:

“Real World” Diastology

Variable Measurable

(%)

E/A 71

DT 73

E/e’ 75

Pulm vein S/D 56

P/A duration 25

Narayanan A,. Circulation 2008 (Abstract);118(18):787

N =100

Case Studies

• 60 y/o male

• DM, HTN, CAD

• 5ft 6in / 270 lbs

• Unable to assess PASP

• No significant valvular dz

• Moderate LAE

• 68 y/o male

• CHF

• CAD/RCA territory

• Inferior WMA’s

• BPEF = 44%

• PASP = 19 mmHg

• No significant valvular dz

• Mild LAE

*Table adapted and modified from Redfield et al

This Patient Has…

E/e’ = 9

Not measured

• 30 y/o female

• Edema

• Borderline tachycardia

• Evaluate RV/LV fx

• PASP = 17 mmHg

• No significant valvular dz

• NL LA size

e’

a’

e’

a’

This Patient Has…

Normal E’ velocity

Not measured

Not measured

Not measured

64 y/o male

CAD, Dyspnea

Borderline tachycardia

EF = 25-30%

Multiple WMAs

PASP = 50 mmHg

No significant valvular DZ

Moderate LAE

Vp = 61

This Patient Has…

E/e’ = 17

Discrepancy!

• 82 y/o female

• HHD/CHF

• Multiple WMA’s

• PASP = 48 mmHg

• EF = 35-40%

•Moderate/severe LAE

• Severe MAC

This Patient Has…

Discrepancy!

Not measured

29 y/o male

CP, mild DOE

PASP = 25 mmHg

No valvular dz

NL LA size

EF = 60-65%

No WMA’s

This Patient Has…

E/E’ = 7

Not measured

Not measured

• 84 y/o female

• H/O HTN, CAD, CHF

• Dyspnea, new pedal edema

• Multiple WMAs

• PASP = 45 mmHg

• Severe LAE

BP EF = 33%

Significant “Down Time”: MPI

a’

e’

IVRT s’ IVCT

E/e’ Unreliable 2 MAC

Elevated CVP = Pedal Edema

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2009;2:107-33

At the End of the Day…