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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 listening!oh.jae@mayo.edu

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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

©2011 MFMER | slide-44

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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