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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…
