ECHOCARDIOGRAPHIC EVALUATION of LEFT VENTRICULAR DIASTOLIC FUNCTION toufiqur rahman NICVD

ECHOCARDIOGRAPHIC EVALUATION of LEFT VENTRICULAR DIASTOLIC FUNCTION

Dr. Md.Toufiqur Rahman

MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,

FAPSC, FAPSIC, FAHA, FCCP, FRCPG

Associate Professor of CardiologyNational Institute of Cardiovascular Diseases(NICVD),

Sher-e-Bangla Nagar, Dhaka-1207

Consultant, Medinova, Malibagh branch

Honorary Consultant, Apollo Hospitals, Dhaka and

STS Life Care Centre, Dhanmondi [email protected]

One decade and a half back, diastole of the heart thought

to be wholly passive. Though it occupies the greater part

of cardiac cycle. We thought that this period is meant for

the passive filling of the ventricle and subsequent systole

does the job of left ventricular function. In the course of

different observations there was a puzzle in that, there was

good contraction but yet there is feature of ‘heart failure’.

We have now solved the puzzle and identify that functions

of the left ventricle depend on either systolic or diastolic-

sometimes on both.

INTRODUCTION

Assessment of Diastolic Ventricular Function

Defining diastole

Methods to assess diastole

Patterns of diastolic disease

Age-related changes

When does diastole occur?Required for every heart beat

Systole

Diastole

Isovolumic relaxation Early rapid filling Diastasis ( slow diastolic filling phase) Atrial contraction

4 Phases of diastole

Phases of Diastole

Isovolumetric relaxation

Rapid filling◦ E-wave

2/3 LV filling Diastasis

Atrial contraction◦ A-wave

1/3 LV filling

Factors Affecting Diastole Ventricular function AV valve function Rate of relaxation Ventricular compliance Atrial systolic function Preload Heart rate and rhythm

Ventricles receive blood at a regular fashion in diastole which encompasses the isovolumic relaxation and filling phases of the cardiac cycle and has active and passive components.

Diastolic function of the heart:

Active myocardial relaxation -mediated by intracellular calcium and ATP Passive Pressure-Volume relationship of left

ventricle -Elastic nature of the myocardium -Chamber size and shape -Wall thickness -Right & left ventricular pressure-volume

interaction -Intrathoracic pressure -Pericardial restraint - Incomplete active myocardial relaxation Left atrial function

DETERMINANTS OF DIASTOLIC FUNCTION

It implies impaired filling of ventricle at its usual low filling pressure

Ventricular filling is slow, delayed or incomplete, with a normal atrial pressure

DIASTOLIC DYSFUNCTION

a) Impaired Relaxation Myocardial infarction

b)Decreased compliance of LV Restrictive cardiomyopathy Endomyocardial fibrosis Elderly people, particularly ladies Diabetes mellitus

Aetiology of diastolic dysfunction

c) Both compliance and relaxation abnormality

Hypertensive heart disease Hypertrophic obstructive cardiomyopathy IHD Aortic valvular disease

d)Co-existent with systolic dysfunction

IHD Cardiomyopathy

Aetiology of diastolic dysfunction

a) Clinical parameters:Features of underlying aetiologyAbsence of other causes of dyspnoeaFeatures of LV dysfunction

b) ECG: LVH, LA enlargement, IHD

c) CXR: Normal heart size

Assessment Of LV diastolic dysfunction

c) Doppler Echocardiographic Evaluation

Mitral valve inflow pattern Pulmonary venous flow pattern Mitral inflow at peak valsalva maneuver Colour M-mode ( CMM) –propagation study Doppler tissue imaging (DTI) of the mitral

annulus

d) Cardiac catheterization

e) Radionuclide techniques

Assessment Of LV diastolic dysfunction

LV filling patterns are assessed using pulsed wave Doppler mitral flow velocity recordings.

4 useful variables are- E-peak early diastolic transmitral flow velocity A-peak late diastolic transmitral flow velocity DT-early filling decelerayion time A dur-A wave duration

MITRAL VALVE INFLOW PATTERN

Peak E wave velocity: 53-105 cm/sec Peak A wave velocity: 26-70 cm/sec E/A ratio: >0.75 & < 1.5 DT: 160-220 m sec

NORMAL MITRAL INFLOW PATTERN

MITRAL INFLOW IN STAGE I – DIASTOLIC DYSFUNCTION

( ABNORMAL RELAXATION)E/A ratio: ≤ 0.75DT > 240 m sec

MITRAL INFLOW IN STAGE I I– DIASTOLIC DYSFUNCTION (PSEUDONORMALIZATION)

E/A ratio: > 0.75, < 1.5 DT : > 140 m sec

MITRAL INFLOW IN STAGE III– DASTOLIC DYSFUNCTION(REVERSIBLE RESTRICTIVE)

E/A ratio : > 1.5 DT : < 140 m sec

MITRAL INFLOW IN STAGE IV– DASTOLIC DYSFUNCTION(FIXED RESTRICTIVE)

E/A ratio : > 1.5 DT : < 140 m sec

EVALUATION OF DIASTOLIC DYSFUNCTION

In pseudo normal ( stage II ) LV diastolic dysfunction Valsalva strain unmasks underlying impaired LV relaxation and causes E/A ratio < 1

Stage III pattern at Valsalva maneuver may turn into stage II or even Stage I pattern. But if unchanged, it indicates fixed restrictive abnormality .

MITRAL INFLOW AT PEAK VALSALVA MANEUVER

Mitral Inflow

Apical 4-chamber view

Align Doppler beam to be parallel to mitral inflow

Pulsed-wave sampling at tips of MV leaflets◦ Decreased velocity if

sampled within LA

Pulsed-wave Mitral Valve Inflow

Peak E and A velocities, ratio E/A Mitral A-wave duration (to compare with PV AR

duration) Mitral deceleration time(from peak of E-wave to base) Mitral Doppler VTI (and valve area)

Mitral Valve Doppler Evaluation

In a 5 chamber view◦ Continuous-wave

across tips of MV through LVOT

◦ Obtain mitral inflow & LV outflow

◦ Measure Isovolumetric Relaxation Time (IVRT)

Tissue Doppler Measures displacement of myocardium

while avoiding blood flow detection throughout the cardiac cycle

For our purposes:◦ Mitral valve annular junction◦ Septal annular junction◦ Tricuspid annular junction

Mitral and tricuspid data is relatively volume load independent, including respiratory cycle

TDI Methodology

Using Doppler pulsed cursor, 3-5 mm

Set Nyquist limits to 15-30 cm/s

Using lowest wall filter

Set dynamic range to 30-35db

Sweep speed of 100-150 mm/s

TDI Pulsed-wave

Ea ( or E´), Aa ( or A´), Sa ( or S´) waves IVRT and Isovolumetric Contraction Time

(IVCT) Important to maintain a parallel line of

annular motion with the imaging beam

Color M-mode Flow Propagation

Estimate of ventricular filling to correlate with LV relaxation, even at increased LA pressures

Not affected by preload Varies with changes of lusitropic conditions Correlates in ischemic heart disease


In apical 4 chamber view

Align M-mode cursor through LV apex and orifice of MV

Apply Color Doppler Switch to M-mode

acquisition Decrease Nyquist

limit until color inflow shows line of aliasing


Demonstrated by Garcia et al., JACC 1999, that in both dogs with occluded IVC and in adults undergoing CABG, under partial CPB, measures were not affected◦ Although, MV E waves and associated measures were impacted by

each scenario◦ In dogs, under various doses of dobutamine and esmolol, there

were expected changes of Vp correlating to measured changes of LVEDp

Calculations using Vp

Border et al, JASE 2003 20 pts age 6.6yrs ± 6yrs Indicated L heart cath w/o MV

stenosis/arrhythmia Found E/ Vp > 2.0,

◦ LVEDp >15mmHg◦ Sensitivity 100%◦ Specificity 77%◦ PPV: 70%◦ NPV: 100%

Calculations using Vp(FPV)

Gonzalez-Vilchez, JACC 1999 Adults in ICU w Swan’s 20 test, 34 study patients Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-9 Simplified to:

◦ 103/[2•IVRT]+FPV◦ Value ≥5.5, correlates to PCWP > 15mmHg (r=0.89)

Calculations using Vp

Use of TDI and Color M-mode in Infants

Study by Larrazet et al, Pediatric Critical Care Medicine, 2005

Studied infants 3-8 months of age, immediately post-operatively for VSD/AVCD repair w LA line in place

For LA pressure > 10mmHg◦ E/Ea > 15 – Sensitivity 94%, Specificity 72%◦ E/Vp >2.0 – Sensitivity 83%, Specificity 89%

Place Apical 4 w PW in Distal PV

Pulmonary Venous Inflow

Apical 4-chamber view

Identify RUPV or LUPV inflow parallel to beam

Pulsed-wave sampling ◦ 1-2 cm distal to

orifice Alternatives views:

◦ Parasternal◦ Suprasternal◦ Subcostals

Pulsed-wave Pulmonary Vein Inflow

Identify peak S and D velocities Measure atrial reversal (AR) duration

◦ AR presence is variable. It is indicative of abnormal elevated LA pressure in a neonate, but may be normal in a child with more compliant pulmonary veins. The duration of flow reversal is more helpful in relation to atrial systole

Note: S-wave may be biphasic owing to differences of atrial relaxation and mitral valve annular displacement

Should take the highest of the peaks

Pulsed-wave Pulmonary Vein Inflow

It is an additional source of information to evaluate diastolic dysfunction.

Obtained by 3 to 4 mm pulsed Doppler sample volume in the right paraseptal vein from the apical 4-chamber view.

4 useful variables are of pulmonary venous flow-

S wave: Peak systolic PV flow velocity (normal value- 40 to 90 cm/sec)

D wave: Peak diastolic PV flow velocity (normal value- 30 to 70 cm/sec; S/D ratio: > 1)

AR velocity: Peak PV atrial reversal flow velocity (normal- < 25 cm/sec)

AR dur: AR duration ( normal- A dur/AR dur >1 )

PULMONARY VENOUS FLOW PATTERN

Peak systolic ( S ) and diastolic PV flow velocity waves do not add any incremental value in assessment of the diastolic dysfunction as they are also volume dependent and follow a parabolic pattern.

AR dur > A dur + 30 m sec and AR value> 35 cm/sec is associated with moderate and severe diastolic dysfunction.

PULMONARY VENOUS FLOW PATTERN

EVALUATION OF DIASTOLIC DYSFUNCTION

A recent work in NICVD, Dhaka, on diastolic dysfunction (MD thesis, 2003) showed a negative correlation of Doppler estimated left atrial pressure wave transit time ( A- Ar interval) with left ventricular passive elasticity and end diastolic pressure.

Sample volume of pulsed Doppler is placed at about 1 cm distal to aortic valve in LV outflow tract to detect A-Ar interval

Normal value of A-Ar interval is 25 to 80 m sec. Shorter the interval, more likely to have severe LV diastolic dysfunction.

OTHER DOPPLER PARAMETERS

EVALUATION BY A-Ar INTERVAL

Left ventricular end diastolic pressure ( LVEDP ) & Pulmonary capillary wedge pressure are two important determinants of LV diastolic dysfunction.

CARDIAC CATHETERISATION

LA Volume

In adults, atrial dilation has correlated as a risk for first CV event (a-fib, stroke, CHF)

Defined as: women ≥ 30cm2/m2, men ≥ 33cm2/m2 Not routinely measured in children, but recent norms established

8/3π[(A1)(A2)/(L)] obtained from Apical 2 & 4 chamber views

LA Volume in Children Data collected by 3D Echo and separated by

BSA◦ 0.5-0.75m2 : 19.6 mL/m2 ◦ 0.75-1.0m2 : 21.7 mL/m2 ◦ 1.0-1.25m2 : 22.0 mL/m2 ◦ 1.25-1.5m2 : 24.5 mL/m2 ◦ >1.5m2 : 27.4 mL/m2

No normative values for RA established in kids

Tricuspid and Right Heart Evaluation

Usual measures performed on MV, are influenced by variable preload through the respiratory cycle.

With inspiration amongst children◦ Peak E may increase by 26%◦ Peak A may increase by 20%


SVC inflow invariably does not have AR amongst healthy children

AR-wave usually seen with:◦ Right atrial hypertension◦ Tricuspid stenosis

Reversal with ventricular systole◦ Significant tricuspid regurgitation◦ Loss of AV-synchrony◦ Restrictive physiology

Decreased flow of systemic veins or TV inflow with Exhalation seen with Tamponade◦ MV E-wave decreases by >25% during onset of

INhalation


In a restrictive, non-compliant RV, which acts essentially as a conduit for the PA◦ Forward flow may be seen in PA with atrial systole◦ Only in settings with low PVR or absence of distal

stenoses◦ May be seen in those with history of Tetralogy or

Pulmonary valve abnormalities

Classification of Diastolic Dysfunction

Classification of Diastolic Dysfunction

Abnormal LV Relaxation The ability of the LV myocardial filaments to

actively uncouple after systole, is delayed

Ventricular compliance is unaffected

IVRT is prolonged, as time needed to decrease LV pressure < LA pressure is extended

Abnormal LV Relaxation

LA-LV pressure difference in early diastole narrowed – max E-wave velocity decreased

LV relaxation is slower, so E-wave is prolonged

A-wave increased as a compensatory to complete LV filling

Insert fig 8.14

Insert fig 8.15

Abnormal LV Relaxation

Infamous “L-wave” seen in MV inflow pattern◦ Described by Keren in 1986◦ Presence of LA-LV pressure gradient in diastasis◦ Occurs with MARKEDLY delayed LV relaxation

Abnormal LV Relaxation … and LA Hypertension

Also called “Pseudonormalization” Result of worsened ventricular compliance

with transmitted increase of atrial pressure Ultimately, relative pressure difference

between LA-LV is similar to normal, just at higher pressure

Pulmonary vein inflow pattern helpful to distinguish this from normal


TDI has been shown to be relatively independent of preload◦ Abali et al, JASE 2005, studied 100+ adult males

after 500mL blood donation, found no differences in TDI measures or Color M-mode, Vp

◦ Eidem et al, JASE 2005, found that children with chronic LV preload (VSD’s) and preserved systolic and diastolic function, did not have changes in TDI Those with chronic afterload (AS) demonstrated

decreases of TDI measures


Nagueh et al, JACC 1997 125 adults, 60 cathed for PCWP, separated

Normal from Impaired Relaxation from Pseudnormalized (EF low in this group)

Found E/Ea >10 correlated to PCWP of >12mmHg◦ Sensitivity 91%, Specificity 81%

TDI in Pseudonormalization

Nagueh et al, JACC 1997, 30; 1527-33

Color M-mode in Pseudonormalization

Helpful to differentiate normal MV inflow patterns from ‘pseudonormalization’

Decreased rate of flow propagation (Vp) correlate with delayed relaxation, even with elevated LA pressure

Measures are preload independent Measure of MV peak E velocity to rate of

flow propagation, E/ Vp > 2.0 predicts LVEDp >15mmHg (sensitivity 100%, specificity 77%)

Restrictive Physiology/Decreased Ventricular Compliance

Ventricle is significantly stiff, non-compliant, that with small increases of volume, pressures increase disproportionately

On MV inflow, the E-wave is accelerated with short deceleration time due to rapid rise of ventricular pressure and the end of inflow

A-wave is remarkably small, if not absent all together, as atrial systole minimally generates a pressure gradient across the AV valve◦ Instead prolonged reflux in PV observed

Restrictive Physiology/Decreased Ventricular Compliance

IVRT shortened due to atrial hypertension with early opening of MV and ventricular filling

Measures through childhood

Infants◦ Very limited early diastolic flow◦ Significant contribution from atrial systole◦ Limited tolerance to changes in preload◦ Improved compliance around 2 months

Childhood◦ Limited variability of measures (Inflow/TDI)

through childhood and adolescence◦ Noted changes with increasing IVRT likely

associated with age-related decreased HR

Tables of normative values for children are available

Tables of normative values for children are available

Doppler Echocardiography has emerged as a highly versatile tool for evaluation of diastolic function.

Anatomic and functional evaluation of heart along with interrogation of mitral valve inflow & PV flow parameters may accurately disclose LV diastolic dysfunction.

Valsalva maneuver, CMM & DTI are useful adjuncts for complete evaluation of diastolic dysfunction.

CONCLUSION

Thank [email protected]

Asia Pacific Congress of Hypertension, 2014, February

Cebu city, Phillipines

Seminar on Management of Hypertension, Gulshan, Dhaka

Health & Medicine

ECHOCARDIOGRAPHIC EVALUATION of LEFT VENTRICULAR DIASTOLIC FUNCTION toufiqur rahman NICVD