Echocardiographic Evaluation of Diastolic Function

Welcome to the eLearning Echocardiographic Evaluation of Diastolic Function.   This presentation was created by: Wendy Barnhardt, MAEd, RDCS, RDMS Clinical Sales Specialist Upon completion of this presentation the participant will be able to: Define the systolic and diastolic components of the cardiac cycle Describe diastolic function and the physiologic components used to quantitate and qualitate Describe new and existing technology used to evaluate diastolic function Describe the effects of pathology on diastolic function Disclaimer All information in this presentation is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine.  Any healthcare practitioner reading this information is reminded that they must use their learning, training, and expertise in dealing with their individual patients.  This material does not substitute for that duty and is not intended by Siemens Medical Solutions USA, Inc. to be used for any purpose in that regard. The length of time required to complete this course will vary depending on, but not limited to, expertise of subject matter, reading speed, interruptions, and Internet connection speed.  The accrediting agency is responsible for determining the number of CE credits awarded for this course. This activity may be available in multiple formats such as web-based training and an actual live event.  The ARRT does not allow CE activities such as Internet courses, live events, home study programs, or directed readings to be repeated for CE credit in the name of any subsequent biennium. Any of the protocol(s) presented herein are for informational purposes and are not meant to substitute for any clinical judgment in how best to use any medical devices.  It is the clinician that makes all diagnostic determinations based upon education, learning, and experience. This presentation content was prepared by the speaker and not Siemens.   Diastolic Function Virtually all forms of acquired organic heart disease are associated with a component of LV diastolic dysfunction: Hypertensive heart disease Hypertrophic cardiomyopathy Dilated cardiomyopathy Valvular heart disease Symptomatic CAD Diastolic Dysfunction Diseases that elevate diastolic pressure are often more likely to be associated with secondary pulmonary hypertension MS vs MR Diastolic dysfunction is a significant contributor to the development of heart failure Reasons to Assess Diastolic Function To distinguish systolic or diastolic heart failure from pulmonary disease or other processes resulting in dyspnea To determine prognosis To identify underlying heart disease and its best treatment Assessment of patients with cardiac risk factors SYSTOLE SYSTOLE DIASTOLE PHONOCARDIOGRAM ELECTROCARDIOGRAM VENTRICULAR VOLUME VENTRICULAR PRESSURE ATRIAL PRESSURE AORTIC PRESSURE ATRIAL SYSTOLE DIASTASIS VOLUME (ml) PRESSURE (mmHg) ISOMETRIC CONRACTION PROTODIASTOLE EJECTION ISOMETRIC RELAXATION RAPID INFLOW 1st 2nd 3rd P Q R S Aortic valve closes Aortic valve opens A-V valve closes A-V valve opens v c a IVRT   Early rapid diastolic filling   Diastasis   Late diastolic filling 1 0.5 0 LVOT Flow LVOT Flow IVRT IVCT Em Am Aarea Earea Diastasis Late Ventricular Filling RAPID FILLING Decel Time 2/3 of heart cycle Relaxation IVRT Time constant of relaxation (tau)   Compliance dP/dV – Chamber stiffness dV/dP – Chamber compliance   Ventricular diastolic pressures   Ventricular diastolic filling curves   Atrial pressures and filling curves Normal vs. Abnormal Filling Pressures Anatomy Based Continuous left ventricular volume Diastolic filling rate   Flow Based   Mitral valve inflow patterns E/A ratio (velocity or area) Deceleration time   Isovolumetric relaxation time   Pulmonary vein flow   Doppler Tissue Imaging Mitral annular diastolic velocity (EA) Mitral valve E-wave/EA ratio   Color m-mode flow propagation Identify, characterize, and quantify diseases that have resulted in diastolic dysfunction: Cardiac amyloidosis   Nonobstructive hypertrophic cardiomyopathy   Hypertensive cardiovascular disease with preserved LV function Mitral Inflow PW Patterns: Isovolumetric Relaxation Time   E wave velocity   A wave velocity   E/A ratio   Deceleration Time Mitral Inflow display IC IR E A ET Diastolic Function Quantification Parameters Deceleration Time: Prolonged with delayed relaxation   Shortened in the presence of elevated LV diastolic pressure   Changes in deceleration time also affect P1/2 t 1 0.5 0 LVOT Flow LVOT Flow IVRT IVCT Decel Time Left Ventricular Filling RAPID FILLING Em Am Earea Aarea ♥ Normal deceleration time - 160 to 240 msec (can be lower in young patients) Mitral flow velocities are maximal at the tips of the mitral leaflets Displays myocardial velocity   Spectral display of systolic and diastolic velocities within the myocardium   Spectral DTI patterns indicate physiologic changes in cardiac cycle Sample volume placed in the IVS and/or the lateral wall of the ventricle near the mitral annulus showing phases of the cardiac cycle. Diastolic Function – Quantification Parameters   Doppler Tissue Imaging with Pulsed Wave Doppler: s wave (systolic myocardial velocity)   e wave (early diastolic myocardial velocity)   a wave (atrial contraction  myocardial velocity)   e/a ratio Isovolumetric relaxation Isovolumetric contraction Systole Diastasis s e a Diastolic Function – Quantification Parameters Doppler Tissue Imaging with Pulsed Wave Doppler: Normal s wave values range from 8 to 12 cm/sec   Normal e wave values range from 12 to 20 cm/sec   Normal a wave values range from 9 to 13 cm/sec   Normal e/a ratio is > 1 PW-DTI vs Mitral Inflow with Varying Preload Conditions DTI display Mitral Inflow display S IC ET IR E A e a Source: Farias et al, JASE Aug. 1999;12:8 Other parameters used to assess LV diastolic function include: E/e wave ratio: Ratio >8 or 9 = elevated LV diastolic pressure Evaluation of Mitral Inflow Monitoring the mitral inflow pattern during the Valsalva maneuver may demonstrate evidence of delayed relaxation A decrease in the E/A ratio greater than or equal to 0.5 indicates increased filling pressures associated with a pseudo normal or restrictive reversible filling pattern. Determine end systolic volume Apical 4-chamber Apical 2-chamber Vp > 50cm/sec is considered normal   Normal  60 – 100ms   Impaired relaxation >100ms   Pseudo normal  60 – 100ms   Restrictive  ≤ 60ms Pulmonary venous PW flow patterns: S wave (pulmonary venous systolic flow velocity D wave (pulmonary venous diastolic flow velocity) S/D ratio AR (pulmonary venous atrial reversal velocity Pulsed wave Doppler across the mitral valve, pulmonary veins and DTE Source: http://www.phaonlineuniv.org/Journal/Vol5No1Spring06/DiagnosticDilemmas Ventricular Segment eVelocity cm/sec aVelocity cm/sec e/a Ratio Basal Septum Mid Septum Apical Septum 12.6 +/- 2.8 11.6 +/- 2.03 8.3 +/- 2.1 7.3 +/- 1.7 6.4 +/- 1.8 4.4 +/- 1.7 1.8 +/- 0.5 1.9 +/- 0.5 1.9 +/- 0.6 Basal Anterior Mid Anterior Apical Anterior 12.9 +/- 2.5 11.6 +/- 2.3 9.3 +/- 2.5 5.9 +/- 1.8 5.3 +/- 1.6 4.8 +/- 1.5 2.4 +/- 0.9 2.3 +/- 0.7 2 +/- 0.6 Basal Lateral Mid Lateral Apical Lateral 16.1 +/- 1.2 15.1 +/- 3.2 11.2 +/- 3.1 7.8 +/- 3.1 6.6 +/- 2.7 5.5 +/- 2 2.3 +/- 0.8 2.6 +/- 1.1 2.2 +/- 1.1 Basal Inferior Mid Inferior Apical Inferior 11.8 +/- 1.8 12.1 +/- 2.5 8.9 +/- 1.8 5.3 +/- 1.6 6.6 +/- 1.3 5.1 +/- 1.2 2.2 +/- 1.1 2 +/- 0.86 1.7 +/- 0.5 Mitral Flow Mitral annulus velocity Normal Abnormal relaxation Pseudo-normalization Restrictive E E E E A A A A A' A' A' A' E' E' E' E' Ambiguous Information Heart Motion Angle of Incidence Operator Error Improper Gain Settings Angle Uncorrected Velocity 0 1.00 m/s 15 0.97 m/s 45 0.71 m/s 60 0.50 m/s 75 0.26 m/s 90 0.00 m/s ~ 5 million Americans with heart failure    400,000 – 700,000 new cases diagnosed/year    The single most frequent cause of hospitalization in patients older than 65 years    1-year mortality rate is about 10-15%    5-year mortality rate approaches 50% Despite Current Drug Therapies, Heart Failure Morbidity and Mortality Remain High 30% - 40% of patients are in NYHA class III or IV Re-hospitalization rates: 2% at 2 days 20% at 1 month 50% at 6 months 5-year mortality ranges from: 15% to more than 50% Asymptomatic LVD ~ 15% Mild-moderate HF ~ 35% Advanced HF ~ > 50% What is the leading cause of death in the USA? #1  Heart Failure  450,000 per year #2  Stroke 160,000 per year #3  Lung Cancer  157,400     Breast Cancer    40,200