ASSESSMENT OF LV DIASTOLIC FUNCTION BY DOPPLER ECHOCARDIOGRAPHY
10/16/2011
ASSESSMENT OF LV DIASTOLIC FUNCTION BY DOPPLER ECHOCARDIOGRAPHY S Bakhoum, Bakhoum, MD Assistant Professor of Cardiology Cairo University
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ASSESSMENT OF LV DIASTOLIC FUNCTION BY DOPPLER ECHOCARDIOGRAPHY S Bakhoum, Bakhoum, MD Assistant Professor of Cardiology Cairo University
PHYSIOLOGY OF DIASTOLE
Normal diastolic function is defined as the ability of the LV to accommodate an adequate filling volume to maintain CO while operating at low pressure.
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AVC
IVRT
Rapid Early Filling
LV Diastasis
Atrial Systole
MVO S2
MVC
LA
D S1 A wave
E wave
AR
PV Flow
MV Flow
Doppler Indices of Diastolic Function Isovolumic
relaxation time.
Transmitral Pulmonary
flow.
vein flow.
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Isovolumic Relaxation Time
LV
LVOT
MV
LA
Isovolumic Relaxation Time
IVRT
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Isovolumic Relaxation Time Clinical Applications Normal value: value: 65 + 20 msec msec.. Prolonged in various ario s diseases (> (>90 90 msec) that result in impairment of myocardial relaxation.. relaxation Non invasive predictor of: of: – Doxorubicin Doxorubicin--induced cardiomyopathy cardiomyopathy.. – Early cardiac transplant rejection Shortened in stages 2(< (30 msec, is higly predictive of a LVEDP > 15 mm Hg. p g Rossvol et al. JACC 1993; 21: 1687
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Other Markers of Diastolic Function Non
Invasive Assessment of Tau.
Color
MM-mode Propagation Velocity.
Tissue
Doppler Mitral Annular Velocity.
LA
Volume
Other Markers of Diastolic Function Non
Invasive Assessment of Tau.
Color
MM-mode Propagation Velocity.
Tissue
Doppler Mitral Annular Velocity.
LA
Volume
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Non Invasive Measurement of Tau τ
Measurement of “Tau τ (TL)” Normal values: values: 25 – 40 msec msec.. Higher i h values l represent reduced d d early l
diastolic distensibility due to slow relaxation.. relaxation It does not however describe events during phases of ventricular filling filling.. It is only applicable in patients with a complete MR envelope. envelope.
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Other Markers of Diastolic Function Non
Invasive Assessment of Tau.
Color
MM-mode Propagation Velocity.
Tissue
Doppler Mitral Annular Velocity.
LA
Volume
Color MM-mode Flow Propagation Velocity
E
Vp A
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Color MM-mode Flow Propagation Velocity
The slope of the early filling wave front “Vp V ” is Vp” i a useful f l non invasive i i index i d off LV relaxation.. relaxation
“Vp Vp”” < 55 cm/sec in the young or < 45 cm/sec in older individuals identifies impaired LV relaxation. relaxation.
It is less affected by preload than TM or PV flow.. flow
Color MM-mode Flow Propagation Velocity
E/Vp E/ Vp ratio can be used to estimate PCWP PCWP..
PCWP = [5.27 x E/ E/Vp Vp]] + 4.6 (in mmHg) Garcia et al. JACC 1997;29: 448
Positive and negative predictive values for E/Vp E/ Vp > 1.5 to predict PCWP >12 mm Hg were 93% 93% and 70% 70% respectively. respectively. Garcia et al. JACC 2000; 35: 201
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Other Markers of Diastolic Function Non
Invasive Assessment of Tau.
Color
MM-mode Propagation Velocity.
Tissue
Doppler Mitral Annular Velocity.
LA
Volume
Tissue Doppler Mitral Annular Velocity
S
a’ e’
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TD Mitral Annular Velocity
Impaired LV Relaxation
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TD Mitral Annular e’ Velocity Is related to LV relaxation. relaxation. Reduced and delayed in impaired LV relaxation, relates inversely with the time constant of LV relaxation. relaxation. It is relatively load independent. independent. Patients with pseudonormal LV filling are separated from normal by an e’ < 8.5 cm/sec and an e’ /a’ ratio < 1.
E/e’ Ratio
E/e’ > 15 identifies patients with LVEDP >12 mm Hg .
E/e’ should not be used to estimate LV filling in : – – – – – – –
Normal subjects. Significant annular calcification. Surgical rings. Mitral stenosis. stenosis. Prosthetic mitral valves. Moderate to severe mitral regurge. regurge. Constrictive pericarditis. pericarditis.
Recommendations for the Evaluation of LV Diastolic Function by Echocardiography. European Journal of Echocardiography 2009: 10; 165–193
TE-e´ Interval The time interval between the QRS complex and the onset of mitral E velocity is subtracted from the time interval between the QRS complex and e´ onset to derive (TEe´). It is advantageous to use:
– subjects with normal cardiac function – those with mitral valve disease – when the E/e´ E/e´ ratio is 8 to 15
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TE-e´ Interval
An IVRT/TE-e´ ratio < 2 has reasonable accuracy in identifying patients with increased LV filling pressures. pressures.
Tau
τ (msec) = 32 + 0.7 x (TE-e’) Rivas-Gotz et al. J Am Coll Cardiol 2003; 42:1463–70.
Other Markers of Diastolic Function Non
Invasive Assessment of Tau.
Color
MM-mode Propagation Velocity.
Tissue
Doppler Mitral Annular Velocity.
LA
Volume
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LA Volume
An increase in LA size is a morphologic expression i off chronic h i diastolic di li dysfunction d f dysfunction. i .
Although non specific, it reflects both the duration and severity of the disease. disease.
LA volume indexed to BSA has both diagnostic and prognostic value value..
Novel markers of diastolic function Global diastolic strain
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Novel markers of diastolic function
Global diastolic myocardial strain rate: – SRIVR has a strong correlation with time constant of LV pressure decay. – SRE is significantly related to LVEDP. – E/ SRIVR is most useful in patients with E/e’ ratio: 8 to 15 and is more accurate than E/e’ in patients with normal EF and regional dysfunction Wang, et al. Circulation. 2007;115:1376-1383
Novel markers of diastolic function
Regional diastolic myocardial strain rate: – to evaluate diastolic stiffness during stunning & infarction.. infarction – correlates with the degree of interstitial fibrosis.. fibrosis
LV twist: twist: – Both rate and extent of untwisting can be quantified.. quantified
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Recommendations for the Evaluation of LV Diastolic Function by Echocardiography. European Journal of Echocardiography (2009) 10, 165–193
CONCLUSION
LV filling is the result of a variety of complex forces forces..
No single parameter can be derived that will adequately describe diastolic function.. function
Diastolic filling patterns do not remain static in either health or disease disease..
