Defining diastole Methods to assess diastole Patterns of diastolic disease Age-related changes echocardiogram, diastolic dysfunction, cardiology, color doppler

1. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National 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
drtoufiq19711@yahoo.com

2. 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.

3.  Defining diastole
 Methods to assess diastole
 Patterns of diastolic disease
 Age-related changes

4. Required for every heart beat
Systole
Diastole

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

6.  Isovolumetric
relaxation
 Rapid filling
◦ E-wave
 2/3 LV filling
 Diastasis
 Atrial contraction
◦ A-wave
 1/3 LV filling

7.  Ventricular function
 AV valve function
 Rate of relaxation
 Ventricular compliance
 Atrial systolic function
 Preload
 Heart rate and rhythm

8. 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.

10.  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

11.  It implies impaired filling of ventricle at its
usual low filling pressure
 Ventricular filling is slow, delayed or
incomplete, with a normal atrial pressure

12. a) Impaired Relaxation
 Myocardial infarction
b)Decreased compliance of LV
 Restrictive cardiomyopathy
 Endomyocardial fibrosis
 Elderly people, particularly ladies
 Diabetes mellitus

13. c) Both compliance and relaxation
abnormality
 Hypertensive heart disease
 Hypertrophic obstructive cardiomyopathy
 IHD
 Aortic valvular disease
d)Co-existent with systolic
dysfunction
 IHD
 Cardiomyopathy

14. a) Clinical parameters:
Features of underlying aetiology
Absence of other causes of dyspnoea
Features of LV dysfunction
b) ECG:
LVH, LA enlargement, IHD
c) CXR:
Normal heart size

15. 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

16. 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

17.  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

18. MITRAL INFLOW IN STAGE I – DIASTOLIC
DYSFUNCTION
( ABNORMAL RELAXATION)
E/A ratio: ≤ 0.75
DT > 240 m sec
MITRAL INFLOW IN STAGE I I– DIASTOLIC
DYSFUNCTION (PSEUDONORMALIZATION)
E/A ratio: > 0.75, < 1.5
DT : > 140 m sec

19. 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

21.  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 .

22.  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

23.  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)

24.  In a 5 chamber view
◦ Continuous-wave
across tips of MV
through LVOT
◦ Obtain mitral inflow &
LV outflow
◦ Measure Isovolumetric
Relaxation Time (IVRT)

25.  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

26.  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

27.  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

28.  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

29.  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

30.  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

31.  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%

32.  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)

35.  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%

36. Place Apical 4 w PW in Distal PV
 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

37.  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

38.  Note: S-wave may be biphasic owing to
differences of atrial relaxation and mitral
valve annular displacement
 Should take the highest of the peaks

39.  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 )

40.  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.

43.  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.

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

46.  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

47.  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

48.  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%

49.  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

50.  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

53.  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

54.  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

55.  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

56.  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

57.  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

58.  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%

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

60.  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%)

61.  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

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

63.  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

66.  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.

67. drtoufiq19711@yahoo.com
Asia Pacific Congress of
Hypertension, 2014, February
Cebu city,
Phillipines
Seminar on Management
of Hypertension,
Gulshan, Dhaka