DIASTOLOGYLECTURE 2,3 DIASTOLIC FUNCTION
WHAT IS DIASTOLIC DYSFUNCTION
DIASTOLIC DYSFUNCTION IS THE ABNORMAL STIFFENING OF THE
VENTRICULAR WALLS WITH INADEQUATE FILLING
MANY PATIENTS WITH HEART FAILURE HAVE NORMAL SYSTOLIC
FUNCTION WITH PREDOMINANT DIASTOLIC DYSFUNCTION
DIASTOLIC DYSFUNCTION MAY BE AN EARLY SIGN OF CARDIAC
DISEASE
THE DEGREE OF DIASTOLIC DYSFUNCTION MAY EXPLAIN DIFFERENCES
IN CLINICAL SYMPTOMS BETWEEN PATIENT WITH SIMILAR DEGREES OF
SYSTOLIC DYSFUNCTION
THE PHASES OF DIASTOLE; PHASE 1
IVRT; ISOVOLUMETRIC RELAXATION
PHASE 2
EARLY RAPID DIASTOLIC FILLING;
BLOOD FLOWS FROM LA TO LV WITH RATE AND COURSE CONTROLLED
BY THE LA/LV PRESSURE DIFFERENCE, VENTRICULAR RELAXATION, AND
THE RELATIVE COMPLIANCE OF THE 2 CHAMBERS
PHASE 3: DIASTASIS
LITTLE FILLING OCCURS DURING DIASTASIS.
PHASE 4: ATRIAL CONTRACTION
THE PARAMETERS OF DIASOTLIC
FUNCTION
VENTRICULAR RELAXATION
VENTRICULAR COMPLIANCE
PRESSURES
WHAT ARE SOME CAUSES OF DIASTOLIC
DYSFUNCTION?
CAD
HTN
DM
CHRONIC RENAL DISEASE
HCM (HYPERTROPHIC CARDIOMYOPATHY)
RCM (RESTRICTIVE CARDIOMYOPATHY)
HEART TRANSPLANT REJECTION
CONSTRICTIVE PERICARDITIS
DRUG RELATED TOXICITY
CONDUCTION DISORDER
SYMPTOMS
DYSPNEA WITH EXERTION
PALPITATIONS
CONGESTIVE HEART FAILURE
SUPRAVENTRICULAR TACHYCARDIA
CHEST PAIN NOT RELATED TO CAD
OUR JOB AS SONOGRAPHERS?
ECHOCARDIOGRAPHIC IMAGING MEASUREMENTS
DOPPLER EVALUATION OF THE LV FILLING
TISSUE DOPPLER
LEFT ATRIAL FILLING
MEASUREMENT OF THE TR JET
LA VOLUME MEASUREMENTS
M MODE PROPAGATION VELOCITY
EVALUATING LV FILLING
PULSED WAVE TAKEN AT THE MITRAL VALVE LEAFLET TIPS FROM THE
APICAL 4 CHAMBER VIEW.
MEASUREMENT OF THE E WAVE
MEASUREMENT OF THE A WAVE
MEASUREMENT OF THE DECELERATION TIME; FROM PEAK E TO ZERO
BASELINE
EVALUATING THE PRESENCE OF THE MITRAL “L” WAVE
TISSUE DOPPLER
THIS TOO IS TAKEN FROM THE APICAL 4 CHAMBER VIEW
UTILIZES SPECTRAL ANALYSIS; MEASURES THE VELOCITY OF HEART MUSCLE
THROUGH PHASES OF 1 OR MORE BEATS
THESE SIGNALS HAVE INCREASED AMPLITUDE BUT DECREASE VELOCITIES
SUMMARIZES THE LONGITUDINAL CONTRACTION DURING SYSTOLE AND
ELONGATION DURING DIASTOLE**
TAKEN AT THE BASE OF THE MITRAL VALVE ANNULUS ON BOTH THE SEPTAL
AND LATERAL SIDES
MEASURE e’ AND a’~~
E/e’ RATIO
S WAVE IS A GOOD INDICATOR FOR SYSTOLIC FUNCTION
IVRT
THIS IS THE TIME INTERVAL BETWEEN AORTIC VALVE CLOSURE TO MITRAL
VALVE OPENING
NORMAL IS APPROXIMATELY 50-100MS (WILL VARY WITH HR AND AGE)
TAKEN FROM THE APICAL 5 CHAMBER VIEW
MEASURE FROM THE MIDDLE OF THE AV CLOSURE CLICK TO THE ONSET OF
THE MV FLOW
LA FILLING
UTILIZING THE APICAL 4 CHAMBER VIEW
MEASURE THE LA INFLOW FROM THE RSPV
EVALUATING THE S, D, AND A WAVE
PV A WAVE DURATION
AR-A DURATION***
Vp; PROPAGATION VELOCITY
PERFORMED IN THE APICAL 4 CHAMBER VIEW UTILIZING COLOR
FLOW
M MODE SCAN LINE IS PLACED THROUGH THE CENTER OF THE MITRAL
INFLOW FROM THE APEX, BASELINE SHIFTED UP TO LOWER THE
NYQUIST LIMIT SO THAT THE CNETRAL HIGHEST VELOCITY JET IS BLUE
Vp IS MEASURED AS THE SLOPE OF THE FIRST ALIASING VELOCITY
DURING EARLY FILLING (OTTO PG 173)
Vp GREATER THAN 50CM/S IS NORMAL
A DECREASE IN Vp IS INDICATIVE OF IMPAIRED RELAXATION
EVALUATION OF TRICUSPID REGURGE
UTILIZING CW DOPPLER
THIS IS AN INDIRECT ESTIMATE OF LAP
UTILIZING ANY VIEW THAT ALLOWS YOU TO BE MOST PARALLEL TO THE
TR JET
OBTAIN THE MAX VELOCITY OF THAT JET
THE VALSALVA MANUEVER
LOOKING FOR THAT PSUEDONORMAL PATTERN
RECORD INFLOW CONTINUOUSLY THROUGH PEAK INSPIRATION AND
AS PATIENT PERFORMS FORCED EXPIRATION FOR 10 SECONDS WITH
MOUTH AND NOSE CLOSED
A DECREASE E/A RATIO OF GREATER THAN 50% OR AN INCREASE IN
A WAVE VELOCITY DURING THE MANEUVER IS ASSOCIATED WITH
INCREASED LV FILLING PRESSURE (C/W GRADE II)
THE PHASES OF THE VALSALVA
STRAIN PHASE: INCREASE BP DECREASE HR
VENOUS RETURN THEN FALLS WITH DECREASE IN BP AND INCREASE IN
HR
RELEASE: FURTHER DECREASE BP THEN INCREASE OF VENOUS RETURN
TO RIGHT HEART
FURTHER INCREASE IN CARDIAC OUTPUT AND INCREASE BP. HR FALLS
UTILIZED TO UNMASK MVP, HOCM, PSEUDO NORMAL, AND PFO
FACTORS THAT AFFECT DOPPLER
EVALUATION OF LV DIASTOLIC FUNCTION
RESPIRATION
HR
AGE
PR INTERVAL
OK, WHAT IS NORMAL????????????
NORMAL LVEF AND NO RWMA
NORMAL LV RELAXATION
NORMAL LAP
MITRAL E/A >0.8
AVERAGE E/e’ 2.8M/SEC
INCREASED IN LA VOLUME INDEX
What is the stage? 31 y/o male referred for murmur
LVEF of 65%
IVS/LVPW 0.8/0.8
LA volume 29ml/m2
E/e’ 12
The e’ 8
TR jet not significant
What is the stage?
63 year old male with recurrent dyspnea on daily activity, bilateral
ankle swelling, and orthopnea
Known DM on insulin
HTN
Chronic renal disease
BP is 160/85mmhg
Summary of findings
Clinical data consistent with cardiac disease
e/a ratio >0.8 and 34mL/m2
TR jet = 3.6m/s
Case 2
66 year old woman with history of previous MI and recurrent
episodes of dyspnea with daily activities
HTN, DM and hyperlipidemia
BP is 116/68mmhg
Echo findings
Apical 4 chamber demonstrates akinesis of the septum and apex
LVEF was calculated at 33%
E/A ratio is greater than 2
Pulmonary vein S/D ratio is less than 1
LA volume is increased
WHAT IS THE STAGE???????????????????????????????
CASE 3
40 YEAR OLD FEMALE
RECENT PALPITATIONS
FAMILY HISTORY OF CAD
HR IS 80bpm
BP is 130/85mmhg
Echo findings
LVEF of 65%
Average E/e’ is 9
Septal e’ is 6cm/s
Lateral e’ is 11cm/s
TR jet velocity is 2m/s
LA volume is 32ml/m2
Case 4
65 year old male
Previous CABG
HTN
Echo ordered for Pre-op clearance
Findings:
LVEF of 43%
Wall thickness is normal
E/A 1.6 E/e’ 19 TR 2.5m/s LAVI 40ml/m2
WHAT IS NEEDED TO APPLY THE
GUIDELINES CORRECTLY
CLINICAL FINDINGS ARE COLLECTED AND CONSIDERED CAREFULLY
2 D DATA OF GOOD QUALITY AND ACCURATELY ANALYZED
DOPPLER SIGNALS OF OPTIMAL QUALITY
LIMITATIONS OF DOPPLER SIGNALS SHOULD BE CONSIDERED (IE mac
AND ANNULUS VELOCITIES
IN SYMPTOMATIC PATIENTS WITH NORMAL LAP AT REST SHOULD
CONSIDER DIASTOLIC STRESS TEST.
DIASTOLOGY STRESS TESTING
CAN BE UTILIZED IN THE EVALUATION FOR HRpEF
SIMULTANEOUS INVASIVE-ECHOCARDIOGRAPHIS STUDY
CHALLENGING AND RELIES LARGELY ON DEMONSTRATION OF
ELEVATED CARDIAC FILLING PRESSURES (pcwp)
REST/EXERCISE ECHOCARDIOGRAPHY E/e’ RATIO HELPFUL
DATA TO SUPPORT THIS PRACTICE IS CONFLICTING
Hemodynamics as it
Pertains to Cardiac
Doppler
PRELOAD
AFTERLOAD
►
THE PRESSURE OR VOLUME AT
END DIASTOLE
►
►
THE GREATER THE PRELOAD THE
GREATER THE FORCE OF
CONTRACTION (INCREASE
VOLUME=INCREASE
CONTRACTILITY)
THE RESISTANCE AGAINST
WHICH THE VENTRICLE MUST
PUMP
►
THE PRESSURE THE LV MUST
OVERCOME TO EJECT BLOOD
►
WHAT ARE SOME FACTORS TO
CAUSE INCREASE AFTERLOAD???
►
INCREASE MYOCARDIAL FIBER
LENGTH=INCREASED TENSION
►
ANYTHING THAT INCREASES
VOLUME IS GOING TO INCREASE
PRELOAD
The Interval-Strength Relationship:
-the longer the interval between heartbeats the
stronger the contraction required to eject the
blood
Syncope?
Near Syncope?
EF/Loss of bodily function
• The Interval-Strength Relationship:
-the longer the interval between heartbeats
the stronger the contraction required to
eject the blood
• The Interval-Strength Relationship:
-the longer the interval between heartbeats
the stronger the contraction required to
eject the blood
Afterload; ANOTHER LOOK
►
Refers to the resistance the heart must pump against
►
This resistance can be within the heart or elsewhere in
the circulatory system
►
Some examples within the heart?
►
As, IHSS, PS (these are all outflow tract obstructions)
►
CIRCULATORY?
►
Systemic HTN, pHTN, coarctation
What are some MANEUVERS that we do
to alter cardiac physiology?
► VALSALVA
►
CONSISTS OF TWO PHASES: BEARING DOWN OR
STRAINING FOLLOWED BY RELEASE
►
DURING THE BEAR DOWN PHASE THE VENOUS
RETURN, STROKE VOLUME, AND CARDIAC OUTPUT
DECREASE
►
WHAT HAPPENS TO MOST MURMURS?????
What are some MANEUVERS that we do
to alter cardiac physiology?
► THE VALSALVA DECREASES MOST MURMURS
►
EXCEPTION???
►
IHSS – WILL HAVE THE OPPOSITE EFFECT
►
UPON RELEASE THE VENOUS RETURN, SV, AND CO
INCREASE
►
WHAT HAPPENS TO MOST MURMURS???
►
INCREASE UPON RELEASE
AMYL NITRATE INHALATION
►
USUALLY COMES IN A SMALL CAPSULE THAT MUST BE BROKEN AND THE
PATIENT IS ASKED TO INHALE THE FUMES
►
THE REACTION IS DECREASED PERIPHERAL RESISTANCE WHICH GIVES A
CHRONOTROPIC RESPONSE? MEANING WHAT??
►
INCREASE HR, SV, AND CO
►
ADDITIONAL MANEUVERS: INSPIRATION, EXPIRATION, SQUATTING, AND
STANDING
►
ALL WILL HAVE AN EFFECT ON VENOUS RETURN, SV, AND CO
►
INSPIRATION: INCREASE
►
EXPRIATION: DECREASE
►
SQUATTING: INCREASE
►
STANDING: DECREASE
REVIEW SOME FORMULAS AND
DEFINITIONS
►
STROKE VOLUME
►
EDV-ESV WITH NORMAL RANGE 60-100ML
►
EJECTION FRACTION
►
EF=SV/EDV x 100
►
NORMAL RANGE 55-70%
►
CARDIAC OUTPUT
►
CO=SV x HR
►
NORMAL RANGE IS 4-8 L/MIN
►
CARDIAC INDEX
►
CI=CO (L/MIN/bsa(SQR.METER)
►
NORMAL RANGE AT REST IS 2.6-4.2 L/MIN/METER2
HOW TO CALCULATE BSA
►
ONE COMMON WAY IS THE MOSTELLER FORMULA:
►
BODY SURFACE AREA (M2)= ( HEIGHT (CM) X WEIGHT (KG) /
3600 )1/2
►
BSA=(HT x WT / 3600) ½
►
BSA= HT (INCHES) x WEIGHT (LBS) / 3131) ½
►
NORMAL BSA IS 1.73M2 HOWEVER IT DEPENDS ON GENDER
AND AGE
►
THERE ARE A VARIETY OF FORMULAS TO CALCULATE THE
MOSTELLER FORMULA APPEARS TO BE THE EASIEST
Hemodynamics as it Pertains to Cardiac
Doppler
MORE FORMULAS!!!!!!!
DOPPLER STROKE VOLUME
►
STROKE VOLUME= VTI* CSA
►
WHAT IS THE VTI?
►
VELOCITY TIME INTERGRAL- REPRESENTS HOW FAR THE
BLOOD TRAVELS IN CM WITH EACH EJECTION
►
NORMAL IS 12CM FOR MITRAL AND 20CM FOR AORTIC FLOW
►
ALSO REFERRED TO AS TVI, FVI (TIME VELOCITY
INTERGRAL, FLOW VELOCITY INTERGRAL) KNOW ALL!!!!
CSA?????
►
►
►
►
►
CSA IS THE CROSS SECTIONAL AREA, D IS THE DIAMETER OF ANY
ORIFICE
CSA= 3.14*(D/2)2
CROSS-SECTIONAL AREA = 3.14 X ½ THE DIAMTER SQUARED
OR 0.785 X D2
GOOD NEWS; THIS IS CALCULATED FOR YOU BY YOUR MACHINE
► BAD NEWS; NOT HERE!!! YOU MUST KNOW AND
BE ABLE TO CALCULATE
CALCULATE THIS CSA
BERNOULLI EQUATION
►
THE BERNOULLI EQUATION IS A FORMULA THAT RELATES
THE PRESSURE DROP (GRADIENT MMHG) ACROSS AN
OBSTRUCTION TO MAN FACTORS. FOR PRACTICAL USE IN
DOPPLER ECHOCARDIOGRAPHY THIS FORMULA HAS BEEN
SIMPLIFIED
► 4 X VELCITY
► 4(V)
2
2
CONTINUITY EQUATION
►
THE CONTINUITY EQUATION IS BASED ON THE PRI
►
NCIPLE OF THE CONTINUITY OF FLOW. THE STROKE VOLUME JUST PROXIMAL
TO THE VALVE IS EQUAL TO THE STROKE VOLUME IN THE STENOTIC VALVE
ORIFICE. THIS CAN BE APPLIED TO ANY VALVE
►
FOR THE AORTIC VALVE THIS IS HIGHLY USED.
►
FORMULA IS: SV Lvot = SV Ao
►
Recall: SV= CSA*VTI
►
Thus: CSA Lvot * VTI Lvot = CSA Ao* VTI Ao
►
Solving for CSA Ao (also called AVA)
►
AVA= CSA Lvot * VTI Lvot/VTI Ao
Simplified; because we like simplified!!
► AVA=0.785 x LVOT D2* LVOT MAX
VELOCITY/ AV MAX VELOCITY
► HOW ARE WE GOING TO
OBTAIN??????????
AVA NORMAL RANGES
► AVA BY VTI
► AVA BY MAX VELOCITY
► AVA
VELOCITY RATIO…AKA DIMENSIONLESS
INDEX
► VELOCITY RATIO= VTI Lvot/VTI Ao
► This is useful with prosthetic valves and
heavily calcified valves where the LVOT
becomes difficult to measure in the case of
aortic stenosis
Normal ranges—you must know!!!
##########s lots and lots of #####s!
► Velocity ratio
► Normal near 1.0
► Mild >.5
► Moderate .25-.50
► Severe
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