Evaluation of Diastolic Dysfunction by Echocardiography

1. Evaluation of Diastolic Dysfunction by Echocardiography Brandon Kuebler, MD Pediatric Cardiology Fellow Wednesday, February 09, 2011

2. Assessment of Diastolic Ventricular Function • Defining diastole • Methods to assess diastole • Patterns of diastolic disease • Age-related changes

3. When does diastole occur? • Is it around tea time? • No • Required for every heart beat Systole Diastole

4. Phases of Diastole • Isovolumetric relaxation • Rapid filling • E-wave • 2/3 LV filling • Diastasis • Atrial contraction • A-wave • 1/3 LV filling

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

6. 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 Place Apical 4 w PW in Distal PV

7. 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

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

9. 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

10. 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)

11. 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)

12. 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

13. 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

14. 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

15. 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

16. Color M-mode Flow Propagation • 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

17. Color M-mode Flow Propagation • 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

18. 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

19. 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)

20. Calculations using Vp

22. 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%

23. 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

24. 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

25. 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%

26. Tricuspid and Right Heart Evaluation • 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

27. Tricuspid and Right Heart Evaluation • 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

28. Classification of Diastolic Dysfunction

29. Classification of Diastolic Dysfunction

30. 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

31. 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

32. 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

33. 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

34. Abnormal LV Relaxation … and LA Hypertension • 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

35. Abnormal LV Relaxation … and LA Hypertension • 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%

36. Nagueh et al, JACC 1997 Could predict mean PCWP= 1.24(E/Ea ) +1.9

37. TDI in Pseudonormalization Nagueh et al, JACC 1997, 30; 1527-33

38. 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%)

39. 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

40. Restrictive Physiology/Decreased Ventricular Compliance • IVRT shortened due to atrial hypertension with early opening of MV and ventricular filling

41. 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

42. Tables of normative values for children are available

43. Tables of normative values for children are available

46. Let’s apply our data 52.4 cm/s 57.0 cm/s