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Diastology and Plenty of it!Jeffrey C. Hill, BSBA, ACS, FASE
Chair, Joint Review Commission on Education in CVT
Program Director, Clinical Coordinator, School of CVT
The Hoffman Heart & Vascular Institute of CT
Saint Francis Hospital, Hartford, CT
E/e’ Ratio for Estimation of Filling Pressures
Peak mitral E velocity
Peak DTI e’ velocity
Nagueh et al, JACC 1997, Ommen et al, Circ. 2000
Image adapted and modified from: Oki T, et al. Am JCardiol April 1997;79:921– 8
• Tau is time constant of isovolumic relaxation
• Tau > 48 ms = abnormal relaxation
• e’ velocity showed significant correlation with Tau
• Longer Tau = slower relaxation = lower e’ velocity
r = - 0.78, p <0.0001
N =50
Tissue Doppler e’ Velocity Validation
E/e’ Ratio Validation
Images obtained and modified from: Nagueh et al. J Am Coll Cardiol, November 1997;30:1527–33
Open Circles= PN
“E/e’>10 = PCWP >15”
Lateral DTI E’ only
LA End-Systolic Volume Index (LA-ESV): What to Avoid
4-chamber 2-chamber
Aurigemma et al. Circ Cardiovasc Imaging 2009;2:282-289Abhayaratna , et al. J Am Coll Cardiol 2006;47:2357-63
IAS
Pulm Vein
Tenting Vol
Pulm Vein
Image obtained and modified from: Jansen et al. JACC: CV Imaging 2014;7:529-33.
Left Atrial Volumes: Should We Reset the Reference Standard?
Current Published Reference Value(LAVI 22 +/- 6 mL/m2)
Mean LAVI in 285 Healthy Pts(LAVI 30 +/- 6 mL/m2)
Hill, Palma. J Am Soc Echocardiogr 2005;18:80–90
Bierig, Hill. J Diagn Med Sonography 2011;27:65–78.
Effects of SV Positioning on DTI
Effects of Gain on DTI Waveforms
Spectral broadening: e’ = 16 cm/s
Optimized: e’ = 12 cm/s
Faint waveforms: e’ = 8 cm/s
Waggoner AD, Bierig SM. J Am Soc Echocardiogr 2001;14:1143-52.
MAC Influences the E/e’ Ratio
Soeki, et al, Jpn Circ J 2001
e’ = 5 cm/s: E/e’ = 11 e’ = 9 cm/s: E/e’ = 5
MACBelow MAC
Effects of Respiration on DTI
Hill, Palma, JASE 2005
Normal RespirationAve e’ = 10
End-apneaAve e’ 7
• 93 y/o female
• Lower extremity edema
• No significant valvular dz
• PASP = 40 mmHg
• Severe LAE
• EKG demonstrates…
Case courtesy of Daniel Bourque, MS, RCS
• 84 y/o female
• H/O HTN, CAD, CHF
• Dyspnea, new pedal edema
• Multiple WMAs
• PASP = 45 mmHg
• Severe LAE
*Table adapted and modified from Redfield et al
Perfect Picture
Image modified from Redfield et al, JAMA. 2003;289:194-202
“Real World” Diastology
Variable Measurable
(%)
E/A 71
DT 73
E/e’ 75
Pulm vein
S/D56
P/A duration 25
Narayanan A,. Circulation 2008 (Abstract);118(18):787
N =100
• 68 y/o male
• CHF
• Inferior WMA’s
• BPEF = 44%
• No significant valvular dz
• PASP = 19 mmHg
• Mild LAE
• 64 y/o male
• Fresh STEMI
• Borderline tachycardia
• EF = 25-30%
• Multiple WMAs
• No significant valvular DZ
• PASP = 50 mmHg
• Severe LAE
• 60 y/o male
• CAD, Dyspnea
• Dynamic EF
• No significant valvular DZ
• PASP = 30-35 mmHg
• Severe LAE
• 82 y/o female
• HHD/CHF
• Multiple WMA’s
• PASP = 48 mmHg
• EF = 35-40%
•Moderate/severe LAE
• Severe MAC
• 53 y/o female
• S/P arrest
• HR = 78 BPM
• New LBBB
• ICD Placement
• No valvular dz
• PASP = 19 mmHg
• NL LA ESV
• EF = 50 ish %
• 30 y/o female
• Edema
• Borderline tachycardia
• Evaluate RV/LV fx
• PASP = 17 mmHg
• No significant valvular dz
• NL LA size
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