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

Evaluation of Evaluation of Diastolic Diastolic

Dysfunction by Dysfunction by EchocardiographyEchocardiography

Brandon Kuebler, MDBrandon Kuebler, MD

Pediatric Cardiology FellowPediatric Cardiology Fellow

Wednesday, February 09, Wednesday, February 09, 20112011

Assessment of Diastolic Assessment of Diastolic Ventricular FunctionVentricular Function

Defining diastoleDefining diastole

Methods to assess diastoleMethods to assess diastole

Patterns of diastolic diseasePatterns of diastolic disease

Age-related changesAge-related changes

When does diastole When does diastole occur?occur?

Is it around tea time?Is it around tea time? NoNo

Required for every heart beatRequired for every heart beat

SystoleDiastole

Phases of DiastolePhases of Diastole Isovolumetric Isovolumetric

relaxationrelaxation

Rapid fillingRapid filling E-waveE-wave

2/3 LV filling 2/3 LV filling

DiastasisDiastasis

Atrial contractionAtrial contraction A-waveA-wave

1/3 LV filling1/3 LV filling

Factors Affecting Factors Affecting DiastoleDiastole

Ventricular functionVentricular function AV valve functionAV valve function Rate of relaxationRate of relaxation Ventricular complianceVentricular compliance Atrial systolic functionAtrial systolic function PreloadPreload Heart rate and rhythmHeart rate and rhythm

Place Apical 4 w PW in Distal PV

Pulmonary Venous InflowPulmonary Venous Inflow Apical 4-chamber Apical 4-chamber

viewview Identify RUPV or Identify RUPV or

LUPV inflow parallel LUPV inflow parallel to beamto beam

Pulsed-wave sampling Pulsed-wave sampling 1-2 cm distal to orifice1-2 cm distal to orifice

Alternatives views:Alternatives views: ParasternalParasternal SuprasternalSuprasternal SubcostalsSubcostals

Pulsed-wave Pulmonary Pulsed-wave Pulmonary Vein InflowVein Inflow

Identify peak S and D velocitiesIdentify peak S and D velocities Measure atrial reversal (AR) durationMeasure atrial reversal (AR) duration

AR presence is variable. It is indicative of abnormal AR presence is variable. It is indicative of abnormal elevated LA pressure in a neonate, but may be normal in a elevated LA pressure in a neonate, but may be normal in a child with more compliant pulmonary veins. The duration child with more compliant pulmonary veins. The duration of flow reversal is more helpful in relation to atrial systoleof flow reversal is more helpful in relation to atrial systole

Note: S-wave may be biphasic owing to Note: S-wave may be biphasic owing to differences of atrial relaxation and mitral differences of atrial relaxation and mitral valve annular displacementvalve annular displacement

Should take the highest of the peaksShould take the highest of the peaks

Mitral InflowMitral Inflow

Apical 4-chamber Apical 4-chamber viewview

Align Doppler beam Align Doppler beam to be parallel to to be parallel to mitral inflowmitral inflow

Pulsed-wave Pulsed-wave sampling at tips of sampling at tips of MV leafletsMV leaflets Decreased velocity if Decreased velocity if

sampled within LAsampled within LA

Pulsed-wave Mitral Valve Pulsed-wave Mitral Valve InflowInflow

Peak E and A velocities, ratio E/APeak E and A velocities, ratio E/A Mitral A-wave duration (to compare with PV AR Mitral A-wave duration (to compare with PV AR

duration)duration) Mitral deceleration time(from peak of E-wave to base)Mitral deceleration time(from peak of E-wave to base) Mitral Doppler VTI (and valve area)Mitral Doppler VTI (and valve area)

Mitral Valve Doppler Mitral Valve Doppler EvaluationEvaluation

In a 5 chamber In a 5 chamber viewview Continuous-wave Continuous-wave

across tips of MV across tips of MV through LVOTthrough LVOT

Obtain mitral inflow Obtain mitral inflow & LV outflow& LV outflow

Measure Measure Isovolumetric Isovolumetric Relaxation Time Relaxation Time (IVRT)(IVRT)

Tissue DopplerTissue Doppler

Measures displacement of myocardium Measures displacement of myocardium while avoiding blood flow detection while avoiding blood flow detection throughout the cardiac cyclethroughout the cardiac cycle

For our purposes:For our purposes: Mitral valve annular junctionMitral valve annular junction Septal annular junctionSeptal annular junction Tricuspid annular junctionTricuspid annular junction

Mitral and tricuspid data is relatively Mitral and tricuspid data is relatively volume load independent, including volume load independent, including respiratory cyclerespiratory cycle

TDI MethodologyTDI Methodology

Using Doppler Using Doppler pulsed cursor, 3-5 pulsed cursor, 3-5 mm mm

Set Nyquist limits to Set Nyquist limits to 15-30 cm/s15-30 cm/s

Using lowest wall Using lowest wall filterfilter

Set dynamic range to Set dynamic range to 30-35db30-35db

Sweep speed of 100-Sweep speed of 100-150 mm/s 150 mm/s

TDI Pulsed-waveTDI Pulsed-wave

EEaa ( or E´), A ( or E´), Aaa ( or A´), S ( or A´), Saa ( or S´) waves ( or S´) waves IVRT and Isovolumetric Contraction Time IVRT and Isovolumetric Contraction Time

(IVCT)(IVCT) Important to maintain a parallel line of Important to maintain a parallel line of

annular motion with the imaging beamannular motion with the imaging beam

Color M-mode Flow Color M-mode Flow PropagationPropagation

Estimate of ventricular filling to correlate with Estimate of ventricular filling to correlate with LV relaxation, even at increased LA pressuresLV relaxation, even at increased LA pressures

Not affected by preloadNot affected by preload Varies with changes of lusitropic conditionsVaries with changes of lusitropic conditions Correlates in ischemic heart diseaseCorrelates in ischemic heart disease

Color M-mode Flow Color M-mode Flow PropagationPropagation

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

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

Calculations using Vp

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(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)

Calculations using Vp

Use of TDI and Color M-Use of TDI and Color M-mode in Infantsmode in Infants

Study by Larrazet et al, Pediatric Study by Larrazet et al, Pediatric Critical Care Medicine, 2005Critical Care Medicine, 2005

Studied infants 3-8 months of age, Studied infants 3-8 months of age, immediately post-operatively for immediately post-operatively for VSD/AVCD repair w LA line in placeVSD/AVCD repair w LA line in place

For LA pressure > 10mmHgFor LA pressure > 10mmHg E/Ea > 15 – Sensitivity 94%, Specificity E/Ea > 15 – Sensitivity 94%, Specificity

72%72% E/E/Vp >2.0 – Sensitivity 83%, Specificity 89%

LA VolumeLA Volume In adults, atrial dilation has correlated as a risk In adults, atrial dilation has correlated as a risk

for first CV event (a-fib, stroke, CHF)for first CV event (a-fib, stroke, CHF) Defined as: women ≥ 30cmDefined as: women ≥ 30cm22/m/m22, men ≥ 33cm, men ≥ 33cm22/m/m22 Not routinely measured in children, Not routinely measured in children,

but recent norms establishedbut recent norms established

8/3π[(A1)(A2)/(L)] obtained from Apical 2 & 4 chamber views

LA Volume in ChildrenLA Volume in Children

Data collected by 3D Echo and separated Data collected by 3D Echo and separated by BSAby BSA 0.5-0.75m0.5-0.75m22 : 19.6 mL/m : 19.6 mL/m22 0.75-1.0m0.75-1.0m22 : 21.7 mL/m : 21.7 mL/m2 2 1.0-1.25m1.0-1.25m22 : 22.0 mL/m : 22.0 mL/m22 1.25-1.5m1.25-1.5m22 : 24.5 mL/m : 24.5 mL/m22 >1.5m>1.5m22 : 27.4 mL/m : 27.4 mL/m22

No normative values for RA established No normative values for RA established in kidsin kids

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%


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


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

Classification of Diastolic Dysfunction

Classification of Diastolic Dysfunction

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

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

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

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


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


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%

Nagueh et al, JACC 1997

Could predict mean PCWP= 1.24(E/Ea ) +1.9

TDI in Pseudonormalization

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

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%)

Restrictive Restrictive Physiology/Decreased Physiology/Decreased

Ventricular ComplianceVentricular Compliance Ventricle is significantly stiff, non-compliant, that Ventricle is significantly stiff, non-compliant, that

with small increases of volume, pressures increase with small increases of volume, pressures increase disproportionatelydisproportionately

On MV inflow, the E-wave is accelerated with short On MV inflow, the E-wave is accelerated with short deceleration time due to rapid rise of ventricular deceleration time due to rapid rise of ventricular pressure and the end of inflowpressure and the end of inflow

A-wave is remarkably small, if not absent all A-wave is remarkably small, if not absent all together, as atrial systole minimally generates a together, as atrial systole minimally generates a pressure gradient across the AV valvepressure gradient across the AV valve Instead prolonged reflux in PV observedInstead prolonged reflux in PV observed

Restrictive Restrictive Physiology/Decreased Physiology/Decreased

Ventricular ComplianceVentricular Compliance IVRT shortened due to atrial IVRT shortened due to atrial

hypertension with early opening of hypertension with early opening of MV and ventricular fillingMV and ventricular filling

Measures through Measures through childhoodchildhood

InfantsInfants Very limited early diastolic flowVery limited early diastolic flow Significant contribution from atrial systoleSignificant contribution from atrial systole Limited tolerance to changes in preloadLimited tolerance to changes in preload Improved compliance around 2 monthsImproved compliance around 2 months

ChildhoodChildhood Limited variability of measures (Inflow/TDI) Limited variability of measures (Inflow/TDI)

through childhood and adolescencethrough childhood and adolescence Noted changes with increasing IVRT likely Noted changes with increasing IVRT likely

associated with age-related decreased HRassociated with age-related decreased HR

Tables of normative values for children are available

Tables of normative values for children are available

Let’s apply our data

52.4 cm/s57.0 cm/s


144 cm/s

72 cm/s

2.0

130

108 ms

90 ms


13.1 cm/s

11

VpVs= x Li

Vs = strength of early filling

Vs Strength of Filling

In a recent article by Stewart et al., JACC Imaging 2011

Found that in addition to a decreased filling velocity (Vp) with diastolic dysfunction, the velocity further slowed closer to the MV than the apex (Li)

Vs= Vp x Li

Found this measure to have better correlation to gold-standard than Vp alone

Would like to see used with other measures to further strengthen accuracy and separation of abnormal states

Looking at Vp

69 cm/s

E/Vp= 2.0

Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-94.5(103/[2•60]+69)-9= 15 mmHg

Simplified version = 103/[2•IVRT]+FPV 103/[2•60]+69= 5.2

To summarize our non-invasive data

E/Vp= 2.0

So by our echo data…

I would classify this patient as having

RESTRICTIVE PHYSIOLOGY

He just so happened to have been cathed just before I

obtained these measures… I did not know these results

Disease states

Hypertrophic cardiomyopathy Chronic disease states

HOCM

Abnormalities of E/Ea, color M-mode flow propagation, and diastolic strain rates have correlated with abnormal relaxation and predict LV filling pressures.

TDI (DTI) has been found to be predictive of adverse outcomes E/Ea >12 predicted risk for SCD, Cardiac

Arrest, and VT Those without, events had range 7.4-11.2 Those with symptoms had ratio higher

compared to those without (11.9 vs 8.1)

Distinguishing HOCM from Athletic Heart

Diastolic TDI annular patterns, IVRT, and LA volume have identified HOCM in absence of pathologic changes

Early diastolic TDI velocities (Ea) Athletes: normal to increased HOCM: consistently decreased, often

Ea/Aa <1.

Children with Chronic Dz’s

Renal failure Those on dialysis had changes on echo

compared to normal controls: Increased LV mass with preserved systolic function Evidence of diastolic dysfunction: higher E’s, lower

Ea’s and therefore increased E/Ea ratios

Obesity Demonstrated changes with Ea (↓) and Aa (↑)

velocities where the ratio Ea/Aa was < controls Demonstrated changes with strain rate imaging

also noted

Children with Chronic Dz’s

Obstructive sleep apnea Evidence of diastolic dysfunction

correlated with severity of sleep apnea Measures improved with effective

therapies Anthracycline toxicity

Demonstrated changes with Ea (↓) and Aa (↑) velocities, Ea/Aa ratio is ↓↓↓

Persists over time, even without evidence of systolic dysfunction

Congenital Heart Disease

Aortic Stenosis Measures are more pronounced in more

severe disease Does not resolve immediately with relief

of obstruction Changes/improvement correlate more

with degree of ventricular hypertrophy


Single ventricles Demonstrated impaired relaxation,

decreased peak E velocities, presence of mid-diastolic filling waves, decreased E/A velocity ratio

Different pulmonary venous inflow patterns due to different sources of pulmonary antegrade blood flow

In well functioning single ventricles, biphasic pulmonary venous inflow still seen (mid-systolic peak, and late diastolic peak)


Single ventricles With decrease ventricular systolic function

Decreased systolic flow in PV Increased late diastolic flow in PV Seems to correlate with changes in EF

Serial studies in HLHS No differences in early stages within 1st

year of life Need more longitudinal studies


TGA Atrial Switches (Senning/Mustard)

Found to have decrease IVCT, and sensitive to changes of systemic RV dysfunction in adolescents and young adults

Measures of TDI are lower than normals, as expected

More data needed for the population, esp Arterial Switches

References Frommelt, P. (2009). Diastolic Ventricular Function Assessment. In WW Lai, LL

Mertens, MS Cohen, T Geva (Eds), Echocardiography in Pediatric and Congenital Heart Disease (1st Edition, p95-118). Hoboken, USA: Wiley-Blackwell.

Garcia MJ, et al. Color M-mode doppler flow propagation velocity is a preload insensitive index of left ventricular relaxation: animal and human validation. JACC 2000; 35: 201-8.

Nagueh SF, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. JACC 1997; 30: 1527-33.

Eidem BW, et al. Impact of chronic left ventricular preload and afterload on doppler tissue imaging velocities: a study in congenital heart disease. J Am Soc Echocardiogr 2005; 18: 830-8.

Larrazet F, et al. Tissue doppler echocardiographic and color M-mode estimation of left atrial pressure in infants. Pediatr Crit Care Med 2005; 6: 448-53.

Gonzalez-Vilchez F, et al. Combined use of pulsed and color M-mode doppler echocardiography for the estimation of pulmonary capillary wedge pressure: an emperical approach based on an analytical relation. JACC 1999; 34: 515-23.

Border WL, et al. Color M-mode and doppler tissue evaluation of diastolic function in children: simultaneous correlation with invasive indices. J Am Soc Echocardiogr 2003; 16: 988-94.

Abali G, et al. Which doppler parameters are load independent? A study in normal volunteers after blood donation. J Am Soc Echocardiogr 2005; 18: 1260-5.

Stewart KC, et al. Evaluation of LV diastolic function from color M-mode echocardiography. J Am Coll Cardiol Img 2011; 4: 37-46.

Documents

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