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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

Disclosures

• Philips Healthcare: Consultant

Must Read!

The Role of PASP in Left Heart Filling Pressures

Bouchard et al. Am J Cardiol 2008;101:1673–1676

Mitral A wave

Strain phaseRest

Dumesnil JG, et al. Am J Cardiol. 1991;68:515–519

Strain phaseEarly phase

Dumesnil JG, et al. Am J Cardiol. 1991;68:515–519

Release phase

Systolic waveforms (S1,S2)Diastolic waveform

Atrial reversal waveform

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

Invention of Tissue Doppler

Isaaz et al. Am J Cardiol. 1989 Jul 1;64:66-75.

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

Role of DTI in Fused E/A

Sohn DW. J Am Soc Echocardiogr. 1999 Mar;12(3):203-8.

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

LA Discrepancy

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)

Lang et al, ASE 2005 Guidelines

Lang et al, ASE 2015 Guidelines

Chahal, et al. European Journal of Echocardiography. 2010 11, 51–56.

EAE A

Where’s the Decel?

Where’s the Peak e’ Velocity?

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

S D

• 84 y/o female

• H/O HTN, CAD, CHF

• Dyspnea, new pedal edema

• Multiple WMAs

• PASP = 45 mmHg

• Severe LAE

e’

a’

E/e’ = 8

e’

a’

E/e’ = 8

Significant “Down Time”: MPI

a’

e’

IVRT

s’

IVCT

E/e’ Unreliable 2° MAC

*Table adapted and modified from Redfield et al

Perfect Picture

Image modified from Redfield et al, JAMA. 2003;289:194-202

Discrepant Diastology

“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

29 y/o male

CP, mild DOE

No valvular dz

EF = 60-65%

NL LA size

PASP = 25 mmHg

This Patient Has…

Not measured


• 68 y/o male

• CHF

• Inferior WMA’s

• BPEF = 44%


• PASP = 19 mmHg

• Mild LAE


This Patient Has…

Not measured

• 82 y/o female

• H/O Diastolic CHF

• DOE

• PASP = 45-50 mmHg

• Severe LAE


This Patient Has…

• 64 y/o male

• Fresh STEMI

• Borderline tachycardia

• EF = 25-30%

• Multiple WMAs

• No significant valvular DZ

• PASP = 50 mmHg

• Severe LAE


This Patient Has…

• 60 y/o male

• CAD, Dyspnea

• Dynamic EF

• No significant valvular DZ

• PASP = 30-35 mmHg

• Severe LAE

Ave = 14


This Patient Has…

14

Discrepancy!

• 82 y/o female

• HHD/CHF

• Multiple WMA’s

• PASP = 48 mmHg

• EF = 35-40%

•Moderate/severe LAE

• Severe MAC


This Patient Has…

Discrepancy!

• 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 %


This Patient Has…

Not measured

• 30 y/o female

• Edema

• Borderline tachycardia

• Evaluate RV/LV fx

• PASP = 17 mmHg


• NL LA size


This Patient Has…

Not measured

Take-Home

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2016

Information modified from: Nagueh et al, J Am Soc Echocardiogr. 2016