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Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography

Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography. LAM- 1965AO (07/13) For Broker/Dealer Use Only. Diastole and Systole.

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Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography

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  1. Diastolic Dysfunction as Diagnosed and Quantified by Echocardiography LAM-1965AO(07/13) For Broker/Dealer Use Only

  2. Diastole and Systole • Diastole: The normal rhythmically occurring relaxation and dilatation of the heart chambers, especially the ventricles, during which they fill with blood. • Systole: The contraction, or period of contraction, of the heart, especially of the ventricles, during which blood is forced into the aorta and pulmonary artery.

  3. Cardiac Cycle

  4. What is Diastolic Dysfunction? • Changes in the ventricle which may result in impaired relaxation, reduced compliance and elevated pressures • Diastolic Dysfunction ≠ Diastolic Heart Failure

  5. What is Diastolic Dysfunction? • Who is more likely to develop DD? Elderly* Women Obese • What diseases are more likely to produce DD? HTN LVH CAD VHD (AS) • Text book Example: Older lady overweight with long history of hypertension with exercise intolerance

  6. What is Diastolic Dysfunction? • 3 Stages to Diastolic Dysfunction I) Impaired Relaxation II) Pseudonormal III) Restrictive • Primary measurements include peak E & A transmitral velocities, E/A ratio, DT (Deceleration Time) and IVRT (Isovolumetric Relaxation Time) • Additional measurements E/e’, LA volume index, Pulmonary Vein Flow ( S/D & AR) and Vp (Propagation Velocity)

  7. What is Diastolic Dysfunction? Figure 2 Doppler echocardiogram shows normal pattern of diastolic filling. Opening of the mitral value produces increased flow velocity through the valve annulus, which is represented as a large E wave (E). During late diastolic filling, the transmitral pressure gradient increases once again, with atrial contraction producing a smaller A wave (A). (3)

  8. What is Diastolic Dysfunction?

  9. What is Diastolic Dysfunction?

  10. What is Diastolic Dysfunction? I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance), ECG: electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocity of flow progression, LA: left atrium, PASP: pulmonary artery systolic pressure.

  11. What is Diastolic Dysfunction? • 1st use E/A, DT, and IVRT • 2nd use E/e’ (<8,8-15,>15) and LA vol index (< 28 ml/M2 WNL and > 34 ml/M2 increased mortality) • 3rd use Pulmonary Vein Flow ( S/D & AR) and Vp (Propagation Velocity)

  12. What is Diastolic Dysfunction? Normal E/A Ratio (>1) • Good: < 60 yo, no risk factors, no evidence of increased filling pressures ( E/e’ > 15, S<D, inc AR, dec Vp ) • Not Good: > 70 yo with risk factors (HTN/LVH, CAD, ♀ ), evidence of increased filling pressures E/A < 1 ( Grade I DD, Impaired Relaxation) • NBD: > 70 yo and no HTN/LVH or CAD • BD: < 50 yo with HTN/LVH or CAD Grade II DD, Pseudonormal and LA vol index (> 34 ml/M2) • BAD ( until proven otherwise) Grade III or IV, Restrictive • BAD BADBAD

  13. Diastolic Dysfunction Case Study • 74 yo male applying for $5 mil , no h/o HTN, heart disease , diabetes or cancer • 6’ 0” , 185 lbs, 125/82 mmHg , 62 reg • Labs and EKG WNL • APS: 2012 echo….LV size and function WNL , EF 65%, LVPWd 1.1 cm, R & L atrium WNL, Grade I DD, no significant valvular disease….GXT: exercised 13 min to 14 METS, no ischemic changes • Offer?

  14. Diastolic Dysfunction Case Study • 72 yo female applying for $5 mil , long h/o HTN, no heart disease , diabetes or cancer • 5’2” , 220 lbs, 154/92 mmHg , 92 reg • Labs WNL except NTproBNP 320 pg/ml and EKG LAD, LVH & LAE • APS: 2012 echo….LV size and function WNL , EF 65%, LVPWd 1.6 cm, L atrium 5.2 cm, E:A 2.2, E/e’ 20, no significant valvular disease….GXT: exercised 3 min to 4 METS, no ischemic changes • Offer?

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