0508-1015-Oh-Echocardiographic Evaluation Of Diastolic Function PDF Free Download

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4/23/2018Assessment of Diastolic FunctionChallenging, but Can be SimpleASE Echo Board Review CourseMay 8th, 2018Jae K. Oh, MDSamsung Professor of CV Diseases 2018 MFMER 3712003-1Learning Objectives for DiastologyAfter this talk, you will be able to Understand physiology and hemodynamics of diastole Know correlation between Echo diastolic parameters andunderlying hemodynamics Classify and grade diastolic function Estimate filling pressure reliably in most patients at rest and withexercise Understand pitfalls of Echo diastolic function assessment 2018 MFMER 3712003-21

4/23/2018Diastolic Filling with Relaxation 2018 MFMER 3712003-3Circulation 1980Myocardial relaxation is one of the earliest manifestations ofmechanical dysfunction of the human LV. The time constant tau(Ƭ) is higher in the elderly and patients with HCM, CAD, andcardiomyopathies. 2018 MFMER 3712003-42

4/23/2018Echo evaluation of diastolic functionTrans-mitral inflow velocity 2018 MFMER 3712003-5Diastolic Function GradingMitral Inflow (U estrictive400LAPNL ( 15)TAUNL ( 45)GradeNormal123Concept from Appleton and Hatle, 1985CP1254003-13 2018 MFMER 3712003-63

4/23/2018Mitral Inflow and Pulmonary Vein FlowDiastolic Function AssessmentGrade 1Grade 2Grade 3 2018 MFMER 3712003-7LV Relaxation by Cath and Echo (tau) vs e’ (mitral annulus velocity)120Tau (msec)100y -6.80x 85.68r 0.70P 0.0018060402000246e’ (cm/sec)81012Firstenberg et al: J Appl Physiol 90:299, 2001, Nagueh et al: JACC 1997Oki et al: AJC 1997 , Sohn et al:JACC 1997, Ommen et al: Circ 2000 Opdahl et al: Circulation119:2578, 2009, and more 2018 MFMER 3712003-84

4/23/2018Assessment of LV Relaxation by Echoe’ velocity reflects LV relaxationMyocardial Relaxation is the Key for DiastoleCP1254003-8 2018 MFMER 3712003-9Myocardial Relaxation (e’)e’ 12 cm/se’ 7 cm/se’ 4 cm/s 2018 MFMER 3712003-105

4/23/2018Evaluation of Diastolic FunctionMitral Inflow and Annulus VelocityNormalAb RelaxGrade 1PseudoRestrictiveGrade 2Grade 3Mitral flowPreload dependentMitral annulusvelocityPreload independentSohn et al: JACC, 1997CP1254003-30 2018 MFMER 3712003-11As LV fillingpressure Mitral EAnnulus EPCWP (mm Hg)4540y 1.9 1.24xr 0.87n 603530252015105E/ENagueh et al: JACC, 1997Ommen et al: Circ, 200005101520253035E/E CP1254003-31 2018 MFMER 3712003-126

4/23/2018Estimation of LV Filling PressuresE/e’ (Medial MV annulus)40LV filling pressure3530EF 50%EF 50%2520151050E/E 8E/E 8-15E/E 15Ommen SR et al: Circulation 102:1788, 2000 2018 MFMER 3712003-13What are normal values for e’ and E/e’ ? 2018 MFMER 3712003-147

4/23/201820-4040-60 6020-4020-40Septal e’ based on Age Groups40-6040-60 60 60Septal E/e’ based on AgeGroupsLuis Caballero et al. EHJ 2015Ritzema et al JACC Imaging 2011 2018 MFMER 3712003-15 2018 MFMER 3712003-168

4/23/2018LA Volume Index vsDiastolic Dysfunctionr 0.78n 147 pt6050403020NormalIIIIIIDiastolic function gradeCP1041500-8 2018 MFMER 3712003-17Hypertensive Heart Disease vs HFpEFImportance of PASP and E/e’1.0p 0.01*vs line of noinformation;†vs PASP0.8SensitivityIndexed LA volume700.6PASP*E/e' ratio*†Left atrial volume index*†Relative w all thickness*†Left ventricular mass index†Line of no yLam C et al, JACC, 2009 2011 MFMER slide-18 2018 MFMER 3712003-189

4/23/2018Four Major Parameters in DiastologyNormal valuesFour Major Diagnostic ParametersNormal Values1. E’ velocity 7(med), 10 (lat) cm/s2. E/e’ 14 (Av), 15(Med)3. TR velocity 2.8 m/sec4. LAVI 34 mL/m2JASE and EJ CV Imaging April 2016 2018 MFMER 3712003-19New Criteria for Diastolic Function AssessmentIn pts with normal LVEF 50%1 – Septal e’ velocity 7 cm/s orlateral e′ velocity 10 cm/s2 – Average E/e′ 14 , 15 (Med)3 – TR velocity 2.8 m/s4 – LA volume index 34 mL/m2 3 Normal2 and 2 3 AbnormalNormal diastolic functionIndeterminateDiastolic dysfunctionCriteria for diagnosis of LV diastolic dysfunction in patients withnormal LVEF in JASE 2016 2018 MFMER 3712003-2010

4/23/2018Normal Diastolic FunctionMedial e’ 12 cm/sLateral e’ 16 cm/s 2018 MFMER 3712003-21True Normal Diastolic Function 2018 MFMER 3712003-2211

4/23/201871 year old woman with LAVI 39 mL/m2E/e’e’LAVITRLateral e’ 10 cm/secE/e’ 9NL 14NL 7EnlargedNL 2.8Medial e’ 9 cm/secE/e’ 10 2018 MFMER 3712003-2371 year old woman with LAVI 39 mL/m2E/e’e’LAVITRNL 14NL 7EnlargedNL 2.8Lateral e’ 10 cm/secE/e’ 9LVOT TVI 26 cm 2018 MFMER 3712003-2412

4/23/2018Reasons for LA enlargement Diastolic dysfunction Increased filling pressure Increased volume Athlete’s heart Measurement error 2018 MFMER 3712003-25Normal or Grade 1 Diastolic Dysfunction ?LAVI 28 mL/m2E 50 A 100 E/A 0.5e’ 6 cm/secE/e’ 8E/e’ NL 14e’ ABNL 7LAVI NormalTR NL 2.8 2018 MFMER 3712003-2613

4/23/2018New Criteria for Diastolic Function AssessmentIn pts with normal LVEF 50%1 – Septal e’ velocity 7 cm/s orlateral e′ velocity 10 cm/s2 – Average E/e′ 14 , 15 (Med)3 – TR velocity 2.8 m/s4 – LA volume index 34 mL/m2 3 Normal2 and 2 3 AbnormalNormal diastolic functionIndeterminateDiastolic dysfunctionNormal Diastolic FillingPressureIncreased Diastolic FillingCriteria for diagnosis of LV diastolic dysfunctionPressurein patients with normal LVEF 2018 MFMER 3712003-29Diastolic Function AssessmentTake Home Point #1 LV myocardial relaxation is reduced in all stages of diastolicdysfunction Mitral annulus e’ velocity reflects myocardial relaxation Normal e’ Normal diastolic function Algorithm #1 separates normal filling from elevated fillingpressure Initial assessment of diastolic functon is based on E’, E/e’, TR velocity, and LAVI 2018 MFMER 3712003-3015

4/23/2018Diastolic Function?E 120 cm/sA 20 cm/sE/A 6e’ ABNL 7E/e’ ABNL 14LAVI ?TR NL 2.8e’ 4 cm/secE/e’ 30TR 4 m/sec 2018 MFMER 3712003-31Mitral inflowE/A 0.8 E 50cm/sE/A 2E/A 0.8 E 50 cm/sorE/A 0.8- 23 criteria to be evaluated*2 of 3negative1 – Average E/e′ 142 – TR velocity 2.8 m/s3 – LA volume index 34 mL/m22 of 3 or3 of 3positiveWhen only 2 criteria are available2 negativeNormal LAPGrade I diastolicdysfunctionIf symptomatic considerCAD or proceed todiastolic stress test1 positive and1 negative2 positiveCannot determine LAP anddiastolic dysfunctiongrade* LAPGrade II diastolicdysfunction LAPGrade III diastolicdysfunctionIn patients with depressed LVEFor normal EF with diastolic dysfunction 2018 MFMER 3712003-3216

4/23/201867 yo man with ischemic CM and HFGr. 1 dysfunction with normal filling pressureGrade 1 DysfunctionE/A 0.8E 50 cm/secE 45 cm/sec A 90 cm/secE/A 0.5 2018 MFMER 3712003-3367 yo man with ischemic CM and HFGr. 1 dysfunction with normal filling pressureGrade 1 DysfunctionE/A 0.8E 50 cm/secE/e’ NL 14e’ ABNL 7LAVI ABNLTR NL 2.8E 45 cm/sec A 90 cm/secE/A 0.5Medial e’ 4 cm/sE/e’ 11 2018 MFMER 3712003-3417

4/23/2018Grade 1 Diastolic DysfunctionGrade 1 DysfunctionE/A 0.8E 50 cm/secE 45 cm/sec A 90 cm/secE/A 0.5Medial e’ 4 cm/sE/e’ 11E 50 A 100 E/A 0.5e’ 6 cm/secE/e’ 8 2018 MFMER 3712003-3567 year old man with ischemic CM and HFE 45 cm/s E/A 0.5E/e’ 12Medial e’ 4 cm/s2 months beforeE 120 cm/sec E/A 0.9E/e’ 30TR Vel 3 m/sec 2018 MFMER 3712003-3618

4/23/201867 yo man with ischemic CM and HFGr. 2 dysfunction with increased filling pressureE 120 cm/sec E/A 0.9E/e’ 30TR Vel 3 m/sec 2018 MFMER 3712003-37Ischemic Cardiomyopathy Echo PredictorSTICH Trial (N 1511)Best survival with E/A 0.6-0.8Lin et al. 2014 AHA 2018 MFMER 3712003-3819

4/23/2018Grade 3 DysfunctionL waveE 120 cm/sA 20 cm/sE/A 6e’ ABNL 7E/e’ ABNL 14LAVI ?TR NL 2.8e’ 4 cm/secE/e’ 30TR 4 m/sec 2018 MFMER 3712003-39Mid-diastolic mitral flow (L)Delayed relaxationA. FibFrommelt et al: J Am Soc Echocardiogr 16:176, 2003CP1100934-2 2018 MFMER 3712003-4020

4/23/2018Distribution of 2D and Doppler VariablesMitral E/A ratio 0.8 E 50 cm/sElevated fillingpressure(n 165)Normal fillingpressure(n 155)023Mitral E/A ratio 2535None of the cutoff valuesmet for the 3 variables inpatients with diastolicdysfunction15703 abnormalLAV 34 ML/m2, E/e 14, and TRV 2.8 m/s2502 abnormal (2 of 3 listed)LAV 34 mL/m2, E/e 14, TRV 2.8 m/s357LAV 34 mL/m2, E/e 14, TRV 2.8 m/s118LAV 34 mL/m2, E/e 14, TRV 2.8 m/s81LAV 34 mL/m2632E/e 1484TR 2.8 m/s451 abnormal Normal Filling Pressure 3 normal parameters LAVI 34 mL/m2 E/A 0.8 E 50 cm/s Increased Filing pressure E/A 2 E/e’ 14 LAVI 34 mL/m2 3 abnormal 2 abnormalAndersen et al: J Am Coll Cardiol 2017;69:1937-48 2018 MFMER 3712003-4123 YO with HCM1. Grade 12. Grade 23. Grade 34. Possibly normalE 70 cm/s A 30 cm/sE/A 2.3 2018 MFMER 3712003-4221

4/23/2018E 70 cm/s23 yo with HCMMedial e’ 8 cm/secLateral e’ 10 cm/secE/e’ 9E/e’ 7Can he have a normal diastolic function ? 2018 MFMER 3712003-4323 yo man with HCMLAVI 29 mL/m2TR 2 m/secIVRT 120 msec 2018 MFMER 3712003-4422

4/23/2018IVRT 100 msecValsalva in 23 yo HCMNormal filling pressureE/A 2.3E/A 2.0 2018 MFMER 3712003-45Mitral A duration is shorter than PV ARIncreased LVEDP 2011 MFMER slide-46 2018 MFMER 3712003-4623

4/23/2018EDP(mm Hg)DopplerDeterminationof LVEDPMitral flow velocity454035302520151050-100r 0.68P 0.001-50LV pressure050100PVad-Ad (ms)Rossvoll and Hatle:JACC, 199325 mm Hg0.5Ma 100 msPVa 165 ms0.5Pulmonary veinLVEDP can be increased with normal mean LVdiastolic pressureCP1057136-18 2018 MFMER 3712003-47Diastolic Function AssessmentTake Home Message #2 Grade 1 diastolic dysfunction is the best pattern for thepatients with Heart Failure Evidence for diastolic dysfunction needs an objectiveevidence Hypertension Hypertrophic CM Old ageThe best evidence is reduced relaxationReduced e’L waveProlonged IVRT 2018 MFMER 3712003-4824

4/23/2018Difficult Situations Assess diastolic function or filling pressure in 2 normal and 2 abnormal HCM LBBB MAC Atrial Fibrillation Additional supportive parameters Pulmonary vein Valsalva IVRT and timing intervals Strain 2018 MFMER 3712003-4967 year old woman with HPT and SOBLAVI 54 and TR 2.8 m/sE 90 A 40 E/A 2.31. E’ /2. E/e’ NLLat e’ 8E/e’ 12Med e’ 7E/e’ 133. TR 2.84. LAVI 2018 MFMER 3712003-5025

4/23/2018Indeterminate ? E’ / E/e’ 15 LA 34 TR 2.8 m/secTR 2.83 m/s 2018 MFMER 3712003-51Pulmonary Vein VelocityPVs decreases as filling pressure increasesPVsPVdPVaNormalImpairedrelaxation compliance LAP compliance LAP 2018 MFMER 3712003-5226

4/23/2018Valsalva Maneuver : E/A reduced 0.5Grade 2 DysfunctionE 90 A 40 E/A 2.3E 60 A 60 E/A 1.0 2018 MFMER 3712003-53Conclusions—In 100 symptomatic patients with HCM, Doppler echoestimates of LV filling pressure correlate modestly with directmeasurement of LAP. Given the complex nature of diastolicdysfunction in HCM, precise characterization of LV filling pressure inan individual patient cannot be determined with the use of thesenoninvasive parameters. (Circulation. 2007;116:2702-2708.) 2018 MFMER 3712003-5427

4/23/2018Medial E/e’ Ratio Versus Mean LAP60All studiesAll 0.45x 11.5r 0.44P 0.001Simultaneous studiesy 0.28x 13.8r 0.28P 0.07Simultaneous studies 48 hours between studiesMedial E-e’ ratio50403020100051015202530354045Mean LAP (mmHg)Geske et al: Circulation; 116:2702, 2007 2018 MFMER 3712003-55Mean LAP vs Medial E-e’ ratioHypertrophic CMMean LAP (mmHg)4540Simultaneous studies 48 hours between studies35302520151050 88-15 15Mean E-e’ RatioGeske et al: Circulation; 116:2702, 2007 2018 MFMER 3712003-5628

4/23/2018Diastolic Function Evaluation in HCM E’ velocity is reduced in almost all patients E/e’ predicts clinical outcome Use following parameters (ASE 2016 Guideline) E/e’ 15 LAVI 34 mL/m2 TR velocity 2.8 m/sec PV Ar-A duration 30 msec The majority rules 2018 MFMER 3712003-5772 yo woman with HCMMed e’ 2 E/e’ 40E 80 A 95 E/A 0.85Lat e’ 5 E/e’ 15 2018 MFMER 3712003-5829

4/23/201872 yo woman with apical HCMGrade 2 dysfunction with LAVI 37 mL/m2TR 3 m/sec 2018 MFMER 3712003-59Mitral annulus e’ velocity ASE/EACVI recommends average value E’ from one location is acceptable We need a caution in using e’ Primary pulmonary hypertension Pacemaker LBBB Wall motion abnormality Mitral annulus calcification Hypertrophic CM 2018 MFMER 3712003-6030

4/23/201867 yo woman with LBBBMedial e’ 3 cm/s E/e’ 23E 60 A 80 E/A 0.7Lat e’ 9 cm/s E/e’ 8 2018 MFMER 3712003-6167 yo with LBBBTR 2.4 m/sec 2018 MFMER 3712003-6231

4/23/2018Mitral annulus calcification and TAVRE 100 cm/secLat e’ 4 cm/sMed e’ 3 cm/s 2018 MFMER 3712003-63Mitral annulus calcification and TAVRE 100cm/seccm/sE 100Lat e’ 4 cm/sPulmonary VeinMed e’ 3 cm/sTR 2.4 m/sec 2018 MFMER 3712003-6432

4/23/2018Mitral annulus e’ velocity vs MACMean age 73 yearsGroup 1n 79no MACGroup 2n 38mild MACGroup 3n 38mod-severe MAC01-119 119Septal e’5.96 1.825.15 1.565.05 1.930.01Lateral e’7.37 2.446.89 2.716.28 1.810.01Average e’6.63 26.02 1.795.67 1.690.01E/avg e’ ratio13 4.9315 8.9518 8.26 0.001VariableAgatston ScoreP for trendLV diastolic parameters are altered in the presence of MAC. This could be due todirect effects of MAC or might reflect truly reduced diastolic function. Interpretationof diastolic parameters in patients with MAC should be performedwith caution.Codolosa et al: Am J Cardiol 2016;117:847-852 2018 MFMER 3712003-65Representative Images of Patients With Mitral Annular CalcificationMildModerateSevereAbudiab et al: Am Coll Cardiol Img, 2017 2018 MFMER 3712003-6633

4/23/2018Correlation of Selected Doppler Variables With LeftVentricular Filling Pressure150r 0.66, P 0.0013IVRTMitral E/A4210r -0.50, P 0.0011005000204060020LVFP (mm Hg)50E/e (avg)4060LVFP (mm Hg)r 0.42, P 0.0034030201000204060LVFP (mm Hg)Abudiab et al: Am Coll Cardiol Img, 2017 2018 MFMER 3712003-67Proposed Clinical Algorithm for Estimationof Left Ventricular Filling Pressure inSubjects With Mitral Annular CalcificationInitial Cohort (n 50):Sensitivity: 81%Specificity: 100%PPV: 100%NPV: 67%Mitral E/A 0.80.8-1.8Normal LVFPInitial: 8/9 (89%)Total 12/13 (92%)Total Cohort (n 71):Sensitivity: 85%Specificity: 95%PPV: 97%NPV: 78% 1.8IVRT 80 msHigh LVFP10/10 (100%)11/11 (100%) 80 msNormal LVFPHigh LVFP4/9 (44%)9/14 (64%)16/16 (100%)23/24 (96%)Abudiab et al: Am Coll Cardiol Img, 2017 2018 MFMER 3712003-6834

4/23/2018Diastolic Function in A. Fib DT 160 msec (with reduced EF) DT 130 msec poor survival (Hurley, Oh) Other measurements E acceleration 1900 cm/sec2 IVRT 65 msec E/e’ 11 IVRT/ T E-e’ TR velocity 2018 MFMER 3712003-69E 120E’ 6L waveE/e’ 20JASE 1999 2018 MFMER 3712003-7035

4/23/2018Atrial FibrillationVariation in E velocities : NL PressureDT 210 msecDT 100 msec 2018 MFMER 3712003-71Atrial FibrillationVariation in E velocities and E/e’ 11E/e’ 9 2018 MFMER 3712003-7236

4/23/201866 yo woman with dyspnea and EF 20%Lat e’ 5 cm/secE/e’ 21E-A 105 cm/secMedial e’ 7 cm/secE/e’ 15 2018 MFMER 3712003-7366 yo woman with HF and severe MRLVEF 20%TR 2.9 m/sIVRT 75 msec 2018 MFMER 3712003-7437

4/23/2018Nagueh et al Circulation 1998 2018 MFMER 3712003-75My Recommendations For patients with reduced EF ( 35%) or with preserved EF with knowndiastolic dysfunction, evaluate diastolic function based on E/A ratio For all other patients, based on the 4 parameters Normal : 3 normal (for patient’s age) Abnormal : 3 abnormal (grade 2 or 3 based on E/A) Indeterminate : Need help from PV, IVRT, Valsalva, Time interval,Exercise, Strain Imaging 2018 MFMER 3712003-7638

4/23/2018My recommendation based on e’ velocityLV relaxation is the key for normal diastole True Normal Medial e’ 10 cm/sec or Lateral e’ 15 cm/sec Age-related Normal Medial e’ 7-10 cm/s or Lateral e’ 10-15 with normal TR Abnormal Medial e’ 7 cm/s or lateral e’ 10 cm/s Grade 1, 2, and 3 based on E/e’, TR, and LAVI 2018 MFMER 3712003-77Thank you!Oh.jae@mayo.edu 2018 MFMER 3712003-7839

ASE Echo Board Review Course May 8th, 2018 Jae K. Oh, MD Samsung Professor of CV Diseases 2018 MFMER 3712003-2 Learning Objectives for Diastology After this talk, you will be able to Understand physiology and hemodynamics of diastole Know correlation between Echo diastolic parameters and underlying hemodynamics