7. Ventricular Diastolic Function

Question 1

Phases of diastole

Answer 1

1. Isovolumic relaxation 2. Early, rapid LV inflow 3. Diastasis 4. Atrial contraction

Question 2

LV relaxation vs compliance

Answer 2

LV Relaxation: involves the resequestration of calcium from the cytosol back into the SR * active process using Ca pumps * allows myofibrils to relax LV compliance: depends on the passive properties of the ventricle

Question 3

Mitral Inflow, IVRT and deceleration time

Answer 3

IVRT: time from end systole to beginning of E wave DT: time from peak E wave velocity to zero Impaired relaxation: IVRT >110ms (delayed MV opening) DT > 250ms Decreased compliance: IVRT < 60ms (early MV opening due to high LA pressures) DT < 140ms

Question 4

Transmitral Inflow, impaired relaxation

Answer 4

The initial abnormality in most cardiac disorders - ischemia/MI - hypertrophy - hypertrophic cardiomyopathy - infiltrative disorders Characteristics - E/A reversal (E/A < 1) - Prolonged DT - Prolonged IVRT

Question 5

Transmitral Inflow, restrictive pattern

Answer 5

Markedly decreased LV compliance causing increased left atrial pressures - Restriction coexists with impaired relaxation, but overwhelms changes caused by impaired relaxation Characteristics: - Elevated E wave (due to elevated LAP) - Decreased A wave (poor atrial contractility) - E/A > 2 - shortened IVRT - shortened DT

Question 6

Transmitral inflow pattern changes with preload reduction

Answer 6

Decreasing preload by NTG, reverse T-berg, vasalva - healthy individual has proportional decrease in E and A wave - pseudonormal will slide back to impaired relax pattern - restrictive will slide back to pseudonormal, unless end-stage and irreversible

Question 7

Pulmonary Venous Flow Tracing

Answer 7

1. Anterograde systolic velocity (S) - Often biphasic * S1 = left atrial relaxation * S2 = RV stroke volume, LA compliance, early ventricular systole (many things together) 2. Diastole (D) - LA serves as open conduit from PV to LV 3. Atrial flow reversal (A) - LA contraction

Question 8

Pulmonary Vein Tracing, Normal Values

Answer 8

1. S wave - Equal to or greater than diastolic - VTIsys/(VTIsys+VTIdias) < 40% denotes in left atrial pressures 2. A wave - Duration same or less than transmitral A wave (>30ms longer is abnormal) * Denotes more blood going forward (normal) than backwards - Peak velocity 35cm/s or more greater than mitral A wave is abnormal

Question 9

Pulmonary Vein Tracing, Impaired Relaxation

Answer 9

• Reduce D wave velocity (parallels decrease in mitral E wave velocity) - Compensatory increase in S wave - ** Systolic predominance

Question 10

Pulmonary Vein Tracing, Pseudonormal

Answer 10

• Systolic blunting (due to reduced ventricular compliance) - A wave with prolonged duration and increased velocity

Question 11

Pulmonary Vein Tracing, Restrictive

Answer 11

• Systolic blunting (due to reduced ventricular compliance) - A wave with decreased velocity, often due to failure of atria - Diastolic wave DT shortened (similar to transmitral E wave DT shortening with restrictive defect)

Question 12

Transmitral and Pulmonary Vein Limitations

Answer 12

• Preload, afterload, HR, rhythm all have effects

Question 13

Tissue doppler to assess mitral annular motion, general considerations

Answer 13

• Use ME 4 chamber view - Best alignment to assess lateral wall * Septal wall possible, although velocities are lower and blood flow in LVOT can obscure measurements

Question 14

TDI of mitral annular motion, normal

Answer 14

• Mirror image of transmitral flow velocities, with lower velocities (E’, A’, S’) - E’ normal 8-15 cm/s *** PRELOAD INSENSITIVE ***

Question 15

TDI of mitral annular motion, pathology

Answer 15

Impaired relaxation: E’ wave decreased while A’ wave remains normal (similar to transmitral flow) Pseudonormal and Restrictive: A’ begins to fall, BUT E’/A’ remains decreased such that E’/A’ <8 (differs from transmitral flow here)

Question 16

Propagation Velocity

Answer 16

• velocity at which flow propagates into the ventricle - slope of the color wavefront of transmitral flow (first aliasing velocity) starting at mitral annulus extending 3cm into LV - ME 4 chamber *** PRELOAD INSENSITIVE *** Normal: >45-50

Question 17

Methods of Assessing RV Diastolic Dysfunction

Answer 17

1. Transtricuspid Flow Velocities 2. Hepatic Vein Flow 3. IVC

Question 18

Transtricupid Flow Velocity

Answer 18

Similar to transmitral flow with E and A waves with similar changes in impaired relaxation

Question 19

Hepatic Vein Flow

Answer 19

Morphology 1. Small reversal following atrial contraction (A wave) 2. Antegrade systolic phase (S wave) 3. Small flow reversal end systole (V wave) 4. Antegrade diastole (D wave)

Question 20

IVC and RV diastolic dysfunction

Answer 20

IVC Normal (Right atrial pressure 0-5mmhg) - IVC diameter 50% of original diameter with spontaneous inspiration Elevated RAP (>20mmhg) - Large diameter - Little respiratory variation

Question 21

Pericardial Tamponade

Answer 21

• Early diastole RV collapse - Late diastole - early systole RA collapse - Abnormal ventricular septal motion - > 25% respiratory variation in mitral and tricuspid flows

Question 22

Comparison of Doppler measures of diastolic function

Answer 22