Test DAy

Question 2

What mitral annular velocity values (usually) indicate normal diastolic function?

Answer 2

• septal (E’) = ≤ 7
• lateral (E’) = ≤ 10

Question 3

What are the first two parameters to check in the assessment of diastolic function?

Answer 3

• LA volume indexed (LAVI)
• Doppler Tissue Imaging –> E’ (septal and lateral)

*** if both normal then most likely normal diastolic function

Question 4

What is an easy way to determine normal LA pressure when assessing Left Atrial Inflow or Pulmonary Vein Flow (PVF) in assessment of diastolic function?

Answer 4

S > D

• 85% have normal LA pressure

Question 5

In the assessment of diastolic function:

• How is the valsalva response obtained/measured?
• What does it determine?
• How can the Valsalva maneuver help to distinguish between normal/pseudonormal?

Answer 5

• Continuously recording mitral inflow (PW doppler) for 10s during the straining phase of the maneuver
• whether restrictive LV filling is reversible or not
• decrease in E/A ratio of ≥ 50%, not caused by E and A velocities fusion, is highly specific for increased LV filling pressures (supporting presence of diastolic dysfunction)

***Continuous recording of mitral inflow during standardized Valsalva maneuever for 10s –> decrease in E/A ratio with straining, which is consistent with elevated LV filling pressures

Question 7

What are the four principal measurements in assessing presence of diastolic function in a patient with normal LVEF?

Answer 7

• E/e’ ratio > 14
  
  • e’ averaged between septal and lateral annulus
• Tissue Doppler velocity (medial and lateral annuli) - e’
  
  • medial < 7 cm/s
  • lateral < 10 cm/s
• Peak continuous wave TR velocity > 2.8 m/s
• LA volume index > 34 cc/m2

**diastolic dysfunction present if > 50% positive

***indeterminate if 50% positive

****nromal diastolic function if < 50% positive

Question 8

Describe the initial step in the grading of diastolic dysfunction

(in patients with depressed LVEF’s and patients with myocardial disease and normal EF)?

Answer 8

• Transmitral Inflow ratio
  
  • E/A ≤ 0.8 + E ≤ 50 cm/s
    
    • –> normal LAP, Grade I DD
    • if symptomatic –> consider CAD, or diastolic stress test
• E/A ≤ 0.8 + E > 50 cm/s or E/A > 0.8 - < 2
  
  • –> 3 criteria to be evaluated
• E/A ≥ 2
  
  • –> increase LAP, Grade III DD

Question 9

In assessment of the AV/Aorta which measurements should be measured:

• leading edge to leading edge
• inner edge to inner edge

Answer 9

• Leading-to-leading edge (during mid-systole)
  
  • LVOT diameter
  • Aortic valve annulus
• Inner-to-inner edge
  
  • sinuses of Valsalva
  • sinotubular junction
  • ascending aorta

Question 12

Describe the algorithm differentiating CP and Restrictive Cardiomyopathy?

Answer 12

Question 13

Describe the parameters to evaluated in grading diastolic function for those with:

E/A ≤ 0.8 + E > 50 cm/s or E/A > 0.8 - < 2

Answer 13

• Average E/e’ > 14
• TR velocity > 2.8 m/s
• LAVI > 34 ml/m2

Question 14

Describe the findings of Grade II diastolic dysfunction

Answer 14

• LV relaxation - impaired
• LAP - Elevated
• Mitral E/A ratio - > 0.8 - < 2
• Average E/e’ ratio - 10-14
• Peak TR velocity (m/s) - > 2.8
• LAVI - Increased

Question 15

Describe the diastolic filling pattern?

Answer 15

Grade 2 diastolic dysfunction

Pseudonormal

Question 16

Describe the second step in determining diastolic function grade when all 3 parameters are known?

Answer 16

• 2/3 or 3/3 positive –> increased LAP or Grade 2 diastolic dysfunction
• 2/3 or 3/3 negative –> normal LAP or Grade I diastolic dysfunction

Question 17

Describe the second step in determining diastolic function grade when only 2 parameters are known?

Answer 17

• 2 positive –> increased LAP or Grade 2 diastolic dysfunction
• 1 positive/1 negative –> indeterminate
• 2 negative –> normal LAP or Grade I diastolic dysfunction

Question 19

What are supportive findings of CP with mixed mitral medial e’ (6-8 cm/s) in assessment of CP vs. RC?

Answer 19

• Annulus reversus
  
  • Mitral lateral e’ < medial e’
  • Most likely constriction if present
• Hepatic vein expiratory end-diastolic reversal velocity / forward flow velocity = > 0.8
  
  • ​definitely constriction if present