LV diastolic dysfunction explained concisely

Lv diastolic dysfunction

1. Echocardiographic Assessment Of Left Ventricular Diastolic Dysfunction Presented By: Dr. Anjali Patel Under Guidance of: Dr. S. S. Kothari Sir Dr. Jayal Shah Sir Dr. Riyaz Charaniya Sir Dr. Tarun Madan Sir Dr. Devrat Sir

2. BASIC PRINCIPLES : 1)CAUSES OF DIASTOLIC DYSFUNCTION 2)PHASES OF VENTRICULAR DIASTOLE 3)PARAMETERS OF DIASTOLIC FUNCTION 4)RESPIRATORY VARIATION ECHO AND DOPPLER EVALUATION OF LV FILLING AND DIASTOLIC FUNCTION TISSUE DOPPLER MYOCARDIAL IMAGING LEFT ATRIAL PARAMETERS: 1)LA DOPPLER FILLING CURVES, 2)LA VOLUMES LEFT VENTRICULAR PARAMETERS: 1) IVRT , 2) PROPOGATION VELOCITY, 3) RATE OF LV RELAXATION (-Dp/dt) CONFOUNDING FACTORS CLINICAL CLASSIFICATION (GRADING) OF LV DIASTOLIC DYSFUNCTION ADDITIONAL PARAMETERS OF DIASTOLIC FUNCTION DIASTOLIC STRESS TEST ASSESSMENT IN SPECIAL POPULATIONS

3. Diastole - in Greek means to “ set apart ” or expand Normal LV diastolic function may be clinically defined as the capacity of the LV to receive a LV filling volume able in its turn to guarantee an adequate stroke volume, operating at a low pressure regimen. It is described as impaired LV relaxation and increased LV stiffness. L VDD is extremely prevalent in patients with hypertension and in older pts. The historical “gold standard” for assessment of diastolic function has been the invasively obtained pressure-volume loop, in which diastolic function is assessed as the instantaneous relationship between pressure and volume. By echocardiography, assessment of, left atrial pressure, left ventricular end-diastolic pressure (LVEDP) and diastolic dysfunction is multifaceted. Mitral Inflow Patterns Mitral inflow Doppler can be used to assess flow from the left atrium to the left ventricle during diastole. INTRODUCTION

4. CAUSES OF DIASTOLIC DYSFUNCTION PRIMARY MYICARDIAL DISEASE: DILATED CARDIOMYOPATHY RESTRICTIVE CARDIOMYOPATHY HYPERTROPHIC CARDIOMYOPATHY SECONDARY HYPERTROPHY:HTN,AORTIC STENOSIS CONG. HEART DISEASE CORONARY ARTERY DISEASE:ISCHEMIA AND INFARCTION EXTRINSIC CONSTRAINT:PERICARDIAL TAMPONADE PERICARDIAL CONSTRAINT

5. Diastole can be divided into four phases : Isovolumetric relaxation Early rapid diastolic filling Diastasis – slow filling Late diastolic filling caused by atrial contraction LA functions as Reservoir during systole; conduit during diastasis and pump during late diastole

6. DIASTOLIC PRESSURE CURVES IVRT is interval starts with aortic valve closure  rapid decline in LV pressure. When LV pressure falls below LA pressure  mitral valve opens. Maximal opening of the mitral leaflets occurs rapidly, within 100 ± 10 msec of valve opening, in normal individuals.

7. DIATOLIC FILLING (VOLUME) CURVES Rapid early-diastolic filling : Rate of LA to LV flow determined by: pressure difference ventricular relaxation relative compliances of 2 chambers Diastasis : Little or no flow, duration dependent on HR: longer at slow HR entirely absent at faster HR Late diastolic filling: caused by atrial contraction: contributes 20% of total ventricular filling.

8. PARAMETERS OF VENTRICULAR FUNCTION 1.Ventricular relaxation 2.Myocardial or chamber compliance 3.Filling pressures 4.Additional parameters: Elastic recoil of ventricle Effect of pericardial constraint

9. 1.VENTRICULAR RELAXATION1. Abnormal relaxation  Prolonged IVRT Reduced early peak filling rate Measures of LV relaxation IVRT - dP /dt : Max. rate of pressure decline Tau or τ : Time constant of relaxation IVRT RAPID FILLING PHASE Diastasis Atrial systole

10. ISOVOLUMETRIC RELAXATION TIME Time interval between Aortic valve closure and till the mitral valve opening. Provides insight into the rate of early diastolic LV relaxation. Very sensitive to change in heart rate and arterial pressure,systolic function. Relaxation is prolonged when mitral valve opening is delayed or more arterial pressure. and hence IVRT is increased. ≤70ms in normal subjects >110 ms -earliest doppler sign of poor LV relaxation .

11. ISOVOLUMETRIC PRESSURE DECAY Simplest way to measure the rate of pressure fall is dP /dt Altered by changes in loading conditions Increase in After load slows the rate of isovolumetric pressure decay Increase in dP /dt signifies increase in time of myocardial relaxation or rise of aortic pressure. HFpEF have larger dP /dt. During myocardial ischaemia , dP /dt decreases and increases in response to ß-adrenergic stimulation.

12. Time constant of ventricular relaxation or Tau Described in 1976 by Weiss  et al . Best index to evaluate LV diastolic function Time constant, τ (tau) describes the rate of LV pressure decline throughout isovolumetric relaxation LV pressure( dP /dt) = P e -t/τ where P is LV pressure at end ejection and τ is the exponential time constant The larger the value of τ, the longer it takes for the LV pressure to fall and the more impaired is relaxation Full LV relaxation completed by 3.5 times tau, where τ being 30-40 ms.

13. 2. Ventricular Compliance Compliance : Ratio of change in volume to change in pressure ( dV / dP ) Stiffness is the inverse of compliance: dP / dV Can be divided into Myocardial compliance Chamber compliance Extrinsic factors Pericardium RV volume Pleural pressure

14. EARLY DIASTOLIC FILLING While ventricular diastolic function is a major factor affecting diastolic filling, these two concepts are not identical. Several physiologic parameters affect diastolic filling. Peak early-diastolic filling rate is affected by, Changes in preload that affect the initial pressure difference between the ventricle and the atrium (e.g., increased with volume loading, decreased with volume depletion) change in transmitral volume flow rate (e.g., increased with coexisting MR) change in atrial pressure (e.g., elevated LVEDP or a v-wave caused by MR)

15. LATE DIASTOLIC FILLING Late diastolic filling rate is affected by, Cardiac rhythm Atrial contractile function Ventricular end-diastolic pressure Heart rate The timing of atrial contraction (PR interval) Ventricular diastolic function

16. 3.ATRIAL PRESSURE AND FILLING CURVES Atrial filling patterns ~ JVP Pulmonary and hepatic vein patterns appear “opposite” in direction Hepatic vein : TTE subcostal, direction of flow is away from the transducer (into the RA) Pulmonary Vein : TTE apical, direction of flow is toward the transducer (into the LA).

17. NORMAL RESPIRATORY CHANGES With inspiration, negative intrapleural pressure  increase venous return to thorax  increase RA volume and pressure  Transient increase in RV diastolic filling volumes and velocities up to 20% v/s end-expiratory values. LA filling does  not  increase with inspiration because pulmonary venous return is entirely intrathoracic and thus not affected significantly by respiratory changes in intrathoracic pressure.

18. Echo assessment of LV Diastolic function BASIC INDICES: Mitral inflow at leaflet tips and at annulus by PW Mitral Annular Tissue Doppler Velocity by PW Pulmonary venous return by PW Left Atrial Volume Index by 2D or 3D imaging Peak systolic TR Velocity ( by CW of TR jet)+ RAP=Pulmonary systolic pressure ADDITIONAL INDICES: LA strain by speckle tracking LA imaging IVRT by PW flow propagation velocity by Color M-mode - Dp /dt from MR jet

19. MITRAL INFLOW Apical 4C view : Small sample volume, ~2mm, PW at mitral leaflet tips, End-expiration Sweep speeds of 25 to 50 mm/s for evaluation of respiratory variation of flow velocities, as seen in patients with pulmonary or pericardial disease If variation is not present, sweep speed is increased to 100 mm/s at end-expiration, and averaged over 3 consecutive cardiac cycles. Factors affecting mitral inflow: Sinus tachycardia and first-degree atrioventricular (AV) block, which tend to fuse the E and A waves Atrial fibrillation, which eliminates the A wave Mitral valve disease, which independently alters the velocity pattern

20. TRANSMITRAL VOLUME FLOW RATE DOPPLER GUIDED QUANTITATIVE LEFT VENTRICULAR FILLING CURVE MITRAL INFLOW 90-110 msec 0.6-0.8 m/s Doppler velocity curve shows E/A ratio,VTI,IVRT,EDDT,DT,Atrial filling period,total diastole duration Peak rapid filling rate(PRFR)ml/s=E velocity*CSA

21. MITRAL INFLOW PATTERNS (preload dependent) Mitral E-wave velocity Reflecting the LA-LV pressure gradient during early diastole. Directly related to LA pressure. Inversely related to LV compliance Affected by preload and alternations in LV relaxation Mitral A-wave velocity Reflecting the LA-LV pressure gradient during late diastole Affected by LV compliance and LA contractile function E-wave DT ( N= 140 - 240ms) Inversely proportional to chamber stiffness & influenced by LV relaxation, compliance ,LV diastolic pressures following mitral valve opening

22. MITRAL “L” VELOCITY Markedly delayed LV relaxation in the setting of elevated LV filling pressures allows for ongoing LV filling in mid diastole and thus L velocity. Patients usually have bradycardia When present in patients with known cardiac disease (e.g., LVH, HCM), it is specific for elevated LV filling pressures <20 cm/s are not clinically significant.

23. Tissue Doppler Mitral Annular Velocity: It measures velocity of longitudinal myocardial lengthening and shortening during diastole and systole. Tissue doppler MA velocity is PRELOAD INDEPENDENT. 4C view sample volume: from 1 cm of the mitral annulus,1-3 mm length. Both the septal (medial) and lateral annulus Sweep speed: 50 to 100 cm/sec Measurement of ≥3 consecutive cycles should be obtained at end-expiration Peak annular velocity in early diastole (e') depends on LV relaxation diastolic dysfunction: e' is relatively independent of preload normal diastolic function: e' increases with higher filling pressure

24. Early diastolic velocity peak E’ (Normal value 0.10-0.14 cm/s) Late diastolic velocity peak A’ Normally E’/A’ >1 Reduced E’/A’ ratio indicates impaired relaxation. E’/A’ : It helps to distinguish normal lv filling from pseudonormalized pattern in pt with moderate to severe LV dysfunction. Rationale for the E/E’ ratio of blood flow to tissue velocity is that the transmitral E velocity reflects both LA to LV pressure gradient, filling pressure and the amount of blood entering into the ventricle. Very high filling pressure E/E’ >15 is specific for LV filling pressures. It is not sensitive Because of many ptwith elevated filling pressure have a ratio between 8-15.

25. In sev MR- e’ will be raised. MS- E reflects orifice narrowing. e’ decreases. Severe MAC - E will increase due to narrowing of orifice. e’ decrease due calcification. LBBB/RBBB/Biventricular Pacing- underestimate septal e’- due to paradoxical motion. Underestimation of lateral e’ due to irregular rocking movement of LV in LBBB. Constrictive Pericarditis- lateral e’ decreased. septal e’ may increase compensatory(Annulus Reversal). CAVEATS OF E/E’:

26. Pulmonary Venous Doppler Flow Patterns : -Pulmonary flow patterns are complementary to mitral inflow Doppler patterns for assessment of diastolic function. -Pulmonary vein flow has three components: (1) the S wave, which consists of forward flow from the pulmonary veins to the left atrium during ventricular systole; (2) the D wave, which consists of passive flow during ventricular diastole; (3) the AR wave, which is the slight flow reversal into the pulmonary veins during atrial contraction. Patients with impaired LV relaxation will demonstrate blunting of the S wave relative to the D wave. Reduced LV compliance may also result in greater flow into the pulmonary veins during atrial contraction (broader A wave).

27. If there is a two systolic peak in pulmonary vein flow doppler (s1 and s2) in case of bradycardia ,first degree heart block, it is recommended that the second value S2 to be used. Young normal subjects have a predominant diastolic wave. With increasing age S/D ratio increases. Left atrial compliances decreases and pressure rises so the S/D ratio decreases and the systolic fraction is usually less than 40 %.

28. Pulmonary Venous Flow Patterns Apical 4C view Sample volume within RUPV/LUPV, ~5mm from junction of atrium Fast sweep speed 3 components Systolic wave (which often has two peaks, PVs1 & PVs2) Diastolic wave ( PVd ) Peak atrial reversal velocity or A retrograde wave ( Ar ) corresponding to atrial systole

29. PULMONARY VEIN FLOW DOPPLER Increase in LAP will lead to drop in S wave velocity. So, S/D ration will be less than 1 suggestive of increased LAP.

30. PULMONARY S / D REVERSAL

31. DURATION OF PULMONARY AR WAVE- A WAVE FLOW REVERSAL AR-A > 30ms accurately reflects increased LVEDP. It will be present before mean left atrial pressure becomes abnormal. AR-A most sensitive and earliest indicator of elevated LAP. Also accurate in patient with MR and HCM. Difficult to interpretate in S. tachycardia or 1 st degree AV block, where E and A fuse, also in A fib.

32. LA VOLUME AREA BY PLANIMETRY IN APICAL 4C AND 2C VIEW LA VOLUME MEASURMENT BY AREA LENGTH METHOD LA VOLUME MEASUREMENT BY 3 ORTHOGONAL DIAMETERS D1 D2 D3 OF LA

33. DIASTOLIC MR Seen with Significant elevations of LVEDP. When LV operational compliance is severely diminished, LV pressure exceed LA before systole, and blood regurgitates. B-Bump recording on M mode.

34. TE-e’ TIME INTERVAL Time between QRS and Beginning of E wave deducted from Time between peak of R wave and the beginning of e’ velocity. LVFP is estimated by ratio of IVRT to TE-e’. If LAP increase, E wave will start early and e’ will be late. So this interval will increase.

35. SPECKAL TRACKING ECHOCARDIOGRAPHY A reduced absolute LV global longitudinal strain (GLS) value is indicative of reduced longitudinal fiber LV function (a marker of LV subendocardial function, which is often affected by risk factors that lead to HFpEF) even in the setting of a preserved LVEF. Generally, an absolute GLS value of >18% is considered normal, 16% to 18% borderline, and <16% abnormal .

36. LA Longitudinal Strain 3 components- reservoir, conduit, and booster strains. LA reservoir strain is indicative of the ability of the LA to fill during ventricular systole; when reduced, it is associated with poor prognosis and reflects increased LA pressure and/or reduced compliance of the LA. LA conduit strain reflects the ability of the LA to empty properly during passive filling of the LV in early diastole. LA booster strain is indicative of the ability of the LA contractile function. When LA strain indices are abnormal out of proportion to the extent of LV dysfunction, a primary LA myopathy as a cause of HFpEF should be considered.

37. LA Global longitudinal strain: useful in Diagnosing, severity and monitoring of treatment. LA volume is a insensitive marker of early phases of LVDD. LA phasic function can be assessed by 3D echo and strain/strain rate analysis(using speckle tracking) Improves Diagnostic accuracy and prognostic value for both LVDD and HFpEF.

38. Propagation velocity cm/s Cm/s >50 <50 <50 <50

39. Transmitral Flow Doppler.

40. Normally in individuals younger than 65, E >A wave height, with ratios of 1.0 or higher. LV compliance declines with age. So, the E wave generally diminishes. Simultaneously, the A wave typically increases as atrial contraction augments to compensate for the reduced LV compliance. Moreover, the deceleration time (DT) of the E wave increases as compliance worsens initially .However, as diastolic function continues to worsen and LA pressures rises, the E wave will heighten again, and the size of the A wave declines as LV pressure rises and LA function begins to worsen, so the E/A ratio may revert to relatively normal (pseudo-normalization). Because pseudo-normal patterns can appear similar to normal patterns, E and A measures alone can be misleading.

41. The e′ velocity ranges up to greater than 20 cm/sec in children and young adults but declines rapidly in early adulthood and beyond. Values less than 5 cm/sec are seen in patients with severe diastolic dysfunction (e.g., amyloidosis). Because E velocity reflects the atrial-to-ventricular pressure gradient, it is dependent on both LV compliance and LA pressure (i.e., preload dependent). In contrast, DTI e′ in principle is a measure of LV compliance alone. Therefore, E/e′ reflects LA pressure, which usually approximates LVEDP. An E/e′ ratio greater than 14 is considered abnormally high at any age and is usually indicative of elevated LVEDP. However, this ratio may be insensitive to acute changes and thus may not be suitable for monitoring patients during therapy.

42. Trans-mitral flows and gradings Grade 1 - Delayed Relaxation filling pattern- decrease E wave and increased A wave , prolonged IVRT 1a- normal LVEDP 1b- elevated LVEDP . As LV end diastolic pressure rapidly increase A wave duration decrease. A wave DT of less than 60ms correspond to LVEDP of more than 18mmHg.

43. Grade 2- PseudoNormal Filling pattern significant reduction in LV Compliance. Reduced early filling, so LA residual volume increase and LAP increase. So peak E wave increase. So, mitral flow is now dependent more on high LAP rather than active relaxation. Increased LVEDP shortens A wave duration. So E/A increase. Also as LA pressure is increased, IVRT will also decrease, as MV opens early.

44. VALSALVA MANEUVER: Preload manipulation is an integral part of comprehensive diastolic function examination. Valsalva involves forced expiration against a closed nose and mouth. In the normal appearing Mitral inflow pattern, during the strain phase LV preload reduces that unmask the pseudonormal state of diastolic dysfunction grade 2. In normal subjects, during Valsalva general reduction in velocity, affecting E and A similar degree. But in pseudonormal stage of DD, VALSALVA maneuver will change pattern of one resembling impaired relaxation. This is because pseudo- normalisation causes a moderate increase in filling pressure superimposed on delayed relaxation. So, Lowering the preload delayed relaxation pattern is unmasked. Thus during Valsalva strain phase, decrease in E/A raio >50% is a useful indicator of elevated filling pressure (restrictive filling pattern).

45. Grade 3- Restrictive filling Pattern Further decrease in LV compliance(E wave DT less than 160ms), more increase in LAP(further increase in peak E), more increase in LVEDP(shorter A wave duration). IVRT further decreases. This grade 3 E/A pattern may be normally seen in healthy individuals of less than 40 years., due to robust diastolic suction of LV)

46. GRADE 4 DIASTOLIC DYSFUNCTIÖN Grade 3 is reversible and Grade 4 is not. Valsalva is used to distinguish between them. Strain phase will decrease preload. Reversal of restrictive pattern to either Pseudonormal or even impaired relaxation filling profile suggestive of grade 3 dysfunction. If no reversal, suggestive of grade 4 dysfunction.

47. ASE algorithm for diagnosis of LV diastolic dysfunction in (A) subjects with normal LVEF; (B) in patients with depressed LVEF and patients with myocardial disease and normal LVEF after consideration of clinical and other 2D data

48. 2022 European Imaging society update

49. Diastolic Stress test Recommended in patients with dyspnea and grade 1 DD. Supine bike or treadmill used. Measured during exercise or 1-2 min after cessation, when E and A are not blended. All 3 should be met to consider positive- Average E/e’ >14 or septal E/e’ >15 Peak TR velocity >2.8 m/s Septal e’ velocity <7cm/s

50. Atrial Fibrillation Peak TR velocities of more than 2.8 m/sec are indicative of increased LAP. If incomplete TR jet, other parameter that can be used, E/e’ of more than or equal to 11. This suggest LVEDP of more than 15mm hg Lack of variation of peak E wave velocity despite altering RR- indicator of increased LAP in A fib patients.

51. AV block and Pacing First degree AV Block- E/A and all other parameters hold true till E and A are not fused. LBBB/RV pacing/Post CRT- Mitral annular velocities and E/e’ accuracy is reduced.

52. Passive leg raising

53. ON EXCERCISE

54. HFpEF AND FAST HR It is very important not to apply the absolute values of diastolic function parameters in patients with HF when presenting with tachycardia. Since heart rate affects diastole before it affects systole, and all diastolic intervals become shorter. Therefore, correcting all time intervals to heart rate is strongly advisable. HFpEF AND CAD Early subendocardial dysfunction has been shown to be predominantly diastolic, and as it worsens, it becomes systolic. So, CAD evaluation should also be considered in HFpEF patients.

55. MS- IVRT/TE-e’ of <4 predicts PCWP of more than 15mmHg. MR- Ar -A dur of >30ms, IVRT of <60ms(increased mean LAP), IVRT/TE-e’ <3(increased PCWP). In Mod to severe MAC,

56. AS & AR In AS, regardless of severity, all parameters can be used. In severe AR, either acute or chronic, Premature MV closure, diastolic MR, LA enlargement, average E/e’ of >14, and TR peak velocity >2.8m/s, are associated with higher LVFPs.

57. THANK YOU