Diastology Patrick Feng, PGY1

Outline Definition Clinical significance Technique Measurements Analysis Pearls Pitfalls References

Definition Measurement of diastolic function with echocardiography Relaxation Compliance First described by Kitabatake. A, et al (1982). Jpn Circ J Determined transmitral blood flow with pulse Doppler to describe diastolic behavior Jpn Circ J. 1982 Jan;46(1):92-102.

Clinical Significance Heart failure is a large burden on society CHF affects 5.7 million in US Costs $34.4 billion/year 50% of CHF is diastolic Incidence of diastolic HF increases per decade 10.1016/j.ajem.2015.05.013 10.1093/ejechocard/jep007

Benefits of Diastology Improves diagnosis of acute LV HF Better accuracy compared to BNP and Boston Criteria Worse outcomes in several disease states Post-MI Sepsis Afib ESRD Cardiomyopathy Nazerian. P, et al (2010). Academic Emergency Medicine Diastology vs Boston Criteria vs BNP in diagnosis of HF? Method 145 Pts with dyspnea 4 EPs with 4 hrs of echo training from cardiologists scanned for diastolic heart function Gold standard for HF dx was all clinical data besides BNP and echo Results Improved sensitivity (82%) and specificity (90%) of in diagnosing HF with diastology compared to reduced EF Improved accuracy of diagnosing HF with diastology (75%) compared to BNP and positive Boston Criteria (both 49%) doi:10.1016/j.echo.2008.11.023 10.1093/eurheartj/ehr351.

Technique Probe: Phased Array View: Apical 4 Chamber Measurements Mitral valve inflow Tissue Doppler imaging

Measurements LA size Mitral value annulus movement Mitral valve inflow Qualitative Quantitative LA size Mitral value annulus movement Mitral valve inflow Tissue Doppler imaging Pulmonary vein flow Mitral inflow propagation Isovolumetric relaxation time Nagueh, S., et al, (2009). Journal of the American Society of Echocardiography Qualitative LA size Mitral value annulus movement Other Quantitative Pulsed wave mitral valve inflow Tissue Doppler imaging Pulmonary vein flow Mitral inflow propagation Isovolumetric relaxation time

Measurements in the ED LA size Mitral value annulus movement Qualitative Quantitative LA size Mitral value annulus movement Mitral valve inflow Tissue Doppler imaging Pulmonary vein flow Mitral inflow propagation Isovolumetric relaxation time Evaluate qualitatively before deciding whether to take quantitative measurements Bess. R, et al (2006). Echocardiography Why MVI and TDI? Method One sonographer (>20 yrs experience) scanned 80 pts Five cardiologists interpret diastology echos Data Success rate = at least 4/5 cardiologists have same interpretation Time to record Results Highest recording success rate (MVI = 99, TDI = 100%) Shortest times to record (MVI = 36.3 +/- 20.7 sec, TDI = 29.3 +/- 18.4 sec)

Measurements in the ED LA size Mitral value annulus movement Qualitative Quantitative LA size Mitral value annulus movement Pulsed wave mitral valve inflow Tissue Doppler imaging Pulmonary vein flow Mitral inflow propagation Isovolumetric relaxation time Take these measurements in the ED since they can be obtained quickly and accurately Bess. R, et al (2006). Echocardiography Why MVI and TDI? Method One sonographer (>20 yrs experience) scanned 80 pts Five cardiologists interpret diastology echos Data Success rate = at least 4/5 cardiologists have same interpretation Time to record Results Highest recording success rate (MVI = 99, TDI = 100%) Shortest times to record (MVI = 36.3 +/- 20.7 sec, TDI = 29.3 +/- 18.4 sec)

Measurements in the ED Can Emergency Physicians diagnose and classify diastolic dysfunction? Methods EPs trained 3 hrs on MVI and TDI 62 patients, 52% with diastolic dysfunction Compared interpretation with 3 Cardiologists Results EPs can diagnose diastolic dysfunction Sensitivity 92% (60-100) Specificity 69% (50-82) EPs have moderate agreement with cardiologists on severity of diastolic dysfunction K = 0.45 Weighted K = 0.52 Ehrman, R. et al (2015). American Journal of Emergency Medicine

Qualitative - Mitral Valve Inflow

Qualitative - Mitral Valve Inflow Ultrasound Podcast

Qualitative - Mitral Valve Inflow E/A < 0.8 E/A < 1.5 E/A > 2 http://ehjcimaging.oxfordjournals.org/content/9/3/368 Flow from LA to LV occurs in 2 phases E: LV relaxation A: atrial kick In normal heart, E > A

Qualitative - Tissue Doppler Imaging Ultrasound Podcast

Qualitative - Tissue Doppler Imaging e’ > 8 cm/s e’ < 8 cm/s e’ < 8 cm/s e’ < 8 cm/s http://ehjcimaging.oxfordjournals.org/content/9/3/368

Grading Diastolic Dysfunction http://ehjcimaging.oxfordjournals.org/content/9/3/368

Grading Diastolic Dysfunction Perform TDI e’ < 8 Perform MVI A > E E < 100 Grade III/IV: Restrictive Normal Diastolic Function Grade I: Impaired Grade II: Pseudonormal

Grading Diastolic Dysfunction Pts can move between Grades I - III http://ehjcimaging.oxfordjournals.org/content/9/3/368 Grade IV is irreversible

E/e’ = LVEDP and PCWP E/e’ < 10 E/e’ < 10 E/e’ > 10

Preload: IVC vs Diastology IVC shows preload to RV Right heart failure R MI PE Pulmonary hypertension Diastology shows preload to LV

IVC vs Diastology Right sided heart failure Right sided MI PE Increased Preload to RV Increased Preload to LV Right sided heart failure Right sided MI PE Pulmonary Hypertension Left sided heart failure Chronic hypertension Aortic stenosis Right heart failure R MI PE Pulmonary hypertension

Pearls Determine etiology of common clinical presentations Determine response to treatment Prognosis for various pathologies Guide use of fluids or pressors

Pitfalls Highly operator dependent Pathology can interfere with diastology measurements Irregular rates/rhythms Tachycardia Afib Cardiomyopathys Restrictive cardiomyopathy Hypertrophic cardiomyopathy

References Diastology archives. (2016, September 30). Retrieved October 3, 2016, from Ultrasound Podcast, http://www.ultrasoundpodcast.com/tag/diastology/ Bess RL, Khan S, Rosman HS, Cohen GI, Allebban Z, Gardin JM. Technical aspects of diastology: why mitral inflow and tissue Doppler imaging are the preferred parameters?. Echocardiography. 2006;23(4):332-9. Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012;33(7):895-903. Nazerian P, Vanni S, Zanobetti M, et al. Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide. Acad Emerg Med. 2010;17(1):18-26. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10(2):165-93. Kitabatake A, Inoue M, Asao M, et al. Transmitral blood flow reflecting diastolic behavior of the left ventricle in health and disease--a study by pulsed Doppler technique. Jpn Circ J. 1982;46(1):92-102.