1. Non-Invasive Estimation of Filling Pressures of the Left Ventricle by Doppler. Correlation to Hemodynamic Measurement Dr. Jorge A. Lax Hospital GCBA Dr Cosme Argerich Hospital Argerich

5. E/A < 1 DT > 250 IVR > 90 ms LA pressure < 15 mmHg Slowing of Velocity of Ventricular Relaxation

7. 30 pts (67±8.6 y.o., 63%♀), with unexplained dyspnea of 1 year of evolution, certified by graduated ergometer test and EF>50%. Catheter with transducer of P left and right, P/V curves and basal V rigidity, hand grip, lower limb elevation, and EV dobutamine. 20 pts (67%)  PCP>16 mmHg by greater diastolic function (DF) and P/V ratio DF shifted upward (>P with equal V).

9. A significant proportion of patients in the office, with unexplained dyspnea, have HF with normal EF. Significant DD in most, with LVEDP  by increase of ventricular rigidity as the main pathophysiologic mechanism. When applying strict current criteria for DD in a non-invasive way, a significant proportion of patients may remain undiagnosed.

10. Pseudonormal E/A 1-1.5 DT 150-240 IVR < 90 ms LA pressure ~15-25 mmHg

11.  LA pressure  LA parietal pressure  LA dilatation as indicator of  LVFP. Marker of severity and chronic DD, mostly in HF with normal EF. Prognostic predictor: AF stroke Post-AMI mortality Mortality and hospitalization in dilated cardiomyopathy

12. Olmsted Minnesota Cross-section of general population. n=2045, >45 y.o. LA remodeling associated to DD severity, regardless of co- variables: age, gender, cardiovascular disease, EF, and LV mass LA volume is not enough to define mild degrees, but it is prognostically significant for DD; however, DD severity is a better predictor of mortality Cut value: 31 ml/m2 Pritchett AM JACC 2005; 45: 87-92.

13. Ha JW. JASE 2004; 17: 428

14. Triphasic pattern (D or L wave) indicates increase of LVEDP. HTN or LVH. HR-dependent dynamic phenomenon, that could be triggered with maneuvers. In patients with normal EF, it is a prognostic indicator of development of CHF Ha JW. JASE 2004; 17: 428

15. VALSALVA

16. Diastolic dysfunction NormalRelazation slowingPseudo-normal Restrictive Mitral valve flow Pulmona ry veins flow Tissue Doppler

17. Tissue Doppler An E wave <8 suggests increase of LVEDP and <5 confirms it e´=0.04 e´=0.13

18. Tissue Doppler E/e´ 12 increased It may be measured in AF* and tachycardia  echo-stress* It has independent prognostic power** E/e´= 43/3=14 * Kusunose K. JACC Img 2009; 2: 1147-56 **HA JW JASE 2005; 18:63-8 *** Hillis GS, JACC 2004; 43. 360-7

19. 122 p (55±89 y.o., 55%♀). EF>50%. Echo-doppler and simultaneous catheterization E/e´ ratio>13  Sensitivity 70%, Speficity 93% to predict PCP >15 mmHg. LA vol >31 ml/m2  Sensitivity 78%, Specificity 76% to predict PCP >15 mmHg. E/e ratio 8-13 + LA vol >31 ml/m2  Sen 87%, Sp 88% to predict PCP > 15 mmHg. Dokainish H. JASE 2010; 23: 156-161

20. Tissue Doppler

21. E/e´= 105 / 7 =15 Pseudonormal: Increased filling pressures S D AR

22. M Mode Color Doppler Normal >50 cm/sec. E/Vp 15 mmHg(*): EF>50% with Sen 71% and Sp 73% EF<50% with Sen 78% and Sp 77% (*) Rivas Gotz C. AJC 2003; 91: 780.

23. Atrial Strain

26. Positive global LA strain: 23±7. Negative global LA strain: -14±3. Total global LA strain (summation): 38±7. Positive global LA SR: 2±0.6. Early negative global LA SR: -2±0.6. Peak negative global LA SR: -2.3±0.5. Saraiva RM. JASE 2010; 23: 172-180 Vianna Pinton R. JASE 2009 22: 299-305

27. Atrial Strain Peak LA Strain <15.1% predicts PCP≥18 mmHg: Sensitivity 100% Specificity 93% Diagnosic accuracy 0.93 Cameli M. Cardiolv Ultrasound2010; 8: 14.

28. E/A >2 DT < 140 ms IVR < 60 ms LA pressure >25 mmHg Disfunción Diastólica NormalEnlentecimiento Relajación Pseudonor mal Restricti vo Restrictive (Degree III)

29. Conclusions 1 Echo-doppler is the natural non-invasive technique to assess LV filling pressures. Multiple compared studies vs hemodynamics show a good correlation, not only with impaired EF, but also in normal EF. Many signs by echo have been described, and those shown here are the best ones currently In the next few years, strain will be added to confirm the good initial results However…

30. Conclusions 2 However…there are still difficulties to correlate some patients because Of the impossibility of the technique to measure absolute pressures Of the impossibility to construct true P/V curves Of the multifactorial nature of DD, and Of the greater or lesser dependence of load conditions of all measurements. All measurements are a simplifying approach to a complex pathophysiology that tries to include active relaxation, compliance, and rigidity, ventricular interdependence, dyssynchrony, and load conditions. However…

31. Conclusions 2 However…we are still using them daily with good results. Thank you very much