1. Evaluation of Diastolic Dysfunction by Echocardiography
Brandon Kuebler, MD
Pediatric Cardiology Fellow
Wednesday, February 09, 2011

2. Assessment of Diastolic Ventricular Function
Defining diastole
Methods to assess diastole
Patterns of diastolic disease
Age-related changes

3. When does diastole occur?
Is it around tea time? No
Required for every heart beat
Systole
Diastole

4. Phases of Diastole Isovolumetric relaxation Rapid filling Diastasis
E-wave
2/3 LV filling
Diastasis
Atrial contraction
A-wave
1/3 LV filling

5. Factors Affecting Diastole
Ventricular function
AV valve function
Rate of relaxation
Ventricular compliance
Atrial systolic function
Preload
Heart rate and rhythm

6. Pulmonary Venous Inflow
Apical 4-chamber view
Identify RUPV or LUPV inflow parallel to beam
Pulsed-wave sampling
1-2 cm distal to orifice
Alternatives views:
Parasternal
Suprasternal
Subcostals
Place Apical 4 w PW in Distal PV

7. Pulsed-wave Pulmonary Vein Inflow
Identify peak S and D velocities
Measure atrial reversal (AR) duration
AR presence is variable. It is indicative of abnormal elevated LA pressure in a neonate, but may be normal in a child with more compliant pulmonary veins. The duration of flow reversal is more helpful in relation to atrial systole

8. Note: S-wave may be biphasic owing to differences of atrial relaxation and mitral valve annular displacement
Should take the highest of the peaks

9. Mitral Inflow Apical 4-chamber view
Align Doppler beam to be parallel to mitral inflow
Pulsed-wave sampling at tips of MV leaflets
Decreased velocity if sampled within LA

10. Pulsed-wave Mitral Valve Inflow
Peak E and A velocities, ratio E/A
Mitral A-wave duration (to compare with PV AR duration)
Mitral deceleration time(from peak of E-wave to base)
Mitral Doppler VTI (and valve area)

11. Mitral Valve Doppler Evaluation
In a 5 chamber view
Continuous-wave across tips of MV through LVOT
Obtain mitral inflow & LV outflow
Measure Isovolumetric Relaxation Time (IVRT)

12. Tissue Doppler
Measures displacement of myocardium while avoiding blood flow detection throughout the cardiac cycle
For our purposes:
Mitral valve annular junction
Septal annular junction
Tricuspid annular junction
Mitral and tricuspid data is relatively volume load independent, including respiratory cycle

13. TDI Methodology Using Doppler pulsed cursor, 3-5 mm
Set Nyquist limits to cm/s
Using lowest wall filter
Set dynamic range to 30-35db
Sweep speed of mm/s

14. TDI Pulsed-wave Ea ( or E´), Aa ( or A´), Sa ( or S´) waves
IVRT and Isovolumetric Contraction Time (IVCT)
Important to maintain a parallel line of annular motion with the imaging beam

15. Color M-mode Flow Propagation
Estimate of ventricular filling to correlate with LV relaxation, even at increased LA pressures
Not affected by preload
Varies with changes of lusitropic conditions
Correlates in ischemic heart disease

16. Color M-mode Flow Propagation
In apical 4 chamber view
Align M-mode cursor through LV apex and orifice of MV
Apply Color Doppler
Switch to M-mode acquisition
Decrease Nyquist limit until color inflow shows line of aliasing

17. Color M-mode Flow Propagation
Demonstrated by Garcia et al., JACC 1999, that in both dogs with occluded IVC and in adults undergoing CABG, under partial CPB, measures were not affected
Although, MV E waves and associated measures were impacted by each scenario
In dogs, under various doses of dobutamine and esmolol, there were expected changes of Vp correlating to measured changes of LVEDp

18. Calculations using Vp Border et al, JASE 2003 20 pts age 6.6yrs ± 6yrs
Indicated L heart cath w/o MV stenosis/arrhythmia
Found E/ Vp > 2.0,
LVEDp >15mmHg
Sensitivity 100%
Specificity 77%
PPV: 70%
NPV: 100%

19. Calculations using Vp(FPV)
Gonzalez-Vilchez, JACC 1999
Adults in ICU w Swan’s
20 test, 34 study patients
Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-9
Simplified to:
103/[2•IVRT]+FPV
Value ≥5.5, correlates to PCWP > 15mmHg (r=0.89)

20. Calculations using Vp

22. Use of TDI and Color M-mode in Infants
Study by Larrazet et al, Pediatric Critical Care Medicine, 2005
Studied infants 3-8 months of age, immediately post-operatively for VSD/AVCD repair w LA line in place
For LA pressure > 10mmHg
E/Ea > 15 – Sensitivity 94%, Specificity 72%
E/Vp >2.0 – Sensitivity 83%, Specificity 89%

23. LA Volume
In adults, atrial dilation has correlated as a risk for first CV event (a-fib, stroke, CHF)
Defined as: women ≥ 30cm2/m2, men ≥ 33cm2/m2
Not routinely measured in children,
but recent norms established
8/3π[(A1)(A2)/(L)] obtained from Apical 2 & 4 chamber views

24. LA Volume in Children Data collected by 3D Echo and separated by BSA
m2 : mL/m2
m2 : mL/m2
m2 : mL/m2
m2 : mL/m2
>1.5m2 : mL/m2
No normative values for RA established in kids

25. Tricuspid and Right Heart Evaluation
Usual measures performed on MV, are influenced by variable preload through the respiratory cycle.
With inspiration amongst children
Peak E may increase by 26%
Peak A may increase by 20%

26. Tricuspid and Right Heart Evaluation
SVC inflow invariably does not have AR amongst healthy children
AR-wave usually seen with:
Right atrial hypertension
Tricuspid stenosis
Reversal with ventricular systole
Significant tricuspid regurgitation
Loss of AV-synchrony
Restrictive physiology
Decreased flow of systemic veins or TV inflow with Exhalation seen with Tamponade
MV E-wave decreases by >25% during onset of INhalation

27. Tricuspid and Right Heart Evaluation
In a restrictive, non-compliant RV, which acts essentially as a conduit for the PA
Forward flow may be seen in PA with atrial systole
Only in settings with low PVR or absence of distal stenoses
May be seen in those with history of Tetralogy or Pulmonary valve abnormalities

28. Classification of Diastolic Dysfunction

29. Classification of Diastolic Dysfunction

30. Abnormal LV Relaxation
The ability of the LV myocardial filaments to actively uncouple after systole, is delayed
Ventricular compliance is unaffected
IVRT is prolonged, as time needed to decrease LV pressure < LA pressure is extended

31. Abnormal LV Relaxation
LA-LV pressure difference in early diastole narrowed – max E-wave velocity decreased
LV relaxation is slower, so E-wave is prolonged
A-wave increased as a compensatory to complete LV filling
Insert fig 8.14
Insert fig 8.15

32. Abnormal LV Relaxation
Infamous “L-wave” seen in MV inflow pattern
Described by Keren in 1986
Presence of LA-LV pressure gradient in diastasis
Occurs with MARKEDLY delayed LV relaxation

33. Abnormal LV Relaxation … and LA Hypertension
Also called “Pseudonormalization”
Result of worsened ventricular compliance with transmitted increase of atrial pressure
Ultimately, relative pressure difference between LA-LV is similar to normal, just at higher pressure
Pulmonary vein inflow pattern helpful to distinguish this from normal

34. Abnormal LV Relaxation … and LA Hypertension
TDI has been shown to be relatively independent of preload
Abali et al, JASE 2005, studied 100+ adult males after 500mL blood donation, found no differences in TDI measures or Color M-mode, Vp
Eidem et al, JASE 2005, found that children with chronic LV preload (VSD’s) and preserved systolic and diastolic function, did not have changes in TDI
Those with chronic afterload (AS) demonstrated decreases of TDI measures

35. Abnormal LV Relaxation … and LA Hypertension
Nagueh et al, JACC 1997
125 adults, 60 cathed for PCWP, separated Normal from Impaired Relaxation from Pseudnormalized (EF low in this group)
Found E/Ea >10 correlated to PCWP of >12mmHg
Sensitivity 91%, Specificity 81%

36. Nagueh et al, JACC 1997
Could predict mean PCWP= 1.24(E/Ea ) +1.9

37. TDI in Pseudonormalization
Nagueh et al, JACC 1997, 30;

38. Color M-mode in Pseudonormalization
Helpful to differentiate normal MV inflow patterns from ‘pseudonormalization’
Decreased rate of flow propagation (Vp) correlate with delayed relaxation, even with elevated LA pressure
Measures are preload independent
Measure of MV peak E velocity to rate of flow propagation, E/ Vp > 2.0 predicts LVEDp >15mmHg (sensitivity 100%, specificity 77%)

39. Restrictive Physiology/Decreased Ventricular Compliance
Ventricle is significantly stiff, non-compliant, that with small increases of volume, pressures increase disproportionately
On MV inflow, the E-wave is accelerated with short deceleration time due to rapid rise of ventricular pressure and the end of inflow
A-wave is remarkably small, if not absent all together, as atrial systole minimally generates a pressure gradient across the AV valve
Instead prolonged reflux in PV observed

40. Restrictive Physiology/Decreased Ventricular Compliance
IVRT shortened due to atrial hypertension with early opening of MV and ventricular filling

41. Measures through childhood
Infants
Very limited early diastolic flow
Significant contribution from atrial systole
Limited tolerance to changes in preload
Improved compliance around 2 months
Childhood
Limited variability of measures (Inflow/TDI) through childhood and adolescence
Noted changes with increasing IVRT likely associated with age-related decreased HR

42. Tables of normative values for children are available

43. Tables of normative values for children are available

46. Let’s apply our data
52.4 cm/s
57.0 cm/s

51. Let’s apply our data
144 cm/s
2.0
72 cm/s
130
108 ms
90 ms

54. Let’s apply our data
13.1 cm/s 11

55. Vs= Vp
x Li
Vs = strength of early filling

56. Vs Strength of Filling
In a recent article by Stewart et al., JACC Imaging 2011
Found that in addition to a decreased filling velocity (Vp) with diastolic dysfunction, the velocity further slowed closer to the MV than the apex (Li)
Vs= Vp x Li
Found this measure to have better correlation to gold-standard than Vp alone
Would like to see used with other measures to further strengthen accuracy and separation of abnormal states

57. Looking at Vp 69 cm/s E/Vp= 2.0
Estimated PCWP = 4.5(103/[2•IVRT]+FPV)-9
4.5(103/[2•60]+69)-9
= 15 mmHg
Simplified version = 103/[2•IVRT]+FPV
103/[2•60]+69
= 5.2

58. To summarize our non-invasive data

59. E/Vp= 2.0

60. So by our echo data… RESTRICTIVE PHYSIOLOGY
I would classify this patient as having
RESTRICTIVE PHYSIOLOGY

61. He just so happened to have been cathed just before I obtained these measures… I did not know these results

62. Disease states
Hypertrophic cardiomyopathy
Chronic disease states

63. HOCM
Abnormalities of E/Ea, color M-mode flow propagation, and diastolic strain rates have correlated with abnormal relaxation and predict LV filling pressures.
TDI (DTI) has been found to be predictive of adverse outcomes
E/Ea >12 predicted risk for SCD, Cardiac Arrest, and VT
Those without, events had range
Those with symptoms had ratio higher compared to those without (11.9 vs 8.1)

64. Distinguishing HOCM from Athletic Heart
Diastolic TDI annular patterns, IVRT, and LA volume have identified HOCM in absence of pathologic changes
Early diastolic TDI velocities (Ea)
Athletes: normal to increased
HOCM: consistently decreased, often Ea/Aa <1.

65. Children with Chronic Dz’s
Renal failure
Those on dialysis had changes on echo compared to normal controls:
Increased LV mass with preserved systolic function
Evidence of diastolic dysfunction: higher E’s, lower Ea’s and therefore increased E/Ea ratios
Obesity
Demonstrated changes with Ea (↓) and Aa (↑) velocities where the ratio Ea/Aa was < controls
Demonstrated changes with strain rate imaging also noted

66. Children with Chronic Dz’s
Obstructive sleep apnea
Evidence of diastolic dysfunction correlated with severity of sleep apnea
Measures improved with effective therapies
Anthracycline toxicity
Demonstrated changes with Ea (↓) and Aa (↑) velocities, Ea/Aa ratio is ↓↓↓
Persists over time, even without evidence of systolic dysfunction

67. Congenital Heart Disease
Aortic Stenosis
Measures are more pronounced in more severe disease
Does not resolve immediately with relief of obstruction
Changes/improvement correlate more with degree of ventricular hypertrophy

68. Congenital Heart Disease
Single ventricles
Demonstrated impaired relaxation, decreased peak E velocities, presence of mid-diastolic filling waves, decreased E/A velocity ratio
Different pulmonary venous inflow patterns due to different sources of pulmonary antegrade blood flow
In well functioning single ventricles, biphasic pulmonary venous inflow still seen (mid-systolic peak, and late diastolic peak)

69. Congenital Heart Disease
Single ventricles
With decrease ventricular systolic function
Decreased systolic flow in PV
Increased late diastolic flow in PV
Seems to correlate with changes in EF
Serial studies in HLHS
No differences in early stages within 1st year of life
Need more longitudinal studies

70. Congenital Heart Disease
TGA
Atrial Switches (Senning/Mustard)
Found to have decrease IVCT, and sensitive to changes of systemic RV dysfunction in adolescents and young adults
Measures of TDI are lower than normals, as expected
More data needed for the population, esp Arterial Switches

71. References
Frommelt, P. (2009). Diastolic Ventricular Function Assessment. In WW Lai, LL Mertens, MS Cohen, T Geva (Eds), Echocardiography in Pediatric and Congenital Heart Disease (1st Edition, p95-118). Hoboken, USA: Wiley-Blackwell.
Garcia MJ, et al. Color M-mode doppler flow propagation velocity is a preload insensitive index of left ventricular relaxation: animal and human validation. JACC 2000; 35:
Nagueh SF, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. JACC 1997; 30:
Eidem BW, et al. Impact of chronic left ventricular preload and afterload on doppler tissue imaging velocities: a study in congenital heart disease. J Am Soc Echocardiogr 2005; 18:
Larrazet F, et al. Tissue doppler echocardiographic and color M-mode estimation of left atrial pressure in infants. Pediatr Crit Care Med 2005; 6:
Gonzalez-Vilchez F, et al. Combined use of pulsed and color M-mode doppler echocardiography for the estimation of pulmonary capillary wedge pressure: an emperical approach based on an analytical relation. JACC 1999; 34:
Border WL, et al. Color M-mode and doppler tissue evaluation of diastolic function in children: simultaneous correlation with invasive indices. J Am Soc Echocardiogr 2003; 16:
Abali G, et al. Which doppler parameters are load independent? A study in normal volunteers after blood donation. J Am Soc Echocardiogr 2005; 18:
Stewart KC, et al. Evaluation of LV diastolic function from color M-mode echocardiography. J Am Coll Cardiol Img 2011; 4: