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Echo 2 > C3: Diastolic Dysfunction > Flashcards

C3: Diastolic Dysfunction Flashcards

1
Q

relaxation phase of ventricular filling includes which phases

A

IVRT, early filling only

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2
Q

what is compliance

A

change in volume over change in pressure (Dv/Dp)

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3
Q

compliance is inverse to what

A

stiffness (Dp/Dv)

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4
Q

filling pressure include which 2 values

A

LVEDP - pressure after the ventricle has filled

Mean LA pressure - avg press during the filling period of the LA

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5
Q

IVRT is influenced by what 3 things

A 
conduction abnormalities or mechanics
loading conditions (pre load and LAP)
age
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6
Q

what causes the ‘sucking’ in early filling

A

elastic recoil properties of ventricular relaxation

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7
Q

why does DT occur

A

the LA/LV press gradient starts to fall which slows down blood entering the LV

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8
Q

rapid filling in influenced by what 4 things

A

rate of LV relaxation
elastic recoil of LV
chamber compliance
LAP

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9
Q

what determines the length of diastasis

A

HR

slow = longer
fast = short or absent
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10
Q

is atrial kick abscent w/ afib

A

yes

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11
Q

is diastolic dysfunction and increased LV filling pressure the same thing

A

no… elevated filling pressures occur as a result of diastolic dysfunction

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12
Q

describe a compliant ventricle

A

can increase its volume w/o increasing its pressure significantly

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13
Q

review pressure and volume graphs

A

/

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14
Q

how does high preload effect pressure

A

ventricle will have an increased EDP

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15
Q

2D changes to the LV mass w/ diastolic dysfunction

A

LV will hypertrophy making it less compliant, then when the heart starts to fail, the LV will dilate

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16
Q

does LV mass increase w/ either an increase in wall thickness or w/ an increase in chamber dimension?

A

yes

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17
Q

2D changes to the LA volume w/ diastolic dysfunction

A

Mean LA pressures will start to increase and the LA will dilate

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18
Q

in diastolic dysfunction, does the LA dilate before the LV

A

yes, it has thinner walls (2-3mm)

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19
Q

when can the LA volume appear normal when it really isnt?

A

if the patient is obese, LA volume is indexed to BSA, so this value will be inaccurate

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20
Q

norm value for LA volume index

severely abnorm

A

N: = 34 ml/m^2

AB: >/= 48ml/m^2

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21
Q

4 causes of diastolic dysfunction

A
  1. Primary myocardial disease
  2. Secondary myocardial disease/hypertrophy
  3. CAD
  4. Extrinsic factors
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22
Q

which cause of diastolic dysfunction is most common

A

Secondary hypertrophy/myocardial disease

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23
Q

How does primary myocardial disease cause diastolic dysf.

give examples

A

Through changes to the ventricle muscle itself

eg. dilated cardiomyopathy (CMO)
infiltrative myocardial disease
hypertrophic CMO

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24
Q

How does secondary myocardial disease cause diastolic dysf.

give examples

A

changes to the ventricle muscle, due to another disease cause the dysf.

eg. HTN
AS
severe MR

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25
What is the most common cause of secondary myocardial disease
HTN
26
why does CAD cause diastolic dysf. give examples
wall segments can’t contract or properly properly due to lack of blood supply eg. ischemia infarction
27
what extrinsic factors can cause diastolic dysf.
pericardial tamponade pericardial constriction these conditions constrict the heart
28
7 factors effecting all diastolic measures
``` HR rhythm preload LV systolic function respiration age PR interval/conduction of the heart ```
29
what can artificially increase the height of the E wave on mitral inflow
``` Anything that increased preload: MR too much sodium pregnancy obesity ```
30
what are the grades of diastolic dysfunction for the LV
normal Grade I: impaired relaxation (mild) Grade II: pseudo-normal (moderate) Grade III: restrictive filling (severe)
31
4 parameters assessed to grade diastolic dysfunction (DD) of the LV in all patients (normal OR depressed EF)
MV inflow (E/A ratio) Avg E/e pime ratio LA volume index TR jet velocity (RVSP) these are the minimum requirements to grade DD and LA pressure
32
in patients w/ normal EF, how can we determine if LV DD is present
look at: 1. Avg E/e pime ratio 2. septal and lateral e' velocities 3. TR velocity 4. LA volume index <50% + = norm func. 50% + = indeterminate >50% + = DD
33
is LAP elevated in grade 1 DD | grade II an III
GI: no GII and III: yes
34
what one parameter can indicate the patient has grade III DD of the LV
E/A ratio >/= 2
35
norm value for LV diastolic press and LAMP
3-12 mmHg
36
norm value for E/A ratio norm value for E velocity
E/A: 0.8-2 E: 0.6-1.3 m/s
37
norm value for DT
160-220ms
38
describe the changes seen w/ grade I DD on MV inflow and TDI
theres a smaller press gradient b/w the LV and LA due to a stiffer ventricle which causes delayed or slowed myocardial relaxation w/ norm filling press... - reduced e/a ratio - reduced E velocity - IVRT and DT are prolonged - reduced TDI
39
what determines the height of the E inflow wave
press gradient b/w the LV and LA
40
when would it be norm for the E/A ratio to be revered/reduced
>60 years of age
41
norm value for E/e ratio
<8.... 8-12 may be indeterminate in terms of diagnosing DD
42
describe the changes seen w/ grade I DD on MV TDI
both e prime values will be reduced (< 7 cm/s and <10 cm/s)
43
whats the only way to tell the difference b/w pseudo normal and normal
compare the E wave of MV inflow to the e prime TDI. w/ pseudo-normal, patient will have norm E wave and reduced e prime because the ventricle is stiff
44
which parameters will still be norm w/ grade I DD of the LV
E/e prime | TR jet velocity
45
symptoms (Sx) of GI DD of the LV
mild shortness or breath w/ exertion
46
when theres no pulmonary or R heart disease, TR jet velocity is an accurate reflection of what?
left heart filling pressures
47
when the Tr jet is > 2.8 m/s, what does that indicate
increased filling press and ore severe grade of DD
48
describe GII LV DD
pseudo-normal -impaired relaxation and moderate reduction of LV compliance which increases LAP
49
why does the MV inflow look norm w/ GrII DD
the increased LAP increases the driving press across the MV when it opens which makes it look normal.... ....basically both pressures are elevated so the press. gradient b/w the LV and LA is essentially the same as w/ a norm heart.
50
MV inflow and TDI characteristics w/ Gr II DD
everything looks normal except e' prime which is reduced and the E/e prime ratio is elevated (~ 10-14)
51
which MV inflow parameter shortens in duration as LAP increases
A wave
52
Sx of Gr II LV DD
SOB and lower levels of activity than G I
53
w/ Gr II LV DD, how can you force the MV inflow to look abnormal how does this work
valsalva... this reduces venous return to the RT heart, then the LT heart, which reduced preload..... .... if you reduce preload you reduce the LA pressure and Gr II MV inflow will convert to a Gr I MV inflow appearance E wave will reduce >50% in velocity if +
54
why would you see mid diastolic flow with Gr II LV DD
the LV/LA pres gradient can sometimes be maintained into diastasis which results in flow across the MV is this phase
55
name of the wave seen during diastasis w/ Gr II LV DD when is it commonly seen
L wave (think ELA, names of waves, to remember) if the patient has LVH and lower HR
56
with higher HR's would you still see the L wave?
no | E and L would fuse
57
what is a B bump?
extra bump seen on MV M-mode tracing, b/w the A and C waves (think A,B,C, names of waves, to remember)
58
what do the B bump and L wave indicate
increased LAP
59
describe Gr III LV DD what are the most important parameters that will be altered?
reduced Lv compliance and increased filling press, LAP ++ ``` see waveforms and list on page 40 of DD.... (-reduced DT -E/A ratio >2 -increased E/e prime -small e prime) ```
60
symptoms of Gr III LV DD
dyspnea w/ minimal exertion and reduced exercise tolerance | pedal or abdo seems
61
why is IVRT shortened w/ Gr III LV DD
LAP ++ so the press gradient b/w LV and LA is increased, and blood moves very quick into the LV
62
how will MV inflow of Gr III LV DD change
increase e velocity short DT short IVRT E/A ratio >2
63
how will MV TDI of Gr III LV DD change
very small e prime and a prime | E/e prime ratio increased (over 14)
64
how will pulmonary venous flow change w/ Gr III LV DD
larger a wave velocity a wave reversal increases in duration s will become very small diastolic dominant flow.... d wave will get larger
65
is the PV flow profile useful in LV DD patients w/ normal EF
no, it will look normal
66
what happens to the duration of the A wave on MV inflow w/ Gr III LV DD why
decreases in duration and has a lower velocity the LA cant empty into the LV easily due to high press so the blood takes the path of least resistance and travels back into the PV instead
67
where should you place your SV when measuring the MV A wave duration
MV annulus
68
norm PV a - MV A duration severely abnormal value (indicating Gr III DD)
N: < 20 ms >/= 30 ms
69
PV profile w/ Gr I LV DD
taller S and smaller D
70
PV profile w/ Gr II LV DD
normal
71
PV profile w/ Gr III LV DD
small S, tall D and larger A
72
treatment for LV DD
treat the underlying condition (HTN, obesity, etc)... otherwise exercise is the only treatment that directly alters DD
73
key differences b/w RV and LV DD
1. RV inflow velocites vary w/ breathing due to intrathoracic press 2. Rv inflow velocities are lower b/c the TV is larger 3. RV diastolic filling time in longer, Tv opens before and closes after the MV
74
grades of DD for RV
GI: impaired relaxation (mild) GII: pseudo-normal GIII: restrictive filling
75
criteria for GI DD of RV
E/A <0.8
76
criteria for GII DD of RV
E/A 0.8-2.1 | E/e prime >6 ( or HV diastolic flow predominance
77
criteria for G III DD of RV
E/A >2.1 | DT <120 ms
78
how will RV DD effect the IVC
will be dilated and won't collapse
79
what does norm HV flow look like abnormal?
like PV flow but inverted DIASTOLIC FLOW PREDOMINANCE smaller S wave larger D wave larger A wave

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