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What is diastolic heart failure

defined as a condition in which filling of the LV is impeded resulting in symptoms of low cardiac output, elevated LV filling pressure or both.


What are 4 phases of diastole

Isovolumetric relaxation time (IVRT)--closure AV to open of MV
Rapid ventricular filling (E wave velocity) MV opens, accumulating blood from LA LV increasing LVP
Diastasis (slope of filling)
Atrial contraction


What are patterns that diastolic dysfunction can present itself

impaired relaxation--reduced LV relaxation rate but relatively normal compliance and filling pressure

Pseudo normal---combined pattern of abnormal relaxation and restrictive physiology.

Restrictive--profound abnormalities of LV relaxation, compliance and mardedly increased filling pressure

Normal filling pattern


List 4 echocardiographic grades of diastolic dysfunction

Grade 1: abnormal relative E < A
Grade 2: Pseudonormal relaxation E > A
Grade 3: reversible restrictive filling E >> A
Grade 4: fixed restrictive filling E >>>A
Components of mitral valve inflow pattern
E = early wave represents early diastolic left ventricular phase
A (Atrial) - late diastolic ventricular filling phase associated with left atrial contraction
AT = accerleration time occurs from the onset of mitral diastolic time to the peak of the E wave
DT = deceleration time occurs from the peal of the E wave to the end of the early mitral flow

Normal is 1-2:


Phil Jones 5 measurements of Diastolic dysfunction

1. Transmitral E wave deceleration time
2. Isolvolumic relaxation time
3. transmitral E:A ratio
4. Ratio of transmitral A wave duration to pulmonary atrial reversal wave duration
5. Pulmonary vein S:D ratio


What 4 tests are on the echo are you going to ask for when it comes to diastolic dysfunction

Transmitral doppler flow
check for DT
E and A ratio (if E < A then you have a problem)
Pulmonary Vein Flow Dopper
A blunted pulmonary vein flow pattern is found in diastolic dysfunction
Tissue Doppler imaging
displays the velocities of the myocardium during contraction and relaxation
Color M mode transmitral flow


Dr. Mcarthry diastolic dysfunction

Tissue Doppler imaging - reduction in the ventricular myocardial E' relaxation velocity, reversal of the E':A' ratio (mirroring the mitral E:E ratio) and a E:E' ratio greater than 15 are also indicators.

The presence of left atrial dilation is usually seen and reflects chronic elevation in filling pressures which accompanies diastolic dysfunction.

LV hypertrophy is also usually present.


What is "E"

This is deceleration time from peak to baseline

If > 24 ms is impaired relaxation


What is IVRT

Isolcolumetric relaxation time

if > 90ms its impaired relaxation


What are features of diastolic dysfunction

Elevated filling pressure (LVEDP > 16mm Hg) or PCWP * Done in Cath
Rate of LV myocardial relaxation is reflected by monoexpoentioal course of LV pressure fall, assuming (R = 0.97). to amonoexponential pressure decay.
Tau is a time constant that is widely accepted invasive measure of the rate of LV relaxation.
T > 48 ms
Isovolumetric relaxation time
Diastolic trans-mitral valve blood flow (E wave = early diastolic filling A = atrial contraction
E wave > A wave 1.5 to 1.0 ratio
If E to A < 1.0 then stiff heart and take long to relax
Really high E to A ratio > 2.0


What test can evaluate diastolic dysfunction

Brain Natriuretic peptide levels can be predictive.

If really high > 900s then both
if 500 think systolic
if low then 300s then systolic


describe diastolic filling issues

Changes in the passive component of diastole (shift of end-diastolic pressure-volume relationship (EDPVR). A left ward/upward shifted EDPVR (decreased ventricular capacitance results in a need for increased filling pressure to achieve filling volumes necessary for the heart to generate a normal stroke volume and blood pressure.


What is principle for Dopppler in diastolic heart failure

Pulse-waved Doppler tracing of mitral inflow are frequently used to study LV filling.

The normal filling velocity in early diastole is 1m/s if active relaxation is slowed early inflow is slower and loast for a longer duration.

This is responsible for the E/A reversal seen in pt.


What is Tissue Doppler

Newer, sophisticated technique to evaulate LV filling dynamics
directly measure the velocity of myocardial displacment as the LV expands in diastole.

The tissue velocity measured durning early filling (E-prime) can be considered a surrogate marker for tau

The ratio of of peak early transmitral flow velocity (E) to the peak early myocardial tissue velocity E-prime) is frequently cited as convincing evdience of myocardial diastoluc dysfunction.


What is an advantage of a Valsalva maneuver for assessing diastolic function

In cardiac patients a decrease of >50% in the E/A ratio is highly specific for increased LV filling pressure.

A smaller magnitude of change does not always indicated normal diastolic function.


What is Isovolumic relation time

when myocardium relaxation is impaired, LV pressure falls slowly, which results in a longer time before it drops the LA pressure.

Therefore, mitral opening is delayed and IVRT is prolonged.


What are main indicators of abdnormal relaxation

Isvolumetric or early diastolic annulur motion or LV strain


Main indicators of reduced operating compliance

DR of Mitral E velocity
A-wave transit time
ratio of VEDP to LV end-diastolic volume

surrogates of of increased LVEDP
mitral A-wave duration
reduced A prime
and prolonged Ar during in pulmonary venous flow


What are indicators of early diastolic LV and LA pressures

E/eprime ration
DR of mitral E velocity in patients withe decpressed EF


What are the standard 2D echo views

Parasternal long axis
Parasternal short axis
Apical 4 chamber
Apical five chamber
apical long axis two chamber view
right parasternal view


What is a grading system for aortic atheroma

Grade 1: normal
Grade 2: intimal thickening
Grade 3 Protrudes < 5 mm into aortic lumen, irregular, sessile
Grade 4: protrudes > 5 mm into aortic lumen, irregular, sessile
Grade 5: mobile atheroma of any size

4 and 5 are associated with stroke


What are TEE findings of ischmic MR

Central MR
Dilated LV
MItral annulus dilated
posterior and apical displaced papillary muscle
decreased posterior medial annular angle (could be papillary muscle)
Tethering of mitral leaflet


How do you identify true and false lumen during dissection

Expands during systole
color prominent
expands during diastole
color less prominent
clot/smoke present


What are the images for TTE



What are quantitative features of severe IMR

EROA (mm2) > 30

Regurg volume > 60

+ enlargement of cardiac chambers/vessels


List quantitative features of severe TR

EROA (mm2) > 40mm2

> 45ml/beat of R vol

RV, RA, and Inferior vena cava dilation


What are quantitative findings for severe primary MR

EROA (mm2) > 40

R vol > 60

LV and LA enlargement


List quantitative features of secondary MR

EROA (mm2) = > 20
R vol > 30


List qualitative features of severe MR

fail leaflet/ruptured papillary muscle/large coaptation defect
central jet or eccentric jet adhering, swiring, and reaching the posterior wall of the left atrium
large flow convergence zone

> 7 mm vena contracta
systolic pulmonary vein flow reversal
E-wave dominant > 1.5
TVI mitra/TVI aortic > 1.4


List qualitative features of AR

abnormal/fail/large coaptation defect
large central jet, variable in eccentric jets
Dense CW
Holodiastolic flow reversal in descending aorta (EDV > 20 cm)

> 6 mm vena contracta width (mm)
Pressure half-time < 200 ms


List qualitative features of TR

abnormal fail/large coaptation defect
very large central jet or eccentric wall

> 7 vena contracta
systolic hepatic vein flow reversal
E-wave dominant > 1 m/s
PISA radius > 9 mm


What are TTE pericardial compression signs

LV septal displacement with respiration
Increased mitral inflow with expiration and reduction with inspiration


What are risk factors for esophageal injury in pt undergoing TEE

Previous esophageal injury
throacic aortic aneurysm
prlonged steroid use
large LA
advanced age
previous thoracic irradiation


What is normal thickening of myocardium with contraction

> 40% wall thickening with systole


What is hypokinetic

< 30% wall thickening with systole


Define Akinetic and dyskinetic wall motion on echo

Akinetic < 10% wall thickening

Dyskinetic--segmental outward motion during systole (usually some thickening)


What are tamponade findings on echo

IVC dilation
invagination of the RA wall in diastole
expiratory collapse of the RV


Echo signs consistent with pericardial constriction

thickened perciardium > 6 mm
ventricular interaction: idicates a fixed peridcardial space with leftward septal shit (septal bounce)
decreased mitral inflow with inspiration
decreased pulmonic inflow with inspiration
increased TV inflow during inspiration
diastolic hepatic venous flow reversal with expiration


What is the significance of color on the colour-mapping Doppler

Blue Color represents flow away from the probe

Red color presents flow towards the probe


What is modified Bernoulli equation

Using this equation two difference pressure gradients can be calculated across a cardiac valve

Change in Pressure = 4V2 (squared)

a peak gradient : which is calculated from peal velocity
mean gradient: which is calculated from the mean velocity


What are two major assumptions of doppler-calculated gradients

All measurements assume linear flow---valvular stenosis produced trubulent flow

All measurements assume ultrasound beam is parallel to the direction of blood.


What is continuity equation

Based on the principle of conservation of mass, hence the flow of blood across the outflow tract of a chamber must be the same as the flow of blood across the valve of that chamber

Volume of blood flow = cross-sectional area (A) X velocity of blood


How can you measure Pulmonary artery systolic pressure by echocardiography

Use a modified Bernoullie equation

RVSP = 4 V2 + JVP

assuming there is no pulmonary stenosis, RVSP also represents the pulmonary artery systolic pressure (normally less then 25)


Define vena contracta

narrowest segment of regurgitant flow stream and typically occurs just beyond the reguritant orifice


What are echo risk factors for SAM

Septum > 15mm
Small LV cavity
Hyperdynamic LVEF 65%
Aorto mitral angle < 120
Short coaptation-septal distance< 25 mm
Too small annuloplasty ring
Excessive height of posterior leaflet post repair


What is diastolic dysfunction

limitation of the ventricle to fill to normal end-diastolic volume without an abnormal increase in end-diastolic pressure at rest or during exercise

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