Module 7: LV diastolic function Flashcards
1
Q
What is diastole?
A
Phase of the heart cycle where the chambers relax and fill with blood
2
Q
What is the time interval for diastole?
A
Interval from AV closure to MV closure
3
Q
What does relaxation mean?
A
Relaxation of the ventricule
3
Q
What does relaxation mean? Including IVRT and early phase of ventricular filling
A
Relaxation of the ventricular filling
4
Q
What does compliance mean for Diastole?
A
Change in volume/ change in pressure (DV/DP) in the LV during diastole
5
Q
What is the inverse to stiffness?
A
Compliance
6
Q
A complaint ventricle is able to do what?
A
Increase its volume without increasing its pressure significantly
Think of the balloon - easily stretch
7
Q
What is the inverse of compliance?
A
Stiffness
8
Q
What is stiffness?
A
Change in pressure/ Change in volume in the LV during diastole
9
Q
A stiff ventricle has a disproportionate increase in what?
A
Pressure for a relatively small increase in volume
10
Q
What is filling pressure? What does it include?
A
Includes LV EDP (LV end diastolic pressure) and mean LA pressure
11
Q
What is LV EDP? 2
A
- Left ventricular end diastolic pressure
- Reflects LV pressure after filling is complete
12
Q
Where is LV EDP located on the MV doppler wave?
A
After the MV doppler “A” wave
13
Q
What is Mean LAP?
A
Average pressure during the LV filling period
14
Q
What does LV filling pressures include? 2
A
- LV end diastolic pressure (LVEDP)
- Mean LA pressure (LAP)
15
Q
What does this image represent?
A
LV filling pressures
16
Q
What is normal diastolic function?
A
Means that the LV can fill to an adequate volume to ensure forward stroke volume at low filling pressures during rest or exercise
17
Q
What is diastolic dysfunction (DDfxn)?
A
Increasing stiffness of the LV means that the LV can fill to ensure a normal forward volume, but only when the filling pressures increase to abnormal levels
18
Q
What causes Diastolic dysfunctions? 5
A
- Aging
- Hypertension
- DM
- Renal dysfunction
- Infiltrative diseases
19
Q
How does aging affect diastolic dysfunction?
A
As we age, our stiffness increases and compliance decreases
20
Q
How does hypertension affect diastolic dysfunction?
A
Causes high afterload which may lead to Left ventricle LVH, which leads to decrease in compliance
21
Q
What is the only treatment for diastolic dysfunction?
A
Exercise is the only treatment which directly alters diastolic function
22
Q
What other s/s of diastolic dysfunction might be treated with exercise? 4
A
- Hypertension
- Obesity
- Sodium intake
- Smoking may also be treated
23
Q
A program of aerobic ______ training can __________ the ___________ function of the heart and can be very helpful in _________ _____________. In fact, an ________ program is the only treatment that has been demonstrated to improve the quality of life in patients with Diastolic dysfunction
A
- Exercise
- Improve
- Diastolic
- Diastolic dysfunction
- Exercise
24
Diastolic dysfunction has been previously described as an increased filling pressures, are they the same thing?
No
25
Elevated filling pressure is a consequence of what?
Diastolic dysfunction
26
Why is elevated filling pressure a consequence of diastolic dysfunction?
When the LV loses its ability to relax and becomes more stiff, then the filling pressures rise to maintain flow
27
What is Normal LV filling?
LV fills at low pressures because the myocardium is compliant
28
In a normal filling LV what would happen if the LV was stiff what would happen to the filling pressure?
It would rise above normal
29
What does this image demonstrate?
LV normal filling.
30
What are some factors that affect filling? 2
1. Chamber compliance
2. Extrinsic factors
31
What are some chamber compliance factors that affect filling in the LV? 3
1. Hypertrophy/ infiltrative disease
2. LV muscle remodeling (post Myocardial infarction scar tissue)
3. Normal change with aging (fibrotic changes in the LV stiffness as we age)
32
What are some extrinsic factors that affect filling?
Pericardial stiffness
33
What are some factors that specifically affect early diastolic filling? 3
1. Volume load (preload)
2. Hyper/Hypovolemia
3. Excessive mitral regurgitation (increases the volume of blood moving past the MV)
34
What are some conditions that specifically affect late diastolic filling? 5
1. Cardiac rhythm
2. Atrial contractile function
3. Increased LV EDP
4. HR
5. Ventricular diastolic function
35
As we get older (_____) or if we are under _____ with diseases stated on the previous slide, the LV muscle becomes _____ __________ during diastole
1. >60 years
2. 60
3. Less compliant
36
During impaired LV filling what happens in the early filling stage? 3
1. LV does not expand as quickly
2. LV/LA pressure gradient is reduced which reduces the E wave peak velocity
3. Leads to lower velocity E wave and relatively higher velocity A wave
37
What are the four phases of diastole?
1. IVRT
2. Early phase
3. Diastasis
4. Late phase
38
During the IVRT phase of Diastole: There is no change in ventricle volume but pressure in ventricle is __________
Falling
39
During the early phase of diastole: ________ filling of the LV
Rapid
40
During diastasis of diastole: Pressure ___________ between LV and LA
Equalize
41
What happens during the late phase of diastole?
Atria contract and push the rest through "atrial kick"
42
During IVRT what happens to the valves?
They are all closed
43
During IVRT what is the pressure?
Rapidly falling
44
What is IVRT?
Period between AV closure and MV opening
45
What is the volume like during IVRT?
Constant
46
What is IVRT influenced by?
1. conduction abnormalities or conduction mechanics
2. Loading conditions (preload and LAP)
3. Age
47
What is Normal IVRT?
50-100ms
48
What is the timing of Early/ rapid filling?
Period between V opening and diastasis
49
What is the valves like during early/ rapid filling?
AV valves open
50
What is the pressure during Early/ rapid filling? 3
1. LV pressure low
2. Ventricle has "elastic recoil"
3. Blood is effectively "sucked" from LA to LV
51
What is the volume during the early filling phase?
Increasing
52
During the early- rapid filling stage LA/LV PG begins to fall resulting in what? what is this called?
1. Slowdown of blood entering the LV
2. Deceleration time
53
Rapid filling is influenced by what? 3
1. Rate of LV relaxation
2. Chamber compliance
3. LAP
54
How much filling is done during the early/ rapid filling phase?
70%
55
What is the normal DT for the early filling phase?
160- 220ms
56
What is the time for diastasis?
Between early and late filling
57
What is the valves like during diastasis?
MV hovering barely open
58
What is the pressure like during diastasis?
1. LV/LA pressure almost equal, LV pressure increasing as it fills
2. LAP decreasing as it empties
59
What is the LV volume during diastasis?
Small amount of blood may flow due to inertia
60
What is the diastasis length determined by? 2
HR
1. Slow = long diastasis
2. Fast: Short/ absent diastasis
61
What is the time of atrial contraction? ( on ecg)
After P wave on ECG
62
What is the valves like during atrial contraction?
MV opens more again due to atrial contraction
63
What is the pressure like during atrial contraction?
Once the LV is full, it's pressure will rise aboev the LAP and the MV will close
64
The atrial contraction phase will be absent with what?
Atrial fibrillation
65
What is the LV volume increase during atrial contraction?
30% of diastolic filling
66
What does this image demonstrate?
Normal MV inflow valves
67
What is the normal MV E velocity?
0.8 - 1.3 m/s
68
What is the normal MV value for DT?
160-220 ms
69
What is the normal E/A value for MV inflow?
0.8 - 2.0
70
Most of the LA filling from the PV occurs during when?
Systole while the atrium is relaxing
71
When the LA fills from the PVs during systole, what does this lead to?
1.an S wave which is higher than the D wave
72
Younger adults may have a ______ ________ LV with high suction and higher _
1. Super relaxing
2. D
73
Atrial reversal can be found near what?
The P wave
74
The MV annuli moves__________ as the the ventricle fills
downward
75
What are the normal TDI values for med and lat?
1. Med >7cm/sec
2. Lat >10cm/sec
76
Normal TDI velocities in young adults may be has high as what? Why?
1. 30cm/s
2. The young and more athletic you are, you can expect higher velocity TDI because your heart is more efficient
77
A healthy TDI resembles a mirror image of what?
MV inflow
78
What is grade 1 diastolic dysfunction also called
1. Mild diastolic dysfunction
2. Impaired relaxation
79
When does grade 1 DD happen?
Early stages of diadtole, the LV relaxation becomes impaired
80
How can we measure Grade 1 DD?
We can measure this by measuring the annular velocity during diastole (TDI)
81
For grade 1DD what should E' look like? What about TDI?
1. E' should be low
2. TDI is reduced
82
What does abnormal TDI values?
Med <7cm/s
Lat <10cm/s
83
What does this image demonstrate?
Grade 1 DD
84
If the relaxation is impaired, how will this affect LV?
The LV will take a longer time to fill
85
How does the MV E wave deceleration time look during Grade 1 DD?
1. Longer MV E wave deceleration time
2. DT > 220ms
86
Grade 1 DD is common with what demographic of people?
Ages >60 years
87
During Grade 1 DD LV filling is now more dependent on what?
Atrial Filling than early filling
88
Why is LV filling more dependent on atial filling than early filling? 3
1. Increased A wave
2. Decreased E wave velocity <50 cm/sec
3. Reduced E/A ratio <0.8
89
How does the IVRT appear during grade 1 DD?
1. It will be increased
2. >100ms
90
When LV pressures increase, it takes longer for the LV pressure to do what during grade 1 DD?
It takes longerfor the LV pressure to dip below the LA pressure
91
During Grade 1 DD does the patient show any signs or symtoms? 2
1. Usually not
2. Possible SOB
92
As DD worsens, the LV becomes ______ __________
Less compliant
93
As DD worsens the LV becomes less compliant which leads to what?
Pressure increase in the LV when it is filling (and its volume is increase)
94
What is pseudonormaliztion?
The process of becoming pseudonormal, such as: A change in the waves on an electrocardiogram whereby abnormal or unusual waves become closer to normal-looking but not necessarily for the reasons that would produce a truly normal wave.
95
What does this image demonstrate?
A grade 2/ modified diastolic dysfunction.
*Note the E/A, also look at the E and A wave*
96
What is another name for grade 2 diastolic dysfunction?
Pseudo normalization phase
97
What is a way to reveal a pseudonormal waveform?
Get the patient to do a Valsalva maneuver for 10 seconds
98
Why does doing a valsalva reveal a pseudonormal waveform?
1. Reduces E velocity
2. Peak E velocity should reducec >50% if pseudonormal
99
What does this image demonstrate?
The effect of valsalva revealing a pseudonormal waveform.
*note the reduced e velocity, it reduced more then 50%*
100
For a grade 2 DD with __ ______ ________, the mv opens earlier, decreasing the IVRT <50ms
LA pressure increased
101
What does this image demonstrate?
How with LA pressure increase, the MV opens earlier, decreasing the IVRT <50ms
102
What is the L wave?
When LA pressure increases, we may see flow across the MV during diastasis
103
When do we see the L wave?
Seen in lower heart rates and with LVH (LV hypertrophy)
104
Why do we do not see much flow during diastasis?
Because the pressures are equal
105
What does this image demonstrate?
The "L" wave
106
With grade 2 DD, increased LA pressure leads to what?
1. PV failing to fill well during systole
2. S
107
What does this image demonstrate?
Grade 2 DD
108
During grade 2 DD, increased LA pressure leads to what? 4
1. Pressure backing up into the PVs (PV>lungs>RT heart)
2. Increased RVSP (TR jet) > 35mmHg
3. TR jet >2.8 m/s
4. More severe DD (mod/sev)
109
For increased LA pressure during grade 2 DD what does the LA look like? and what is it prone to?
LA is thin walled, and prone to dilation
110
During increased LA pressure grade 2 DD, the LA thin wall is a result of what? What is the LA volume index after?
LA remodeling, >34ml/m^2
111
What kind of symptoms does patients exhibit during grade 2 DD?
May have SOB at lower levels of activity compared to grade 1 DD
112
What are some grade 3 DD symptoms?3
1. LV becomes less and less compliant increasing the pressure very quickly when the volume increases
2. Quick equilibrium in pressure/ abrupt filling
3. Quick, sharp MV E wave short decel time <150ms
113
What is the E/A for grade 3 DD?
>2.0
114
What does this image demonstrate?
1. Grade 3 DD
2. Very high LV filling pressure and LA pressure and its functions
115
What is other names for grade 3 DD? 2
1. Severe diastolic dysfunction
2. Restrictive filling phase
116
For grade 3 DD what might your patient show? 3
1. Dyspnea with minimal exertion
2. Reduced exercise tolerance
3. Pedal or abdominal edema
117
In order to analyze DD, we look at what? 5
1. MV inflow - by pulsed wave (E/A ratio)
2. E prime values (tissue doppler)
3. Averaged E/e' ratio
4. LA volume index
5. TR jet velocity (RVSP)
118
What are the 4 values we look at for LV DD?
1. Average E/e'
2. Septal E' velocity and lateral E' velocity
3. TR velocity
4. LA volume index
119
What is the E/e' value for LV DD?
>14
120
What is the Septal E' and Lateral E' velocity?
Septal <7cm/s
lateral <10cm/s
121
For normal diastolic function, how much of the criteria is met?
0-1 positive
122
For intermediate DD, how much of the criteria is met?
2 positive
123
For DD how much criteria is met?
3 or 4 positive
124
What does the Mitral shape look during grade 0 normal? And what is E/a?
125
What does Grade 1 MV inflow look like? And what does the E/a ratio?
126
What does Grade 2 DD MV inflow look like? And what is the E/a
127
What does grade 3 DD MV inflow look like?
128
What does TDI look like for normal?
129
What does TDI look like for grade 1
130
What does grade 2 DD TDI look like?
131
What does grade 3 DD TDI look like?
132
What is the numerical values for grade 0 DD
1. E/A >0.8
2. e'>8cm/s
3. E/e' <8
133
What is the numerical values for grade 1?
1. E/A <0.8
2. e'<8cm/s
3. E/e' <8
134
What is the numerical values for grade 2?
1. E/A >0.8
2. e'<8cm/s
3. E/e' 8-15
135
What is the numerical values for grade 3?
1. E/A >2
2. e'<8cm/s
3. E/e' >15
136
What are some factors affecting diastolic measurements?
1. HR
2. Rhythm
3. Preload
4. LV systolic function
5. Aortic insufficiency
6. Age
137
How does HR affect diastolic measurements?
IVRT shortens, E/A fuse with tachycardia
138
How does Rhythm affect diastolic measurements?
A- Fib/PVC make sure to measure 3-5 beats and average the measurements
139
How does preload affect diastolic measurements?
Artificially increases the E wave height (mitral regurg)
140
How does LV systolic function affect diastolic measurements?
Abnormal contraction = abnormal relaxation
141
How does aortic insufficiency affect diastolic measurements?
AI jets typically blow across the AMVL, often making it impossible to assess the MV inflow waveform
142
During _____ _________ the E and A wave may be fused
Sinus tachycardia
143
During sinus tachycardia the A wave may be what?
Falsely elevated
144
During tachycardia, we may not be able to cearly discern what?
The E and A wave
145
Aortic insufficiency jets typically blow across the _____, often making it impossible to assess the ____ ______ _______
1. AMVL
2. MV inflow waveform
146
When there is MV inflow with AI, we can still assess DD using what?
1. E/e'
2. TR peak velocity
3. LA volume
147
What are some MV inflow tips?
1. AMVL is longer and larger than the PMVL, the LV fills laterally and posteriorly. Tilt posteriorly and bring SV out a bit laterally
2. Bring SV closer to annulus
3. Measure the strongest signal
4. TDI SV should be placed at the annulus, not in the IAS and IVS (watch for a few beats)
148
What are some 2D changes with DD?
Hypertension
149
For 2D changes with DD, hypertension is a high afterload condition leading to what?
Increased LV muscle mass and thickness
150
What is the biggest cause of diastolic dysfunction? why?
Hypertension, a thicker LV muscle is a stiffer and less compliant muscle
151
What are three things that usually accompany diastolic dysfunction?
1. LVH
2. LAE
3. Increased LV mass
152
Increased LAEDP and LAP will dilate what?
LA
153
The LA is only ____ thick and dilates easily with an increase in what?
1. 2-3 mm
2. pressure within the chamber
154
What is abnormal LA volume?
>34 ml/m^2
155
What are some less common DD parameters?
1. IVRT
2. DT
3. Aortic regurg
4. RV diastolic dysfunction
156
What are some RV diastolic dysfunction parameters?
1. TV inflow
2. E/e'
3. Hepatic vein flow
157
When we measure AR where do we measure?
MV A wave duration at MV annulus and compare it to PV A reversal wave duration
