echo assessment as per newer guideines

1. ECHOCARDIOGRAPHIC ASSESSMENT
OF
DIASTOLIC DYSFUNCTION
Dr Mahendra Maske

2.  Assessment of diastolic function should be an integral
part of an evaluation of cardiac function because about
50% of patients with heart failure have preserved LVEF.
 Diastolic dysfunction has a major impact on symptom
status, functional capacity, medical treatment, and
prognosis in both systolic and diastolic heart failure
(HF), irrespective of the cause.
 Most imp determinant is age & should be taken into
account while evaluating diastolic dysfunction {DD}.

3. Objectives
• To determine how to identify the presence of
diastolic dysfunction and its assessment with
respect to different parameters.
• To determine the grade of diastolic
dysfunction.
• Practical approach to DD according to 2016
ASE/EACI guidelines.
• To determine DD in special situations like
HCM, A fib.

5. Parameters
1} IVRT – Isovolumic relaxation time
2} Mitral inflow velocity patterns
 Peak E- wave velocity
 Peak A-wave velocity
 E/A ratio
 DT
 With valsalva
3} TDI mitral annular velocity
4} Pulmonary venous flow waveform
-PV S wave, D wave & Ar wave
5} LA volume index
6} Propogation velocity- Vp

8. Normal values:
• E/A > 0.9-1.5
• With valsalva -- E↓ & A↑
• DT --- 140-240 mSec.
• IVRT -- 70-90 mSec

12. Normal values:
Brisk motion of mitral annulus as chamber expand to
accommodate inflow of blood.
• e’ septal > 7 cm/sec
• e’ lateral > 10 cm/sec
• E/e’ <14.. Sp- 92% & Sn- 83%
{Kasner M et all.. Utility of Doppler echocardiography and tissue
Doppler imaging in the estimation of diastolic function in heart failure with normal
ejection fraction: a comparative Doppler-conductance catheterization study.
Circulation 2007;116:637-47}

16. Normal values:
• Vp-- >50cm/sec
• S/D – systolic to diastolic time velocity
integral( areas under velocity curves)
• Normally S≥D
• LA volume index- <34 ml/m2.

19. ASE/EACVI GUIDELINES AND STANDARDS
• Recommendations for the Evaluation
of Left Ventricular Diastolic Function
by Echocardiography:
• An Update from the American Society of
Echocardiography and the European Association
of Cardiovascular Imaging
• Sherif F. Nagueh et al --J Am Soc Echocardiogr 2016

27. Special situations

28. HCM
• variability in muscle mass, phenotype, fibre disarray
• Comprehensive approach with muktiple parameters are
taken into account. Recommended are
 average E/e’ ratio (>14),
 LA volume index (>34 mL/m2),
 pulmonary vein atrial reversal velocity (Ar-A duration > 30
msec),
 peak velocity of TR jet by CW Doppler (>2.8 m/sec).
• The parameters can be applied irrespective of the presence
or absence of dynamic obstruction and MR, except for
patients with more than moderate MR, in whom only Ar-A
duration and peak velocity of TR jet are still valid.

29. Mitral stenosis
• Typically, patients with mitral stenosis have
normal or reduced LV diastolic pressures.
other LV inflow obstruction-
 prosthetic mitral valve
 large LA tumor
 cor triatriatum sinustrum
 Congenital MS
o IVRT
o IVRT/ T (E-e’) -- <3 increase PCWP & LAP

30. MR
• With normal EF
T Ar-A
IVRT/ T E-e’ <3 increase PCWP & LAP
• With low EF
E/e’
AS/AR
• Similar approach

31. A Fib
• Absent A wave & beat to beat variability
 E/e‘ > 11
 Peak TR velocity > 2.8 m/sec is suggestive of elevated
LAP.
 depressed LVEFs - mitral DT <160 msec
other Doppler measurements
• IVRT < 65 msec
• DT of pulmonary venous diastolic velocity < 220 msec
• E/Vp ratio >1.4,

32. Blocks
• Routine parameters remain valid as long as there
is no fusion of mitral E and A velocities.
• 1st degree AV block
200-280msec -- routine paramters
>280 msec fusion of E & A wave occurs– TR
velocity
• RBBB, LAFB,LPFB-- routine parameters.
• LBBB – associated with organic heart disease and
associated diastolic dysfunction.

36. Novel indices
• LV global longitudinal diastolic strain rate
LVGLS by STE have a significant association
with the time constant of LV relaxation-tau.
• LV untwisting rate
• LA systolic strain & its inverse relationship
with mean wedge pressure.

37. • Thank you…!!!