Transcript Feng – Diastology

Diastology
Patrick Feng, PGY1
Outline
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Definition
Clinical significance
Technique
Measurements
Analysis
Pearls
Pitfalls
References
Definition
• Measurement of diastolic function with echocardiography
• Relaxation
• Compliance
• First described by Kitabatake. A, et al (1982). Jpn Circ J
• Determined transmitral blood flow with pulse Doppler to describe diastolic
behavior
Clinical Significance
• Heart failure is a large burden on society
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CHF affects 5.7 million in US
Costs $34.4 billion/year
50% of CHF is diastolic
Incidence of diastolic HF increases per decade
Benefits of Diastology
• Improves diagnosis of acute LV HF
• Better accuracy compared to BNP and Boston Criteria
• Worse outcomes in several disease states
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Post-MI
Sepsis
Afib
ESRD
Cardiomyopathy
Technique
• Probe: Phased Array
• View: Apical 4 Chamber
• Measurements
• Mitral valve inflow
• Tissue Doppler imaging
Measurements
Qualitative
Quantitative
• LA size
• Mitral value annulus movement
• Mitral valve inflow
• Tissue Doppler imaging
• Pulmonary vein flow
• Mitral inflow propagation
• Isovolumetric relaxation time
Measurements in the ED
Qualitative
Quantitative
• LA size
• Mitral value annulus movement
• Mitral valve inflow
• Tissue Doppler imaging
• Pulmonary vein flow
• Mitral inflow propagation
• Isovolumetric relaxation time
Evaluate qualitatively before
deciding whether to take
quantitative measurements
Measurements in the ED
Qualitative
Quantitative
• LA size
• Mitral value annulus movement
• Pulsed wave mitral valve inflow
• Tissue Doppler imaging
• Pulmonary vein flow
• Mitral inflow propagation
• Isovolumetric relaxation time
Take these measurements in
the ED since they can be
obtained quickly and accurately
Measurements in the ED
• Can Emergency Physicians diagnose and classify diastolic dysfunction?
• Methods
• EPs trained 3 hrs on MVI and TDI
• 62 patients, 52% with diastolic dysfunction
• Compared interpretation with 3 Cardiologists
• Results
• EPs can diagnose diastolic dysfunction
• Sensitivity 92% (60-100)
• Specificity 69% (50-82)
• EPs have moderate agreement with cardiologists on severity of diastolic dysfunction
• K = 0.45
• Weighted K = 0.52
Ehrman, R. et al (2015). American Journal of Emergency Medicine
Qualitative - Mitral Valve Inflow
Qualitative - Mitral Valve Inflow
Qualitative - Mitral Valve Inflow
E/A < 0.8
E > 100
E > 150
E/A < 1.5
E/A > 2
Qualitative - Tissue Doppler Imaging
Qualitative - Tissue Doppler Imaging
e’ > 8 cm/s
e’ < 8 cm/s
e’ < 8 cm/s
e’ < 8 cm/s
Grading Diastolic Dysfunction
Grading Diastolic Dysfunction
Perform TDI
e’ < 8
Normal
Diastolic
Function
Perform MVI
A>E
E < 100
Grade I:
Grade II:
Impaired
Pseudonormal
Grade III/IV:
Restrictive
Grading Diastolic Dysfunction
Pts can move between Grades I - III
Grade IV is irreversible
E/e’ = LVEDP and PCWP
E/e’ < 10
E/e’ < 10
E/e’ > 10
E/e’ > 10
Preload: IVC vs Diastology
IVC shows preload to RV
Diastology shows preload to LV
IVC vs Diastology
Increased Preload to RV
Increased Preload to LV
• Right sided heart failure
• Right sided MI
• PE
• Pulmonary Hypertension
• Left sided heart failure
• Chronic hypertension
• Aortic stenosis
Pearls
• Determine etiology of common clinical presentations
• Determine response to treatment
• Prognosis for various pathologies
• Guide use of fluids or pressors
Pitfalls
• Highly operator dependent
• Pathology can interfere with diastology measurements
• Irregular rates/rhythms
• Tachycardia
• Afib
• Cardiomyopathys
• Restrictive cardiomyopathy
• Hypertrophic cardiomyopathy
References
• Diastology archives. (2016, September 30). Retrieved October 3, 2016, from Ultrasound Podcast,
http://www.ultrasoundpodcast.com/tag/diastology/
• Bess RL, Khan S, Rosman HS, Cohen GI, Allebban Z, Gardin JM. Technical aspects of diastology:
why mitral inflow and tissue Doppler imaging are the preferred parameters?. Echocardiography.
2006;23(4):332-9.
• Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and
septic shock. Eur Heart J. 2012;33(7):895-903.
• Nazerian P, Vanni S, Zanobetti M, et al. Diagnostic accuracy of emergency Doppler
echocardiography for identification of acute left ventricular heart failure in patients with acute
dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide.
Acad Emerg Med. 2010;17(1):18-26.
• Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left
ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10(2):165-93.
• Kitabatake A, Inoue M, Asao M, et al. Transmitral blood flow reflecting diastolic behavior of the
left ventricle in health and disease--a study by pulsed Doppler technique. Jpn Circ J.
1982;46(1):92-102.