SHA24/015002

How to assess diastolic function, and pulmonary pressure non invasively?

February 13/2013 Hanan B. ALBackr , MBBS,FRCPC Assistant professor of Medicine , Cardiology consultant King Fahad Cardiac Center, King Khalid University Hospital, College of Medicine, King Saud University

Diastolic Heart Failure • CASE: – 62 yo F with HTN & Parpxysmal AFIB – Previous NYHA I SOB – Echo showed normal LV. systolic function – Now progressive dyspnea with exertion – ER: AFIB at 120 bpm, Pulmonary Edema

Echocardiogram

Frequency of heart failure with normal systolic function author Dougherty et al.

Aguirre et al.

Aronow et al.

Ghali et al.(hospital) Anderson et al.

Mc Dermott et al.

year 1984 1989 1990 1991 1995 1995

patients 188 151 166 81 275 298

% DD 36% 34% 41% 28% 34% 31%

Diastolic Heart Failure - Prognosis Prevalence of diastolic dysfunction unknown, as asymptomatic disease most common • ~ 1/3 presenting with acute HF have normal EF • Annual mortality 5-8% for diastolic HF vs 10-15% with systolic HF; however morbidity rates the same • Prevalence and mortality increases with age.

What parameters can change diastolic properties of the LV? LV pressur e

RV

LA pressur e

LV

Ventricular interaction pericardium

Relaxation ischemia Myocardial stiffness

Elastic recoil

Hypertrophy-RAS,bradykinin fibrosis infiltration

LA

Pericardial restraint

Diastolic Heart Failure - Phsyiology

1) Isometric Relaxation 2) Ventricular Filling 3) Atrial Contraction

ENSURE ATRIAL RHYTHM 1

2

3

Impaired LV relaxation

Reduced diastolic compliance

Evaluation of Diastolic Dysfunction What Do We Want to Know • • • •

Is relaxation impaired What are the filling pressures Etiology of diastolic dysfunction Disease severity and prognosis

Quantitating LV Filling Pressures •

What do Echo-Doppler studies measure LV Pre A (Mean LAP), LVEDP

• Integrated approach to quantitation  Mitral inflow  Pulmonary vein flow  Tissue Doppler annular velocities (newer equipment)  Use of Valsalva •  

Understanding limitations Effects of age, loading conditions Technical factors

Diastolic function-echo evaluation normal conditions

LV pressure

LV E/A 1.7+-0.6 LA pressure

79+-26 cm/sec

Early

ECHO trium mitral inflow

48+-22 cm/sec

A

0 E deceleration time 184+-24 msec

A pulmonary 19+-4 cm/sec

Pulmonary vein inflow

LA

Diastolic dysfunction-Echo diagnostic Impaired relaxation LV pressure

E/A < 0.8

E/A 1.7+-0.6 LA pressure

79+-26 cm/sec

Early

48+-22 cm/sec

Atrium

mitral inflow

0 Pulmonary E deceleration time 184+-24 msec

A pulmonary vein inflow 19+-4 cm/sec

E reduced

E deceleration time prolonged

A increased

A pulmonary deeper

Echo-diagnosed diastolic dysfunction Pseudonormalized elevated atrial pressure

LV pressure

E/A normal

E/A 1.7+-0.6 LA pressure

0 mmHg 79+-26 cm/sec

Early

E deceleration time 184+-24 msec

48+-22 cm/sec

Atrium

mitral inflow

E normalised

A normal.

0 cm/sec

Pulmonary A pulmonary vein inflow 19+-4 cm/sec

A pulmonary E deceleration time shortened

deeper

Echo-diagnosed diastolic dysfunction E/A > 2.0

LV pressure

Restrictive pattern

E/A 1.7+-0.6 LA pressure

E increased A small

79+-26 cm/sec

Early

48+-22 cm/sec

Atrium

mitral inflow E deceleration time <<<150 msec

0 Pulmonary E deceleration time 184+-24 msec

0 mmHg

A pulmonary vein inflow 19+-4 cm/sec

A pulmonary deeper

Tissue Doppler â&#x20AC;˘

An important limitation of Doppler echocardiography is that altered left ventricular preload affects transmitral flow indices.

â&#x20AC;˘

An alternative approach is tissue Doppler imaging, which permits direct measurement of myocardial velocity in real time

Echo Measurements

Summary-Echo Doppler Evaluation of Diastolic Function • Assessing diastolic function requires an integrated approach of MV, PV, Tissue Doppler • Diastolic dysfunction is an important cause of symptoms in many cardiac diseases • CHF often is due to diastolic dysfunction alone or complicating systolic dysfunction • Echo-Doppler studies can accurately evaluate impairment of relaxation and filling pressures but requires an understanding of uses and limitations

noninvasive diagnosis of pulmonary hypertension: Doppler echocardiography

Estimation of Pulmonary Pressures • PH is still defined as mean pulmonary artery pressure (mPAP) > 25 mm Hg at rest; • a diagnosis of pulmonary arterial hypertension (PAH) requires ≥ PVR 3 mm Hg/L/min (Wood units [WU]) and PCWP, left atrial pressure, or left ventricular (LV) end-diastolic pressure ≤ 15 mm Hg.

Pressure Estimation 60 yo man BP 100/65, HR 70, AS murmur • TR jet 3.2 m/sec, IVC (2.0 cm, >50% resp variation), LVOT D=2.0cm, Ao jet 4 m/sec, mean AVG=45mmHg, AR end-diastolic velocity=3.7 m/sec, PR jet 2.2 m/sec Calculate RVSP, RVDP, RAP, PASP, PADP • RAP = 10 • RVSP = 40 + 10 = 50, RVDP ≈ RAP = 10 • PASP = RVSP = 50, PADP = 20 + RAP = 30

Pressure Estimation • ∆P = 4 (V22 – V12) How to calculate……

PA diastolic pressure • 4 x (PR end-diastolic velocity)2 + RAP PA systolic pressure • 4 x (TR systolic velocity)2 + RAP

Pressure Estimation RVSP • RVSP = TR gradient + RAP • RVSP = Systolic BP – VSD gradient RVDP • RVDP = RAP ( in absence of TS)

Tricuspid regurgitation

Correlation of doppler echo with Invasive measurment of PASP Denton CP, Cailes JB, Phillips GD, Wells AU, Black CM, Bois RM. Comparisonof Doppler echocardiography and right heart catheterization to assess pulmonary hypertension in systemic sclerosis. Br J Rheumatol1997;36:239-43.

Kim WR, KrowkaMJ, Plevak DJ, Lee J, Rettke SR, Frantz RP, et al.

Accuracy of Doppler echocardiography in the assessment of pulmonary hypertensionin liver transplant candidates. Liver Transpl 2000;6:453-8.

â&#x20AC;˘ Although the application of this technique to estimate sPAP has been widely validated, its precisionis debatable â&#x20AC;˘ in studies that have compared echocardiographically estimated values and true values measured by right-heart catheterization,the mean difference ranged from 3 to 38 mm Hg, and sPAP

RA pressure

mPAP â&#x20AC;˘ Peak PRv represents the diastolic pressure gradient between the pulmonary artery and the right ventricle. â&#x20AC;˘ Masuyama et al demonstrated that the application of the Bernoulli equation to peak PRv would provide an estimate of mPAP

dPAP -

The application of the simplified Bernoulli equation to enddiastolic PRv enables the calculation of the pressure gradient between the right ventricle and the pulmonary artery in end-diastole

- The pressure gradient added to RAP estimates dPAP was found to have a high correlation with invasive dPAP measurements

Pulmonary Artery Acceleration Time

â&#x20AC;˘ Pulsed-wave Doppler interrogation of the pulmonary artery. RVET is measured from the onset of RV ejection to that of zero flow. â&#x20AC;˘ PAAT is the interval from the onset of RV ejection to peak flow velocity

Pulmonary blood flow velocity

. Doppler pulmonary flow velocity curves in a patient without pulmonary hypertension (Type I) and in two patients with pulmonary hypertension (Types II and III). Type I: normal, dome-like contour with a maximum velocity in the middle of systole. Type II: triangular contour, with a sharp peak in early systole, and a decreased acceleration time. Type III: similar to Type II, but with a midsystolic notching.

Relationship between log10(TR-derived EPSPAP) and PAAT

(J Am Soc Echocardiogr 2011;24:687-92.).)

Echocardiographic Indexes for the Non-Invasive Evaluation of Pulmonary HemodynamicsSummary â&#x20AC;˘ The study of pulmonary hemodynamics is of great importance in many diseases directly or indirectly involving the cardiopulmonary apparatus. â&#x20AC;˘ Over the past few years, evolution in ultrasonographic imaging has allowed the development of new indexes to noninvasively estimate many parameters previously measurable only with right-heart catheterization