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Introduction to Diastology

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Jones, Byars, Feyzeau

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PGY-9

PGY-04

PGY-12

PGY-10

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OVERVIEW

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  • Very Basic Introduction
  • Definitions and classifications
  • Complicated Algorithms
  • Complicated Case

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Basic Intro to Diastolic Function and LAP Assessment

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HFrEF

HFpEF

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Clarification of Terms

  • Diastolic dysfunction = Impaired Ventricular Relaxation

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  • Diastolic CHF = Syndrome of congestive heart failure with impaired ventricular relaxation in the setting of preserved LV function and Increased filling pressures

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Who Cares?

  • Want to be able to accurately evaluate CHF?

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  • Want to perform the gold standard test for tamponade?

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  • Want to be able to obtain a Non-invasive approximation of Pulmonary Artery Catheter Wedge Pressure (left atrial pressure)??

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What Causes it?

  • HTN
  • HTN
  • HTN
  • CAD, Cardiomyopathy (Abnormal EF), Valvular Pathology, Obesity
  • Commonly will see mild diastolic dysfunction in elderly

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Is LV Relaxation Normal?

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Is LV Relaxation Normal?

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Is LV Relaxation Normal?

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Is LV Relaxation Normal?

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Ideal = gate oriented parallel to blood flow

Cosine of 0 or 180 degrees = 1

Cosine of 90 degrees = 0

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Patterns of Diastolic Function

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Normal

Grade 1 (Mild)

Grade 2 (Pseudonormal)

Grade 3 (Restrictive)

PWD

TDI

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Super-normal Diastolic Function

E/A Ratio > 2 e’ > 20

Seen in young healthy athletes

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Normal Diastolic Function

Normal Echo, Age < 45, E>A = No need for TDI

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Grade 1 Diastolic Dysfunction (Abnormal Relaxation)

E < A

e’ < a’

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Grade 2 Diastolic Dysfunction (Pseudonormal)

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E > A

e’ < a’

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https://www.youtube.com/watch?v=qdLkbcFe_DI

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Normal or Pseudo-

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Grade 3 Diastolic Dysfunction (Restrictive)

E : A > 2

e’ ≅ a’ (Small)

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34

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35

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Case 1: Parasternal Views

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Case 1: AP4 VIEW

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Case 1: PWD

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Case 1: PWD and TDI

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Case 2

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Case 2

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Case 2

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Case 2

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Case 2

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Case 3

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Case 4

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Case 5

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Case 5

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Other Diastology Applications

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Do you need to do a PWD measurement in every case??

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ULTRASOUNDIDIOTS.COM

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The normal pulmonary capillary wedge pressure is between 4 to 12 mmHg.

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Questions?

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Complicated Shit

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The normal pulmonary capillary wedge pressure is between 4 to 12 mmHg.

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Normal SPAP ≤ 35 mmHg

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Normal peak VTR ≤ 2.9 m/s

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MATH

35 = RAP(0) + 4(x2)

35/4 = x2

√(35/4) = 2.9

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Hemodynamics

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Case

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40 Pack Year Hx

CAD and MI 5 years prior with EF 40%

ED order Lasix and Nitro paste and called ICU

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Afebrile

HR 110 Sinus Tach

BP 145/80

RR 17

Sat 95% on Bipap

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You do an Echocardiogram

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Do you continue with the plan?

Do you hold the lasix?

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Please save your diastolic examples and I will add them to the lecture

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Images needed from fellows!!!

  • Example of super-normal
  • Example of PWD variation in tamponade

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Questions??

Performing the Valsalva maneuver causes an increase in intrathoracic pressure, leading to a reduction in preload to the heart