as mentioned in part one heart failure divided in two categories: systolic
and diastolic. in systolic we have pumping problem and in diastolic filling
problem in another word in diastolic dysfunction left ventricular becomes
stiffer and blood goes hardly to the left ventricular (cavity) .in that case with progressing
diastolic dysfunction finally left atrium pressure increased
increasing left atrium pressure transport to pulmonary venous that at
capillary level in lung it causes high hydrostatic pressure and result of that
is interstitial edema and alveolar edema that is the seemed the reason for
symptom sign of shoulders of bread in the osterlich dysfunction the normal
mean left atrial pressure or feeling pressure is about eight to ten
millimeter in the diastolic dysfunction it goes higher than this changes in the
diastolic dysfunction follow a specific pattern in Doppler as you see here in
this chart the left column is normal and the other three are different degree
of the diastolic dysfunction. in early stage of the diastolic function the
relaxation of left ventricular decreased so it relax a little bit delay that we
will see here with become increasing IVRT or isovolumetric relaxation time and
the blood flow to the left ventricular slow so the E drop and it takes more
time to fill completely so E becomes wider or in another word deceleration time
increased and with atrial contraction since at t early diastolic function
as you see here all the blood didn't go to the left ventricular some blood
remain at the end of the early diastolic so at atrial contraction blood goes
faster to the left ventricular and cause A taller than usual even thought in this
phase of atrial contraction pressure in atrial goes higher than normal but
generally mean atrial pressure stays in the
normal range and doesn't increase . that is the reason with this stage of diastolic
dysfunction we called it impaired relaxation and left atrial pressure will
be normal with progress in diastolic dysfunction not only relaxation has
problem expansion of the left ventricular has problem too and becomes
harder in other word left ventricle becomes stiffer so with that change
little by little blood retention in the left atrium and for pushing the
blood goes to the left ventricular pressure increased with this increasing
pressure in left atrium E starts go again higher because pressure goes
higher when diastole starts blood goes faster
so start again he goes higher and becomes shorter and deceleration
decrease and in when established diastolic dysfunction the IVRT and
deceleration time goes to the normal range and E becomes taller but compared
to the normal if we evaluate the same patient E becomes taller than
normal here we have cutoff for 50 centimeters per second so he become
taller than 50 centimeter per second in that case
left atrial pressure goes higher than normal and we will called it abnormal
and this is stage 2 or pseudo normal. with progressing diastolic dysfunction
the left atrial pressure goes higher and so the result is taller E and narrower
E wave . so deceleration decreased and E velocity increased. in one point E
velocity become two times the A or even more. the same pattern changes happened
to the pulmonary vein Doppler. in the early diastolic dysfunction in early
stage in impaired relaxation since the blood flow at the E in early diastolic phase
decreased so the blood flow from pulmonary vein to the left atrium decreased
- that is correspond with the D wave we will see D becomes shorter.
with increasing right atrial pressure and worsening diastolic dysfunction at this when
pressure goes high in left atrium with starting diastole, early diastole, blood
rush very fast to the left ventricular so the blood pressure at the E point
drops suddenly and this drop suddenly pressure in left atrium blood from
pulmonary vein to the left atrium increased and you will see again D
increase even more than normal and become higher than S wave and with continue
worsening diastolic dysfunction in one point D becomes very higher than S wave. the
same way, A wave is represent atrial contraction so we will see the
same when A increased A increased and little by little becomes taller.
on tissue Doppler at the beginning at early-stage e prime affect a lot and
decreases more than a prime so each e prime to a prime becomes reversed with
progressing diastolic dysfunction e prime and a prime
become less or reverse and both of them decrease velocity. the velocity
decreases as you see here. now let's see the new guideline. based on the new
guideline on diastolic dysfunction evaluation we can divided patients in
three groups first those patients that has serious pathology including moderate
to severe valvular disease like MR or mac, mitral annulus calcification, serious
arrhythmias like atrial fibrillation tachycardia, bundle branch block, heart
transplant, restrictive cardiomyopathy hypertrophic cardiomyopathy cardiac
pulmonary hypertension or other situation like the patient is under
ventilation or is very critical like the patient is in a septic shock in
those cases the evaluation of the diastolic function will be a little complex
and we are not going to talk about this in this lecture in another lecture
we're going in details. the other two groups are those patient with normal
ventricular ejection fraction and low ejection fraction. the cutoff for normal
ejection fraction in this category is EF equal or more than fifty percent not 53
to 55 percent in the patient with normal EF we go evaluate four parameters or
variables average E/e', septal and lateral e' velocity
velocity. TR velocity and left atrium volume index. average R/e'
is when we measured both medial and lateral e'. if we use only medial e
prime for this ratio cut-off will be 13 if we use lateral e' velocity
cut-off will be 15. for septal e' velocity cut off is seven and for
lateral is ten. if any of these two meet this criteria we take it as positive
parameter for TR we use cutoff 2.8 m/s the reason we use this level because at
this velocity pulmonary artery systolic pressure becomes upper limit normal and
increasing over this amount we will have high pulmonary pressure
now if among of these four parameters
three of them are positive patient has diastolic function; if
three of them are negative- only one positive - patient has normal diastolic
function; if two of them positive and two negative it cannot be determined
if the patient has diastolic dysfunction or no? we called it
indeterminate and is inconclusive when we found patient those has those
three dysfunction for grading we go to the next step in this step that we can
use it for the first group and those patient that patients that have low
ejection fraction as we mentioned in first part almost all patient with low
ejection fraction they have some degree of diastolic dysfunction that is
reason in the this diagram we don't see any normal diastolic function at
this evaluation so, this mitral inflow which check it for
two parameters E/A and A velocity: based on that if E/A is equal or more than two
and the patient is not athletic and young this patient has severe diastolic
dysfunction or type three and left atrial pressure is very high. if E/A
is less than point eight and E velocity is less than 50 centimeter per
second patient has diastolic dysfunction type one, means we have
impaired relaxation but left atrial pressure will be normal in this group of
patients if the patients are symptomatic they have for example shortness of
breath during activity or any other symptom related to the heart failure we
have to check it for coronary artery disease or we go for doing more study
including diastolic stress test now if the patient doesn't go to any of
these two group we go evaluate three other parameters if two of them are
positive patient has the diastolic dysfunction type two or pseudo normal if
two of these three are negative patient has diastolic dysfunction type 1 if we
don't have TR that many patients doesn't have TR
we check it the other two: if both of them are positive patient has the
diastolic dysfunction type II; if both of them are negative patient has diastolic
dysfunction type 1 if one of them positive or negative then we go check
the other parameters the most important parameters in this case will be ratio S
to D if S is less than D patient has high left atrial pressure and goes to
category of grade two. now let's put it in more practical way as rule of thumb
all patients that have low ejection fraction or they have e prime less than a prime always
we have a kind of diastolic dysfunction rule 2: if E taller than A and e'
is taller than a' and E to e prime is less or equal 14 patient has normal
diastolic function if E to e prime is less than normal and e prime less than a
prime here and E velocity is less than 50 we have grade 1 or impaired
relaxation and left atrial pressure is normal; if E/A goes to the normal
range we have two options: first we go we can go to do Valsalva maneuver in
valsalva maneuver during strain phase if E/A becomes reverse or E/A ratio
decrease more than 50% this will be positive and patient will have pseudo
normal diastolic dysfunction if we don't do that or wasn't conclusive we go and
check these other these 3 parameters if two are positive grade II; if two of
them are negative grade I ; if we don't have TR then we go again repeat those
two other factors two positive grade II; two negative grade I;
if 1 negative, 1 positive again we go check it
other parameters including S to D ratio and final rules is when E to A is more
than 2 and e prime is less than 7 centimeter/s patient has
diastolic dysfunction type III and left atrial pressure is very high or in those
patients that have other character findings of the diastolic dysfunction we see S/D
ratio: if it is less than 40% or Ar duration, Ar duration - A duration,
is more than 30 millisecond differences between Ar and A duration we will have
dust dysfunction type 3.
up to next time have a wonderful time