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