 Okay, this is the first time I'm recording a lecture. I hope fully it will be okay We are talking about evaluation of left ventricular diastolic function by echo cardiography And this talk is based on the last guideline of American Society of Echo and European Association of Cardiovascular Imaging about diastolic function assessment this first guideline about assessment of diastolic function by echo was published in 2004 in that time the guideline Classified the diastolic dysfunction as a grade one two three four one was mild Two was so to normal three was reversible reversible restrictive pattern and number four was irreversible in guideline 2009 they took the reversible irreversible out and just make it as a reverse as a restrictive pattern and in 2016 They changed the guideline based on the two algorithm One in normal LV systolic function and one in abnormal LV systolic function and I'm going to show you but again between all the guidelines that American Society of Echo in Combination with European Association of Cardiovascular Imaging or without them made it This guideline is a month one of the most confusing guideline that American Society has it and most of the time when we go for Scientific session of American Society of Echo There's lots of criticizing against this guideline and I think they are going to change it But anyway now we have to learn it based on this So first of all we have to define what is the systolic and what is the diastolic? This definition is based on this diagram is called vigorous diagram It shows that the systolic starts with mitral valve closing The pressure inside the LV goes up, but the volume will not change This time is called isofolumic contraction time. It's about 50 millisecond Mitral valve closes eortic valve open is not open and Then is the ejection time the time that aortic valve opens and the blood goes out from LV to the aorta That's the ejection time at the end of the ejection time. That's the end of the systolic The aortic valve will close When the aortic valve closed the diastolic starts From aortic valve closing to the mitral valve opening That is about 50 to 60 millisecond is called isofolumic relaxation time In the isofolumic relaxation time aortic valve is closed Mitral valve still is not open the LV is relaxing Then when the mitral valve opened is a rapid filling of the LV Is a diastasis it means not much flow from LA to LV and Is a atrial contraction at the end of the diastolic that after the p-wave of the ECG happens and LA will empty the rest of the blood inside to the LV So we can say the diastolic has a forest stage The stage one is a very short is 60 millisecond is isofolumic relaxation Stage two is a rapid filling stage three is a diastasis and stage four is atrial contraction If somebody is not in sinus rhythm does not have that atrial contraction Diastolic dysfunction used to be assessed by Invasive method because most of the hemodynamic assessment at the beginning was invasive. We didn't have a echo so Like before 1980 All diastolic dysfunction assessment was measured in the cat lab based on Measurement that is called negative DP to DT or tau And this tau was showing how the LV pressure will come down and LV will relax And this tau index is not measured anymore these days because we have an echo We could measure the diastolic dysfunction by M mod all time so M mod came after Invention of the echo in which of the echo was in 1953 So the M mod if you look at the mitral inflow, this is a very old M mod the mitral inflow has anterior leaflet movement and posterior mitral movement and This is the e wave F wave a wave at the end of the diastasis is a small bump is called B bump this B bump Was used to be called as a sign of diastolic dysfunction If you do the mitral inflow these days You might see the B bump as a sign of diastolic dysfunction, but again, we don't use it these days So what we should measure in assessing LV diastolic function by echo calligraphy There are two Both measurements can be done by transtersic and TE except one We cannot do it by TE and that's a LA volume The rest we can do it So the guideline came based on transtersic echo, but it can be applied to the TE as well except for LA volume The first group of measurement are the measurements that we do it in every patient That's a this table and the second table are the measurement that we do in a special type of patients So the first thing that we measure is the mitral inflow Doppler We put the sample volume at the level of the tip of the mitral leaflets You have to be sure that we are at the tip of the mitral valve And we do it in TE for example, we do it in 4th chamber view 0 degree The sample volume size should be 1 to 3 mm. We measure the evave velocity We can measure the deceleration time and we measure the evave velocity We can measure the IVRT By pulse Doppler again in 5th chamber view. I will show you a slide how we do it We can measure the T-shoot Doppler. So for T-shoot Doppler again, we can measure the E prime lateral and the septal and The sample volume size when we do T-shoot Doppler should be 5 to 10 mm. So it's bigger than the regular Doppler or Bradpool Doppler For my venous flow Doppler velocity, we can measure the S wave D wave and A wave reversal and again because this is a blood pool Doppler the sample volume should be 1 to 3 mm and We have to go deep inside the vein about 1 to 2 cm deep inside the vein TR velocity we can measure it very well epic again in 4th chamber view and We can measure it in other views as well LA volume In translasic we do it in apical 4th chamber and 2th chamber view By method of disc in TE we can measure the LA volume We just can measure the LA dimension and I will show you how we do it These measurements are in a specific disease When we say a specific disease I will show you the list of the specific diseases like MS like MR like atrial fibrillation and We do these measurements only on that type of disease not in every patient So we can measure the mitral inflow a wave duration We can measure the mitral e-wave acceleration rate in atrial fibrillation is very important and I will show you a slide How we do it mitral inflow color propagation velocity pulmonary vein systolic filling fracture D wave deceleration time and a wave reversal duration. I will show you in a slide how we do it Another thing that we can measure it and is very useful in MS patient and MR patient is a time to the e and time to the e prime and Again, I will show you in one the slide Valsalva maneuver we can do it in translasic in TE is not possible This slide is showing the mitral inflow as you can see the e-wave is bigger than a When we are younger the e-wave is bigger than a and sometimes even it might reach to two to one the ratio And when we get older the e-wave will be a smaller a smaller than a but not The ratio of the e to a less than point eight if it goes down to less than point eight That's a sign of a diastolic dysfunction This is again how to use the Epical 4 chamber view to put the sample will you at the tip of the mitral valve and measure the e-wave and a wave Then slide the right side is again the checking the mitral inflow e-wave and a wave by TE in Epical 4 chamber view Sometimes there is another wave between e and a This wave is called L wave This L wave is compatible this Moderate to severe diastolic dysfunction. We can do the L wave. We can measure it by tissue Doppler as well But in blood Doppler is better The reason that this wave was called L wave the first was described by a Echo technician in Mayo Clinic. Her name was Carolin Lam So she described that wave and now we call it L wave because of the lamb Mitral inflow as I said before can be changed by Valsalva Sometimes you have a mitral inflow of one patient here. You don't know e is bigger than a because of so the normal Or it does just the normal can be both of them because in normal e is bigger than a Is so the normal again e will be bigger than a to differentiate these two we can do a Valsalva We can bring the pressure of the la down So we ask the patient do a Valsalva the venous return will decrease and the e pressure the La pressure will come down and e will be a smaller so if we did a Valsalva and E became a smaller than a wave We say that was a pseudo normal. It means La pressure Regularly is high If the e is still after Valsalva was bigger than a wave So we call that one normal. So this was way of differentiation between Normal mitral inflow and so the normal and we don't use it these days because now we have a tissue Doppler This was before 1990 that we didn't have tissue Doppler Again, this is the way that we this cartoon will show how we do it in te How we measure the mitral inflow and how we measure the IVR T We can put a sample volume between the tip of the mitral and the LVOT and measure the IVR T IVR T is between the time of closing of the aortic valve to the opening of the mitral valve this time IVR T normally is 60 to 90 This is the way how we do the La volume This is based on the trans tracic. We cannot do the la volume by T And V if you do it the underestimated but we can measure the La by T see this is the view like a Short axis view of the aortic valve Like a 60 degree this La dimension is Anthroposterior dimension Anthropo is here posterior is here Anthropo still dimension is the same as la dimension in this view of the time static so this view like a 50 60 degree of the Trans is a visual view is the same la dimension as trans tracic And we can measure the dimension, but if we do volume we will underestimate it and it's a paper to show We can measure the TR velocity by trans tracic and we can measure the TR velocity by T as well This slide is showing the use of pulmonary vein For assessment of the diastolic dysfunction The slide in the left side shows that the S wave is always B than D except in a very young people If S became less than D after like the age of 40 or 50 We call it systolic planting and that can be because of diastolic dysfunction or because of the mitral egogetation The D wave deceleration time less than 220 millisecond is compatible with diastolic dysfunction Especially in atrial fibrillation. So this is one of the criteria that we can use it in atrial fibrillation D wave deceleration time less than 220 millisecond and the slide in the right side shows the systolic filling fraction it means we trace the S wave We trace the D wave the ratio of the S wave tracing to the sum of S wave and D wave tracing That's got systolic filling fracture and has a use and when I am showing you the algorithm of this dysfunction I am going to talk about that one. This is again a Pulmonary vein flow by TE as the same as I showed you This is a pulmonary vein in a patient that has a heart failure is preserved EF and This is how we do color propagation color propagation velocity can be done by transtersic and by TE. So you are in an apical 4-chamber view You put the cursor line across the mitral inflow you put the color and you go a Color emote and you can measure from the beginning of the mitral valve up to 4 cm usually color propagation velocity more than 45 cm is normal and less than 35 cm per second for sure is severe dysentery dysfunction Again, this is not a routine measurement. This is a tissue Doppler you are all familiar and You can do it from lateral in transtersic and septal. You can do it by TE as well So this is a tissue Doppler our sample volume is the lateral you have a E prime A prime and S prime is here and this is the diagonal So here we have two important measurement You can do the deceleration time as you see it here, but this is very important in this slide We have a patient that has a atrial fibrillation In atrial fibrillation, you can't measure the e to a wave Ratio because we don't have a wave. So the best measurement in atrial fibrillation is evave a Velocity acceleration rate So we have the mitral inflow You put the cursor line here and we go up to tip of the evave. We measure the acceleration rate So the sharper goes up like a vertical that patient has a dysentery dysfunction Less vertical patient does not have a dysentery dysfunction this acceleration rate more than 1900 centimeter per second two is compatible with this dysentery dysfunction so evave Acceleration rate is one of the very good criteria to measure the diastere dysfunction in AF patient another thing that you can do in the AF patient is D-wave deceleration time in the pulmonary vein flow is wave D wave You can measure the D wave deceleration time if it's less than If it's a more than 220 that patient has 20 millisecond that patient has a diastolic dysfunction and So if it's longer patient has a dysentery dysfunction at the same time you can measure the evave deceleration time And this is how we do systolic filling fracture So you can trace the S wave and the D wave and they take a ratio between S wave tracing to the sum of the S wave and the D wave as it's showing in this formula This timing is very important if the patient has a mitral stenosis and Mitral regorge or mitral regurgitation and you want to measure the diastere dysfunction You cannot use the evave to E prime velocity Because evave in mitral regurgitation and mitral stenosis is increased So the only thing that you can measure is a time to evave To the time to the E prime. So you do the mitral inflow in epical 4 chamber view You measure from our wave to the beginning of the evave Then you go tissue Doppler and Measure the time from our wave to E prime Regularly in patient with no diastere dysfunction this time R to E prime is shorter than this time or to evave if this time Became longer than or to evave that patient has a diastere dysfunction and there is a number I will show you so the time to the tissue Doppler should be normally less than Blood Doppler it became longer patient has a diastere dysfunction So how we apply all this measurement To the patient first of all we have to ask our self Is this patient can have Diastere dysfunction If can have it we do it. Otherwise is no point to do it Type of patient they can have a diastere dysfunction the patient with cornea artery disease They can have a diastere dysfunction The patient that has a LVH Pathologic LVH for any reason like hypertension AS patient they have a diastere dysfunction Patient that they have a LVC stalling dysfunction. They can have a diastere dysfunction So based on this new guideline anybody has a LVC stalling dysfunction by default has a diastere dysfunction If the patient has a heart failure This preserved EF can have a diastere dysfunction if patient has abnormal strain Can have a diastere dysfunction. So we do diastere dysfunction in a patient that has one of this underlying disease Otherwise, we know the patient does not have a diastere dysfunction and we don't have to do the measurement The guideline gave us two algorithm Assume we did all the measurement at that I talked before and Now we put in these two algorithm algorithm a and then next time I will show you the algorithm B algorithm a says assessment of LV diastere dysfunction or LV diastere function in a patient that has a normal EF LV EF is normal We use the four criteria We use average E to E prime When we say average means E prime of the lateral and E prime of The septal we did both of them and we took average This is one criteria criteria number two is Sceptile E prime less than seven or lateral E prime less than ten So this is one Tr venously more than 2.8 La volume index more than 34 milliliters Per meter square. Obviously, we don't have this number four in T. So any time Less than two of them are positive It means only one positive that patient does not have diastere dysfunction. So less than 50 percent If it's more than 50 percent positive that patient has a diastere dysfunction If it's just 50 percent It means to our positive to our negative. We say this is indeterminate It means we cannot say the patient has a diastere dysfunction so Less than two positive no diastere dysfunction More than two positive. There is a diastere dysfunction Too positive to negative is indeterminate Then we go to so first we diagnose that patient has a diastere dysfunction or not and the second algorithm we go and see What is the grade of the diastere dysfunction? This algorithm This algorithm you have to look at it and you have to look at it many time and use it on patient to learn Otherwise, it's difficult again in this algorithm We go based on the e to a ratio if e to a ratio is less than point eight and E wave is less than 50 we go grade one So in grade one diastere dysfunction It means patient La pressure is not high. It's just grade one diastere dysfunction in other way If the e to a ratio is more than two That patient has a grade three or severe diastere dysfunction so grade three diastere dysfunction and Grade one is easy grade one e to a ratio is less than point eight Great three is more than two Any time e to a ratio is between point eight and two or e to a is less than point eight, but the e wave is more than 50 we go to the middle When we are in the middle, it means it's not grade one is not grade three We look at other criteria this all criteria. I showed you how we measure it We go average e to e prime more than 14 TR velocity more than 2.8 La volume more than 34 Again from these three criteria If two of the three or three are negative we go grade one If two of the three or three are positive we go grade two if Only two criteria are available to negative we go to the grade one Two positive we go to the grade two and one positive one negative. We call it indeterminate This is the only group that we cannot determine the diastere dysfunction by echocardiography, so this is a little bit difficult Algorithm and you have to memorize it But if you practice it a couple of times it will be easy There are some special disease That we cannot use our Regular measurement and as I showed you we have to do extra measurements like age of inflation in age of inflation e to e prime ratio instead of 14 More than 11 has a meaning so more than 11 is diastere dysfunction as I said I showed you before peak acceleration rate We can measure it. It is more than one thousand nine hundred centimeter per second to that patient has a dice to this function IVRT we can use it and Deceleration time of the polymer vein less than 220 millisecond Patient has dice to this function. I see in previous table. I said more than 220 less than 220 So less than 220 Is compatible with dice to this function In systolic tachycardia is difficult to assess the dice to this function We have to bring the heart rate down to measure it in a hypertofocardomyopathy again We can take the average of the e to e prime In restrictive cardiomyopathy, that's a measurement that we can use it Sometimes we have a high TR velocity, but patient does not have dice to this function has just long disease In mitral stenosis and mitral regurgitation as I told you before we can measure that time Time of the e minus e prime and the ratio of the IVRT to that time less than four point two in MS or less than five point six in MR is Compatible with dice to this So these three special disease you might Be dealing in the war a F patient mitral stenosis patient and MR patient These are the criteria that you have to measure it to assess the dice to this function in this Special disease so I recommend all of you to remember these three condition a F patient mitral stenosis and mitral regurgitation How we do the dice to this function because This table usually one or two question might come in the exam so this was the first part of my talk about Echo assessment of the dice to this function It is a little bit difficult as I told you the guideline is a difficult guideline Probably this year or next year American Society will change it But still we apply it right now It's so difficult that many a collab even they don't report the dice of this function Even in our a collab Many cases they don't report it at all But we should learn how to do it and if we do it and we do it as a routine It will be gradually easy So the second part of the talk is echocardiography and cardiomyopathy. This is a very short You already you know the cardemopathy is very well. You have it in the war in a lot of room many times We have dilated cardiomyopathy. We have hyper-term cardiomyopathy. You see it always during the myectomy We have a restrictive cardiomyopathy that you usually don't see them in the war Maybe you see them in the heart transplant This is a different shape of the different type Cardomyopathy are the disease of the myocardium Without having coronary artery disease without having Valvular heart disease. So the disease of the myocardium without valvular heart disease without coronary artery disease and this is the classification of WHO for cardiomyopathy disease of the myocardium associated this cardiac dysfunction This is the classification of American Heart Association for cardiomyopathy Again, you can read it and most of this you know it We can classify the cardiomyopathy as a primary as a secondary Primary is it can be a genetic can be mixed can be a quart cardiomyopathy like esteris induced cardiomyopathy prepartum cardiomyopathy Pachycardia induced cardiomyopathy and the secondary cardiomyopathy the most famous one is amyloidosis of the cardiomyopathy And I hope this move is they move So this is a first patient. You see very dilated LV and very poor And you see here There is a severe Mitral regurgitation So this is a short axis of the LV. You see LV function is very poor See the LV Besides the function is poor when you go more to the apex of the LV. This is transverse gekko a Trabuculation of the LV so is a hypertrabuculation When you go to the apex of the LV, you see the LV looks like a highly Trabuculated It's called espondium myocardium. This is a disease. We call it non compaction LV non compaction This is almost a Unclassified cardiomyopathy some people believe this Congenital Because we can see them in pediatric patients as well. We I reported the case Age of five. I published it. You can go by my name and see it in pediatric uh, so This LV none as a deep recesses and mesh work at the LV apex This type of cardiomyopathy is not common, but it's a very bad disease and doesn't have any solution except You can see it takes the apex more so the The definition is if you measure the sickness Of the non compact part ratio to the compact part Is more than two to one So if the non compacted area more than compacted is more than two to one We call it non compaction in our heart in normal heart The ratio of the non compacted part compacted is like a point two point three It means most of the heart is compacted in normal heart in these people heart is not compacted Again, you see the the mesh work of the apex and deep recess Is the apical four chamber view They usually come with all Manifestation of the cardiomyopathy dilated cardiomyopathy. They come with mr They come with lv thrombosis. They come with arrhythmia and they Can have involvement of the rv as well. So most of the lv non compaction Is common in lv but can happen in rv as well And when it happens in rv, you will have a severe tear so this is a Cartoon of that and this is the specimen you see the lv It has lots of triboculation and it's not compacted. It's not like here. It's not compacted So that's a very bad disease and thanks god is not This too is 82 year old man presented to our center due to severe shortness of breath No, he's still a hyper So again, this is a transtersic echo You see there's a severe lvh, but patient doesn't have hypertension. It doesn't have a as as well So anytime you see a patient has a lvh No hypertension No as And an old is old patient probably is amyloidosis cardiac amyloidosis lv myocardium is very bright because it's speckling or sparkling And systolic function at the beginning is normal gradually will decrease This is short axis severe hypertrophy another disease that will give severe hypertrophy Without hypertension is fibrous disease. That's not common, but amyloidosis is almost common That's a mitral influx So this is the strain You have a strain in your machine. You can do it So when we do a strain for amyloidosis You see the apex is contracting very well, but the base is not contracting Contracting is shown by red Is not going to be showed by blue This is the strain of the patient with And here again, you can see it the apex is red is contracting very well. The rest is not contracting So we say the amyloidosis has a apical spading apex is not diseased. The rest has a disease We do a A See here the bull's eye Seventeen segment together you see at the middle is red. The rest is less red and or is blue And this appearance is called Cherry at the top Of the cake Because it's a middle is like a cherry and the rest is not cherry. So this is a very classic appearance of the cardiac At this is a specific of the cardiac amyloidosis severe hypertrophy and you can make a diagnosis with different special type of a stain Okay, thank you very much. Anyway, I hope it was recorded well And I will recommend you especially about diastolic dysfunction To practice it in the war also some Patient younger patient they might not have diastolic dysfunction when they have a valve or disease What you can practice in every patient and the only way to learn it Is just