 This is Dr. Ahmad Ombran. I'm a staff cardiologist and I'm working in Toronto General Hospital under the Department of Anesthesia and Pain Management. This is a lecture for evaluation of left ventricular diastolic function by EcoCatography and this lecture is for cardiac anesthesiology fellows so I'm trying to show the views based on trans-trastic how it looks like in TE as well. So this lecture is based on the guideline of American Society of Eco with European Association of Cardiovascular Imaging and most of my slides belong to this guideline and I added some just picture to show it better especially for TE views. First of all we have to define where is the diastole. So this is a very famous diagram of Vigor's diagram showing the cardiac events inside the heart. This is during the systole, isovolumic contraction and ejection time and this is the diastole. So diastole starts with closing of the aortic valve and then up to opening of the mitral valve is called isovolumic relaxation time. This is about 60-70 millisecond and when the relaxation is impaired this will be prolonged and then is a rapid filling and then is a diastosis and the last part is atrial contraction time. So diastole has a four component isovolumic relaxation, rapid filling, diastosis and atrial contraction. So the term of the LV filling pressure can refer to mean pulmonary capillary wedge pressure which is indirect estimate of LV diastolic pressures, mean left atrial pressure, LV pre-A pressure or A-wave pressure before A-wave pressure, mean LV diastolic pressure and LV endiastolic pressure almost all of them in a many condition they are same. The component of diastolic function is usually the result of impaired relaxation, that's active relaxation, so this will be impaired, reduced restoring forces, restoring forces, this is during the systole and this is during this diastole, this restoring forces and suctioning of the LV will be impaired and increased LV chamber stiffness, so chamber will be stiff and compliance of the chamber will be decreased, so stiffness will increase and chamber compliance will decrease. The diastolic dysfunction or diastolic function can be assessed non-invasively as well by CAT lab and that was a way that they were measuring the diastolic function before echo comes, so by a tau or negative dp to dt measuring and I still I believe in some some centers they might measure it by CAT as well. When the echo calligraphy came even the time of the M-mode people started to assess diastolic dysfunction as well beside the systolic function, this is the M-mode of the mitral valve it shows the E-wave, F-E-F-A the nomenclature of the mitral in M-mode and this is the C closure of the mitral valve and then D an opening of the another one, so in the down slipping between A-wave and C-wave sometimes there is another bump it's called B-bomb or B-wave. If we see a B-bomb in a M-mode of the mitral valve we saw this is a sign of diastolic dysfunction, the reason we see that B-bomb as it's shown in the Doppler as well is at the end of the diastolic because of the LV in diastolic pressure is high it will be higher than LA, so there will be some diastolic MR and it creates M-mode as a B-bomb, so B-bomb was the earliest sign of diastolic dysfunction by echo calligraphy. So now what we should measure by echo calligraphy in assessing LV diastolic function, so when our echo equipment they improve more and more and we have more tools in the echo calligraphy we are we can measure more parameters I remember for example in 1992 when I was an echo calligraphy fellow we were measuring only the mitral inflow and later we were measuring the pulmonary vein as well later like in close to 2000 the tissue Doppler came and was added to assessment of diastolic dysfunction and it was a big revolution in assessment of diastolic dysfunction because the tissue Doppler can measure the velocity of the myocardium and in the past by Doppler we were just able to measure the velocity of the blood so we had blood Doppler in the past and when the tissue Doppler came we have the tissue Doppler what is our routine measurement nowadays for diastolic dysfunction by echo we measure the mitral inflow Doppler at the level of the leaflets tip it's very important we should use a pulse Doppler a sample volume should be one to three millimeter we measure the evave velocity deceleration time and evave velocity so all of them by pulse Doppler IVRT by pulse Doppler again also some centered they use it by continuous Doppler as well but it should be measured by pulse Doppler and should be measured in a five chamber view transtersic or T both of them TDI or tissue Doppler imaging velocity of the E prime lateral and the septal and sample volume for all TDI should be five to 10 millimeter so sample volume size is very important pulmonary venous flow Doppler velocity S wave D wave and evave reversal sample volume size should be one to three millimeter and should be one to two centimeters deep into the vein so we should not put a sample volume at the mouse of the pulmonary vein should go deep inside the TR velocity in RV inflow view and four chamber view or other view that we can get a better alignment of TR velocity so obviously this will be by CW and LA volume in transtersic we can measure it in apical IV and two chamber mu by method of disc this LA volume we cannot measure it by TE if we do measurement by we do measure by TE it will be underestimated so this is the only thing that we cannot use it in TE also we can measure the dimension of the LA in TE as well and I will show you in a slide some of the other measurement in echo are specific for specific diseases we don't have to do it for every patient like a mitral inflow a wave duration sample volume at the level of the mitral annulus this is important that we should put the sample volume at the level of the mitral annulus to measure the a wave duration and I will show you in a slide how we measure it mitral evave acceleration rate for atrial fibrillation patient that's very important and I will show you mitral inflow color propagation velocity that was a very important parameter like 10-15 years ago nowadays it's not in the guideline it's only in one small part I will show you pulmonary vein systolic filling fracture d wave deceleration time and a wave reversal duration again I will show you time from e to the e prime time to the evave and time to the e prime wave this difference and I will show you again in a slide time from r wave of the ecg to beginning of the mitral evave and time from r wave of the ecg to the e prime wave usually they are equal if the patient doesn't have diastolic dysfunction but when we have a diastolic dysfunction this one the second one will increase val salva maneuver especially for trans thoracic we cannot use the val salva maneuver in te patient again val salva maneuver was probably one of the first thing that came for assessment of diastolic dysfunction and differentiate between normal pattern and pseudo normal pattern mitral inflow use use of the val salva maneuver was mainly before tissue doppler comes this is how we measure the mitral inflow so trans mitral flow velocity evave and evave we can measure the velocity we can measure the deceleration time in four chamber view this is a mayo format lv is this side rv is in right side so we should put the pulse doppler sample volume at the tip of the valve we should not use c w here tip of the valve in four chamber view and the sample volume size as we said it should be one to three millimeters so a small sample volume we can measure the evave velocity we can measure the evave velocity and we can measure the deceleration time and this is how we do it in te again in four chamber view again sample volume should be at the tip of the mitral valve and e and a and deceleration time so anything we do in trans thoracic we can copy it in te probably the only thing that we cannot do it is the la volume because our probe is just behind the la in te and we underestimate the volume of the la by te this is a mitral inflow doppler measuring the evave and evave and the deceleration time as we showed in previous one and this is how we measure the tissue doppler e prime from the septal and from the lateral so septal and the lateral so this is from septal this from lateral usually the tissue doppler again as i said sample volume should be five to ten millimeter a lateral is more than septal the only exception is the constrictive precarditis that we call it annulus reversus and i will show you this is a trans thoracic view you can make it upset down and make it te view so that this is in the te so e prime will be at the top of the zero line a prime and s prime s prime we can use it for assessment of systolic function e prime for systolic function this is a mitral inflow l wave so sometimes in the mitral inflow beside the evave and avave you will see at the middle the doppler does not come to the zero dvb another wave is called l wave anytime we saw the l wave doesn't matter in the blood doppler or tissue doppler that is compatible with systolic dysfunction we used to see this l wave always in all guideline and we didn't know what has what does mean why they called it l wave i remember last time in the american society the the previous times two three years ago that we attended in person i asked this from dr. Sharif the head of this chairman of this guideline and the dr oh from meukerik and they told me what does mean that l wave this because this first time was discovered by a sonographer and her name was caroline lamb so that's the l wave this effect of the val salva in transtrasse so if you do a mitral inflow and there's val salva you expect that e to a ratio still stay e bigger than a if e became smaller than a it means this mitral inflow is not normal it is so normal the reason is in during the val salva the the venus return to the la will decrease and the pressure of the la will come down so if the e became smaller than a it shows that pressure was high at the beginning so patient has a high la pressure systolic dysfunction if no the e is still is bigger than a it means this is just normal not so normal uh this is how we do IVRT in transtrasse we go five chamber view we put our pulse Doppler again IVRT should be measured by pulse Doppler we put a sample volume somewhere between mitral tip and the lvot and we measure the IVRT or isofolomic relaxation time and we can do it by tissue Doppler as well and this is how we do it by te so we stay in a five chamber view and our sample volume should be between the tip of the mitral valve and the lvot this is how we measure the la volume by method of disc we use biplane it means we do it in four chamber view and two chamber view and take an average this la volume uh the number and cutoff changed from previous guideline to recent guideline like a guideline of 2009 took 28 milliliter per meter square as a normal and above 28 as abnormal but in the recent guideline uh 2016 this 28 was changed to 34 because they saw many athlete people they have a big la but they don't have diastolic dysfunction still after this 34 we see it in our daily practice that 34 still it can be normal even 35 36 can be normal it depends to the size of the people as well so some big size people they have bigger than 34 milliliter per meter square la volume and they are still normal they don't have diastolic dysfunction so la volume increased is not very specific in diastolic dysfunction this is how we measure the la dimension in te we can measure the volume but dimension this is the best view in short midi's visual short axis view we can measure from the here to the aorta and this will be exactly same as we measure anthropostereo dimension of the la in trans thoracic so this dimension and this dimension are very similar this is a trans thoracic and this is the te and there is a paper to prove that these two are very uh correlated what about tr velocity we can measure the tr velocity in apical four chamber view focus view of the rv apical four chamber and we can measure the tr velocity we can measure the velocity and that velocity velocity 2.8 meter per second is our cutoff and usually we need to have a good uh Doppler velocity if this is a weak velocity weak Doppler signal is not good we might overestimate or underestimate sometimes we might use a little bit agitated sailing to show the tr Doppler better so that's a uh in trans thoracic we can do it in te as well uh like by cable view we can get a good uh tr jet we have to have a good alignment so we can do it in this view this is a pulmonary vein flow systolic wave diastolic wave and every years reversal again we show you that systolic wave is important and every reversal the duration is important velocity is important and we show you in a different example again this is a uh pulmonary vein flow and our sample volume should be 1 to 3 millimeter and should be 1 to 2 centimeter deep in the vein uh this is how we do the pulmonary vein flow in te this is a right upper pulmonary vein again so we can use the te this view or we can use the left upper pulmonary vein uh in the when we see the appendage and comedy and reach so s wave and d wave and this is the a wave reversal if this a reversal the velocity is more than 35 centimeter per second this is one of the parameter that we can use it for diastolic dysfunction again this is when we use the te color propagation color propagation as i said it was a part of the guideline in 2009 now is not our routine measurement in the guideline of 2016 but there's one or two specific disease that color propagation is important and i will show you how we do the color propagation this by te this by trans drastic we put the color in the mitral inflow four chamber view of the te or four chamber view of the trans drastic okay we put the m mod across the mitral inflow and we measure from the mitral to four centimeter adjacent to the color propagation yes we have to bring the nyquist limit down to side we make it like a 30 or 40 centimeter per second so here is 38 now so nyquist limit down to see the aliasing and we measure the from here to the mitral annulus to the tip to the four centimeter and that will be in centimeter per second not second per second centimeter per second and more than 45 centimeter per second is normal less than 35 centimeter per second for sure is diastolic dysfunction and the middle part is moderate form in the mitral inflow the other thing that we can measure we can measure the time of the a wave especially that's very important and we can measure the e wave acceleration rate the e wave acceleration rate so we can put the the Doppler we can measure it from here to here as an acceleration rate machine will measure it for us and the peak acceleration rate more than 1900 centimeter per second two is compatible with diastolic dysfunction this is very useful in patient with atrial fibrillation so this is again another mitral inflow e wave deceleration time a wave avrt and a wave duration so a wave duration is important and this is again another example how we measure the e wave acceleration rate and more than 1900 centimeter per second two is compatible with severe diastolic dysfunction this is how we measure the a reversal duration okay this duration should not be more than a wave of the mitral inflow with more than a wave of mitral inflow that patient has a diastolic dysfunction so if it's 30 millisecond more than duration of the a wave mitral inflow a wave that patient has a diastolic dysfunction so the velocity 35 is a cutoff and in terms of the duration anytime became 30 millisecond more than the time of the a wave has a significance and the fraction is important as well so systolic filling fraction it means the velocity of the systole divided by velocity of systole and diastole but this not the velocity alone is a velocity time velocity integral so time velocity integral of s wave time velocity integral of the d wave and we put in this formula we call it systolic filling fraction and we use that one as well for assessment of diastole dysfunction the another important criteria is measuring the time from r wave of the ecg to the beginning of the e wave and the time from r wave of the ecg to the beginning of the e prime wave normally this one that is for mitral inflow Doppler blood pool Doppler this is longer than this or they are equal so this time r to e wave is almost equal to r to e prime but r to e prime if became bigger than this that patient has a diastolic dysfunction that's called time of e minus e prime so if this is bigger than this for example 20 30 40 millisecond this time became bigger than this patient has a diastolic dysfunction and i will show you the cutoff the reason that in diastolic dysfunction this time will be longer because the mitral annulus and lv cannot relax easily so because as a impairment of relaxation this time will be longer because e prime starts when the lv relaxed so the relaxation as it delayed this time will be more delayed and bigger than this time so how to apply all of this measurement in assessment of diastole dysfunction i showed you what criteria we should measure so what parameter we should measure in transtersic and t and i showed you all the parameters that we can measure by echo how we use it first of all we should ask ourselves is there diastolic dysfunction or there is any highly likelihood of having diastolic dysfunction in this patient for example if the patient doesn't have any lv hyper to v doesn't have a coronary artery disease doesn't have a hypertension and doesn't have any like a muscular hypertrophy there's no reason to have a diastolic dysfunction probably in that type of patient we should not even assess the diastolic dysfunction so to assess diastolic dysfunction we should have any reason that will give diastolic dysfunction this is a list of the disease that the patient might have diastolic dysfunction known coronary artery disease pathologic left ventricular hypertrophy when we say pathologic not a benign left ventricular hypertrophy that we see it in athletes hypertensive cardiovascular disease hypertension lvh or la enlargement lv systolic dysfunction as noted by depressed lvef so anytime patient has lv systolic dysfunction for sure has a diastolic dysfunction established clinical diagnosis of heart failure with preserved ef abnormal global strain so abnormal global strain heart failure with preserved ef and other other reason so if you have one of this reason this is a high chance that we have a diastolic dysfunction we and we assess it if you don't have any of this probably is not necessary even to assess in some lab they don't assess the diastolic dysfunction as routine in every patient but many a collab they reported even is normal it should be reported so the guideline of 2016 made it two algorithm these two algorithm in somehow they made it to simplify the assessment of diastolic dysfunction but in some part it made the job more difficult most of the echocardiographer including myself we really don't agree with these two algorithm and even there was a discussion many time in the american society that should we take these two algorithm and make it just one one that is number b that i will show you this number a now and i remember they did one survey between all echocardiographer in 2000 in american society of echo and they said the guideline of diastolic dysfunction is the most hated guideline because it is very complicated probably the guideline of 2009 was much much easier also the people that they developed this guideline they believe that this is the easier than 2009 guideline but anyway there's two algorithm algorithm a and algorithm b algorithm a is in patients with normal e f they say in normal e f we take average e to e prime more than 14 that's one criteria septal e prime velocity less than seven or lateral e prime velocity less than 10 so seven and 10 this is one criteria so one parameter parameter number two parameter number three tr velocity more than 2.8 and parameter number four la volume index more than 34 milliliter per meter square and i told you this is the weakest parameter so we have four parameters if less than 50 percent of this four so less than 50 percent of four will be one only if only one is positive that patient does not have any diastolic dysfunction is a normal diastolic function so i wish this was five instead of four because 50 percent is difficult say less than 50 will be only one if is more than 50 positive it means more than two are positive so three or four so if it's just one positive will go to this part if it's three or four positive will go to this four this patient has a diastolic dysfunction if it stayed 50 percent it means two are positive two are negative that is called indeterminate it means we cannot say the patient has a diastolic dysfunction or not and this indeterminate is like a calling in medicine idiopathic disease idiopathic means we don't know the reason so when i was medical student all the disease were idiopathic because we didn't know why happens now we know that many of idiopathic disease they have a cause they have a reason like innocent member in the member they are not they don't they are not innocent so anyway indeterminate is a big problem in assessment of diastolic dysfunction in echo as i remember one of this big debate in american society of echo dr julius garden one of the very senior echo person was saying that the fellows they like this indeterminate it's easy to call every patient when you report the diastolic dysfunction just say indeterminate what about algorithm b algorithm b says this is for lv filling pressure and grading lv diastolic function in patients with depressed ef so the first one was normal ef and patient with myocardial disease and normal lv systolic function this makes problem normal lv systolic function and myocardial disease so what does mean normal lv systolic function it goes to a algorithm one that's the reason that people believe that if we take the algorithm one nothing will happen we can go only by algorithm two because if we go in a patient that has a normal lv function and doesn't have any of this disease probably does not have diastolic dysfunction anyway in algorithm b they said we go based on the mitral inflow and we look at the e to a ratio if e a ratio is less than 0.8 and e a ratio is more than two that will be severe diastolic dysfunction okay we come to this later e a ratio less than 0.8 in a condition that e wave is less than 50 centimeter that will be grade one so e a ratio less than 0.8 e less than 50 if his e is less than 50 does not go to this column should be less than 50 if it's more than 50 is not here is in this column so e to a ratio less than 0.8 and e itself less than 50 centimeter per second it will go to the this column is normal left atrial pressure and is a grade one diastolic dysfunction so grade one is normal la pressure okay and if it's a symptomatic consider coronary disease or proceed to diastolic stress test so the grade one diastolic dysfunction should not be symptomatic what we mean about symptom patient should not have a shortness of breath if the patient has a shortness of breath probably is in this category so if by the echo measurement goes to this category we should stress the patient do a stress diastolic function assessment column middle one e to a ratio less than 0.8 but e wave is bigger than 50 here was less here is bigger or e to a ratio is between 0.8 and 2 because 2 will go here between 0.8 and 2 we go three criteria to be evaluated average e to e prime tr and la volume index if two of the three or all three are negative again goes to the grade one if two hour two of the three or all three are positive goes to the grade two if became one positive one negative we make a decision like this but again there is a column is called cannot determine la pressure and diastolic dysfunction grade so still there is a good number of the patient that we cannot assess the diastolic dysfunction by echo so these are grade two if the e to a ratio is more than two for sure is grade three so e to a ratio more than two is easy is grade three e to a ratio less than 0.8 is easy is grade one condition of e less than 50 but the middle part sometimes is difficult so based on that we go to three category or four category normal grade one grade two grade three this is our report we call it either normal or call it grade one call it grade two call it grade three grade three in an old time like a 2004 guideline that i remember i remember all of this guideline from 1992 when i became fellow so changing changing in 2004 guideline they made the grade three as a two grade three reversible grade three irreversible or grade four but now again came back to three grade only the normal means lv relaxation is normal la pressure is normal mitral e to a ratio is more than 0.8 average e to e prime ratio is less than 10 and peak tr velocity is less than point less than 2.8 meter per second grade one it really relaxation is prolonged is impaired la pressure is low or normal mitral e to a ratio is less than 0.8 less than 0.8 and he didn't say that 50 average e to a ratio e to a prime ratio is less than 10 and the tr velocity is less than 2.8 in grade two relaxation is impaired but lv pressure is high ratio is between 0.8 to 2 average e to a prime is 10 to 14 and tr is more than 2.8 and grade three again relaxation is impaired but lv pressure is elevated ratio is more than 2 14 and 2.8 so you see how much is important this tr velocity this ratio and the la pressure that will be elevated here they didn't put the la number so most of the patients are easy by the criteria that we put it and we know the small group of them will be indeterminate but there are some diseases that we cannot use this normal we cannot use these two algorithm a and b unfortunately most of our patients you know like a tertiary care center most of them are they fit in these exceptions so that algorithm a and b probably is good for ecolab that is a community-based ecolab outpatient ecolab not like a Toronto general hospital ecolab so that can be used but most of our patients they feel they fit in one of these exception because they are tertiary patient a tertiary care center and they are advanced disease so af patient many of our patients they have af what we should use we cannot use the algorithm one a or b we should use all of this peak acceleration rate is very important i v r t is important the acceleration time of the pulmonary vein is important less than 220 millisecond that's dice of this function ratio of the e wave to velocity propagation more than 1.4 is important and e to e prime more than 11 is abnormal cutoff in non af patient was 14 here is 11 sinus tachycardia the problem is sinus tachycardia is e and a will be merged so you cannot use it but again you can use these criterias hypertocardomyopathy we have many of them in our ore especially e to a prime you can use it a wave reversal minus a wave of the mitral more than 30 millisecond has a value tr velocity as a value and la volume la volume is very important in hypertocardomyopathy assessment probably you remember our late mentor dr weigel that is a founder of our hypertocardomyopathy clinic in toronto general hospital always when he was coming to the echo lab the first thing about his patient hypertocardomyopathy the first thing he was asking was what's the size of the la in that time we were not measuring the la volume was just the size i'm talking about 30 years ago so that was the most single important criteria to assess the diastolic dysfunction in hypertocardomyopathy in restrictive cardiomyopathy e to a ratio is very important will be more than two even will be more than 2.5 and deceleration time IVRT restrictive cardiomyopathy we don't have too many amyloidosis one of the good example of this i'm filtrate cardiomyopathy or example of this but we don't have too many of the restrictive cardiomyopathy non-cardiac pulmonary hypertension that's very important sometimes patient has a pulmonary hypertension but it's not related to cardiac it's non-cardiac like all the patients that you see it in our or in room nine they have a pulmonary hypertension but they're not cardiac that's the reason that we do echo we do te for them just to see there's any cardiac element or not so non-cardiac pulmonary hypertension they don't have tissue Doppler abnormal their e to e lateral e prime is less than eight so their tissue Doppler is normal but their tr velocity is more than 2.8 so have they have only one criteria of the diastolic dysfunction that's a tr velocity mitral stenosis many of the patients mitral stenosis they don't have diastolic dysfunction except you have a mitral stenosis plus hypertension or mitral stenosis plus mr they might have diastolic dysfunction so in mitral stenosis you cannot use the mitral inflow e wave a wave because the mitral e wave increased in mitral stenosis you cannot use it so you can use the IVRT and you can use the ratio of the IVRT to the time difference between r to e wave minus r to e prime if this is less than point less than 4.2 that's one of the criteria i'm mitral a wave velocity this is the only time that a wave velocity has used that's on mitral stenosis mr is almost similar to the ms we have more mr patient in our echo our OR a wave reversal minus a wave more than 30 millisecond IVRT that ratio but here the cutoff is 5.6 and e to e prime more than 14 has a value i will show all of this in another algorithm to you as well so probably the three most important thing that we should be aware in the OR especially is af mr and ms and hybrid of cutoff property so the task for some american society of echo to make it a bit similar for this exceptional disease a specific disease made some more algorithm and i will show you that algorithm as well so this algorithm are based on the guideline was was made mainly for this specific diseases and you can have them in your mobile and use it always in hypertrophic cut the property patient so average e to a ratio more than 14 index pulmonary vein and TR jet can be used and this is the algorithm and if the presence of restrictive feeling pattern that will be a very advanced digestive dysfunction in hypertrophic cut property rarely we see it in the OR very advanced one because we have a hypertrophic cut off the clinic here and they send the patient for medical or surgical treatment very early so they don't reach to that level restrictive cut the property patient again at the earliest stage they are grade one in advanced age they are grade three and you go based on this algorithm these algorithms are very good to to have it and when you report the echo just use it so for restrictive cut off body you can use this algorithm for valvular disease for ms as we said before for mr for a patient that has a mac and for patients as AS and AR so AS and AR they are not making any problem for assessment we can use the regular guideline and even in the AR we can use it so the regular guideline criteria is useful in AS AR but for ms mr and mac is not useful AR patient AS patient they have diabetes function for sure AR patient especially if they have a chronic AR because they develop lv dilatation lv hypertrophy that is eccentric hypertrophy they have diabetes function and we should assess it heart transplant is very difficult because in heart transplant even with normal lv systolic function their assessment they look like a restrictive pattern so if they we are doing a heart transplant patient dissect this function assessment and we see a restrictive pattern we should not say oh this is severe dice to this function this is a rejection i remember when i was fellow in like in 90 to 93 we were calling many of this pattern as a rejection and some of them they had lv biopsy biopsy was okay so now we know that we cannot use the parameter for heart transplant probably the only thing they can use it we can use it is tr velocity if tr velocity is high there is something wrong with that transplant at heart patient with arrhythmia especially for av block they might make a problem for assessment especially if it's a long pr interval you might have a merging of the e and a wave but there are criteria that you can use it atrial fibrillation is very difficult peak acceleration rate IVRT deceleration time in the pulmonary vein and ratio of the e to velocity propagation and septal e to a prime ratio more than 11 is the cutoff thank you very much for listening to this lecture and i hopefully in our meeting i will be present to answer the question