Question #1 Choose the grading of diastolic …5/8/2018 1 ©2018 MFMER | 3712003-1 Choose the...

5/8/2018

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©2018 MFMER | 3712003-1

Choose the grading of diastolic function in 82 yo woman E= 80 cm/s A= 70 cm/s LAVI < 34 mL/m2

1= Grade 1 2= Grade 2 3= Grade 3 4= Normal 5= Indeterminate

Question #1

©2018 MFMER | 3712003-2

Choose the grading of diastolic function in 82 yo woman E= 80 cm/s A= 70 cm/s LAVI < 34 mL/m2

1= Grade 1 2= Grade 2 3= Grade 3 4= Normal 5= Indeterminate

Medial e’ = 8 cm/sE/e’ = 10 TR =2.7 m/sec

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82 year old woman with normal diastolic function

TR = 3.2 m/sec TR =2.7 m/sec

©2018 MFMER | 3712003-4

Grade diastolic function in 80 YO man with dyspneaTR = 3.5 m/sec

1. Grade 1

2. Grade 2

3. Grade 3

4. Normal

5. Indeterminate

E= 60 cm/s

A= 80 cm/s

E/A = 0.75 Medial e’ = 2 cm/s

E/e’ =30

Lat e’ = 6 cm/s

E/e’ = 10

Question #2

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80 YO man with dyspneaSeptal e’ is reduced due to PHT

1. e’ is reduced

2. E/e’ +/-

3. LAVI normal

4. TR is high

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80 year old man with dyspnea and PHTCardiac Cath Data

• RA pressure 2 mmHg

• RVSP 50 mmHg

• Mean PASP 28 mmHg

• PCWP 4 mmHg

• LVEDP 13 mmHg

• Cardiac Index 1.5 L/min/m2

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Diastolic Function in 65 yo man with hypertension ?LAVI = 20 mL/m2 & TR = 3 m/s

1. Grade 1

2. Grade 2

3. Grade 3

4. Normal Filling Pressure

5. Indeterminate

E=127 cm/s

A= 135 cm/sMedial e’= 5 cm/sec

E/e’= 25

Lat e’= 8 cm/sec

E/e’= 16

Question #3

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LV volume measurement

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65 yo man with hypertension

E/A = 1.0 E/A = 0.77

©2018 MFMER | 3712003-10

Good Quality in Measurements is the Key!No data is better than wrong data !

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78 yo woman with 21 mm CE AVR 2010 for severe ASReferred for Valve in Valve with high gradient and dyspnea

Aorta 3 cm

©2018 MFMER | 3712003-12

78 yo female with 21 mm CE AV prosthesis and SOBHow do you grade her diastolic function?

4 m/sec

AT 75 msec

i EOA < 0.65E =45 A= 140

E/A = 3

1. Grade 1

2. Grade 2

3. Grade 3


5. Indeterminate

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78 yo female with 21 mm CE AV prosthesis and SOBWhat is you next diagnostic step?

4 m/sec

AT 75 msec

i EOA < 0.65E =45 A= 140

E/A = 3

1. Aortic valve replacement

2. Refer to pulmonary

3. Exercise test

4. TEE

5. Old age and Observe

©2018 MFMER | 3712003-14

Pericardial Aortic ProsthesisAT >100 ms AT ≤100 ms

Pathologic

Obstruction

(normal flow)

Pathologic

Regurgitation

iEOA <0.65

cm2/m2

Severe

PPM

High

flow

iEOA ≥0.85

cm2/m2

Norma

l

MG >20

mmHg

MG ≤20

mmHg

iEOA <0.65

cm2/m2

MG >20

mmHg

MG ≤20

mmHg

Pathologic

Obstruction (low

flow)

Severe PPM ±

Pressure

Recovery

Aortic root

diameter ≥3

cm

Aortic root

diameter <3

cm

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Exercise Cardiac CatheterizationPPM + Pressure Recovery

Rest

LVEDP 12, PAWP 8

CO 2.8, CI 1.5, MG 17 mmHg

AVA 1.1 cm2

Exercise

PAWP 41, LVEDP 44, mean PA 46

Aortic pressure 220

CO 5.7, CI 3.1, gradient 10, AVA 2.0 cm2

©2018 MFMER | 3712003-16

Mitral inflow

E/A ≤0.8 + E <50 cm/s

E/A ≤0.8 + E >50 cm/sor

E/A >0.8-<2

E/A ≥2

Normal LAP

Grade I diastolic dysfunction

3 criteria to be evaluated*

1 – Average E/e′ >14

2 – TR velocity >2.8 m/s

3 – LA volume index >34 mL/m2

2 of 3 negative

2 of 3 or3 of 3

positive

2 negative1 positive and

1 negative2 positive

When only 2 criteria are available

Cannot determine LAP and diastolic dysfunction

grade*

LAP

Grade II diastolic dysfunction

LAP

Grade III diastolic dysfunction

If symptomatic consider CAD or proceed to diastolic stress test

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CP1082496-61

73 yo woman with Hypertension and ExertionalDyspneaNo ischemia

E = 50 cm/s DT = 250 ms

e’ = 7 cm/s

E/e’ = 7

“This patient has delayed myocardial

relaxation, but filling pressure is not

increased at rest”

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0

2

4

6

8

0 5 10 15 20 25 30 35

Change in CI and PCWP with Exercise Normal and Abnormal Diastolic Function

Cardiac

index

(L/min/m2)

PCWP (mm Hg)

Normal

CP1082496-59

Diastolic

dysfunction

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Dynamic DiastologyFilling Pressure (E/e) with Exercise

E e E/e

Normal

Abnormal

CP1254003-44

LV filling pressure (E/e’) does not increase much with exercise in

normal heart, but increases in symptomatic patients with diastolic

dysfunction. 5/8/2018

©2018 MFMER | 3712003-20

Diastolic Stress TestBaseline and Peak (or Post) Exercise

• Supine bike or Treadmill

• 25 watts (3 min) increments

• Assess LVEF, size, and wall motion

• Mitral inflow (E, A, and DT)

• Mitral annulus velocity

• E/e’ ratio

• TR velocity

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Diastology Exercise Test Normal Values

Ha J et al: AJC, 2003

Baseline Exercise

E (cm/s) 73±19 90±25

A (cm/s) 69±17 87±22

DT (ms) 192±40 176±42

e (cm/s) 12±4 15±5

E/e 6.7±2.2 6.6±2.5

CP1254003-465/8/2018

Mean age 59±14 yrs

©2018 MFMER | 3712003-22

0

2

4

6

8

10

12

Rest Exercise

02468

101214161820222426

Rest Exercise0

20

40

60

80

100

120

140

160

180

Rest Exercise

LV Diastolic Function at Rest and With StressDiastolic Stress Echocardiography in the Young: Nonathletic (NA) and Endurance-Trained (ET) Healthy Subjects

Bruengger et al: JASE, 2014

e’ s

ep

tal (c

m/s

)

E (c

m/s

)

E/e

’ se

pta

l

ET

NA*

Mean age 29 yrs

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E = 50

DT = 250

e’ = 7

Baseline

E/e’ = 7

TR = 2.4

CP1082496-61Supine Bike

E = 85

DT = 140

e’ = 7

E/e’ = 12

TR = 3.8

Exertional Dyspnea

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Echo-Cath Correlation

E/e’ = 16 E/e’ = 25

Ha et al. JASE 2005

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0

5

10

15

20

25

30

35

40

0 5 10 15 20 25 30 35

Mean LVDP vs E/e’Rest and Exercise

E/e′

Mean LVDP (mm Hg)

Rest: y=0.44x + 6.70r=0.67, P<0.01

Burgess et al: JACC 47:1891, 2006

Exercise: y=0.46x + 6.61r=0.59, P<0.01

CP1254003-535/8/2018

©2018 MFMER | 3712003-26

0

10

20

30

40

50

NCD HFpEF

Echocardiographic Hemodynamic and Ventricular Function Indices During Exercise

0

10

20

30

40

50

NCD HFpEF

Obokata M et al: Circ 135:825-838, 2017

E/e

′ me

dia

l

A B

P<0.000120% Non measurable

P<0.000111% Not measurable

Submaximal (20W) Peak

E/e

′ me

dia

l

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Exercise Echo for Dyspnea

5/8/2018

E= 50 cm/s E= 100 cm/s

e’= 5 cm/s e’= 6 cm/s

©2018 MFMER | 3712003-28

Exercise Echo for Dyspnea

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e’= 5 cm/sec

E= 100 cm/s

E= 150 cm/s

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Which of following clinical situation is best suited for using E/A ratio as the initial

diastolic assessment parameter?

1. Age > 80 years

2. Uncontrolled hypertension

3. LVEF 45%

4. AL Cardiac Amyloidosis

5. Hypertrophic cardiomyopathy

6. Marked mitral annulus calcification

Question #4

©2018 MFMER | 3712003-30

79 year old with bigemini

E= 60 A=70 E/A= 0.8 Med e’ = 7 E/e’= 8

Question #5

1. Grade 1

2. Grade 2

3. Grade 3


5. Indeterminate

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79 yo with bigemini

TR – 2.4 m/sec

Valsalva

E=40 A= 60 E/A= 0.67

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69 year old man with dyspneaPFO velocity

LAP- RAP = 36 mmHg

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PFO Velocity for estimating LA pressure

Baseline After Diuresis

Peak V = 3.2 m/s Peak V = 1.6 m/s

From Chandra, MD & Will Miranda, MD

©2018 MFMER | 3712003-34

Atrial Fib. And Mitral Regurgitation

Medial e’ = 8 cm/s E= 90 cm/s E/e’=11

TR = 2.5 m/sec

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©2018 MFMER | 3712003-35

Atrial Fib. And Mitral Regurgitation with exercise

Medial e’ = 8 cm/s

E= 90 cm/s

TR = 2.5 m/sec

E= 130 cm/s and DT 120 msec


TR = 3.2 m/sec

©2018 MFMER | 3712003-36

Mitral E, e’ and Pulmonary Vein

Normal Grade 1 Grade 3

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Questions & Discussion

©2018 MFMER | 3712003-38

Pericardial DiseasesQuestions

Jae K. Oh, MD

5/8/2018

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©2018 MFMER | 3712003-39

Who from following patients has the highest medial e’velocity expected?

1. 35 year old woman with CP after radiation treatment

2. 65 year old woman with CP after viral illness

3. 55 year old man with CP after CABG

4. 45 year old man with cardiac Fabry’s

5. 75 year old woman with HFPEF

Question #6

©2018 MFMER | 3712003-40

VBaseline

Primary CP Secondary CP Primary CP Secondary CP

Medial e’ 14.6 ± 3.4 10.3 ± 3.5 9.0 ± 2.9 7.0 ± 2.0

Lateral e’ 12.8 ± 3.8 10.3 ± 2.8 10.0 ± 3.0 7.6 ± 2.0

Veress et al. Circulation CV Imaging July 2011

Baseline Post Pericardiectomy

e’ 15 cm/s e’ 10cm/s

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Tissue Doppler in Constriction vs Restriction

E’ normal to high in constriction, low in myocardial disease

©2018 MFMER | 3712003-42

Normal vs RCM vs CPMedial Mitral e’ velocity (LV Relaxation)

Medial e’ 13 cm/s Medial e’ 3 cm/sMedial e’ 14 cm/sUsually > Lateral e’

(Annulus Reversus)

Normal RCM CP

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©2018 MFMER | 3712003-43

A 26 year old woman with a previous pericardiectomy, for tbc CP presenting with edema

Doppler demonstrates ?

1. Recurrent CP

2. Normal

3. Restriction

4. Respiratory distress

Lateral e’ = 10 cm/s Medial e’ = 15 cm/s

Question

#7

©2018 MFMER | 3712003-44

A 26 year old woman with a previous pericardiectomy, presenting with edema

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©2018 MFMER | 3712003-45

©2012 MFMER |

3213949-45

Cho and Schaff et al. Annal Thorac Surgery 2012

41 pts

1993 -2010

©2018 MFMER | 3712003-46

Which of following statements is correct regarding Kussmaul sign ?

1. Expiratory increase in JVP

2. Cannot be correct since opposite to Hepatic Vein

3. Due to increased IVC flow

Question #8

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©2018 MFMER | 3712003-47

T Meyer AJC 1989

©2018 MFMER | 3712003-48

42 year old man with dyspnea

• Gradual onset of chest tightness and dyspnea

• Physical Examination

• HR 90 BPM

• JVP mildly elevated

• Increased S2 intensity

• GR 1/6 systolic murmur

• Mild pitting edema

Question #9

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©2018 MFMER | 3712003-49

42 year old man with dyspneaWhat is his diastolic function?

1= Grade 1 2= Grade 2

3= Grade 3 4= Normal

5= Constriction

E= 120 A= 30 cm/sec E/A =4

Lat e’ = 12 cm/sec

E/e’ = 10Med e’ = 9 cm/sec

E/e’ = 13

©2018 MFMER | 3712003-50

42 year old man with dyspnea and high output

LVOT D = 2.3 m/sec LVOT TVI = 26cm

SV= (2.3)2 x 0.785 x 26 = 108 mL

CO = SV x HR = 108 x 80 = 8.6 L

CI = CO/BSA = 8.6 /1.93 = 4.48 L/m2

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©2018 MFMER | 3712003-51

What is the most common cause of HF seen in this 42 year old man?

1. Shunt

2. Obesity

3. Liver Disease

4. Pheochromocytoma

SV= (2.3)2 x 0.785 x 26 = 108 mL

CO = SV x HR = 108 x 80 = 8.6 L

CI = CO/BSA = 8.6 /1.93 = 4.48 L/m2

©2018 MFMER | 3712003-52

42 year old man with high output HFBefore and after treatment (Thyrotoxicosis)

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©2018 MFMER | 3712003-53

Etiologies of High Output FailureCardiac Index > 4.0 L/m2

• Obesity (31%)

• Liver Disease (23%%)

• Shunt (22%)

• Diastolic function can be normal

Reddy et al JACC 2017

©2018 MFMER | 3712003-54

47 year old man with chest painWhat is your next step?

1. Cardiac Cath

2. TEE

3. CT

4. Stress Echo

Question #10

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Congenital Absence of the Pericardium

Snoopy Sign

©2018 MFMER | 3712003-56

Pericardial Cyst

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A large pericardial cyst

©2011 MFMER |

slide-57

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Cardiac Tamponade

RV collapse Mitral inflow variation HV expiratory reversal

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66 year old woman with dyspneaPneumo-pericardium

PneGastro-pericardial fistulau

©2018 MFMER | 3712003-62

23 year old woman from Middle East withascites several month after acute pericarditis and pericardial

effusion

Medial e’ = 14 cm/s Lateral e’ = 11 cm/s

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23 year old woman from Middle East withascites several month after acute pericarditis and

pericardial effusion (Thrombotic CP)


Courtesy of H. Schaff , MD

©2018 MFMER | 3712003-64

35 yo man presents with dyspnea and feverBP 80/40 mmHg

Hepatic vein

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35 yo man with tamponade and feverTEE after pericardiocentesis

©2018 MFMER | 3712003-66

©2012 MFMER |

3213949-66

Final Pericardial Disease Case45 yo male with chest pain x 4 days

• Pain preceded by heavy lifting while camping. No relationship to exercise.

• MVA with pelvic and rib fractures. Chest tube and IVC filter placement 6 yrs ago.

• Many CV risk factors

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©2018 MFMER | 3712003-67©2012

MFMER |

Echocardiographic images in 45 yo with chest pain

©2018 MFMER | 3712003-68

©2012 MFMER |

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Chest and Cardiac CT

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©2012 MFMER |

3213949-69

CT scans now and 8 years ago

©2018 MFMER | 3712003-70

©2012 MFMER |

3213949-70

Embolic strut from IVC Filter

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©2018 MFMER | 3712003-71

©2012 MFMER |

3213949-71

©2018 MFMER | 3712003-72

Constriction or Myocardial Disease ? Diagnostic Algorithm

Syed, Schaff, Oh Nature Review Sep 2014

Medial e’ 12 cm/sMedial e’ 5 cm/s

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Thank You !

[email protected]

[email protected]

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Welles-04-07.mov

Echo-Guided Pericardiocentesis

18%3%

Chest wall

79%

SubcostalLocation

mailto:[email protected]

Question #1 Choose the grading of diastolic …5/8/2018 1 ©2018 MFMER | 3712003-1 Choose the...

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