Diastolic Function Cases - American Society of ...asecho.org/.../uploads/2017/02/Wilansky_Diastolic-Function-Cases.pdf · Diastolic Function Cases 2017 Susan Wilansky MD, FRCP(C),

2/14/2017

1

Diastolic Function Cases 2017

Susan Wilansky MD, FRCP(C), FACC, FASE

DISCLOSURE

Relevant Financial Relationship(s)

None

Off Label Usage

None

2/14/2017

2

3022501-3

Case

•67 year old male

•NYHA class II

•2005: renal failure

3022501-4

Septum 17 mm Posterior wall 16 mm

2/14/2017

3

3022501-5

EF 69% LAVI 24 cc/m2

3022501-6

E: 60 cm/s

E/A: 0.67

TRV: 2.5 m/sec

E/e’: 7.5

2/14/2017

4

3022501-8

E: 60 cm/s

E/A: 0.67

TRV: 2.5 m/sec

E/e’: 7.5

50

Grade 1

3022501-9

Right heart cath

•RAP: 6 mmHg

•PAP: 28/11

•PCW: 9 mmHg

•CI: 1.7 L/min

2/14/2017

5

3022501-10

Amyloidosis

3022501-12

The story continues

•Regular hematology follow up

•Chemotherapy for rising light chains

• “Outside” cardiology follow up

•Presents to ER (1/2013) now NYHA class IV

•New systolic murmur

2/14/2017

6

3022501-13

EF 54% LAVI 49 cc/m2

3022501-14

Mean gradient: 23 mmHg

AVA: 1.3 cm2

2/14/2017

7

3022501-15

E/A: 0.67

E/A: 1.13

E:0.8cm/s

3022501-16

2007 LVOT

Vel: 0.9 m/s

2010 LVOT

Vel: 0.9 m/s

2/14/2017

8

3022501-17

E: 80 cm/s

E/A: 1.13

E/e’: 18

TRV: 3.3 m/sec

What is diastolic function grade?

1. Grade I

2. Grade II

3. Grade III reversible

4. Grade III irreversible

E: 80 cm/s

E/A: 1.13

E/e’:18

TRV: 3.3 m/sec

2/14/2017

9

Grading LV filling pressuresDepressed EF/ myocardial disease and

normal EF

E/A > 2

Grade III DD

E/A < 0.8 +

E < 50cm/s

Normal LAP

Grade I DD

E/A < 0.8 + E > 50 cm/ OR

E/A > 0.8 - < 2

1. Av E/e’ > 14

2. TR > 2.8 m/s

3. LA vol >34 cc/m22/3 or 3/3

negative

2/3 or 3/3

positive

Grade II DD

E: 80 cm/s, E/A: 1.13, E/e’:18,

TRV: 3.3 m/sec, LAVI:49 cc/m2

3022501-21

Case• 85 year old male presents to ER

with fatigue and dyspnea on exertion

•HR 70 BPM BP 90/60 mmHg

• JVP at angle of jaw

•Grade II/VI PSM apex

•Bibasilar crackles

2/14/2017

10

3022501-22

EF 44% LAVI 62 cc/m2

3022501-23

2/14/2017

11

3022501-24

RV: 78 cc ERO: 0.52 cm2

3022501-25

E/A: 2.6

E/e’: 22

TRV: 3.7 m/sec

2/14/2017

12

3022501-26

? Diastolic Function Grade

1. Grade II

2. Cannot grade

3. Grade III reversible

4. Grade III irreversible

E/A: 2.6

E/e’: 22

3022501-27

E/e’ does not reflect filling pressures in the following MV disorders

> Moderate MR

Mitral annular calcification

Mitral stenosis

Mitral anuloplasty rings

Mitral prostheses

2/14/2017

13

3022501-28

Case

• 57 year old male presents to the ER with progressive angina

•PMH: ACB 1998 and 2012; CHF, hypertension and familial hyperlipidemia

3022501-29

EF 60% LAVI 47 cc/m2

2/14/2017

14

3022501-30

E/A: 3.7

DT 111 ms

E/e’: 50

REST VALSALVA

3022501-31

?Diastolic Function Grade

E/A: 3.7

DT 111 ms

E/e’: 50

1. Grade II

2. Grade III reversible

3. Grade III irreversible

E/A > 2

2/14/2017

15

3022501-32

Case

•88 year old woman

•Echo for F/U PHT

•Asymptomatic

3022501-33

EF 65% LAVI 43 cc/m2

2/14/2017

16

3022501-34

E/A: 1.3

DT: 177 ms

E/e’: 30

3022501-35

What is this flow and what does it mean?

1. L wave: don’t know

2. B notch: high LVEDP

3. L wave: high LAP

4. Artifact

2/14/2017

17

3022501-36

Triphasic mitral inflow with mid-

diastolic flow is related to elevated

filling pressures, delayed

relaxation and slow heart rate

indicating advanced diastolic

dysfunction. JASE 2004; 17:428

3022501-37

Case

• 89 year old woman presents to ER with progressive dyspnea

•PMH: hypertension

•Exam: BP 168/96 mmHg; mildly increased JVP; bibasilar crackles

•CXR: mild vascular redistribution, bilateral pleural effusions

2/14/2017

18

3022501-38

EF 66%; Mild LVH; LAVI 62 cc/m2

3022501-39

E vel: 1.4 m/s; E/A: 2; DT: 133 ms

DO WE NEED ANY MORE INFO?

Grade III DD: E/A > 2

2/14/2017

19

3022501-41

Case

• 40 year old female referred for transplant evaluation

• 2012: fatigue and dyspnea

• 2013: Syncope on Midodrine Rx

•Bilateral hand paresthesia

•Recurrent admissions for CHF

•Now NYHA class III

3022501-42

Septum 14 mm

Posterior wall 14mm

2/14/2017

20

3022501-43

3022501-44

2/14/2017

21

3022501-45

Peak E wave: 0.7 m/s

E/A: 3.5

DT: 155 ms

e’ velocity: 0.03

E/e’: 23

3022501-46

What is the most likely diagnosis?

1. Hypertrophic cardiomyopathy

2. Amyloid cardiomyopathy

3. Hypertensive heart disease

2/14/2017

22

3022501-47

?Diastolic Function Grade

E/A: 3.5

E/e’: 23

1.Grade II

2.Grade III

3.Grade III(reversible)

4.Grade III

3022501-48

Case

• 49 year old woman: palpitations and near syncope

•Mild chest pressure on exertion

•Mother had cardiac issues

•No family history SCD

2/14/2017

23

EF 70% LAVI 47 cc/m2

3022501-50

2/14/2017

24

3022501-51

3022501-52

2/14/2017

25

3022501-53

?Diagnosis

1. Apical HCM

2. Hypertensive HD

3. Apical HCM with apical pouch

4. Need more information

3022501-54

E velocity: 0.3 m/s

E/A: 0.75

DT: 240 ms

E/e’: 10

2/14/2017

26

3022501-55

?Diastolic Function Grade

E wave: 0.3 m/s

E/A: 1.33

E/e’: 10

1.Grade I

2.Grade II

3.Grade III

4.Need more

information

3022501-56

A duration: 122 ms

A(PV) duration: 195 ms

A(PV) – A(MV) = 63 ms

LVEDP

2/14/2017

27

3022501-57

Case

• 39 year old male: NYHA Class IV

•Cardiac cath: inoperable 3 vessel disease

•Referred for transplant evaluation

3022501-58

EF 18% LA 45 cc/m2

2/14/2017

28

3022501-59

E/A: 4.5 E/A: 2.7

REST VALSALVA

Diastolic function grade?

1. Grade II

2. Grade III reversible

3. Grade III irreversible

3022501-60

Case

• 78 year old woman: dyspnea on exertion

•S/P MVR St. Jude #29 10 years prior

2/14/2017

29

3022501-61

3022501-62

2/14/2017

30

3022501-63

?Doppler abnormality

1. Normal prosthesis

2. Irregular profile due to atrial fib

3. Increased LVEDP

4. High filling pressures

3022501-64

Case• 52 year old male:

abnormal stress test

•Asymptomatic

•Remote smoker

2/14/2017

31

3022501-65

EF 65% LAVI 45 cc/m2

3022501-66

E wave: 0.9m/s

E/A: 2.25

TRV: 2.4 m/sec

e’: .13 ms

E/e’: 9

2/14/2017

32

3022501-67

?Diastolic Function Grade

E/A: 2.25

E/e’: 9

1.Grade I

2.Grade II

3.Grade III

4.Normal filling

pressures

3022501-68

Assessment of Diastolic Dysfunction in Patients with Normal LVEF1. Average E/e’ >14

2. Septal e’ velocity <7 cm/s OR lateral e’ velocity <10 cm/s

3. TR velocity >2.8 m/s

4. LA volume index >34 ml/m2

<50% positive

Normal diastolicfunction

50% positive

>50% positive

IndeterminateDiastolic

dysfunction

2/14/2017

33

3022501-69