diastolic dysfunction in my daily practice · diastolic dysfunction diastolic heart failure...
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DIASTOLIC DYSFUNCTION IN MY DAILY PRACTICE
Alina Nicoara MD, FASE Associate Professor of Anesthesiology Duke University Medical Center
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Outline
• What is diastolic dysfunction?
• Can we measure diastolic function?
• Is our measurement accurate?
• How do we use this information?
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Relaxation Compliance
MVO
AVC
SYSTOLE IVR RAPID FILLING
SLOW FILLING
ATRIAL CONTRACTION
LV Pressure
LA Pressure
Diastole
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Diastolic Dysfunction
Diastolic Heart Failure
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Diastolic Dysfunction
Diastolic Heart Failure
Inability to fill at low pressure, asymptomatic
Decreased cardiac output, symptomatic
NormalDiastolic
dysfunction
Diastolic heart failure
Left ventricular volume
Left
vent
ricul
ar p
ress
ure
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Diastolic dysfunction“ … 60% of surgical patients >65 years of age and with normal LVEF had diastolic filling abnormalities …”
Philip et al Anesth and Analg 2003;97:1214-21
• arrhythmias
• tachycardia
• myocardial ischemia
• fluid shifts
• myocardial edema
⇒ Diastolic Heart Failure
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Perioperative risk factor?
• Difficult separation from cardiopulmonary bypass
• Predictor of mortality in cardiac surgery patients
• Prolonged and more complicated ICU or hospital stay
• Merello et al., J. Ann. Thorac. Surg. 2008; 85:1247-1255 • Bernard et al., Anesth. Analg. 2001; 92:291-298 • Sanders et al., Anesthesiology 2008; 109:A1592
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Outline
• What is diastolic dysfunction?
• Can we measure diastolic function?
• Is our measurement accurate?
• How do we use this information?
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• Transmitral Flow• Transmitral Flow
• Pulmonary Vein Flow
• Tissue Doppler Imaging
• Color M-mode flow propagation
Quantification
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Transmitral Flow
Normal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A < 0.8 DT > 200ms
IVRT > 100ms
Impaired Relaxation Pseudonormal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
Restrictive
E/A>2 DT<160ms IVRT<60ms
↓LV relaxation ↓LV compliance ↑LA pressure
↓LV relaxation ↓LV relaxation ↓↓LV compliance ↑↑LA pressure
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Transmitral Flow
Normal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A < 0.8 DT > 200ms
IVRT > 100ms
Impaired Relaxation Pseudonormal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
Restrictive
E/A>2 DT<160ms IVRT<60ms
↓LV relaxation ↓LV compliance ↑LA pressure
↓LV relaxation ↓LV relaxation ↓↓LV compliance ↑↑LA pressure
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Transmitral Flow
Normal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A < 0.8 DT > 200ms
IVRT > 100ms
Impaired Relaxation Pseudonormal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
Restrictive
E/A>2 DT<160ms IVRT<60ms
↓LV relaxation ↓LV compliance ↑LA pressure
↓LV relaxation ↓LV relaxation ↓↓LV compliance ↑↑LA pressure
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Transmitral Flow
Normal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A < 0.8 DT > 200ms
IVRT > 100ms
Impaired Relaxation Pseudonormal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
Restrictive
E/A>2 DT<160ms IVRT<60ms
↓LV relaxation ↓LV compliance ↑LA pressure
↓LV relaxation ↓LV relaxation ↓↓LV compliance ↑↑LA pressure
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Transmitral Flow
Normal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A < 0.8 DT > 200ms
IVRT > 100ms
Impaired Relaxation Pseudonormal
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
Restrictive
E/A>2 DT<160ms IVRT<60ms
↓LV relaxation ↓LV compliance ↑LA pressure
↓LV relaxation ↓LV relaxation ↓↓LV compliance ↑↑LA pressure
↓LV relaxation ↑LA pressure ↓LV compliance
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Transmitral Flow
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
PseudonormalNormal
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Transmitral Flow
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
E/A 0.8-1.5 DT 160-200ms IVRT 70-90ms
PseudonormalNormal
Circ Cardiovasc Imag 2011:4:444-455
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• Pulmonary Vein Flow
• Transmitral Flow
• Pulmonary Vein Flow
• Tissue Doppler Imaging
• Color M-mode flow propagation
Quantification
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Filling Pressures
S D
AR
S D
AR
S D
AR
Normal LVEDP Normal LAP
High LVEDP Normal LAP
High LVEDP High LAP
Continuum of diseaseNormal ↓LV relaxation ↓LV relaxation
↓LV compliance
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• Tissue Doppler Imaging
Quantification
• Transmitral Flow
• Pulmonary Vein Flow
• Tissue Doppler Imaging
• Color M-mode flow propagation
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Tissue Doppler ImagingNormal
Impaired relaxation
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Tissue Doppler ImagingNormal
Impaired relaxation
Elevated LAP:
↑ E velocity
↓ E’ velocity
↑ E/E’
Lateral E’ < 10 cm/s Septal E‘ < 8 cm/s
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• Color M-mode flow propagation
• Transmitral Flow
• Pulmonary Vein Flow
• Tissue Doppler Imaging
• Color M-mode flow propagation
Quantification
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Propagation Velocity
• Vp depends on the intraventricular pressure gradients
• Vp measures LV relaxation
• ↓LV relaxation = ↓Vp
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Outline
• What is diastolic dysfunction?
• Can we measure diastolic function?
• Is our measurement accurate?
• How do we use this information?
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Quantification
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Quantification
TTE TEE
Left lateral decubitus Supine
Breathing spontaneously Positive pressure ventilation
Awake Under general anesthesia
Post-sternotomy
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Quantification
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E’ velocity
E’≥10cm/s E’<10 cm/sec
Grade 0 normal
E/E’≤8 E/A≤0.8
DT>200ms ARdur<Adur
Grade 1 Grade 2 pseudonormal
Grade 3 restrictive
E/E=9-12 E/A=0.8-1.5
DT=160-200ms ARdur-Adur≥30ms
E/E>13 E/A≥2
DT<160ms ARdur-Adur≥30ms
ASE algorithm
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E’ velocity
E’≥10cm/s E’<10 cm/sec
Grade 0 normal
E/E’≤8 E/A≤0.8
DT>200ms ARdur<Adur
Grade 1 Grade 2 pseudonormal
Grade 3 restrictive
E/E=9-12 E/A=0.8-1.5
DT=160-200ms ARdur-Adur≥30ms
E/E>13 E/A≥2
DT<160ms ARdur-Adur≥30ms
ASE algorithm
Total CABG patients 905
62%
Normal 158
Grade 1 152
Grade 2 200
Grade 3 53
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E’ velocity
E’≥10cm/s E’<10 cm/sec
Grade 0 normal
E/E’≤8
Grade 1 Grade 2 pseudonormal
Grade 3 restrictive
E/E=9-12 E/E>13
ASE algorithm, simplified
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E’ velocity
E’≥10cm/s E’<10 cm/sec
Grade 0 normal
E/E’≤8
Grade 1 Grade 2 pseudonormal
Grade 3 restrictive
E/E=9-12 E/E>13
ASE algorithm, simplified
Total CABG patients 905
99%
Normal 158
Grade 1 309
Grade 2 267
Grade 3 161
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ASE algorithmKaplan-Meier Survival curves for MACE
Swaminathan et al, Ann Thorac Surg 2011;91:1844-51
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ASE algorithm, simplifiedKaplan-Meier Survival curves for MACE
Swaminathan et al, Ann Thorac Surg 2011;91:1844-51
012
3
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• Emphasis on reproducible and feasible measurements
• Start with clinical data/ 2D/ color flow Doppler information
• If abnormal EF, likely diastolic dysfunction
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Algorithm for diagnosis of LV diastolic dysfunction in subjects with normal LV EF
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Algorithm for estimation of LV filling pressures and grading LV diastolic function in patients with depressed LVEF and
patients with myocardial disease and normal LVEF
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Mitral Flow
E/A ≤ 0.8 + E ≤ 50 cm/sec
Normal LAP Grade I diastolic dysfunction
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Mitral Flow
E/A > 2
Elevated LAP Grade III diastolic dysfunction
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Mitral Flow
Average E/e’ > 14 TR velocity > 2.8 m/s LA volume index> 34ml/m2
E/A ≤ 0.8 + E > 50 cm/sec 0.8< E/A < 2
2/3 positive → elevated LAP grade II DD
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Outline
• What is diastolic dysfunction?
• Can we measure diastolic function?
• Is our measurement accurate?
• How do we use this information?
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Impaired stress response
• They do not tolerate atrial fibrillation well
• They do not tolerate tachycardia well
• They do not tolerate elevations in systemic blood pressure
• Ischemia results in acute worsening of diastolic dysfunction
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Diastolic dysfunction
DT>200 msE/A < 0.8
E’ < 8
Impaired Relaxation
Grade 1
E/A 0.8-1.5
E’ < 8
Pseudo-Normal
Grade 2
E/A>1.5DT<150 ms
E’ < 8
Restrictive
Grade 3
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Diastolic dysfunction
DT>200 msE/A < 0.8
E’ < 8
Impaired Relaxation
Grade 1
E/A 0.8-1.5
E’ < 8
Pseudo-Normal
Grade 2
↓ LV relaxation
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Diastolic dysfunction
E/A 0.8-1.5
E’ < 8
Pseudo-Normal
Grade 2
E/A>1.5DT<150 ms
E’ < 8
Restrictive
Grade 3
↓ LV compliance
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Decreased LV relaxation (grade 1, 2 DD)
• Require a longer filling time
• Dependent on atrial contraction
• Preload tolerant
Impaired relaxation
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Decreased LV relaxation (grade 1, 2 DD)
Anesthetic management:
• Fluid administration
• Avoid tachycardia
• Avoid hypertension
• Maintain sinus rhythm
Impaired relaxation
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Decreased LV compliance (grade 2, 3 DD)
• Stiff LV → fixed stroke volume
• Preload intolerant
• Dependent on heart rate
• Increased LVEDP → dependent on SVR
Decreased compliance
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• Mild diuresis → better LV filling
Anesthetic management
• Carefully titrate fluids
• Maintain SVR
• Avoid increase in afterload
• Avoid bradycardia
• Mild diuresis → better LV filling
Decreased LV compliance (grade 2, 3 DD)
Decreased compliance
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Decreased LV compliance (grade 2, 3 DD)
• Mild diuresis → better LV filling
LV p
ress
ure
LV volume
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Summary
• The number of patients with DHF will increase
• DD is associated with perioperative morbidity and mortality
• Knowledge of the underlying pathophysiological changes is paramount