Diastology
Patrick Collier
Andrew O. Zurick III
David Verhaert
Allan L. Klein
1. The best two-dimensional (2D) and Doppler echocardiographic finding to differentiate restrictive cardiomyopathy from constrictive pericarditis would be to evaluate:
A. Mitral inflow pattern.
B. Pulmonary venous flow pattern.
C. Atrial size.
D. Inferior vena cava dilatation.
E. Early diastolic mitral annular velocity.
View Answer
1. Answer: E. Differentiating restrictive from constrictive pericarditis by echocardiography can be challenging. A mitral medial e′ velocity ≥8 cm/s has been shown to be highly accurate in differentiating patients with constrictive pericarditis from those with restrictive cardiomyopathy, a point highlighted in the 2016 ASE/EACVI guideline document in an algorithmic form comparing constrictive pericarditis with restrictive cardiomyopathy (Figure 13-17).
In particular, the presence of a normal annular e′ velocity in a patient referred with a heart failure diagnosis should raise suspicion of pericardial constriction. The presence of grade 1 filling or absence of inferior cava dilation makes a diagnosis of constriction/restriction unlikely. Respirophasic ventricular septal shift is an echo correlate of ventricular interdependance whereby one ventricle fills at the expense of the other and is generally present in constriction.
Apart from 2D features that give clues to the differentiation of diseases, tissue Doppler imaging (TDI) can provide important specific information. In patients with restrictive cardiomyopathy, myocardial relaxation (e′) will be severely impaired, whereas patients with constriction usually have preserved mitral annular vertical excursion. Of note, the lateral annular e′ velocity could be decreased if the constrictive process involves the lateral mitral annulus. Figure 13-18A,B illustrates typical tissue Doppler tracings from a patient with constrictive pericarditis as opposed to a patient with restrictive cardiomyopathy.
 Figure 13-17. Algorithm comparing constrictive pericarditis and restrictive cardiomyopathy. Note that restriction is associated with elevated E/A ratio, short deceleration time, and decreased mitral annular velocity (<6 cm/s). Based on data from Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging. 2014;7:526-534. E/A = ratio of peak mitral flow velocity of the early filling wave over peak mitral flow velocity of the late filling wave due to atrial contraction; mitral medial e′ = tissue Doppler early diastolic mitral annular velocity; DT = deceleration time; IVRT = isovolumic relaxation time; E/e′ = ratio of peak mitral flow velocity of the early filling wave over tissue Doppler early diastolic annular velocity; PV = pulmonary vein; LAVI = left atrial volume index; SVC = superior vena cava. (From Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.) |
2. Comorbidities that do not typically confound assessment of diastolic function include:
A. Tachycardia, atrial fibrillation, recent MAZE procedure, or pulmonary vein isolation.
B. Hypertension, aortic stenosis, or pulmonary hypertension.
C. Severe mitral annular calcification, mitral stenosis, or mitral valve surgery.
D. Significant aortic or mitral regurgitation (MR).
E. Ventricular pacing, left ventricular assist device (LVAD) insertion, or cardiac transplantation.
View Answer
2. Answer: B. Diastolic function is particularly useful in left or right ventricular pressure overload where it may offer additional prognostic information. On the contrary, assessment of diastolic function may be limited by the presence of other comorbidities. For example, assessment of mitral inflow is limited in the presence of tachycardia due to E-A fusion (in patients with advanced cardiomyopathies, E-A fusion may even be seen with relatively normal heart rates [HRs]). Equally, the absence of coordinated atrial contraction in atrial fibrillation means an absent “a wave” while after the MAZE procedure or pulmonary vein isolation (PVI), atrial stunning or scar may result in an attenuated mechanical “a wave” despite the presence of an electrical “p wave.” Exclusions to assessment of diastolic function include scenarios where filling pressures are driven more by other confounding variables such as significant (>2+) mitral or aortic regurgitation or LVAD implantation. Atrial enlargement is a feature of all cardiac transplants while preset pacing parameters (such as the AV delay) can independently determine grade of diastolic function. Assessment of left ventricular filling pressures in special populations is summarized in Table 13-5.
 Figure 13-18A,B. TDI Medial Annulus. |
3. How will the pulmonary venous Doppler flow pattern immediately change in the case of left atrial stunning (e.g., after cardioversion for persistent atrial fibrillation)? S1: first velocity of systolic pulmonary venous flow; S2: second velocity of systolic pulmonary venous flow; D: diastolic velocity of pulmonary venous flow. AR: atrial reversal of pulmonary venous flow:
A. The systolic filling fraction (S1) will increase.
B. The systolic filling fraction (S2) will increase.
C. A decrease will be seen of the diastolic filling fraction (D).
D. A decrease will be seen of the systolic filling fraction, particularly S1.
E. An increase in the AR velocity will be seen.
View Answer
3. Answer: D. There are two systolic velocities (S1 and S2), mostly noticeable when there is a prolonged PR interval since S1 is related to atrial relaxation. S2 should be used to compute the ratio of peak systolic to peak diastolic velocity. S1 velocity is primarily influenced by changes in left atrial pressure and left atrial relaxation or contraction, whereas S2 is related to stroke volume and pulse wave propagation in the pulmonary arterial tree. The diastolic velocity D is influenced by changes in LV filling and compliance and changes in parallel with mitral E velocity. Pulmonary venous atrial flow reversal (AR) velocity and duration are influenced by LV late diastolic pressures, atrial preload, and left atrial contractility. Atrial fibrillation or atrial stunning will result in a blunted S wave, mainly due to a loss of S1 with a decreased systolic fraction and absence of AR velocity (Fig. 13-19).
 Figure 13-19. MVF = mitral valve flow; PVF = pulmonary venous flow. |
4. Which of the following statements are true about the pulmonary venous flow pattern?
A. Peak AR >35 cm/s suggests elevated left ventricular (LV) filling pressures.
B. The pulmonary vein S wave is related to LV relaxation.
C. The S/D ratio provides an accurate estimation of LV filling pressures in patients with preserved and reduced systolic function.
D. Pulmonary venous AR duration < mitral inflow A duration indicates an increased LV end-diastolic pressure (LVEDP).
E. Pulmonary venous flow AR can be obtained in only 50% of patients.
View Answer
4. Answer: A. AR may increase with age, but AR >35 cm/s is usually consistent with elevated LV filling pressures particularly at end diastole. The pulmonary D wave is related to LV relaxation. Young and healthy individuals can therefore exhibit large D waves indicating forceful elastic recoil of the LV rather than high left atrial pressure. The pulmonary S wave is related to LV contractility, atrial function, atrial pressure, and mitral regurgitation. Mitral and pulmonary vein inflow patterns are not very reliable for assessment of LV filling pressures in patients with an overall normal systolic function. ARdur-Adur >30 ms is, therefore, a more robust marker of elevated LVEDP in this group of patients. Pulmonary venous atrial reversal can be obtained in more than 70% of patients. A commercially available contrast injection can help enhance the Doppler tracing.
5. In patients with atrial fibrillation, LV filling pressures could be best estimated using which of the following statements?
A. E/é ≥11 correlates well with elevated pulmonary capillary wedge pressure (PCWP).
B. A short deceleration time in patients with a normal ejection fraction (EF) correlates with elevated PCWP.
C. Higher left atrial size (>34 mL/m2) will reflect chronically elevated filling pressures.
D. Peak velocity of the diastolic pulmonary venous flow will reflect atrial pressure.
E. It is impossible to estimate PCWP since there is no A wave and the variability in cycle length precludes any accurate estimation.
View Answer
5. Answer: A. Although sometimes challenging, an estimate of LV filling pressures can be obtained in patients with atrial fibrillation using the E/e′ ratio. Different studies have shown good correlations in this population between filling pressures and the E/e′ ratio (a ratio ≥11 predicting LVEDP ≥15 mm Hg), the mitral deceleration time (<150 ms in the presence of LV systolic dysfunction) or the deceleration time (not the peak velocity) of the pulmonary venous diastolic velocity (≤220 ms associated with higher filling pressures).
Table 13-5. Assessment of LV Filling Pressures in Special Populations | ||||||||||||||||||
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6. A 61-year-old male patient with a history of hypertension complains of exercise intolerance. His lung function tests are normal. His heart rate (HR) at rest is 60 beats/min. He has a normal ejection fraction, mild LV hypertrophy, and no valvular pathology. Doppler echocardiography data are included in Table 13-1. Based on this information:
A. The cause of his symptoms is unlikely cardiac. Refer him to internal medicine.
B. Consider a coronary angiogram. Dyspnea is sometimes a symptom of underlying coronary artery disease.
C. We can conclude that the patient has elevated filling pressures and should be given a diuretic.
D. Consider a diastolic stress test.
E. Brain natriuretic peptide (BNP) is 500 pg/mL.
Table 13-1 | ||||||||||||
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View Answer
6. Answer: D. Figure 13-20 is an algorithm to help decide upon the absence or presence of diastolic dysfunction. Figure 13-21 is an algorithm that goes a step further to help decide upon the grade of diastolic dysfunction present. Table 13-6 shows typical diastology parameter values in normal diastology and in each grade of diastolic dysfunction. This patient has evidence of grade 1 diastolic function with normal to low LV filling pressures at rest with a BNP of 100 pg/mL; however, it can be useful to evaluate LV filling pressure not only at rest but with exercise using a supine bike or treadmill as well. The E/e′ ratio will remain unchanged in subjects with normal myocardial relaxation because both E and e′ velocities increase proportionally. However, in patients with impaired myocardial relaxation, the increase in e′ with exercise is much less than that of mitral E velocity such that the E/e′ ratio increases. Besides filling pressures, stress echocardiography also allows evaluation of systolic function in patients with coronary artery disease, of MR severity in patients with mitral valve disease, and of pulmonary artery pressures.
7. The patient in Question 6 above undergoes stress testing with a supine bike protocol. Doppler echocardiography is performed 2 minutes after peak exercise (HR = 136 beats/min, ˜85% maximum predicted heart rate [MPHR]). Findings are included in Table 13-2. Which statement is true?
A. This patient has stage 1 diastolic dysfunction with exercise.
B. These findings raise concern for pulmonary embolism.
C. More information is needed to make any definite statement concerning the patient’s diastolic function.
D. These are normal values for this patient’s age and gender, given the fact that he just underwent stress testing and his HR is increased.
E. The patient has elevated LV filling pressures with exercise.
Table 13-2 | ||||||||||||
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View Answer
7. Answer: E. Estimation of LV filling pressure from the ratio of transmitral and annular velocities (E/e′) after exercise echocardiography may identify diastolic dysfunction in patients who complain of exertional dyspnea. Elevated exercise E/e′ (septal >14.5) is associated with cardiovascular hospitalization, independent of and incremental to inducible ischemia. Although the clinical implications of this finding have not yet been fully elucidated, one could consider starting therapy with a &bgr;-blocker, thereby preventing exercise-induced tachycardia and maximizing the diastolic filling period in these patients.
8. A dialysis patient undergoes cardiac catheterization. His ventricular angiogram shows normal systolic function. The pulmonary capillary wedge tracing shows significant v-waves. However, the ventriculogram and a carefully performed echocardiogram do not show significant MR. What is the most likely explanation?
A. MR can be very dynamic. In addition, there could be a very eccentric jet.
B. Grade 3 diastolic dysfunction due to LV hypertrophy and volume overload.
C. Atrial rhythm disturbance.
D. Loss of left atrial reservoir function.
E. Congenital anomaly.
View Answer
8. Answer: D. The presence of v-waves in absence of significant MR in this type of patient suggests severely decreased left atrial compliance. Classically, the left atrium has been ascribed to three different functions throughout the cardiac cycle: (1) reservoir function during ventricular systole and isovolumic relaxation (reflected by the pulmonary venous S wave); (2) conduit phase from the moment the mitral valve opens until onset of atrial contraction (reflected by the pulmonary venous D wave); and (3) contractile phase during atrial systole (reflected by the pulmonary venous AR wave and the mitral A wave). LA enlargement may begin as an adaptive response with an initial increase in LA volume, and LA emptying fraction that serves to maintain LV stroke volume and cardiac output. LA enlargement may be considered pathologic when the optimal Frank-Starling relationship is exceeded, resulting in decreased LA compliance, reduced reservoir and contractile pump functions, and eventually increased incidence of atrial arrhythmias.
 Figure 13-20. Algorithm for diagnosis of left ventricular diastolic dysfunction in subjects with normal LVEF. E/e′ = ratio of peak mitral flow velocity of the early filling wave over tissue Doppler early diastolic annular velocity; e′ = tissue Doppler early diastolic annular velocity; TR = tricuspid regurgitation; LAVol Index = = left atrial volume index; LVEF = left ventricular ejection fraction. (From Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.) Note this diagram is used in patients with normal EF that do not have obvious pathology such as CAD with wall motion abnormalities, left ventricular hypertrophy or cardiomyopathy. It also makes it more specific to call abnormal diastolic function since 3/4 criteria have to be satisfied. It applies to someone who may presents with palpitations and no other cardiac pathology. An E/A <1 no longer means diastolic dysfunction. If only 50% of the criteria are positive then it is called indeterminate. |
9. When performing pulsed wave Doppler imaging in the apical 4-chamber view to acquire mitral annular velocities, which of the following is true?
A. The sample volume should be positioned at or 1 cm within the septal and lateral insertion sites of the mitral leaflets.
B. The sample volume should be small enough (usually 2-3 mm) to evaluate the longitudinal excursion of the mitral annulus in both systole and diastole.
C. In general, the velocity scale should be set at ˜30 cm/s above and below the zero-velocity baseline.
D. Angulation up to 40 degrees between the ultrasound beam and the plane of cardiac motion is acceptable.
E. Spectral recordings are ideally obtained during inspiration and measurements should reflect the average of three consecutive cardiac cycles.
View Answer
9. Answer: A. The sample volume should be positioned at or 1 cm within the septal and lateral insertion sites of the mitral leaflets and adjusted as necessary (usually 5-10 mm) to cover the longitudinal excursion of the mitral annulus in both systole and diastole. This contrasts with a sample volume size of 1-3 mm at mitral valve tips for optimal pulsed wave Doppler assessment of mitral valve inflow, and a sample volume of 2-3 mm placed >0.5 cm into the pulmonary vein for optimal recording of pulmonary vein flow. Attention should be directed to Doppler spectral gain settings because annular velocities have high signal amplitude. Most current ultrasound systems have tissue Doppler presets for the proper velocity scale and Doppler wall filter settings to display the annular velocities. In general, the velocity scale should be set at ˜20 cm/s above and below the zero-velocity baseline, although lower settings may be needed when there is severe LV dysfunction, and annular velocities are markedly reduced (scale set to 10-15 cm/s). Minimal angulation (<20 degrees) should be present between the ultrasound beam and the plane of cardiac motion.
10. LV untwisting:
A. Is independent of elastic recoil.
B. Begins in early diastole.
C. Is predominantly generated by basal back-rotation of helically orientated LV muscle fibers.
D. Is mainly responsible for the late diastolic intraventricular pressure gradient.
E. Is a major determinant of the isovolumic relaxation time (IVRT).
View Answer
10. Answer: E. Highlighting the interdependence of systolic and diastolic events, LV untwisting (especially apical back-rotation) is a measurable manifestation of elastic recoil. The energy generated by helically orientated fibers and stored in the heart’s elastic tissue during systole is released before end-systole, creating early diastolic suction, filling the LV for the next cardiac cycle (Fig. 13-22). Elastic recoil, the driving force of early (and not late) diastolic filling, acts by rapidly lowering the intraventricular pressure to permit ventricular filling at low left atrial pressures. If elastic recoil is disturbed, ventricular filling can be achieved only by increasing the left atrial pressure. A decrease in recoil forces will increase the time needed to lower the ventricular pressure below the level of the left atrial pressure, resulting in an increase (not a decrease) in the IVRT.
11. Which statement is false? First-degree AV block:
A. May have the same effect on the mitral inflow pattern as sinus tachycardia.
B. May prolong isovolumetric contraction time.
C. May cause E-A fusion and hamper evaluation of LV diastolic function when only pulsed Doppler interrogation of the mitral inflow is performed.
D. May lead to diastolic MR in the presence of restrictive filling.
E. Will decrease the LV diastolic filling period. Therefore, it may have an adverse effect on filling pressures and cardiac output in patients with severe systolic dysfunction.
View Answer
11. Answer: B. First-degree AV block may lead to fusion of the E and A wave and therefore has a similar effect on mitral inflow as sinus tachycardia. Firstdegree AV block results in delayed onset of ventricular contraction relative to atrial contraction but typically would not affect isovolumetric contraction (the time between mitral valve closure and aortic valve opening). A fused mitral inflow pattern can make an accurate interpretation of diastolic function impossible if no other information is available. In the presence of severely elevated LV filling pressures, first-degree AV block may lead to diastolic MR, as atrial contraction is not immediately followed by ventricular contraction, which is mandatory for complete mitral valve closure. Under these conditions, the atrioventricular pressure gradient may temporarily reverse during atrial relaxation, leading to diastolic MR. Fusion of E and A waves (leading to a decreased LV diastolic filling period) and diastolic MR may, in turn, have an adverse effect on cardiac output and filling pressures in patients with severe systolic dysfunction. Cardiac resynchronization therapy with restoration of optimal atrioventricular mechanical timing may improve LV filling in these patients. See Figure 13-23A,B for an illustration of the impact of PR prolongation on the mitral inflow pattern.
 Figure 13-21. Algorithm for estimation of left ventricular (LV) filling pressures and grading LV diastolic function in patients with depressed LVEF and in patients with myocardial disease and normal LVEF. E/A = ratio of peak mitral flow velocity of the early filling wave over peak mitral flow velocity of the late filling wave due to atrial contraction; E/e′ = ratio of peak mitral flow velocity of the early filling wave over tissue Doppler early diastolic annular velocity; TR = tricuspid regurgitation; LAVol Index = left atrial volume index; LAP = left atrial pressure; LVEF = left ventricular ejection fraction; CAD = coronary artery disease; pulmonary vein S/D = pulmonary vein systolic flow over pulmonary vein diastolic flow. (From Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.) Note this diagram applies to patients with depressed EF or normal EF and diastolic dysfunction as noted from the first diagram (Figure 13-20). This would usually apply to a patient with CAD and wall motion abnormalities, left ventricular hypertrophy or cardiomyopathy. Also note for patients with a depressed EF, a pulmonary vein S/D ratio <1 may suggest elevated LAP. |
Table 13-6. LV Relaxation, Filling Pressures, and 2D/Doppler Findings According to LV Diastolic Function | ||||||||||||||||||||||||||||||||||||||||
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 Figure 13-22 |
12. Color Doppler M-mode (CMM) echocardiography provides information on flow propagation (Vp) which is unique in that it is relatively independent of which of the following?
A. Cardiac output.
B. LV compliance.
C. Left atrial size.
D. Loading conditions.
E. HR.
View Answer
12. Answer: D. CMM echocardiography provides a spatiotemporal map of blood distribution within the heart with a typical temporal resolution of 5 ms, a spatial resolution of 300 microns, and a velocity resolution of 3 cm/s. Assessment of diastolic flow propagation has offered novel information about LV filling dynamics. Vp is unique in that it appears to be relatively independent of loading conditions and therefore may overcome one of the main limitations of Doppler-based techniques. The earliest CMM velocities often occur during isovolumic relaxation. After the mitral valve opens, there is a rapid initial component (phase 1), often followed by a slower component (phase 2). Finally, the last component in late diastole is associated with atrial contraction. See Figure 13-24A,B for examples of CMM and determination of the Vp slope (normal Vp is ≥50 cm/s) (white line). In clinical practice, however, Vp has limited additive utility in that its predictive ability regarding filling pressures is predominantly in patients with systolic dysfunction (where E/Vp ≥2.5 predicts PCWP >15 mm Hg with reasonable accuracy), a scenario where there are often multiple echocardiographic signs of impaired LV diastolic function already present. Often the CMM pattern provides a preview of the pulsed wave Doppler mitral inflow pattern, i.e. the higher wave will have an increased aliasing velocity. In Figure 13-24A this will be the E wave.
 Figure 13-23. A,B: E-A fusion. Mitral inflow. |
 Figure 13-24 |
 Figure 13-24B |
13. What is the strongest determinant of mitral deceleration time?
A. Left atrial mechanical function.
B. LV operating stiffness.
C. Left ventricular end-diastolic pressure (LVEDP).
D. Ejection fraction.
E. Left atrial reservoir function.
View Answer
13. Answer: B. E-wave deceleration time is mostly influenced by the operating stiffness of the LV. Changes in LV compliance (i.e., the relationship between LV pressure and volume) and also changes in ventricular relaxation or early (instead of late) diastolic ventricular pressures will affect the deceleration time. Left atrial mechanical function and ejection fraction are not or weakly and indirectly correlated with deceleration time (Fig. 13-25).
14. In patients with dilated cardiomyopathy, pulsed wave Doppler mitral flow velocity variables and filling patterns correlate with which of the following?
A. Cardiac filling pressures and functional class, but not prognosis.
B. Prognosis, but not filling pressures or functional class.
C. Cardiac filling pressures, functional class, and prognosis, but less so than does LV ejection fraction.
D. Cardiac filling pressures, functional class, and prognosis better than does LV ejection fraction.
E. Cardiac filling pressures, functional class, and prognosis, but to a lesser degree than in patients with LV ejection fraction >50%.
View Answer
14. Answer: D. In patients with dilated cardiomyopathies, pulsed wave Doppler mitral flow velocity variables and filling patterns correlate better with cardiac filling pressures, functional class, and prognosis than with LV ejection fraction. Patients with impaired LV relaxation are the least symptomatic, while a short IVRT, short mitral deceleration time and increased E to A wave velocity ratio characterize advanced diastolic dysfunction, increased left atrial pressure, and a worse functional class. A restrictive filling pattern is associated with a poor prognosis, especially if it persists after preload reduction. Likewise, a pseudonormal or restrictive filling pattern associated with acute myocardial infarction indicates an increased risk of heart failure, unfavorable LV remodeling, and increased CV mortality, irrespective of ejection fraction (Fig. 13-26). In addition to dilated cardiomyopathy, deceleration time has also been shown to be an important predictor of survival in restrictive cardiomyopathy (e.g., cardiac amyloidosis).
15. Which statement is most correct with respect to the application of the Valsalva maneuver in the assessment of diastolic function?
A. The lack of reversibility in E/A ratio with Valsalva in patients with advanced diastolic dysfunction indicates irreversible restrictive physiology and implies a very poor prognosis.
B. The Valsalva maneuver is a sensitive and specific way to differentiate normal from stage 1 diastolic function.
C. The Valsalva maneuver should be used in every patient when assessing diastolic function.
D. In cardiac patients, a decrease of ≥50% in E/A ratio is highly specific for increased LV filling pressures.
View Answer
15. Answer: D. In cardiac patients, a decrease of ≥50% in E/A ratio with application of the Valsalva maneuver is highly specific for increased LV filling pressure. However, a smaller magnitude of change does not always indicate normal diastolic function. One major limitation of the Valsalva maneuver is that not everyone is able to perform this maneuver adequately and it is not standardized. The Valsalva maneuver is performed by forceful expiration (about 40 mm Hg) against a closed nose and mouth. A decrease of 20 cm/s in mitral peak E velocity is usually considered an adequate effort in patients without restrictive filling. Lack of reversibility with Valsalva is imperfect as an indicator that the diastolic filling pattern is irreversible. In a busy clinical laboratory, the Valsalva maneuver can be reserved for patients in whom diastolic function assessment is not clear after mitral inflow and annulus velocity measurements. The Valsalva is obviously of little use in patients with stage 1 diastolic dysfunction but is useful to differentiate stage 2 diastolic function from normal (Fig. 13-27).
16. Figure 13-1 represents three different pulsed wave Doppler recordings of mitral inflow velocity in a 63-year-old man with a diagnosis of cardiac amyloidosis. The Doppler recordings were acquired at different stages in the progression of his disease. Atrial fibrillation is a common complication in these patients. At what stage in his disease would sudden onset of atrial fibrillation most likely cause a marked increase in symptoms?
A. Around the time of the Doppler recording represented in Figure 13-1A.
B. Around the time of the Doppler recording represented in Figure 13-1B.
C. Around the time of the Doppler recording represented in Figure 13-1C.
D. No matter how advanced the diastolic dysfunction, atrial fibrillation is always highly symptomatic in cardiac amyloidosis.
E. More information is needed to answer this question.
 Figure 13-1A |
 Figure 13-1B |
 Figure 13-1C |
View Answer
16. Answer: A. According to the grade of the disease progression, a spectrum of filling abnormalities can be seen in cardiac amyloidosis that varies from delayed relaxation (Fig. 13-1A) to pseudonormal (Fig. 13-1B) to restrictive filling (Fig. 13-1C). Panels B and C in Fig. 13-1 represent these more advanced stages in the disease process where the operating stiffness of the LV becomes increasingly high due to a gradual loss in LV compliance. This is reflected in a short deceleration time (Fig. 13-1C). In spite of the high left atrial pressure (suggested by a high E-wave velocity), atrial contraction itself hardly contributes to LV filling in the most advanced stages of diastolic dysfunction, as suggested by the diminutive A wave in restrictive filling. In contrast, although patients with delayed relaxation may be asymptomatic at rest or with mild exercise, their LV has become more dependent on atrial contraction (low E/A ratio). As such, these patients are most likely to feel a change in symptoms with sudden onset of atrial fibrillation due to loss of the atrial kick.
 Figure 13-25. (From Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: part I: diagnosis, prognosis, and measurements of diastolic function. Circulation. 2002;105:1387-1393.) |
 Figure 13-26. Event-free survival in patients with restrictive and nonrestrictive filling patterns. (From Meta-Analysis Research Group in Echocardiography [MeRGE] AMI Collaborators. Independent prognostic importance of a restrictive left ventricular filling pattern after myocardial infarction: an individual patient meta-analysis: Meta-Analysis Research Group in Echocardiography Acute Myocardial Infarction. Circulation. 2008;117:2591-2598, with permission.) |
 Figure 13-27 |
17. Based on Figure 13-2, what could you say about the underlying diastolic function in this patient?
A. The transmitral gradient suddenly increases in mid-diastole because of a decrease in LV compliance.
B. This type of inflow pattern is sometimes seen in young individuals and can be explained by vigorous LV relaxation.
C. This finding represents a very early stage of diastolic dysfunction.
D. This patient has markedly delayed relaxation. Preload reduction will reveal stage 1 diastolic dysfunction.
E. The Doppler tracing is suggestive of atrial mechanical dysfunction, possibly due to a recent episode of atrial tachyarrhythmia.
 Figure 13-2 |
View Answer
17. Answer: D. The Doppler tracing in Figure 13-2 shows transmitral flow during diastasis, often referred to as a mitral “L-wave.” The result is a triphasic mitral inflow pattern that can be seen in patients without structural heart disease—particularly if the HR is relatively slow. It represents an advanced stage of diastolic dysfunction that is characterized by elevated filling pressures and loss of compliance (notice the high peak of early rapid filling and the short initial deceleration time) in combination with very delayed relaxation. The markedly prolonged relaxation, although not immediately obvious, results in a sudden decrease in LV diastolic pressure during mid-diastole, allowing further LV filling during middiastole. This explains the L wave. Preload reduction will decrease left atrial pressure as well as the operating stiffness of the LV and may unmask the underlying relaxation abnormality.
18. A 35-year-old male athlete complains of exercise intolerance. An echocardiogram shows a normal left ventricular (LV) systolic function (ejection fraction = 60%) and no valvular dysfunction. Based on the Doppler recording of his mitral inflow pattern in Figure 13-3, which additional echocardiographic parameter is most helpful in confirming whether his symptoms should be attributed to elevated filling pressure?
A. Left atrial volume index of 34 mL/m2.
B. The presence of mild concentric LV hypertrophy.
C. Tissue Doppler early diastolic velocity of the mitral annulus of 6 cm/s.
D. Prolonged diastolic filling time.
E. Indexed LV end-diastolic volume of 80 mL/m2.
 Figure 13-3 |
View Answer
18. Answer: C. Athletes not uncommonly have resting bradycardia, mild concentric hypertrophy, and/or mild chamber dilation due to increased pressure and volume loads related to sustained increases in activity. An early diastolic velocity of the mitral annulus derived by tissue Doppler echocardiography (e′) <8 cm/s is, however, a markedly abnormal finding especially in a 35-year-old person.
Combinations of other findings that suggest elevated filling pressures are summarized in an algorithmic form in Figure 13-21.
19. A patient with severe LV dysfunction due to long-standing untreated hypertension is referred for initiation of medical therapy. Based on the Doppler findings in Figure 13-4A,B, one should be extra cautious when starting what medical therapy?
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