AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.
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The patient underwent a CABG w/ECC w/EVH.
LIMA -> LAD, RIMA -> RCA, Left Radial -> OM1
The TEE showed a LVEF of 60% with no significant valvular abnormalities.
The E=A at 60 cm/sec. The PVO showed S>D at 44 and 31 cm/sec. The A was 8 cm/sec.
The IVRT was 134 msec. The DT was 162 msec.
The TDI of lateral wall showed an S` of 5.8, E` of 6.7, A` of 10 cm/sec. T
he CMMVp was 56 cm/sec.
An IASA was present.
All of the diastolic parameters are affected by loading conditions except the TDE of the lateral mitral valve annulus. The E, A, S, D, pulmonary vein A, IVRT, DT, and CMMVp are all affected by preload.
E/Vp has been used to indicate the loading conditions but, in patients with normal chamber sizes and normal ejection fractions, the Vp may not be accurate. There are articles of abnormal filling pressures but a normal Vp in patients with a normal LVEF and normal volumes. Also, Vp can rise with increasing preload in patients with normal OR abnormal LVEFs.
The E/E' ratio can be used to calculate the preload but, agin, it is limited where patients have a normal LVEF. The E/E` ratio showed the best correlation with LVEF < 50%.
The DT can be used to calculate the preload. Using DT, the PCWP is less than 10 mmHg.
Age related changes of the pulmonary vein Doppler occur as patients age.
When they are young the D is greater than S wave.
At about 50 years old the S and D wave equalize.
Over 50-60 years old the he S exceeds the D wave.
The velocities of the S, D and A wave ALL increase with age.
The LVI E is greater than the A when the patient is young.
At about 60 y.o. the E wave equalizes with the A wave.
After 60 years old the E wave is less than the A but just barely (they are essentially equal).
The E/A ratio is > 1 when young but E/A ratio = 1 when the patient is 70 yrs old and older.
The DT becomes shorter (182->177) when aging from young to middle age then lengthens (214) as we become older.
The IVRT increases as we age (71->92)
As we age the S` wave decreases slightly 11.5->10.5, the E wave decreases significantly
from 19.8 -> 12.9. The A wave increases from 10.4 -> 13.5.
With CMMVp the Vp decreases with age from 77-> 43 cm/sec
The pattern with diastolic dysfunction depends upon the filling pressure.
Initial diastolic dysfunction parameters show an E/A < 1, an E`/A` < 1, and CMMVp < 50 cm/sec
and a prolonged DT and IVRT and the S/D is > 1. As the filling pressure increase, LAE is present and
the E/A > 1, the E`/A` approaches 1 as both values decrease, the CMMVp becomes < 35 cm/sec
IVRT and DT normalize and the S/D < 1.
This patient has some parameters consistent with aging and some parameters consistent with diastolic dysfunction. As patients age the ventricle becomes less compliant, so aging is really a pseudonym for decreased compliance in this case. Given that most of the preload parameters were normal (E,A, E/A, S,D, S/D, Vp, DT) and a few were abnormal (IVRT, E`,A`,E`/A`) this patient has mostly age related changes to her myocardium rather than diastolic dysfunction changes to her myocardium.
|Please answer the following questions correctly to obtain your CME.|
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