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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Diastolic Dysfunction or Aging?
Case#: 33
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
79 yo female with a history of CAD, hypothyroidism, HTN.
 She has symptoms of CAD and SOB.
Cardiac Cath showed: LMCA 80%, LAD 90%, Cx 90%, RCA 70%. The LVEF was Normal.
Her current medications are Carvedilol, HCTZ, and Levothyroxine.
Her prior operation was a vein stripping.

After reviewing the TEE exam please consider the following questions:

What diastolic measures are independent of loading (LAP) conditions?
Is her LAP high, normal, or low?
What are the age related changes of LVI (E,A,DT,IVRT), PVn, TDE, and CMMVp?
What are the changes with Diastolic Dysfunction?
Does this patient have aging or diastolic dysfunction changes of her TEE exam?
Does she have Diastolic Dysfunction or is the diastology consistent with Aging?


Case Discussion/CME Questions
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.

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