1. Assessment of LV Diastolic Function by
ECHO
Dr Sanchna Dev S
Dept of Cardiology
TDMC
2. Overview
Introduction
Determinants of diastolic function.
Conventional echo parameters
Echo findings supporting the presence of diastolic dysfunction
New technologies for assessment
Algorithms
Assessment in specific groups
3. Introduction
Diastole –time interval between AV closure and MV closure.
Comprises 4 phases
1. ISOVOLUMIC RELAXATION
2. RAPID FILLING
3. SLOW FILLING (DIASTASIS)
4. ATRIAL CONTRACTION
NORMAL DIASTOLIC FUNCTION – ability of the LV to fill adequately to provide a
normal stroke volume at normal LVFP both at rest and during excercise
4. Physiology
Key determinants of the driving pressures between LA and LV and of LV filling :
1. LV RELAXATION
2. LV COMPLIANCE
3. LA CONTRACTION
In young healthy individuals- most filling occurs in early diastole ( rapid filling
phase)
With impaired relaxation and compliance , filling progressively shifts to late
diastole —> atrial contraction to CO contribution increases ( 20 % to 40%)
5. Ventricular untwisting ( apical clockwise rotation) —mainly
responsible for early diastolic filling- begins in late systole and
extends into first third of diastole
Precedes diastolic lengthening and expansion of myocardial fibre
Responsible for early LV base to apex pressure gradients – diastolic
suction —> fall in LV pressure —> rapid filling phase
LVDD –usually the result of abnormal LV relaxation with or without
reduced restoring forces ( diastolic suction ) and inc LV chamber
stiffness
6. Invasive evaluation of LV diastolic
function
Cardiac catheterisation - gold standard - demonstrating
abnormalities of LV relaxation , compliance and filling —by direct
measurement of LV relaxation time constant, stiffness modulus and
LVFP
“LV filling pressures” –indiscriminately used w.r.t. any of the
following invasive measurements :
1. Mean PCWP >12mmHg
2. Mean LAP
3. LV pre-A pressure
4. Mean LV diastolic pressure
5. LV EDP >16 mmHg
9. Determination of LV Diastolic function
Ventricular relaxation and compliance-Haemodynamic load (afterload)
Synchrony
Cellular mechanisms
LA volume and function
Heart rate
Pericardium.
Derangement of any of the above will lead to abnormal filling pressures and diastolic
dysfunction.
10. Echo Diagnosis Of Diastolic Function
Aptly described as non invasive “Swan ganz catheterization”
2D
M Mode.
Doppler- PW, CW and TDI
Newer modalities like Speckle tracking echocardiography
11. Mitral inflow parameters
Pulmonary Venous flow parameters
Color M mode echo
Tissue Doppler echo
Conventional Echocardiographic parameters
of diastolic function
12. Mitral Inflow parameters
Acquisition –
1. Apical four-chamber with color flow imaging for optimal alignment of PW Doppler with
bloodflow.
2. PW Doppler sample volume(1–3mm axial size)between mitral leaflet tips.
Parameters
MV peak E velocity
MV peak A velocity
MV E/A
MV E DT (msec) –time interval from peak E wave along the slope of LV filling extrapolated to
14. M E/A
Advantages
1. Feasible & reproducible
2. DCM- filling patterns correlate
better with LVFP , FC and
prognosis than LVEF
3. Normal EF- restrictive filling +LA
dilatation a/w poor prognosis
Disadvantages
1. U shaped relation – diff normal
from abnormal
2. Not applicable in AF/ Atrial
flutter
3. Age dependent (decreases with
aging)
MITRAL EDT
Advantages
1. Feasible & reproducible
2. Short EDT in reduced LVEF ~
increased LVFP with high
accuracy in both SR and in AF
Disadvantages
1. EDT does not relate to LVEDP
when LVEF is normal
2. Not applicable in atrial flutter
3. Age dependent ( increases with
aging)
15. Loading conditions and aging are important factors that influence
mitral inflow parameters
The load dependency of mitral inflow parameters can be overcome
by performing Valsalva maneuver
A decrease in E/A ratio of ≥50% during valsalva is highly specific
for increased LVFP
Mitral L velocity
19. Pulmonary Venous Flow parameters
Acquisition –
1. Apical four-chamber with color flow imaging for optimal alignment of PW Doppler with
bloodflow.
2. sample volume(1–3mm axial size) placed at 1-2 cm depth into right upper PV
Parameters
Normal PV flow has two forward waves S (systolic) and D (diastolic) and a reversal wave (Ar) –at
the time of atrial contraction
In normal subjects the S/D is >1 and the Ar wave is usually small
22. As LV compliance decreases and LAP increases – there’s blunting of S
wave and a decrease in the systolic filling fraction.
(The systolic filling fraction = systolic VTI /Total forward flow VTI)
D wave becomes more prominent with shortened deceleration
time
Ar duration and velocity increases
(Ar 35 cm/s suggest increased LVEDP)
≥
Also influenced by loading conditions and ageing
23. Advantages
Reduced S velocity,
S/D ratio <1 ,
systolic filling fraction < 40%
—> INCREASED LAP in pts with
reduced LVEF
D wave deceleration time (DDT)
can be used to estimate LAP in AF
(DDT >220 msec has excellent
accuracy in predicting normal PCWP
in pts with AF)
Disadvantages
Feasibility of recording PV inflow
The relationship between PV
systolic fraction and LAP has
limited accuracy in pts with
normal EF, AF,MV disease or HCM
24. Ar -A duration
The PV Ar > mitral A duration
by >30 msec indicates an
increased LVEDP
Independent of age and EF
Accurate in pts with MR and
HCM
• Feasibility
• Not applicable in pts with AF
• Difficult to interpret in pts with
sinus tachycardia or first degree
AV block with E and A fusion
26. IVRT
Acquisition –
1. Anteriorly angulated A4C with 3–5-mm sample volume midway
between aortic and mitral valves
2. Using CW doppler to simultaneously display end of aortic ejection
and onset of mitral inflow
Normal IVRT is 90-100ms .
IVRT prolongation (>110ms) is an early manifestation of
impaired LV relaxation
Short IVRT (<60 ms) indicates that mean LAP is elevated
27. Advantages
Feasible, reproducible
Can be used in combination with
other parameters viz. mitral
inflow parameters in HFrEF
Combination with LVESP to
estimate the time constant of LV
relaxation
Disadvantages
IVRT duration affected by heart
rate and arterial pressure
More challenging to interpret in
tachycardia
Results differ based on using CW
or PW Doppler for acquisition
28. Colour M-Mode Echo
Acquisition –
1. A4C with color flow imaging for M mode cursor position
Normally pts in sinus rhythm have 2 waves of color flow in diastole –
The first E wave – from mitral annulus to apex ( represents early LV filling)
Second A wave – does not exceed middle portion of LV ( corresponds to atrial
contraction)
2. Slope of inflow from MV plane into the LV chamber during early diastole at 4 cm distance
Flow propagation velocity (Vp) of the E wave
Vp >50 cm/s is considered normal.
Semi quantitative marker of LV diastolic dysfunction- progressively decreases with LVDD
and does not undergo the phenomenon of pseudonormalisation
30. Advantages
Vp is reliable in patients with
depressed LVEF
E/Vp 2.5
≥ predicts PCWP > 15 mm Hg
with reasonable accuracy in patients
with depressed LVEF
Disadvantages
Prediction of LV filling pressures
in patients with normal Ef’s
should be with caution as they
can have misleadingly normal
Vp
Vp is not currently
recommended as a first line
parameter for LVDD
low reproducibility
31. Tissue Doppler echo
PW tissue Doppler imaging (TDI) allows assessment of diastolic
function by measuring the peak diastolic velocities of the mitral
annulus
Acquisition - Apical 4C view
Primary measurements include systolic (S), early diastolic, and late
diastolic velocities.
Early diastolic annular velocity has been expressed as Ea, Em, E´, or e
´, and the late diastolic velocity as Aa, Am, A´, or a´.
33. Parameters
1. e´ septal and e´ lateral diastolic velocities
2. Time interval between QRS complex- e´ onset time is prolonged in
impaired LV relaxation.
3. [QRS-E]- [QRS-e’]=TE-e´ (Time interval between peak of R wave in QRS
complex and onset of mitral E velocity is subtracted from time interval
between QRS complex and onset of e’ velocity)
4. Annular e´/a´
5. Doppler E/e´ ratio is helpful in estimation of filling pressures and LV
34. Septal e´ velocity < lateral e´ velocity & septal E/ e´ > lateral E/ e´ .
With age, e´ velocity decreases, whereas a´ velocity and the E/e´ ratio increase
Septal E/e´ <8 is usually associated with normal LV filling pressures.
Septal E/e´ >15 is associated with increased filling pressures.
IVRT/TE-e´ ratio <2 has reasonable accuracy in identifying patients with increased LV filling
pressures
Limitations
Regional dysfunction in sampled segments
E´ may be decreased in annular calcification, surgical rings, mitral stenosis, and prosthetic mitral
36. Echo findings supporting the presence of
diastolic dysfunction
Pathological LV hypertrophy
LA dilatation
Pulm HTN
37. LV Hypertrophy
Concentric hypertrophy or remodeling can be observed in Diastolic HF.
Eccentric LV hypertrophy in depressed Efs.
LV mass best measured by 3D echo but in 2D echo at least LV thickness should be measured.
LV wall thickness should be measured to arrive conclusions on LV diastolic function.
Relative wall thickness PW+IVS/LVID( diastole)
Relative wall thickness 0.42 used as threshold for pathologic LVH
≥
LV mass index >95 g/m2 in females and > 115 g/m2 in males
38. LA Volume
Apical 4-chamber and 2-chamber views .
Signifies cumulative effect of increased filling pressures.
Normal- 16-34 ml/m2
LA volume index >34 mL/m2
is an independent predictor of death, heart failure, atrial fibrillation,
and ischemic stroke in diastolic dysfunction.
False results- Bradycardia, anemia and other high-output states, atrial flutter or fibrillation, and
significant mitral valve disease.
40. Pulmonary HTN
Symptomatic Diastolic dysfunction assoc Increased pulmonary artery (PA) pressures.
Peak velocity of the tricuspid regurgitation (TR) jet by continuous-wave (CW) Doppler together
with systolic right atrial (RA) pressure are used to derive PA systolic pressure.
PASP = 4 X TR (V)2
+ RAP
PADP = 4 X PR (V)2
+ RAP
PA systolic pressure may be used as a surrogate for measuring LVFP
PA diastolic pressure may be used as a surrogate for measuring mean pulmonary wedge
pressure.
43. DIASTOLIC STRESS TEST
Detect reduced LV systolic and/or diastolic reserve capacity in the setting of diastolic dysfunction
Normal subjects :Increase stroke volume without significantly increasing filling pressures.
DD-Cardiac output achieved at the expense of increased LV filling pressures.
Indicated when resting echocardiography does not explain the symptoms of heart failure or
dyspnoea, especially with exertion.
Most appropriate patient population for diastolic exercise testing is the group of patients
with grade 1 diastolic dysfunction, which indicates delayed myocardial relaxation and
normal LA mean pressure at rest.
44. Stress test is considered abnormal when all of the following
conditions are met :
1. Averaged E/e’ >14
2. Septal E/e’ > 15
3. TR peak velocity >2.8 m/s
4. Septal e’ velocity < 7 cm/s
45. LV strain
Strain is most often expressed as a percentage or fractional strain.
Measured by 2D 3D or 4D speckle-tracking echocardiography
Values <16% -definitely abnormal
Global myocardial strain rate during the iso volumetric relaxation period (by speckle tracking) and
mitral E velocity/global myocardial strain rate ratio predicted LV filling pressure in patients in
whom the E/e´ ratio was inconclusive and was more accurate than E/e´.
46. LV global longitudinal diastolic strain rate measurements during the isovolumic relaxation period
and during early diastole by STE have a significant association with the time constant of LV
relaxation (t).
LV untwisting rate is another parameter that can be used as a surrogate of LV relaxation.
LA systolic strain can be combined with invasive and non invasive measurements of LAP to
estimate LA stiffness.
53. LV filling pressure in special population
HCM with severe MR- Ar‑A duration 30 ms and peak TR jet velocity 2.8 m/s.
≥
AF- short DT (130 ms) , E/e’ and IVRT <65ms , PASP, E/Vp, PV DT <220 ms.
Av block and pacing- Peak velocity of TR >2.8 m/s, E/e’ not reliable.
Aortic stenosis and regurgitation -Average E/e’ ratio >14 ,Peak velocity of TR >2.8 m/s.
MS, MR and MAC- IVRT , IVRT/TE‑e’ ratio,E/e’ not reliable.
Post heart transplantation-peak velocity of TR is only helpful parameter in evaluating mean LAP
provided pulmonary causes are excluded to detect graft rejection.
54. Conclusion
Diastole is a complex, energy-dependent process.
Echo indices of diastolic function include transmitral Doppler inflow, TD velocities, pulmonary
venous Doppler study, and Color M-mode propagation velocity.
Diastolic dysfunction is a measurable, step-wise progression from normal to irreversible.
Ongoing research
57. LAVI more than what value is an independent predictor of
mortality in death in diastolic dysfn
24 mL/m2
34 mL/m2
44 mL/m2
54 mL/m2
Ans: 34 mL/m2
58. All of the following signifies grade IV Diastolic dysfunction all except
DT- 120 msec.
E/é -14
D>S and Ar-A=24
Vp< 45
Ans: D>S and Ar-A=24
59. All the following are true except
Diastolic stress test is done to detect reduced LV systolic and/or diastolic reserve capacity in the
setting of diastolic dysfunction.
Normal Diastolic stress test response is increase stroke volume with increased filling pressures.
LV global longitudinal diastolic strain rate measurements during the isovolumic relaxation period
in speckle tracking echocardiography.
LV untwisting rate is another parameter that can be used as a surrogate of LV relaxation.
Ans: Normal Diastolic stress test response is increase stroke volume with increased filling
pressures.
60. E/e’ is not a useful parameter in all the following conditions
to estimate filling pressures except
Mitral Regurgitation.
LBBB
Atrial fibrillation.
Post transplant.
Ans: LBBB
61. Diastolic dysfunction can be assessed
by all of the following in AF except
A. MV EDT
B. E/e’
C. IVRT
D. PASP
E. E/Vp
F. PV DT
G. Ans :none
![Parameters
1. e´ septal and e´ lateral diastolic velocities
2. Time interval between QRS complex- e´ onset time is prolonged in
impaired LV relaxation.
3. [QRS-E]- [QRS-e’]=TE-e´ (Time interval between peak of R wave in QRS
complex and onset of mitral E velocity is subtracted from time interval
between QRS complex and onset of e’ velocity)
4. Annular e´/a´
5. Doppler E/e´ ratio is helpful in estimation of filling pressures and LV](https://image.slidesharecdn.com/diastolic-dysfunction-250809154825-2dd62c72/85/Diastolic-dysfunction-diastolic-dysfunction-33-320.jpg)
