Diastolic Dysfunction 2016

ASSESMENT OF DIASTOLIC
DYSFUNCTION- NEWER GUIDELINES
(ASE/EACVI 2016)
Presenter- Dr. Abhishek Rathore
Moderator – Prof Dr.B C Srinivas
Dr. Yeriswamy M C

INTRODUCTION
 Diastolic dysfunction is a important cause of left
heart failure and also predicts cardiovascular
events.
 DD is Present in > 25% of adults >40 yrs of age.
 A primary cause of > 50% of heart failure cases.
 So, diastolic function assessment should be
included in every adult echocardiographic
examination.

DEFINITIONS
 Traditional definition of diastole (in ancient Greek language
the term διαστολε means expansion): includes the part of the
cardiac cycle starting at the AoV closure - when LV pressure
falls below aortic pressure - and finishing at the mitral valve
(MV) closure.
 Normal LV diastolic function may be clinically defined as the
capacity of the LV to receive a LV filling volume able in its turn
to guarantee an adequate stroke volume, operating at a low
pressure regimen.
EAE Textbook of Echocardiography 2013

CAUSES OF DIASTOLIC DYSFUNCTION
Structural Abnormalities:
 Hypertrophy
 Fibrosis
 Constriction
Functional Abnormalities:
 Ischemia
 Calcium overload
 ATP depletion

FACTORS AFFECTING DIASTOLE
 Ventricular function
 AV valve function
 Rate of relaxation
 Ventricular compliance
 Atrial systolic function
 Preload
 Heart rate and rhythm

NORMAL DIASTOLIC FUNCTION
 Rapid early filling (E wave) - Result of elastic recoil and active
relaxation of the chamber.
 Also associated with a similar brisk motion of the mitral annulus
as the chamber expands to accommodate the inflow of blood.
This process quantified using tissue Doppler as the e′.
 Diastasis- Little filling occurs in mid diastole, the duration of
which is heart rate dependent.
 Atrial systole (A wave) – contributes small amount of additional
filling.

 As blood enters the ventricle through the mitral valve, it
propagates rapidly toward the apex - evaluated using color
Doppler M-mode, and termed the propagation velocity or Vp.
 Normal pulmonary venous flow consists of a systolic and
diastolic component followed by a brief reversal of flow during
atrial systole .
 Finally, normal diastolic function is associated with a normal left
atrial volume.

STAGES OF DIASTOLIC DYSFUNCTION
Grade Stage Dominant Pathophysiology
1 Impaired relaxation Delayed LV early diastolic active relaxation
Normal LA pressure
Low opening LA-LV pressure gradient
Reduced LV suction force
2 Pseudonormalization Delayed LV early diastolic active relaxation
Mildly elevated LA pressure
Low opening LA-LV pressure gradient
Reduced LV suction force
3 Restrictive filling
(Reversible)
Noncompliant LV chamber (increased stiffness)
Diminished LV suction force
High opening LA-LV pressure gradient
Elevated LA pressure (inflow by “pushing” blood)
Failing LA contractility
Responds positively to preload reduction
4 Restrictive filling
(Irreversible)
Same as Stage 3
No improvement with preload reduction.
Feigenbaum's Echocardiography, 7th edition, 2011.

LV relaxation, filling pressures and 2D and Doppler
findings according to LV diastolic function
Normal Grade I Grade II Grade III
LV Relaxation N Impaired Impaired Impaired
LAP N Low or N Elevated Elevated
Mitral E/A Ratio ≥0.8 ≤ 0.8 >0.8 to <2 >2
Average E/e’
ratio
<10 <10 10-14 >14
Peak TR velocity
(m/sec)
<2.8 <2.8 >2.8 >2.8
LA volume index N N or
Increased
Increased Increased
ASE/EACVI Guidelines And Standards, J Am Soc Echocardiogr 2016;29:277-314

BASIC DIASTOLIC FUNCTION INDICES
IVRT
Mitral Inflow--- E/A
DT
Mitral Annular e’---- E/e’
Pulmonary vein doppler--- Ar-A duration
Propagation Velocity (Vp)
LA size

ISOVOLUMIC RELAXATION TIME
 Duration of relaxation prior to MV opening.
 When relaxation is prolonged, mitral valve opening is delayed and
IVRT is increased.
 Conversely, when left atrial pressure is elevated, mitral valve opening
will occur earlier and IVRT will be shortened.
 It is derived using pulsed Doppler from a modified apical 4C view.
 Simultaneous visualization of left ventricular inflow and outflow.
 Sample volume is placed midway between the inflow and outflow areas so that
mitral and aortic flows are captured simultaneously.
 relatively large sample volume is best.
 Time from middle of the aortic closure click to the onset of the E wave.
 fast sweep speed is used and performed at end-expiration.
 at least three measurements of IVRT should be obtained and averaged.

 Furthermore, IVRT increases with age and is sensitive to
changes in both heart rate and systolic function.
 So, never be used in isolation as a predictor of diastolic function.

MITRAL INFLOW
 Apical 4C view.
 at the tips of the mitral leaflets.
 Small sample volume, ~2 mm.
 End-expiration.
 E wave and A wave velocity
 E/A ratio
 E wave deceleration time
 A wave duration
 Deceleration time is defined as the time interval from early peak inflow
velocity (the E wave) to the cessation of the rapid early filling phase.
 It is inversely proportional to chamber stiffness.
 N= 140 – 240 ms

 Factors that affect the mitral inflow pattern include
 sinus tachycardia and first-degree atrioventricular (AV) block,
which tend to fuse the E and A waves,
 atrial fibrillation, which eliminates the A wave, and
 mitral valve disease, which independently alters the velocity
pattern.

COLOR M-MODE FLOW PROPAGATION
VELOCITY (VP)
 4 C view : M-mode cursor in the center of the column of mitral
inflow, as parallel as possible to flow direction.
 Slope of the early diastolic valve-to-apex contour is used most
often.
 Impaired relaxation will slow the propagation of blood and
thereby reduce the slope of the line.
 N= ≥ 50 cm/s

 factors affect include :
 ventricular geometry,
chamber volume,
 regional dyssynchrony,
 systolic function, and
 Assessed in dilated left
ventricle with reduced
systolic function.
Normal
Diastolic dysfunction

E/Vp Ratio
Correlates with LAP
E/Vp ≥ 2.5 predicts PCWP >15 mm Hg with reasonable
accuracy in patients with depressed EFs.

TISSUE DOPPLER MITRAL ANNULAR VELOCITY
 4C view, the sample volume is positioned on the annulus, near
the insertion site of the mitral valve.
 Both the septal (medial) and lateral annulus.
 Sweep speed between 50 and 100 cm/sec.
 Measurement of ≥ 3 consecutive cycles should be obtained at end-
expiration.
 Peak annular velocity in early diastole (e′) - primarily depends
on LV relaxation.
 When diastolic function is abnormal, e′ is relatively independent of
preload.
 However, when diastolic function is normal, e′ increases with higher
filling pressure.

 E/e′ ratio usually measured rather
than e´.
 e′ should be made from both septal
and lateral locations.
 In most patients, lateral e′ will be
higher than the septal value.
 E/e′ ratio is to predict filling pressure
in the setting of abnormal diastolic
function.
 Normal E/e’ = < 10
 Limitations –
 E and e′, are obtained from different
cardiac cycles and at different times.
 Age, preload, and systolic function
can affect these parameters.
 prosthetic mitral valves, annular rings,
and significant annular calcification
can create technical problems in
measuring e′.

PULMONARY VENOUS FLOW PATTERNS
 Apical 4-C view, recorded at the junction of the veins and left
atrium.
 Sample volume ~ 5 mm within the vein.
Normal Pattern

 Both time velocity integral and peak velocity of each
component is measured.
 Systolic fraction is defined as the ratio of systolic to the diastolic
time velocity integral.
 S/D ratio Most commonly reported value is the ratio of the peak
antegrade velocities in systole and diastole.
Normally- S ≥ D
 Ar– A duration
Ar – A < 0 ms ( > 30ms is abnormal)
Duration of the retrograde atrial wave (Ar), increases with increased
filling pressure.

 Ar – A duration - shown to correlate with LVEDP.
 As left atrial pressure rises, Ar duration lengthens and Ar - A difference
increases.
 most sensitive and earliest indicator of elevated LAP.
 >30 ms indicates elevated LVEDP and will be present before mean
LAP becomes abnormal.
 This may be useful in patients with abnormal relaxation to separate
those with normal from those with elevated filling pressures.

Abnormal pulmonary venous flow patterns
Diastolic predominance (D > S)
Absent systolic wave and forward flow
occur exclusively in diastole

 S/D ratio Affected by several factors.
 Young normal subjects have a predominant diastolic wave.
 With increasing age, the S/D ratio increases.
 As left atrial compliance decreases and pressure rises, the S/D
ratio decreases and the systolic fraction is usually less than
40%.
 Technical challenges in obtaining the recordings, age, heart
rate, PR interval, mitral regurgitation, and systolic function.

LEFT ATRIAL VOLUME
An increase in left atrial size is the morphologic expression of
chronic diastolic dysfunction.
 Reflects both duration and severity of disease.
Measured at end-systole, just prior to mitral valve opening.
Approaches to volume calculation :
 Simpson's Method
Area-length method
Normal LA vol index- 16-28ml/m2
Both diagnostic and prognostic value in the assessment of
diastolic function.

 Mitral annulus is used as inferior border
 Exclude pulmonary veins
 LA volume should be corrected for BSA (ml/m2 )

VALSALVA MANEUVER
 Normal subjects:
 Reduction in velocity, affecting E and A wave to a similar degree.
 so E/A ratio is unchanged.
 Pseudonormal stage , the Valsalva maneuver will change the pattern
to one resembling impaired relaxation.
 because pseudonormalization causes a moderate increase in filling pressure
superimposed on delayed relaxation.
 By lowering preload, the delayed relaxation pattern is unmasked.
 During Valsalva strain phrase,
 a decrease in the E/A ratio of >50% is a useful indicator of elevated filling
pressure.
 In the setting of irreversibly elevated filling pressure (the restrictive filling
pattern), this decrease in E/A may not occur.

Valsalva maneuver in a patient with grade II diastolic dysfunction. At baseline,
E/A ratio is 1.3 (left) and decreases to 0.6 (impaired relaxation pattern) with
Valsalva.

LESS AGE DEPENDENT PARAMETERS
 E/e’ ratio
 Change in mitral inflow velocities with valsalva
 Ar – A duration

IMPAIRED RELAXATION – GRADE I
 Initial or earliest abnormality.
 loss of elastic recoil of the LV in early diastole.
 Prolongation of the isovolumic relaxation time (IVRT).
 With the decrease in suction during early diastole, the left atrial
to left ventricular (LA-LV) pressure gradient also decreased.
 Prolonged DT

 Mitral flow velocity during atrial systole is increased.
 through a combination of increased atrial preload and a more
forceful atrial contraction, a compensatory mechanism.
 Pulmonary venous flow and the E/e′ ratio usually are normal,
consistent with normal filling pressures at rest.

PSEUDONORMALIZATION – GRADE II
 Decrease in chamber compliance (increased stiffness) adds to
the continued delay in relaxation.
 Transmitral flow is increasingly dependent on maintaining a
high left atrial pressure rather than active relaxation.
 Increase in mean left atrial pressure has two subsequent effects:
 First, it contributes to a shortening of IVRT.
 Second, in contrast to impaired relaxation, the early mitral inflow
velocity is restored back to the normal range, due to larger LA-LV
pressure gradient .
Thus, this phase is often referred to pseudonormalization.

 Pulmonary venous flow will usually show :
 diastolic predominance.
 A very small systolic wave (less than 50% of the diastolic wave) -
suggests elevated filling pressures.
 Mitral inflow velocity pattern resembles the normal state due
to the combined effects of
 high filling pressure and
 impaired relaxation.

RESTRICTIVE FILLING (REVERSIBLE),GRADE III
 Left ventricular chamber compliance becomes increasingly abnormal.
 To maintain forward flow, left atrial filling pressure must continue to
increase. This results in –
 further shortening of the IVRT and
 marked increase in the early diastolic mitral inflow velocity.
 The rate of deceleration of flow is marked, result of a noncompliant
left ventricular chamber leading to a rapid equilibration of the LA-LV
pressure gradient early in diastole.
 Filling velocity during atrial contraction is also reduced
 through a combination of elevated left ventricular pressure and failing left
atrial contractility.

 Pulmonary venous flow
 during systole is greatly reduced relative to diastolic flow .
 prominent flow reversal during atrial systole.
 retrograde pulmonary venous Awave duration (Ar) is typically longer
than the mitral A-wave duration (Ar - A > 30 ms), indicating high
filling pressures.
 In some patients, this stage may be reversible.
 with diuresis (or other forms of preload reduction)

RESTRICTIVE FILLING (IRREVERSIBLE),
GRADE IV
 In later stages of the restrictive filling stage, the pattern may
become irreversible.
 No improvement in the filling pattern or the clinical status with
preload reduction.
 Marked intolerance to volume manipulation.

DIASTOLIC DYSFUNCTION GRADES
LV relaxation, filling pressures and 2D and Doppler
findings according to LV diastolic function
Normal Grade I Grade II Grade III
LV Relaxation N Impaired Impaired Impaired
LAP N Low or N Elevated Elevated
Mitral E/A Ratio ≥0.8 ≤ 0.8 >0.8 to <2 >2
Average E/e’
ratio
<10 <10 10-14 >14
Peak TR velocity
(m/sec)
<2.8 <2.8 >2.8 >2.8
LA volume index N N or
Increased
Increased Increased

POLLING QUESTION
 Which finding is consistent with normal mean LAP
in patients with LV diastolic dysfunction?
 A. E/A ratio = 2
 B. LA maximum Vol index= 46ml/m2
 C. Pulmonary vein S/D ratio = 0.3
 D. Septal E/e’ ratio = 18
 E. Peak TR velocity = 2.5m/s
Ans-E

ASE 2009 VS ASE/EACVI 2016
 It incorporates a new algorithm that is based on only four
variables to diagnose the presence or absence of diastolic
dysfunction, and it also offers a new algorithm to estimate LV
filling pressures with fewer variables than the 2009 guidelines.
 The society noted that the approach is similar for patients with
both depressed and normal ejection fractions.
 The grading of diastolic dysfunction is linked to estimation of
LV filling pressures, and a single algorithm is used for both,
according to ASE.
 Primary goal with this update was to simplify the approach
and hopefully increase the usefulness of the guidelines in
daily practice.”

ALGORITHM FOR DIAGNOSIS OF LV DIASTOLIC
DYSFUNCTION IN NORMAL LVEF

ALGORITHM FOR ESTIMATION OF LV FILLING PRESSURES AND GRADING
LV DIASTOLIC FUNCTION IN DEPRESSED LVEF AND NORMAL LVEF

ALGORITHM COMPARING CONSTRICTIVE PERICARDITIS
AND RESTRICTIVE CARDIOMYOPATHY

CASE
 66 year old woman
 H/o previous MI presents with recurrent episodes of
dyspnea with daily activities.
 Onset of dyspnea 6 months ago with a progressive
course.
 H/o HTN, DM and Dyslipidemia
 No H/o pulmonary disease.

MITRAL AND PULMONARY VENOUS FLOW

CASE SUMMARY
 Clinical data consistant with cardiac disease
 LVEF depressed
 E/A ratio > 2
 Pulmonary vein S/D ratio < 1
 LA enlarged >34ml/m2

ALGORITHM FOR ESTIMATION OF LV FILLING PRESSURES AND GRADING LV
DIASTOLIC FUNCTION IN DEPRESSED LVEF AND NORMAL LVEF

DIASTOLIC DYSFUNCTION IN SPECIFIC
PATIENT GROUPS
Atrial Fibrillation
 Peak acceleration rate of mitral E velocity (≥1,900 cm/sec2)
 IVRT (≤ 65 msec)
 DT of pulmonary venous diastolic velocity (≤ 220 msec)
 E/Vp ratio (≥ 1.4)
 Septal E/e’ ratio (≥ 11)
Sinus Tachycardia
 Mitral inflow pattern with predominant early LV filling in EFs <50%
 IVRT ≤ 70 msec is specific (79%)
 Pulmonary vein systolic filling fraction ≤ 40% is specific (88%)
 Average E/e’ >14 (highest specificity but low sensitivity)
 When E and A velocities are partially or completely fused, the presence of
a compensatory period after premature beats often leads to separation of E
and A velocities which can be used for assessment of diastolic function

PATIENT GROUPS CONT…
Noncardiac pulmonary hypertension
 If cardiac etiology is present, lateral E/e’ >13 Noncardiac
etiology, lateral E/e’ is <8
HCM
 Average E/e’ (>14)
 Ar-A (≥ 30 msec)
 TR peak velocity (>2.8 m/sec)
 LA volume (>34 mL/m2).
RCM
 DT (<140 msec)
 Mitral E/A (>2.5)
 IVRT (<50 msec has high specificity)
 Average E/e’ (>14)

Mitral stenosis
 IVRT/TE-e’ (<4.2)
 Mitral A velocity (>1.5 m/sec)
MR
 Ar-A (≥ 30 msec)
 IVRT/TE-e’ (<5.6) may be applied for the prediction of LV
filling pressures in patients with MR and normal EFs
 Average E/e’ (>14) may be considered only in patients with
depressed EFs

After Heart Transplantation
 Restrictive filling pattern in patients with preserved EFs.
 No single diastolic parameter appears reliable enough to predict
graft rejection.
 PASP estimation using the TR jet can be helpful as a surrogate
measurement of mean LAP in the absence of pulmonary disease.
AV block and Pacing
 In first degree AV block, the variables used to evaluate diastolic
function and filling pressures likely remain valid as long as there is
no fusion of mitral E and A velocities.
 Accuracy of mitral annular velocities and E/e’ ratio is less in the
presence of LBBB, RV pacing, and in patients who have received
CRT.
 If only mitral A velocity is present, only TR peak velocity (>2.8
m/sec) can be used as an indicator of LV filling pressures.

POLLING QUESTION
 Which of the following parameter can be applied to
estimate LV filling pressure in HCM, Aortic stenosis,
Atrial fibrillation and Cardiac transplants?
 A. Mitral E/A ratio
 B. LA maximum volume index
 C.Pulmonary vein S/D ratio
 D.Peak TR velocity
 Mitral anuular e’ velocity
Ans- D

DIASTOLIC STRESS TEST
Indication:
 When resting echo does not explain the symptoms of heart failure or dyspnea,
especially with exertion..
 It is performed using supine bike or treadmill stress testing.
 Helpful to evaluate filling pressures in patients with known diastolic dysfunction with no
or mild symptoms.
 At rest, mitral E and annular e’ velocities should be recorded, along with the peak
velocity of TR jet.
 The same parameters are recorded during exercise or 1 to 2 min after
termination of exercise when E and A velocities are not merged.
 The test is considered positive when all of the following three conditions are met
during exercise:
Average E/e’ > 14 or septal E/e’ ratio > 15
Peak TR velocity > 2.8 m/sec and
Septal e’ velocity < 7 cm/sec.

PROGNOSIS IN PATIENTS WITH DIASTOLIC
DYSFUNCTION
 Acute myocardial infarction, a mitral deceleration time <140 ms
predicts a poor short- and intermediate-term prognosis.
 E/e′ ratio has been studied in a variety of conditions and appears to
provide prognostic data.
 Mitral inflow pattern - restrictive filling pattern conveys a poor
prognosis in heart failure.
 Increasing left atrial volume is generally associated with increasing
risk.
 Abnormal untwisting, or torsion, derived from the speckle tracking
technique may prove useful for predicting risk

CONCLUSION
 Factors that affect diastolic function parameters
should be taken into account.
 Diastolic dysfunction parameters should not be
used in isolation.
 Diastolic dysfunction is an important prognostic tool
for future CV outcomes.
 Diastolic function assesment should be a routine
part of comprehensive adult echocardiographic
examination.

 The four recommended variables and their
abnormal cutoff values are annular e’ velocity
(septal e’< 7 cm/sec, lateral e’ < 10 cm/sec),
average E/e’ ratio > 14, LA maximum volume index
> 34 mL/m2, and peak TR velocity > 2.8 m/sec.
 LV diastolic function is normal if more than half of
the available variables do not meet the cutoff
values for identifying abnormal function. LV diastolic
dysfunction is present if more than half of the
available parameters meet these cutoff values. The
study is inconclusive if half of the parameters do not
meet the cutoff values.

Diastolic Dysfunction 2016

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