Diastolic Dysfunction

Presented by
Dr. Salman Abbas
INTRODUCTION

Diastolic dysfunction is an important cause of left heart failure, so

diastolic function assessment should be included in every
echocardiographic examination.

Normal dystolic function is defined as capacity of the LV to receive

filling volume, operating at normal filling pressure.
 PHASES OF DIASTOLE

ISOVOLUMIC RELAXATION:- Duration of relaxation prior to mitral

valve opening.

RAPID EARLY FILLING:- LV filling predominantly occurs early in

diastole because of rapid LV relaxation that sucks blood into the LV,
corresponds to the “E wave” on pulse wave Doppler of transmitral
inflow. As LV expands to accommodate inflow of blood, it causes
brisk motion of mitral annulus quantified using Tissue Doppler
Imaging as E’.
Diastasis:- Little filling occur in mid diastole, the duration of which is
heart rate dependant.

Atrial Systole:- Contributes small amount of additional blood, it

corresponds to the “A wave” on pulse wave Doppler of trans mitral
inflow.
 BASIC DIASTOLIC FUNCTION INDICES

Mitral E/A ratio

Mitral E/e’ ratio
Mitral E velocity Deceleration Time
Isovolumic relaxation time
LA volume index
Pulmonary vein S/D ratio
Ar-A duration
TR systolic jet velocity
Vp and E/Vp ratio
 MITRAL INFLOW

Apical four-chamber with color flow imaging for optimal alignment

of PW Doppler with blood flow.

PW Doppler sample volume (1–3 mm) between mitral leaflet tips.

We can calculate E wave, A wave, E/A ratio, A wave duration and E
wave deceleration time.
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MITRAL E VELOCITY

 E-wave velocity reflects the LA-LV pressure gradient during early

diastole .
 In patients with dilated cardiomyopathy, mitral velocities correlate
better with LV filling pressures, functional class, and prognosis than
LVEF.
In patients with coronary artery disease and patients with HCM in
with LVEF >50%, mitral velocities correlate poorly with LV filling
pressures, More challenging to apply in patients with arrhythmias.
Decreases with age.
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Mitral A velocity

A-wave velocity reflects the LA-LV pressure gradient during late

diastole.
Sinus tachycardia, first-degree AV block and paced rhythm can
result in fusion of the E and A waves.
If mitral flow velocity at the start of atrial contraction is >20 cm/sec,
A velocity may be increased.
Not applicable in AF/atrial flutter patients.
Age dependent (increases with aging).
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Mitral E/A ratio

Mitral inflow E/A ratio is used to identify the filling patterns.

In patients with dilated cardiomyopathy, filling patterns correlate
better with filling pressures, functional class, and prognosis than
LVEF.
If mitral flow velocity at the start of atrial contraction is >20 cm/sec,
E/A ratio will be reduced due to fusion.
 Not applicable in AF/atrial flutter patients.
Age dependent (decreases with aging).
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Mitral E Velocity Deceleration Time

Deceleration time is defined as time interval from early peak inflow

velocity to the baseline. Inversely proportional to LV stiffness.

A short DT in patients with reduced LVEFs indicates increased LVEDP

both in sinus rhythm and in AF.

 DT does not relate to LVEDP in normal LVEF, should not be

measured with E and A fusion and not applied in atrial flutter.

Age dependent (increases with aging).

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Iso-volumic relaxation time

Duration of relaxation from aortic valve closure to mitral valve

opening.

Apical long-axis or five-chamber view, using CW Doppler and

placing sample volume in LV outflow tract.

For IVRT, sweep speed should be 100 mm/sec.

IVRT is 70msec in normal subjects and is prolonged in patients with

impaired LV relaxation but normal LV filling pressures. When LAP
increases, IVRT shortens.
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Pulsed wave TDI e’ Velocity

Apical four-chamber view: PW Doppler sample volume (usually 5–

10 mm axial size) at lateral and septal basal regions so average e’
velocity can be computed.

e’ should be calculated at both septal and lateral locations (lateral

e’ will be higher than septal e’).

E/e’ ratio can be used to predict LV filling pressures. Values for

average E/e’ ratio < 8 usually indicate normal LV filling pressures,
values > 14 have high specificity for increased LV filling pressures.
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Limitations of TDI e’ and E/e’
E and e’ are obtained from different cardiac cycles and at different
times.

Prosthetic mitral valves, annular rings, pericardial disease and

significant annular calcification can create technical difficulties in
measuring e’.

Accuracy is reduced in patients with CAD and regional dysfunction

at the sampled segments.
If E/e’ is 9-14, than one should look for additional features of
elevated filling pressures, which include:
 LA Volume >34 ml/m2
 Pulmonary artery systolic pressures >35mmHg (without primary pulmonary disease)
 Change in E/A ratio with valsalva of >0.5
 Pulmonary vein flow pattern reveals S < D wave peak velocity.
 Pulomary atrial reversal duration(Ar) exceeds mitral A duration i.e. Ar-A >30 ms
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Pulmonary venous flow pattern

• Apical four-chamber with color flow imaging to help position pulsed

Doppler sample volume (1–3 mm) Sample volume placed at 1–2 cm
depth into right (or left) upper PV.

• Normal pattern is triphasic (S1, S2, D) or biphasic with fusion S,

waves along with brief atrial reversal (Ar) at atrial contraction.

• S1 signifies atrial relaxation, S2 signifies propagation of flow through

pulmonary circulation, D wave reflects ventricular relaxation
7
Pulmonary venous flow pattern

• The normal pattern is S dominant wave with brief atrial reversal.

• In patients with AF, DT of diastolic velocity (D) in pulmonary vein flow

can be used to estimate mean PCWP.

• Limited accuracy in patients with normal LVEF, AF, mitral valve disease
and HCM
 GRADE I DYSTOLIC DYSFUNCTION

Characterized by impaired LV relaxation

The E wave velocity is reduced resulting in E/A reversal (ratio < 0.8)
The left atrial pressures are normal.
The deceleration time of the E wave is prolonged measuring > 200
ms.
The E/e’ ratio measured by tissue Doppler is normal.
 GRADE II DYSTOLIC DYSFUNCTION

Characterized by elevated left atrial pressures.

The E/A ratio is normal
The deceleration time is normal
The E/e’ ratio is elevated.
Major clue to the presence of grade II diastolic dysfunction as
compared to normal diastolic function is the presence of structural
heart disease such as left atrial enlargement, left ventricular
hypertrophy or systolic dysfunction.
 GRADE III DYSTOLIC DYSFUNCTION

E/A ratio is > 2.0.

The deceleration time is < 160 ms.
The E/e’ ratio is elevated
 The E/A ratio changes with Valsalva.
 GRADE IV DYSTOLIC DYSFUNCTION

Characterized by very elevated left atrial pressures.

The E/A ratio is > 2.0.
The deceleration time is low.
The E/e’ ratio is elevated.
The major difference distinguishing grade III from grade IV diastolic
dysfunction is the lack of E/A changes with the Valsalva maneuver
(no effect will be seen with Valsalva).
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Ar-A DURATION

The time difference between duration of atrial reversal PV flow and

mitral inflow during atrial contraction.
PV Ar duration > mitral A duration by 30 msec indicates an
increased LVEDP.
Independent of age and LVEF.
Accurate in patients with MR and patients with HCM.
Not applicable in AF patients and difficult to interpret in patients
with sinus tachycardia or first-degree AV block with E and A fusion.
9
LA maximum volume index

Apical four- chamber or two-chamber view, acquire freeze frames

1–2 frames before MV opening
LA volume should be measured in views in which LA length and
transverse diameters are maximized.
Do not include LA appendage or pulmonary veins in LA tracings
from apical four- and apical two-chamber views.
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SYSTOLIC JET VELOCITY TR

Apical four-chamber view with color flow imaging to obtain highest

Doppler velocity aligned with CW.

In the absence of pulmonary disease, increased systolic PA pressure

suggests elevated LAP
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PROPAGATION VELOCITY

Apical four-chamber with color flow imaging for M-mode cursor

position, which is placed in the center of the column of mitral
inflow.

Impaired relaxation will slow the propagation of blood and thereby

reduces the slope of the line.
 PARAMETERS FOR ASSESSMENT OF LV DYSTOLIC
DYSFUNCTION IN SPECIAL CONDITIONS
Atrial fibrillation:
 Mitral E velocity peak acceleration rate
 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 in patients with EFs <50%
 IVRT <70 msec
 Average E/e’ >14
 Pulmonary vein systolic filling fraction <40%
 PARAMETERS FOR ASSESSMENT OF LV DYSTOLIC
DYSFUNCTION IN SPECIAL CONDITIONS
• HCM
• Average E/e’ (>14)
• Ar-A (>30 msec)
• TR peak velocity (>2.8 m/sec)
• LA volume (>34 mL/m2).
• Restrictive cardiomyopathy
• DT (<140 msec)
• Mitral E/A (>2.5)
• IVRT (<50 msec )
• Average E/e’ (>14)
 PARAMETERS FOR ASSESSMENT OF LV DYSTOLIC
DYSFUNCTION IN SPECIAL CONDITIONS
• Mitral stenosis:
• IVRT (<60 msec has high specificity)
• Mitral A velocity (>1.5 m/sec)
• MR:
• Ar-A (>30 msec)
• IVRT (<60 msec has high specificity)
• Average E/e’ (>14) may be considered only in patients with depressed EFs