Assessment of Diastolic Function

Maria Charisse Y. Lim, MD

St. Luke’s Heart Institute
 Objectives:
• To discuss the parameters in
the echocardiographic
assessment of diastolic
function
• To discuss the causes and
echocardiographic properties
of diastolic dysfunction and
its stages

21
Isov Early Diasta Late
olu rapid sis diastolic
mic diastolic filling due to
rela filling atrial
xati contraction
on LAp=LVp

LAp > LVp

Determinants of blood flow

from LA to LV:
1. Filling pressures
2. Ventricular relaxation
3. Chamber compliance

31
 Parameters of Diastolic Function

There is no single measure of overall

diastolic function, but the most
clinically relevant parameters are:
• Filling pressures and volume-
ventricular and atrial
• Ventricular relaxation
• Myocardial or Chamber compliance

41
 Ventricular Relaxation
LV relaxation which occurs during
isovolumic relaxation and the early
diastolic filling period is affected by
1. Internal loading forces (cardiac fiber)
2. External loading conditions (wall
stress, arterial impedance)
3. Inactivation of myocardial contraction
(metabolic, neurohumoral, and
pharmacologic)

51
Measures of Left Ventricular Relaxation

Increased cytosolic Ca
IVRT

Incomplete relaxation

-dp/dt Abnormal relaxation results in:

1. prolongation of the isovolumic
relaxation time

2. Slower rate of decline in

ventricular pressure

3. Reduction in the early peak

filling rate
61
 Ventricular Compliance
• Compliance is the ratio of change in volume to
change in pressure (dV/dP).
• Stiffness is the inverse of compliance; the ratio of
change in pressure to change in volume (dP/dV)
• 2 components of compliance:
1. Myocardium
2. Chamber- influenced by ventricular
size and shape and characteristics of the
myocardium
Extrinsic factors: pericardium, RV volume
and pleural pressure
71
Ventricular Diastolic Pressures
Diastolic filling pressures include:
1. Left ventricular end diastolic pressure
(LV-EDP)- reflects ventricular pressure
after filling is complete
2. Mean left atrial pressue (LAp)- reflects
the average pressure in the
left atrium during diastole;
estimated clinically by the
pulmonary artery wedge
pressure (PAWP)
81
Ventricular Diastolic Filling (Volume) Curves
• Measured by Doppler
echocardiography on a beat-to-
beat basis
• Filling rates are affected by:
1. Changes in preload that affect the
pressure difference between the
ventricle and the atrium
2. Change in transmitral volume
flow rate
3. Change in atrial pressure

91
Ventricular Diastolic Filling (Volume) Curves
Late diastolic filling is affected by:
• Cardiac rhythm
• Atrial contractile function
• Ventricular end diastolic pressure
• Heart rate
• The timing of atrial contraction
(PR interval)
• Ventricular diastolic function

101
DIASTOLIC FUNCTION EVALUATION
 2D-echo/ M-mode evaluation:

 Doppler
1. Mitral Flow Velocity
2. Pulmonary venous flow velocity

 Color M mode propagation velocity

 Tissue Doppler Myocardial Imaging

111
 Doppler Evaluation of LV filling
• characterized by a brief interval between aortic valve
closure and the onset of ventricular filling (IVRT)
• Early peak filling velocity (E velocity) of 0.6-0.8
m/s occurring 90 -110 ms after the onset of flow from
LA to LV
• Deceleration time- interval from the E peak to
where a line following the deceleration slope intersects
with the zero baseline, ranges between 140-200ms.
• Left atrial pressure results in a second velocity peak
(late diastolic or atrial (A) velocity) typically
ranging from 0.19 to 0.35 m/s.

121
Deceleration time Diastasis

131
Doppler Flow Velocities: Mitral Inflow
Determinants:
• early rapid filling wave,
• peak velocity of the late
filling wave due to atrial
contraction and
• the E/A ratio
Tachycardia or 1st deg AV block
may result in fusion of the E
and A velocities

141
Doppler Flow Velocities: Mitral Inflow

151
 Deceleration Time

--Prolonged DT in patients with relaxation abnormality-

longer time for LA and LV pressures to equilibrate
--Shortened DT with rapid filling due to vigorous LV
relaxation and elastic recoil

161
Techniques for Diastolic Doppler Parameters:
Mitral Inflow

171
Techniques for Diastolic Doppler
Parameters: IVRT

181
Tissue Doppler Imaging: Mitral Annulus
• images the motion of tissue with Doppler echocardiography,
records the low velocities (1-20 cm/s) of myocardial tissue

• evaluate diastolic function by measuring mitral annulus velocity

during diastole

• preload independent

• PRINCIPLE: filter out high velocity signal from blood and

amplify low velocity signal from myocardium

• UTILITY: - normal vs. pseudonormal

- fused EA
- constriction vs. restriction
- estimate LV filling

191
Doppler Flow Velocities: Mitral Annulus
• Tissue doppler imaging is the
method of choice for
recording the longitudinal
velocities of the mitral
annulus.
• Recorded from the apical 4
chamber view by placing a 2-
5 mm sample volume over the
lateral or medial portion of
the mitral annulus
201
 Techniques for Diastolic Doppler Parameters:
Mitral Annulus

Am
Em 0.05-0.07 m/s
IVCT IVRT 0.1-0.14 m/s

211
Mitral Annulus Velocities with TDI

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 DIASTOLIC FUNCTION
EVALUATION

 2D-echo/ M-mode evaluation

Doppler
 1. Mitral Flow Velocity :
 - mitral inflow and mitral annulus

2. Pulmonary venous flow velocity

Color M mode propagation velocity

 Tissue Doppler Myocardial Imaging

231
Doppler flow velocity: Pulmonary Venous flow

241
 Pulmonary
Doppler venous
flow velocity: flow: waveforms
Pulmonary Venous flow

0.4-0.8 m/s

0.3-0.6 m/s

0.2-0.35 m/s

251
Doppler flow velocity: Pulmonary Venous flow

Normal pulmonary vein

flow. Nearly continuous,
multiphasic flow is seen
in the normal
pulmonary .Note that
there is higher velocity
of pulmonary vein
inflow during ventricular
systole then during
diastole.

261
Techniques for Diastolic Doppler
Parameters: Pulmonary Venous Flow

PVs
PVd

PVa 271
 DIASTOLIC FUNCTION
EVALUATION

 2D-echo/ M-mode evaluation

Doppler
 1. Mitral Flow Velocity :
 - mitral inflow and mitral annulus
 2. Pulmonary venous flow velocity

Color M mode propagation velocity

 Tissue Doppler Myocardial Imaging

281
 New Methods:
Color M mode (CMM)
• Normal CMM has a rapid
slope with a distinct “E” & “A”
wave propagating into the LV
resembling mitral inflow

• Flow propagation velocity

and early diastolic annular
velocity can be used for
estimation of filling pressure

291
Techniques for Diastolic Doppler Parameters:
Color M Mode

301
Color M-mode

311
 Transmitral flow in AF

DT is useful in patients with depressed LV function

321
Average 10 cardiac cycles for greater accuracy
 Pulmonary venous flow
Diastolic wave Systolic wave Diastolic wave

AF SINUS

A wave 331
Diastolic Dysfunction
 Diastolic Dysfunction
• Heart failure is the most common diagnosis at
hospital dismissal for patients > 65 y and above
• Predicted to reach 35% of this population by
2010
• In the US, 5 million patients have heart failure
and 500,000 new cases occur annually
• ½ of cases with heart failure , the primary cause
is diastolic dysfunction with preservation of the
LV ejection fraction

Oh, Seward, Tajik 2006 351

Causes of Diastolic Dysfunction
4 basic mechanisms of disease
• Primary myocardial disease-
cardiomyopthy: dilated , restrictive,
hypertrophic
• Secondary hypertrophy- hypertension,
aortic stenosis, aortic or mitral
regurgitation, congenital heart disease
• Coronary artery disease- ischemia or
infarction
• Extrinsic constraint- pericardial
tamponade or constriction

361
 Stages of Diastolic Dysfunction

• Stage I- Impaired Relaxation

• Stage II- Pseudonormalization
• Stage III- Reversible Restrictive Pattern
• Stage IV- Irreversible Restrictive Pattern

371
Normal Diastolic Filling Pattern
• E/A is >= 1.5
• DT -160-240 ms
• E’ >= 10 cm/s
• E/E’ < 8
• Vp >= 50 cm/
• IVRT 70-90 msec
• Mitral A dur > PVa
dur
• PVs2 > PVd
• No anatomic
abnormalities

381
Normal Diastolic Filling Pattern

391
401
Grade I Diastolic Dysfunction
(Impaired Myocardial relaxation)
•E/A < 1.0
•DT >240 msec
•IVRT >90 msec
•E’ < 7cm/s
(septal)
•E/E’ <= 8
•PVs2 >> PVd
•Mitral A dur > or
< PVa dur
(depending on
LVEDP)

411
421
431
Grade II Diastolic Dysfunction
(Pseudonormalized Pattern)
•E/A 1-1.5
•E’ < 7 cm/s
•E/E’ >15
•DT 160-200 msec
•IVRT <90 msec
• PVs2 < PVd
•Mitral A dur < PVa
dur
•PVa velocity
increased (>35 cm/s)
•Evidence of
Structural Heart
Disease (low EF, LVH)
•Reversal of EA ratio
with preload
reduction 441
451
461
Pseudonormal vs Normal MIFP:
Valsalva Maneuver

471
Grade III/IV Diastolic Dysfunction
(Restrictive Filling)
•E/A > 2
•DT <160 msec
•IVRT <70 msec
•PVs2 << PVd
•Mitral A dur < PVa
dur
•PVa velocity
increased
•Evidence of
Structural Heart
Disease
•Decreased EA ratio
with preload
reduction

481
491
 Grading of Diastolic Dysfunction by
Pulsed Doppler MV inflow

300

Normal Delayed Pseudonormal Restrictive

EA 1-2 relaxation GRADE 2 EA > 2
EA < 1 EA 1-2 501
Grading of Diastolic Dysfunction by Mitral
Inflow and Mitral Annular Velocities

511
521
STAGES OF DIASTOLIC DYSFUNCTION
Parameters Normal (Adult) Delayed Pseudo- Restrictive
Relaxation normal Filling Filling

E/A (cm/sec) >1 <1 1-2 >2

DT (msec) <220 >220 150-220 <150

IVRT (msec) <100 >100 60-100 <100

S/D >/=1 >/=1 <1 <1

AR (cm/sec) <35 <35 >35 >35

Vp (cm/sec) >45 <45 <45 <45

Em (cm/sec)
E/ Em >8
<8 <8
<8 <8
>10 <8
>10
AR- A wave </=30 </=30 >30 >30
duration
(msec)

Garcia MJ et al:L New Doppler echocardiographic applications for the study of diastolic function. JACC 32;872,1998
531
 CLASSIFICATION OF DIASTOLIC DYSFUNCTION
NORMAL MILD MILD- MODERATE SEVERE
MODERATE
Pathophysiology relaxation relaxation relaxation relaxation
compliance compliance
LVEDP
LVEDP LVEDP
E/A 1-2 <1 <1 1-2 >2

Em/Am 1-2 <1 <1 <1 >1

IVRT (ms) 50-100 >100 Normal

DT (ms) 150-200 >200 >200 150-200 <150

PVs/PVd >1 Pvs>Pvd PVs>PVd PVs<PVd PVs<<PVd

PVa (ms) <0.35 <0.35 >0.35 >0.35 >0.35

adur-Adur <20 <20 >20 >20 >20

(ms)

Based on the Canadian Concesus Guidelines (Rakowi and Yamada etal. J Am Soc Echo, 1996 and 2002; Redfield. JAMA541
2003)
Diastolic Heart Failure

Braunwald 2005

551
Management of Heart Failure
Grade I DD- patients usually are
asymptomatic as long as the diastolic
filling period is sufficiently long to
accommodate the delay in myocardial
relaxation
• Prevent exercise induced tachycadia or the
development of atrial fibrilation
• Beta blockers
• Manage hypertension, obesity, diabetes
mellitus, ischemia

561
Management of Heart Failure
Grade II DD- patients have
moderate increase in filling
pressure in addition to
impaired relxation
• Decrease in preload or venous
congestion
• neurohormonal modulation
with ACE inhibition or ARB

571
Management of Heart Failure
Grade III/IV DD- markedly
increased filling pressure
occur mostly during diastole,
with a relatively fixed stroke
volume
• Caution with beta blockers
• Diuresis is the initial
treatment of choice
• Titrate doses of ACE-I or
ARBs

581
591
601
611
621
 Doppler Evaluation of LV filling

Quantitative Ventricular filling velocity made from the

Doppler velocity curve include:

1. Maximum velocities- the E velocity, the A velocity, and

their ratio (E/A ratio)
2. Velocity time integrals- total, early diastolic, atrial
contribution, first third or half of diastole, and their ratios
3. Time intervals- the IVRT, the total duration of diastole,
the deceleration time and the atrial filing period
4. Measures of acceleration and deceleration- the time
from onset of flow to the E velocity, the maximum rate of rise
in velocity, and the slope of early diastolic deceleration
631
641
Mitral inflow velocity and Doppler tissue annular recording in a
patient with diastolic dysfunction and impaired relaxation. Note the
reversed E/A ratio, (A), which is paralleled by a reduced annular
EA/AA ratio.
651
Mitral inflow velocity
and Doppler tissue
annular recording in a
patient with diastolic
dysfunction and
impaired relaxation.
Note the reversed E/A
ratio, (A), which is
paralleled by a reduced
annular EA/AA ratio.

661
Two left ventricular pressure waveforms show a normal contour and then a
waveform with delayed relaxation producing a prolonged time constant of
relaxation (tau). The pressure coordinates from aortic valve closing to mitral
valve opening, i.e., during the isovolumic relaxation period, can be plotted and
the negative reciprocal of the log plot is the calculated relation value (tau).
671
 Evaluation of ventricular
compliance is based on
the diastolic passive
pressure-volume curves
showing the degree to
which pressure and
volume change in
relation to each other
over the physiologic
range of pressures and
volumes .

681
Atrial Pressures and Filling Curves
• Right atrial pressures -(NV 0-5mmHg)
• Right atrial filling is characterized by:
-small reversal of flow following atrial contraction (a wave)
-systolic phase when blood flows from the SVC and IVC into
the atrium (x descent)
-small reversal of flow at end-systole (v wave)
-diastolic filling phase when the atrium serves as a
conduit for flow from the systemic venous return
to the RV (y wave)

x y

691
Atrial Pressures and Filling Curves
• Left atrial filling from the pulmonary veins
is also characterized by:
-small reversal of flow following atrial contraction (a wave)
-systolic filling phase
-blunting of flow or brief reversal of flow at end-systole (v wave)
-diastolic filling phase
• Normal left atrial pressure is low
(5-10 mmHg) corresponding to
normal LVEDP

701
711
721
Doppler Flow Velocities: Mitral Inflow
• Deceleration time (DT)- the interval from
the peak of the E velocity to its
extrapolation to baseline
• Prolonged DT in patients with relaxation
abnormality- longer time for LA and LV
pressures to equilibrate
• Shortened DT with rapid filling due to
vigorous LV relaxation and elastic recoil
• IVRT generally parallels DT

731
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