Diastolic dysfunction echocardiography: Difference between revisions
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{{Diastolic dysfunction}} | {{Diastolic dysfunction}} | ||
{{CMG}}; '''Associate Editor(s)-in-Chief:''' [[User: Shankar Kumar |Shankar Kumar, M.B.B.S.]] [mailto:kumarshankar@wikidoc.org] | {{CMG}}; '''Associate Editor(s)-in-Chief:''' [[User: Shankar Kumar |Shankar Kumar, M.B.B.S.]] [mailto:kumarshankar@wikidoc.org]; [[User: Rim Halaby|Rim Halaby]] | ||
==Overview== | ==Overview== | ||
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==Echocardiography== | ==Echocardiography== | ||
=== | ===The Principles of the Echocardiographic Evaluation=== | ||
The diagnosis of diastolic dysfunction relies on the evaluation of the status of the left ventricular function and on the presence of any variations in the ventricular filling pressures. | |||
In order to know what to expect as findings in the evaluation of diastolic dysfunction, it is important to understand the physiological role of the left atria (LA) during diastole and how it contributes to ventricular filling. | |||
*The LA functions as a reservoir that receives the venous blood when the mitral valve is closed | |||
* | *The LA functions as a conduit of blood from the atrium to the ventricle when the mitral valve is open | ||
*The LA functions as a pump at the end of diastole to pump the remaining blood in the LA into the LV while preserving a normal LVEDP. | |||
Hence, in diastolic dysfunction, the increased stiffness and diastolic dysfunction of the left ventricle impair the conduit role of the LA and cause a '''decrease in early diastolic atrio-ventricular gradient'''. As a consequence, the "reservoir" and "pump" role of the LA will try to compensate to maintain normal stroke volume and left ventricular end diastolic volume at the expense of an '''elevated LVEDP'''.<ref name="pmid19187853">{{cite journal| author=Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al.| title=Recommendations for the evaluation of left ventricular diastolic function by echocardiography. | journal=J Am Soc Echocardiogr | year= 2009 | volume= 22 | issue= 2 | pages= 107-33 | pmid=19187853 | doi=10.1016/j.echo.2008.11.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19187853 }} </ref> | |||
The predictors of the filling pressure and degree of myocardial disease progression are essentially the mean pulmonary wedge pressure PCWP (which is equal to the mean left atrial pressure in the absence of mitral stenosis) and the left ventricular end diastolic pressure LVEDP. | |||
*Normally, the diastolic phase of the cardiac cycle is characterized by rapid blood filling at low left ventricular pressures. | |||
* | *The hallmark of diastolic dysfunction is elevated left ventricular end diastolic pressure or filling pressure | ||
* | * The cut off values used for the diagnosis of diastolic dysfunction are: | ||
* | **PCWP >12 mmHg | ||
**LVEDP> 16mmHg <ref> Paulus WJ, Tschope C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007;28: 2539-50.</ref> | |||
*The PCWP and LVEDP are obtained by invasive measurements done by cardiac catheterization. | |||
The importance of echocardiography is that it provides a non invasive way to assess the heart for diastolic dysfunction through he evaluation of several parameters: | |||
* | *'''1- LV wall thickness:''' | ||
* | **The evaluation of the left ventricle is important because cardiac hypertrophy, usually secondary to hypertension, is a well known cause of diastolic dysfunction. | ||
* | *'''2- Left atrial volume:''' | ||
* The E/ | **The assessment of the left atria volume helps in the detection of any left atrial remodeling secondary to the diastolic dysfunction.<ref>Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol 2002;90: 1284-9</ref> | ||
*'''3- Pulmonary artery systolic and diastolic pressure:''' | |||
**Increase in pulmonary artery pressure, in the absence of any pulmonary disease, is indicative of diastolic dysfunction.<ref>Bouchard JL, Aurigemma GP, Hill JC, Ennis CA, Tighe DA. Usefulness of the pulmonary arterial systolic pressure to predict pulmonary arterial wedge pressure in patients with normal left ventricular systolic function. Am J Cardiol 2008;101:1673-6.</ref> | |||
*'''4- Left ventricular filling:''' | |||
**The assessment of the left ventricular filling can be derived from the evaluation of: | |||
***'''The mitral inflow velocities''' by Doppler ultrasound. The investigated parameters include the following: | |||
****Peak E: early diastolic mitral inflow velocity | |||
****Peak A: late diastolic mitral inflow velocity | |||
****E/A ratio | |||
****DT: Deceleration time of early filling velocities | |||
****IVRT: Isovolumetric relaxation time | |||
****Middiastolic flow | |||
**'''The pulmonary vein flow velocity''' | |||
**'''Left ventricular annular flow (e')''' and E/e' ratio<ref name="pmid19187853">{{cite journal| author=Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al.| title=Recommendations for the evaluation of left ventricular diastolic function by echocardiography. | journal=J Am Soc Echocardiogr | year= 2009 | volume= 22 | issue= 2 | pages= 107-33 | pmid=19187853 | doi=10.1016/j.echo.2008.11.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19187853 }} </ref> | |||
=== | ===Results of Echocardiography in Diastolic Dysfunction<ref name="pmid19187853">{{cite journal| author=Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al.| title=Recommendations for the evaluation of left ventricular diastolic function by echocardiography. | journal=J Am Soc Echocardiogr | year= 2009 | volume= 22 | issue= 2 | pages= 107-33 | pmid=19187853 | doi=10.1016/j.echo.2008.11.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19187853 }} </ref>=== | ||
The | *The diagnosis of diastolic dysfunction requires the estimation of the left ventricular filling pressures from the calculation of the E/e' ratio: | ||
**E/e' less or equal to 8: Normal LV filling pressure | |||
**E/e' more or equal to 13: Increase left ventricular pressure | |||
**E/e' between 9 and 12: Other measurements are needed to estimate the LV filling pressure. | |||
*The presence of two or more of the following abnormal measurements increase the confidence in the diagnosis of diastolic dysfunction: | |||
**Ar-2-A duration >30 ms | |||
**Change in E/A ratio with the Valsalva maneuver of >0.5 | |||
**PA systolicpressure>35 mm Hg (in the absence of pulmonary disease) | |||
* | **Maximal LA volume >34 mL/m2 | ||
* | |||
* | |||
===Assessment of LV filling pressures in special population<ref name="pmid19187853">{{cite journal| author=Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al.| title=Recommendations for the evaluation of left ventricular diastolic function by echocardiography. | journal=J Am Soc Echocardiogr | year= 2009 | volume= 22 | issue= 2 | pages= 107-33 | pmid=19187853 | doi=10.1016/j.echo.2008.11.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19187853 }} </ref>=== | ===Assessment of LV filling pressures in special population<ref name="pmid19187853">{{cite journal| author=Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al.| title=Recommendations for the evaluation of left ventricular diastolic function by echocardiography. | journal=J Am Soc Echocardiogr | year= 2009 | volume= 22 | issue= 2 | pages= 107-33 | pmid=19187853 | doi=10.1016/j.echo.2008.11.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19187853 }} </ref>=== | ||
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== | ===Diastolic Stress Test=== | ||
*Diastolic dysfunction is characterized by an increase in left ventricular filling pressures. During exercise, the stroke volume and left ventricular filling volumes are increased at the expense of elevated filling pressures. | |||
The evaluation of the LV function during exercise has the same concept of cardiac stress test. | |||
*Interpretation of the E/e' ratio in diastolic stress test:: | |||
**Normal diastolic function: | |||
***E and e' increase proportionally | |||
***E/e' ratios at rest and after exercise are the same | |||
**Impaired myocardial relaxation: | |||
***The increase in e' is significantly inferior to that of E | |||
***E/e' ratio is elevated <ref>Ha JW, Oh JK, Pellikka PA, Ommen SR, Stussy VL, Bailey KR, et al. Diastolic stress echocardiography: a novel noninvasive diagnostic test for diastolic dysfunction using supine bicycle exercise Doppler echocar- diography. J Am Soc Echocardiogr 2005;18:63-8.</ref> | |||
===Approach to grade diastolic dysfunction=== | ===Approach to grade diastolic dysfunction=== | ||
Shown below is a flowchart which provides a scheme for grading diastolic dysfunction. (Av., average; LA., left atrium; Val., Valsalva) | Shown below is a flowchart which provides a scheme for grading diastolic dysfunction. (Av., average; LA., left atrium; Val., Valsalva) | ||
Revision as of 23:29, 21 October 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2]; Rim Halaby
Overview
Diastolic dysfunction, in the presence or absence of diastolic heart failure, is a challenging diagnosis that has several diagnostic approaches. While cardiac catheterization can be used to the establish the diagnosis by invasively demonstrating elevated left ventricular end diastolic pressures and mean pulomnary capillary pressure, echocardiography provides an alternative noninvasive diagnostic approach.
There is no one single echocardiographic parameter that can confirm the diagnosis of diastolic heart failure. The echocardiographic evaluation for diastolic dysfunction includes:
- Blood flow Doppler measurements of the mitral inflow velocity patterns patterns (E: early diastolic; A: late diastolic), pulmonary vein flow patterns, E:A reversal
- Tissue Doppler (TD) measurements of the left ventricular annular flow E' and E/E' ratio
- Echocardiographic calculation of the left ventricle (LV) mass index and left atrial (LA) volume index. [1]
Echocardiography
The Principles of the Echocardiographic Evaluation
The diagnosis of diastolic dysfunction relies on the evaluation of the status of the left ventricular function and on the presence of any variations in the ventricular filling pressures.
In order to know what to expect as findings in the evaluation of diastolic dysfunction, it is important to understand the physiological role of the left atria (LA) during diastole and how it contributes to ventricular filling.
- The LA functions as a reservoir that receives the venous blood when the mitral valve is closed
- The LA functions as a conduit of blood from the atrium to the ventricle when the mitral valve is open
- The LA functions as a pump at the end of diastole to pump the remaining blood in the LA into the LV while preserving a normal LVEDP.
Hence, in diastolic dysfunction, the increased stiffness and diastolic dysfunction of the left ventricle impair the conduit role of the LA and cause a decrease in early diastolic atrio-ventricular gradient. As a consequence, the "reservoir" and "pump" role of the LA will try to compensate to maintain normal stroke volume and left ventricular end diastolic volume at the expense of an elevated LVEDP.[2]
The predictors of the filling pressure and degree of myocardial disease progression are essentially the mean pulmonary wedge pressure PCWP (which is equal to the mean left atrial pressure in the absence of mitral stenosis) and the left ventricular end diastolic pressure LVEDP.
- Normally, the diastolic phase of the cardiac cycle is characterized by rapid blood filling at low left ventricular pressures.
- The hallmark of diastolic dysfunction is elevated left ventricular end diastolic pressure or filling pressure
- The cut off values used for the diagnosis of diastolic dysfunction are:
- PCWP >12 mmHg
- LVEDP> 16mmHg [3]
- The PCWP and LVEDP are obtained by invasive measurements done by cardiac catheterization.
The importance of echocardiography is that it provides a non invasive way to assess the heart for diastolic dysfunction through he evaluation of several parameters:
- 1- LV wall thickness:
- The evaluation of the left ventricle is important because cardiac hypertrophy, usually secondary to hypertension, is a well known cause of diastolic dysfunction.
- 2- Left atrial volume:
- The assessment of the left atria volume helps in the detection of any left atrial remodeling secondary to the diastolic dysfunction.[4]
- 3- Pulmonary artery systolic and diastolic pressure:
- Increase in pulmonary artery pressure, in the absence of any pulmonary disease, is indicative of diastolic dysfunction.[5]
- 4- Left ventricular filling:
- The assessment of the left ventricular filling can be derived from the evaluation of:
- The mitral inflow velocities by Doppler ultrasound. The investigated parameters include the following:
- Peak E: early diastolic mitral inflow velocity
- Peak A: late diastolic mitral inflow velocity
- E/A ratio
- DT: Deceleration time of early filling velocities
- IVRT: Isovolumetric relaxation time
- Middiastolic flow
- The mitral inflow velocities by Doppler ultrasound. The investigated parameters include the following:
- The pulmonary vein flow velocity
- Left ventricular annular flow (e') and E/e' ratio[2]
- The assessment of the left ventricular filling can be derived from the evaluation of:
Results of Echocardiography in Diastolic Dysfunction[2]
- The diagnosis of diastolic dysfunction requires the estimation of the left ventricular filling pressures from the calculation of the E/e' ratio:
- E/e' less or equal to 8: Normal LV filling pressure
- E/e' more or equal to 13: Increase left ventricular pressure
- E/e' between 9 and 12: Other measurements are needed to estimate the LV filling pressure.
- The presence of two or more of the following abnormal measurements increase the confidence in the diagnosis of diastolic dysfunction:
- Ar-2-A duration >30 ms
- Change in E/A ratio with the Valsalva maneuver of >0.5
- PA systolicpressure>35 mm Hg (in the absence of pulmonary disease)
- Maximal LA volume >34 mL/m2
Assessment of LV filling pressures in special population[2]
| Disease | Echocardiographic measurements and cutoff values |
| Atrial fibrillation | Peak acceleration rate of mitral E velocity (≥1,900 cm/s2), IVRT (≤65 ms), DT of pulmonary venous diastolic velocity (≤220 ms), E/Vp ratio (≥1.4), and septal E/e= ratio (≥11). |
| Sinus tachycardia | Mitral inflow pattern with predominant early LV filling in patients with EFs <50%, IVRT ≤70 ms is specific (79%), systolic filling fraction ≤40% is specific (88%), lateral E/é >10 (a ratio >12 has highest the specificity of 96%) |
| Hypertrophic cardiomyopathy | Lateral E/é (≥10), Ar - A (≥30 ms), PA pressure (>35 mm Hg), and LA volume (≥34 mL/m2) |
| Restrictive cardiomyopathy | DT (<140 ms), mitral E/A (>2.5), IVRT (<50 ms has high specificity), and septal E/é (>15) |
| Non cardiac pulmonary hypertension | Lateral E/é can be applied to determine whether a cardiac etiology is the underlying reason for the increased PA pressures (cardiac etiology: E/é >10; noncardiac etiology: E/é <8) |
| Mitral stenosis | IVRT (<60 ms has high specificity), IVRT/ TE - e= (<4.2), mitral A velocity (>1.5 m/s) |
| Mitral regurgitation | Ar - A (>30 ms), IVRT (<60 ms has high specificity), and IVRT/TE - e= (<3) may be applied for the prediction of LV filling pressures in patients with MR and normal EFs, whereas average E/é (><15) is applicable only in the presence of a depressed EF. |
Diastolic Stress Test
- Diastolic dysfunction is characterized by an increase in left ventricular filling pressures. During exercise, the stroke volume and left ventricular filling volumes are increased at the expense of elevated filling pressures.
The evaluation of the LV function during exercise has the same concept of cardiac stress test.
- Interpretation of the E/e' ratio in diastolic stress test::
- Normal diastolic function:
- E and e' increase proportionally
- E/e' ratios at rest and after exercise are the same
- Impaired myocardial relaxation:
- The increase in e' is significantly inferior to that of E
- E/e' ratio is elevated [6]
- Normal diastolic function:
Approach to grade diastolic dysfunction
Shown below is a flowchart which provides a scheme for grading diastolic dysfunction. (Av., average; LA., left atrium; Val., Valsalva)
Estimation of filling pressure in patients with normal ejection fraction
Shown below is a flowchart which provides an algorithm for estimation of LV filling pressures in patients with normal EFs (Av, average).
References
- ↑ Walter J.How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.Eur Heart J(2007)28(20): 2539-2550.doi:10.1093/eurheartj/ehm037
- ↑ 2.0 2.1 2.2 2.3 Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA; et al. (2009). "Recommendations for the evaluation of left ventricular diastolic function by echocardiography". J Am Soc Echocardiogr. 22 (2): 107–33. doi:10.1016/j.echo.2008.11.023. PMID 19187853.
- ↑ Paulus WJ, Tschope C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007;28: 2539-50.
- ↑ Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol 2002;90: 1284-9
- ↑ Bouchard JL, Aurigemma GP, Hill JC, Ennis CA, Tighe DA. Usefulness of the pulmonary arterial systolic pressure to predict pulmonary arterial wedge pressure in patients with normal left ventricular systolic function. Am J Cardiol 2008;101:1673-6.
- ↑ Ha JW, Oh JK, Pellikka PA, Ommen SR, Stussy VL, Bailey KR, et al. Diastolic stress echocardiography: a novel noninvasive diagnostic test for diastolic dysfunction using supine bicycle exercise Doppler echocar- diography. J Am Soc Echocardiogr 2005;18:63-8.