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CHAPTER 5: Diastology

GUIDELINES Source

  • Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2016;29:277–314.

  • This is an essential document for the echocardiographer.

  • There are various resources in the document that can be used without reading it from beginning to end.

  • The pressure tracings, drawings, and echo images are easy to understand. They illustrate key concepts.

  • Key points are separately highlighted and summarized in stepwise fashion.

  • The tables and algorithms organize technical scanning information for the reader.

EVALUATION OF DIASTOLIC FUNCTION

  • Left ventricular diastolic function can be evaluated by measuring indices of left ventricular:

    • - Relaxation.

    • - Restoring forces.

    • - Diastolic compliance.

    • - Filling pressure.

  • By using a combination of indices, diastolic function can be graded and LV filling pressure estimated (Table 5-1).

  • Diastolic function should be determined:

    • - In unexplained exertional dyspnea, or other symptoms or signs of heart failure that cannot be attributed to reduced LV systolic function, or to diseases such as coronary artery disease, valve disease, pulmonary vascular disease, lung disease, or other diseases.

    • - To attempt to answer whether LV filling pressure is elevated in patients with heart failure and reduced LV ejection fraction, and when considering adjustment of diuretics or other heart failure medication.

    • - Grading of diastolic function can be used for risk assessment in asymptomatic subjects and in patients with heart disease.

TABLE 5-1Grading of Diastolic Dysfunction
View Table||Download (.pdf)
TABLE 5-1 Grading of Diastolic Dysfunction
Normal Grade 1 Grade 2 Grade 3
LV relaxation Normal Impaired Impaired Impaired
LA pressure Normal Low or normal 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/s) <2.8 <2.8 >2.8 >2.8
LA volume index Normal Normal or increased Increased Increased

Sources

  • Flachskampf FA, Biering-Sørensen T, Solomon SD, et al. Cardiac imaging to evaluate left ventricular diastolic function. JACC Cardiovasc Imaging. 2015;8:1071–1093.

  • Smiseth OA. Evaluation of left ventricular diastolic function: state of the art after 35 years with Doppler assessment. J Echocardiogr. 2018;16:55–64.

INDICATORS OF DIASTOLIC DYSFUNCTION

  • E/e’ ratio is seldom greater than 14 in individuals with normal filling pressures.

  • Ar-A: An increase in pulmonary vein atrial reversal velocity duration versus mitral A duration is consistent with increased left ventricular end-diastolic pressure.

  • A restrictive left ventricular filling pattern is found in dilated cardiomyopathy (Fig. 5-1).

  • Left atrial size is increased (>34 mL/m2).

  • Tricuspid regurgitation velocity is increased (>2.8 m/s).

  • When systolic LV function is abnormal, diastolic function is presumed to be abnormal as well.

  • In patients with clinical heart failure and apparently preserved systolic function, strain may demonstrate abnormal myocardial systolic and diastolic function.

  • Caution when there is mitral annular calcium (MAC):

    • - LV diastolic parameters, ...

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