4.4 How to assess diastolic function | 123sonography
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4.4 How to assess diastolic
function
written by
Prof. Thomas Binder, MD, FESC
Sun, 28/10/2012
written by
Martin Altersberger, MD
Thu, 02/05/2019
Several techniques and parameters have been introduced to assess diastolic
function of the heart. The complexity of this phenomenon and the
difficulties in interpreting these findings have led to confusion among those
performing echocardiography as well as those who interpret its results. To
cover the entire spectrum of possibilities, the most commonly used
modalities are described in this chapter. A simple and practical approach to
“diastology” is also provided in order to assist you in viewing this
information in the appropriate context. Finally, at the end of the chapter
you will find a few examples of diastolic function in the clinical setting.
If you want to get an overview, read Diastolic Function & Diastolic
Dysfunction first.
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4.4.1 Mitral Inflow signal to assess
diastolic dysfunction
The evaluation mitral inflow plays an important role in grading diastolic
dysfunction in patients with reduced EF or structural heart disease.
The mitral inflow signal visualizes the individual phases of filling as well as
displays the contribution of each individual phase in filling. As mitral
inflow reflects the pressure difference between the atria and the ventricle,
any abnormality of diastolic pressure (as in the presence of diastolic
dysfunction) in the chambers will affect the velocity and shape of the
Doppler inflow signal. Specifically, diastolic dysfunction alters the
relationship between early and late filling (E- and A-wave), how rapidly
flow velocity declines in early diastole (E-wave deceleration time = DT),
and how long it takes for filling of the ventricle to start after the ventricle
relaxes (length of the isovolumetric relaxation time = IVRT).
4.4.1.1 Normal diastolic function
Under normal conditions most of the blood will fill the ventricle during
early diastole (passive filling). Thus, the E-wave is taller than the A-wave.
Mitral E/A ratio - cut off value: ≤ 0.8 & > 2. The shape of the E-wave is
quite symmetrical and the normal deceleration time (DT) - cut off value:
140 - 240 msec. Filling does not start immediately after the end of systole.
First the pressure in the ventricle has to drop below that of the left atrium.
The time until this happens is referred to as the isovolumetric relaxation
time (IVRT). Under normal conditions: Isovolumetric relaxation time
(IVRT) - cut off value: ≤ 70 mm/sec - >100 mm/sec.
Normal pattern of diastolic filling: the E-wave is taller than the A-wave
4.4.1.2 Supernormal filling
Especially young and physically active individuals will demonstrate a
vigorous recoil of the ventricle during diastole. This creates negative
pressure in the ventricle and causes suction of blood from the atrium
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during early filling. The most prominent finding on the Doppler inflow
signal is a very high E-wave. As most of the blood in the left atrium is
emptied during this phase, not much volume will remain in the atrium to
be “pushed” into the ventricle during atrial contraction. Thus the A-wave
will be rather small. In this setting you will find an E/A ratio >2. The IVRT
is short and the deceleration time normal. The spectrum of supernormal
diastolic function may look very similar to a restrictive filling pattern (see
below). You will later see how these two conditions can be distinguished
from each other.
Supernormal filling: the E-wave is at least twice as high as the A-wave.
4.4.1.3 Impaired relaxation - grade 1 diastolic
dysfunction
A stiff ventricle will impair early filling of the ventricle. Thus, the
magnitude of the E-wave will decrease. It will take longer for atrial pressure
to be high enough to initiate filling. The IVRT will increase (> 100 ms) and
the DT will also be prolonged (≥ 240 ms). As less volume is transported
into the left ventricle during early filling, more blood is present at the time
of atrial contraction. Therefore atrial contraction will eject more blood into
the left ventricle. The A-wave will be larger than normal and will typically
also be larger than the E-wave (E/A ratio ≤ 0.8). Thus atrial contraction
basically compensates for the decrease in early filling. This also explains
why patients who develop atrial fibrillation (no atrial contraction) in the
presence of a stiff ventricle (i.e. left ventricular hypertrophy) become highly
symptomatic. Impaired relaxation is termed “grade I diastolic dysfunction”.
Under these circumstances, filling pressure is still normal or just mildly
elevated. It is a common condition and may also be observed in elderly
patients. In fact, it may be considered as a normal aspect of the aging
process.
Disturbed relaxation: the A-wave is taller than the E-wave
Impaired relaxation is a common occurrence. 25% of the adult population
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over 40 years of age have grade I diastolic dysfunction.
GET FREE ECHO LECTURES
4.4.1.4 Pseudonormal filling pattern - grade 2
diastolic dysfunction
Progressive diastolic dysfunction causes left atrial pressure to rise. The
latter increases the pressure gradient between the left atrium and the left
ventricle and will act as a driving force to fill the ventricle during early
diastole. Thus the size of the E-wave relative to the A-wave will increase,
and the E/A ratio will return to the range of 0.8 to 1.5. DT and IVRT (< 90
ms) will also decrease. The spectrum will look very similar to that of
“normal” diastolic function. This condition is therefore referred to as
“pseudonormal”. Pseudonormal filling is classified as grade II diastolic
dysfunction. Several approaches may be used to distinguish between
“normal” and pseudonormal filling:
Pseudonormal filling: the E-wave is taller than the A-wave; the deceleration time is short.
Is diastolic dysfunction likely?
When the echocardiogram is otherwise normal (normal systolic
function, no left ventricular hypertrophy, normal size of the left
ventricle, etc.) and the patient is young, the filling pattern is most
likely indicative of normal diastolic function.
Valsalva maneuver:
The Valsalva maneuver increases intrathoracic pressure and thus
reduces venous return to the atrium. This “unloads” the ventricle and
causes a drop in filling pressure. Thus, the Valsalva maneuver
permits the investigator to unmask elevated filling pressures. In the
presence of pseudonormal filling one will see a “reversal” of the
pattern to that of impaired relaxation (the E/A ratio will drop below
1). Valsalva maneuver unmasks diastolic dysfunction and alters
pseudnormal filling into impaired relaxation. To perform a Valsalva
maneuver let the patient press while he is in mid-breathing level.
Observe the mitral inflow signal. The maneuver is effective once you
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see a rise in heart rate. Usually you will also see a decrease in overall
inflow velocity.
Other modalities:
The use of tissue Doppler at the mitral annulus (see below) permits
the investigator to estimate filling pressure. An average E/e´ ratio
above 14 is indicative of diastolic dysfunction (ratios between 8 and
12 denote possible diastolic dysfunction). The pattern will be that of
pseudonormal filling. Aside from TDI one may also view the
4.4 How to assess diastolic function
pulmonary inflow pattern and flow propagation. These methods will
4.4.1 Mitral Inflow signal to assess
be discussed in the following sections.
diastolic dysfunction
4.4.1.1 Normal diastolic function
4.4.1.2 Supernormal filling
4.4.1.3 Impaired relaxation - grade 1
diastolic dysfunction
4.4.1.4 Pseudonormal filling pattern grade 2 diastolic dysfunction
4.4.1.5 Reversible restrictive filling
4.4.1.5 Reversible restrictive filling pattern - grade 3
diastolic dysfunction
A further increase in filling pressure will increase the gradient between the
left atrium and the left ventricle during early diastole. The E-wave will
pattern - grade 3 diastolic
become even taller and the A-wave shorter. The E/A ratio will be ≥ 2. In
dysfunction
severe forms the A-wave may be so small as to be nearly invisible, and the
4.4.1.6 Irreversible restrictive filling
Pattern - grade 4 diastolic
E/A ratio may reach very high values of 5 or more.
dysfunction
When filling pressures are high, flow into the ventricle will start early and
4.4.1.6 Mitral inflow signal - Problems
filling will terminate quickly. Therefore, typical additional signs of
4.4.1.7 The L-wave
restrictive filling include a short IVRT (≤ 70 ms) and DT (<140 ms). In
4.4.2 Tissue Doppler for the
assessment of diastolic dysfunction
4.4.2.1 Introduction
4.4.2.3 Other tissue Doppler
parameters:
a Valsalva maneuver. When a Valsalva maneuver is able to reverse
restrictive filling to a “pseudonormal” pattern we quantify diastolic
dysfunction as “grade III”. In other words, unloading of the ventricle is still
able to cause a significant drop in filling pressure.
4.4.3 Pulmonary vein flow
4.4.4 Color Doppler M-mode - flow
As mentioned previously, the restrictive filling pattern appears quite
propagation
similar to that of supernormal filling. However, in clinical practice it is
4.4.5 Indirect signs of diastolic
rarely difficult to distinguish between the two phenomena. Patients with a
dysfunction
restrictive pattern have a significantly elevated filling pattern, are thus
GET FREE ECHO LECTURES
4.4.2.2 E/e´ ratio
some patients it will be possible to reduce left atrial pressure by performing
“sick”, and highly symptomatic. Here one is confronted with individuals at
one end of the spectrum. The echocardiogram always shows pronounced
abnormalities (reduced left ventricular function, left ventricular
hypertrophy, enlarged left atrium, etc.) as opposed to supernormal filling.
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Restrictive filling pattern: the E-wave is more than twice the size of the A-wave
4.4.1.6 Irreversible restrictive filling Pattern - grade 4
diastolic dysfunction
This most severe form of diastolic dysfunction (grade 4) differs from grade
3 only by the fact that a Valsalva maneuver is unable to reverse the pattern
to a pseudonormal one (see above). These patients commonly have
advanced forms of heart failure and are usually symptomatic. In general,
the larger the E/A ratio is and the shorter the deceleration time is, the
higher are left atrial filling pressures and the less likely it will be for the
pattern to be “reversed” to a pseudonormal one.
16- 20 years
21- 40 years
41- 60 years
> 60 years
IVRT (ms)
50 ± 9
67 ± 8
74 ± 7
87 ± 7
DT (ms)
142 ± 19
166 ± 14
181 ± 19
200 ± 29
A duration
113 ± 17
127 ± 13
133 ± 13
138 ± 19
E/A
1.88 ± 0.45
1.53 ± 0.4
1.28 ± 0.25
0.96 ± 0,18
In summary, the different filling patterns reflect the degree of diastolic
dysfunction and the magnitude of filling pressures. Although the various
forms do overlap in respect of the true filling pressure, several studies have
shown that this grading scale correlates well with the severity of disease,
NT-ProBNP levels, symptoms, and prognosis.
Grading of diastolic dysfunction based on the mitral inflow signal
4.4.1.6 Mitral inflow signal - Problems
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The major drawback of using the Doppler inflow signal is that it is limited
to patients who have sinus rhythm. Although the deceleration time itself
also reflects diastolic dysfunction and a short deceleration time denotes
elevated filling pressure, it does not permit grading of diastolic dysfunction.
The deceleration time may also be used to estimate filling pressures in a
patient with atrial fibrillation; the E/A ratio cannot be used in these
patients. A short deceleration time ( <130 ms) indicates elevated filling
pressures.
It may be difficult to interpret the spectrum in clinical practice because one
may be confronted with fusion of the E- and the A-wave. In these cases it is
advisable to use provocation maneuvers that slow the heart rate (carotid
massage).
Complete fusion of the E- and the A-wave in a patient with tachycardia followed by carotid sinus
massage, leading to separation of the E- and the A-wave
The E/A ratio may also fluctuate with respiration, such as between
impaired relaxation and pseudonormal filling, and most likely is an
intermediate stage between two patterns. In these cases it would be
advisable to additionally use other modalities to grade diastolic
dysfunction.
The magnitude of the E-wave also reflects transmitral flow volume. The
E/A ratio may be misleading especially in the setting of (severe) mitral
regurgitation.
4.4.1.7 The L-wave
Very little or almost no filling occurs during diastasis. However, when
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diastasis is rather long (bradycardia) and a clear separation is seen between
the E-wave and the A-wave, an additional L-wave may be observed during
mid-diastole. This wave indicates continued pulmonary vein flow through
the left atrium (LA) into the left ventricle (LV) after early rapid filling.
Predisposing factors are reduced left ventricular relaxation in conjunction
with increased left ventricular stiffness and elevated left atrial to left
ventricular gradients. Thus, a prominent L-wave also denotes diastolic
dysfunction. Several investigations have shown that its presence is
correlated with symptoms, prognosis, and elevated filling pressures.
L-wave seen between the E- and the A-wave (mitral inflow signal) and e´and a´ (tissue Doppler
signal)
The presence of an L-wave may help to differentiate a normal filling pattern
from a pseudonormal one. When an L-wave is present you can be certain
that the pattern is pseudonormal.
L-waves are also seen in the M-mode and with tissue Doppler
4.4.2 Tissue Doppler for the assessment
of diastolic dysfunction
4.4.2.1 Introduction
The motion of the mitral valve annulus mirrors systolic as well as diastolic
events. During systole the annulus moves caudally towards the apex, and
during diastole it moves cranially towards the atrium. The motion of the
annulus can be recorded with the help of PW tissue Doppler (TDI) at the
medial (septal) as well as the lateral ring (in a four chamber view).
To measure the velocity of mitral annular motion use tissue Doppler (TDI)
and place the sample volume approximately 1 cm within the insertion of
the mitral valve leaflets.
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Tissue Doppler signal recorded from the medial annulus
On the Doppler tracing the diastolic signal shows a negative deflection.
Similar to conventional Doppler of mitral inflow, you will find an E-wave
and an A-wave. By definition these waves are termed e´ (e prime) and a´ (a
prime). They also represent early and late diastolic filling, respectively.
Tissue Doppler of the mitral annulus permits measurement of both time
intervals (i.e. IVRT, deceleration time, QRS onset to mitral e´) and
maximum velocities (e´ max, a´ max). However, while absolute values with
tissue Doppler provide information about diastolic function, the
relationship between these values and conventional PW Doppler is used
more widely in clinical practice.
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Timing of events based on the tissue Doppler signal at the mitral valve annulus
4.4.2.2 E/e´ ratio
To derive the E/e´ ratio one must divide the maximum velocity of the Ewave of mitral valve inflow by the maximal velocity of E. In normal
individuals the E/e´ ratio is <8. In the presence of diastolic dysfunction /
impaired relaxation, e´ will be rather low. In contrast, the E-wave increases
with elevated filling pressures. Thus the E/e´ ratio will increase in the
presence of diastolic dysfunction. An E/e´ratio >14 is highly suggestive of
elevated filling pressures. The ratio may be employed to directly estimate
filling pressure by using the following formula:
LAP = (E/e´ x 1.25) + 1.9
In addition, studies have shown that the E/e´ ratio increases with the
severity of heart failure, correlates well with NT pro BNP values, and
declines when heart failure improves.
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Mitral inflow Doppler signal and tissue Doppler signal of the medial mitral valve annulus in the
same patient to calculate the E/e´ ratio. The ratio in this patient is 8.5 (0.85ms/0.10 ms).
From the technical point of view, the E/e´ ratio derived from the septal
annulus is usually higher than that obtained from the lateral ring because e
´ velocities are higher in the former. The reason is that the septal annulus
cannot move as freely as the lateral annulus because it is “tethered” to the
rigid intervalvular fibrosa. Velocities at the septal ring are probably also
affected by the motion of the right ventricle. Thus, many investigators
suggest the use of the lateral ring. Studies have shown that those
measurements are more closely correlated with filling pressures. However,
especially in the presence of regional wall motion abnormalities which may
also reduce annular velocity, it is best to use an average of the septal and
the lateral E` wave velocity. The following table shows normal values for
the individual measurement sites:
Tissue Doppler tracing of the medial and lateral annulus in the same patient. The velocity is lower
in the medial aspect (0.6 cm/s) than in the lateral one (10cm/s).
Septal E/e‘ ratio
elevated > 15
Lateral E/e‘ ratio
elevated > 13
Average of septal and lateral
> 14
The major limitation of E/e´ prime is the fact that it is not reliable in
patients with left ventricular dysfunction. It can also be misleading in
normal hearts. Other settings in which E/e´ should not be used are shown
in the following table:
Annular calcification
Mitral valve prosthesis
Mitral stenosis
Moderate to severe mitral regurgitation
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4.4.2.3 Other tissue Doppler parameters:
Both, conventional and tissue Doppler must be performed to calculate TEe. With conventional Doppler one measures the time interval from the
beginning of the QRS complex to the onset of the E-wave. With TDI one
measures the time interval between the QRS complex and the e´wave. The
former value is then subtracted from the latter. Thus, in essence TE-e´
describes the time interval between E an e´. The longer this interval is, the
more severe is diastolic dysfunction.
As these measurements are obtained from different modalities and
different beats, the investigator must ensure that the lengths of the beats
match.
Normal value - IVRT/TE-e´ratio = normal <2
4.4.3 Pulmonary vein flow
A representative inflow signal from the pulmonary veins is best obtained
from a four-chamber view. Use the right upper pulmonary vein and display
the inflow with color-Doppler to determine where the sample volume
should be placed (see Chapter 2, How to Image). The normal spectrum
consists of the following components:
A systolic component which frequently shows two peaks, namely S1
and S2. S1 corresponds to atrial relaxation while S2 occurs between
atrial relaxation and the beginning of diastole (opening of the mitral
valve).
Diastolic component (D), which shows positive deflection during the
early (passive) filling phase and a small negative wave (AR) during
atrial contraction. AR is caused by a small fraction of blood which is
pushed back into the pulmonary veins during atrial contraction.
In the presence of diastolic dysfunction and impaired left atrial filling,
blood flow in the pulmonary vein will be shifted from systole to diastole.
Thus, the systolic wave will become smaller and the diastolic wave larger.
As reduced compliance of the ventricle results in increased resistance to
flow during atrial contraction, more blood will be pumped “backwards”
into the pulmonary veins as the atrium contracts. Thus, the AR wave will
become larger and its duration will increase.
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Doppler signal from the pulmonary vein and severity of diastolic dysfunction
Several parameters and calculations may be derived from the pulmonary
Doppler tracing. Changes in these parameters help to quantify diastolic
dysfunction:
Peak systolic (S) velocity
Peak anterograde diastolic (D) velocity
S/D ratio
Systolic filling fraction (S velocity-time integral/[S velocity-time
integral / D velocity-time integral])
Peak AR velocity in late diastole
Duration of the AR-wave (ARdur)
Time difference between AR velocity and mitral A-wave duration (Ar
/ A)
D velocity DT.
Diastolic dysfunction is most commonly assessed by the S/D ratio, AR and
ARdur and its relationship with the A-wave of mitral inflow velocity. An
S/D ratio less than 40% is associated with an elevated mean left atrial
pressure of 15 mmHg. When the AR velocity is more than 35 cm/s and
ARdur more than 30 msec longer than the mitral inflow A-wave, left
ventricular end-diastolic pressure is usually greater than 15 mmHg.
Despite the firmly established value of the pulmonary-vein approach to
diastolic function, it is rarely used in clinical practice. The main reason is
the difficulty in obtaining reasonable signals. It requires good imaging
skills, time, and adequate image quality. Besides, when the pulmonary
veins are rather small the motion of the heart will cause the sample volume
to shift outside the pulmonary veins, leading to artifacts from the left atrial
wall. Patients with supernormal filling will also demonstrate a larger Dwave because suction during early diastolic filling affects pulmonary flow.
Finally, the A-wave may be very small and difficult to demonstrate in
patients with severely elevated filling pressures.
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4.4.4 Color Doppler M-mode - flow
propagation
The color-Doppler M-mode is another technique to study early diastolic
inflow into the left ventricle and thus diastolic function. This method is
basically a means of determining how rapidly blood travels from the base of
the ventricle towards the apex. In the presence of diastolic dysfunction the
ventricle is stiffer and also applies less suction during early diastole. Thus,
blood flow will be slower.
To display this phenomenon one uses a four-chamber color view and places
the M-mode line through the mitral inflow signal. Ideally the color flow
baseline is shifted below the Nyquist limit (approximately to 0.35 cm/s).
The spectrum will then display a slanted flame-like color plot that is blue at
its center. To measure flow propagation one measures the slope of the
aliased signal (blue) from the mitral valve plane 4 cm into the ventricle. In
normal individuals the slope (Vp) will be greater than 30cm/s. Blood
frequently reaches the apical region before early flow at the level of the
mitral valve has stopped.
In the presence of diastolic dysfunction the slope will decrease and flow
might not even reach the apical regions.
By combining this information with the maximum Doppler inflow velocity
of the E-wave and calculating the E/VP ratio it will be possible to estimate
left ventricular filling pressures. When the ratio is above 2.5, pulmonary
capillary wedge pressure (PCWP) is usually greater than 15 mmHg.
The main limitation of this technique is that the reproducibility of
measurements is rather poor. It may be quite difficult to determine the
exact slope because the color spectrum may be quite “fuzzy”. Besides,
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further progression of diastolic function does not cause the steepness of the
curve to decline much further. Velocities will reduce and exact
measurements may be rendered more difficult.
As the geometry of the ventricle and other flow phenomena affect the color
M-mode spectrum, it is of limited use in very small ventricles, valvular
heart disease (such as mitral stenosis or mitral regurgitation) and
intracavitary obstructions. Finally, patients with tachycardia may
demonstrate fusion of early and late diastolic filling, thus making it
impossible to derive a clear early diastolic color signal.
4.4.5 Indirect signs of diastolic
dysfunction
Diastolic dysfunction and elevated filling pressures are commonly observed
in several conditions. In many of these, it is an inevitable consequence of
the disease. Patients with (moderate to severe) left ventricular hypertrophy
or systolic dysfunction always have a certain degree of diastolic
dysfunction. Thus the mere presence of such findings denotes diastolic
dysfunction. These abnormalities do not merely help to differentiate
between normal and pseudonormal diastolic dysfunction as well as
determine whether filling pressures are elevated, but also provide
information about the primary cause of diastolic dysfunction.
Elevated filling pressures affect the heart. They typically cause atrial
enlargement. One frequently observes bulging of the interatrial septum to
the right, an expanded left atrial appendage, and dilated pulmonary veins.
Further progression of diastolic dysfunction is commonly accompanied by
a rise in pulmonary artery pressures and even severe tricuspid
regurgitation.
Pulmonary hypertension (in the absence of pulmonary disease) indicates
elevated filling pressures.
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!
Large left atrium as an indicator of diastolic dysfunction in a patient with
severe left ventricular hypertrophy.
Look for causes and accompanying signs of diastolic dysfunction.
‹ 4.3 Pathology of diastolic dysfunction
up
4.5 A Simple Approach to Diastolic Dysfunction ›
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