SCA Annual Meeting 2014
Syllabus
“My Patient has Severe Diastolic Dysfunction; Now What?”
Tara Brakke M.D., FASE
The discussion about left ventricular diastolic dysfunction (LVDD) has been occurring since the 1990s. If a patient had symptoms of heart failure and normal systolic function, the patient may have dysfunction of the diastolic component of the heart cycle. Many studies including those by Rakowski, Nagueh, and
Sohn looked into the accuracy and reliability of measuring diastolic data. Then, using that data, classifying and risk stratifying patients with known diastolic dysfunction was studied. The importance of diastolic dysfunction was recognized because of the increase in morbidity and mortality that is associated with its’ diagnosis. Hamill et al found that patients with heart failure who undergo major noncardiac surgical procedures have substantially higher risks of operative mortality and hospital readmission than other patients, including those with coronary disease, admitted for the same procedures. Similar conclusions were made from studies involving vascular and cardiac procedures.
These authors conclude that there is a significant need for further investigation into perioperative management of patients with heart failure.
Diastolic heart failure is diagnosed by satisfying three conditions: 1) presence of signs or symptoms of heart failure; 2) presence of normal or slightly reduced left ventricular ejection fraction (>50%); and 3) presence of increased diastolic filling pressure. The morbidity associated with diastolic heart failure can be substantial and the annual mortality rate is approximately 8%. Diastolic heart failure is an important clinical disorder usually seen in patients with hypertension. Diastolic dysfunction is the precursor leading up to diastolic heart failure. Its’ pathophysiology includes impaired relaxation and poor compliance or increased stiffness resulting in impaired LV filling. Early recognition and therapy of diastolic dysfunction and its’ underlying cause is advisable to prevent further progression to diastolic heart failure.
Diastolic function can be assessed with echocardiography by using the following indices; mitral inflow, tissue Doppler of the lateral and septal annulus of the left ventricle, pulmonary vein flow, propagation velocity (Vp), and right atrial pressure estimation by measuring the inferior vena cava diameter and percentage of collapse on sniff test. The data obtained from these measurements including E/A ratio, E wave velocity, E wave deceleration time, E/e’, E/Vp, pulmonary vein systolic to diastolic ratio, Ar-A duration and pulmonary artery systolic pressure can be used to classify each patients’ diastolic function.
Nagueh et al verified the accuracy of these data points used in the algorithm of the American Society of
Echocardiograpy guidelines for the estimation of LV filling pressures in patients with depressed ejection fraction. These measurements are most useful in a preoperative transthoracic echocardiography (TTE).
Preoperative echocardiography diastolic indices may provide the opportunity to pharmacologically optimize a patient prior to surgery. Preoperative echocardiographic diastolic data also allows perioperative physicians to better manage patients by knowing the severity of current diastolic dysfunction.

It is important to recognize that diastolic function is dynamic, and thus a patient can often move from one grade of LVDD to another under changes in loading conditions. It is important for perioperative physicians to understand that anesthesia management impacts the diastolic function and left ventricular filling pressures. The perioperative physician should identify patients with high filling pressures or those at risk for developing high filling pressures, including patients with hypertension, ischemia, obesity and smokers. Assessing the LV filling pressure should be done as soon as possible using the comprehensive approach in the ASE guidelines, either preoperatively using TTE or intraoperatively using
TTE or transesophageal echocardiography. Unfortunately, the symptoms (dyspnea, fatigue, exercise intolerance), signs (jugular venous distention, pulmonary rales, peripheral edema), and radiographic evidence (pulmonary vascular redistribution, interstitial edema, pleural effusions) of heart failure occur with equal frequency in patients with diastolic heart failure as systolic heart failure. Therefore, the history, physical exam, and chest x-ray are not specific enough to differentiate the two entities, an echo assessment is necessary. Once a patient at risk is identified, pharmacologic and fluid management should be optimized to prevent a patient from getting high filling pressures or improve the status of a patient that started the procedure with high filling pressures. The study by Nagueh et al in 2011 showed hemodynamic changes in patients who underwent repeat studies following a pharmacologic intervention. It is possible to improve a patient’s filling pressure or at least not worsen it, but how?
Current literature regarding the guidelines for the management of diastolic heart failure is limited.
There have been no randomized, double-blind, placebo-controlled multicenter trials performed in patients with diastolic heart failure. Therefore, the management guidelines are based on clinical investigations in relatively small groups, clinical expertise, and concepts based on pathophysiological mechanisms. The treatment regimen applies to symptomatic diastolic heart failure, the benefits of such therapy in asymptomatic patients has not been examined. The majority of surgical patients will be asymptomatic, as elective surgery should be postponed in a patient with heart failure symptoms. Flu et al studied cardiovascular outcomes in 1005 vascular patients and found that 50% had LV dysfunction, either systolic or diastolic and that 80% of those with dysfunction were asymptomatic. Patients with asymptomatic isolated diastolic LV dysfunction were associated with increased 30-day cardiovascular events and long-term cardiovascular mortality. This data suggests the need for preoperative risk stratification that includes a preoperative echocardiography even in asymptomatic patients. One recently published study by Dr. Shillcutt et al at our institution showed the safety and feasibility of performing preoperative TTE exams and identifying patients at risk for increased filling pressures in the perioperative period. Those patients were then randomized to one of two groups. The first received standard anesthetic and fluid management and the second group received echo guided anesthetic management, where diastolic indices were measured serially in the OR . This was a small prospective randomized study that indicated that the LV diastolic function can change following induction of anesthesia and possibly with acute management decisions. We showed that the treatment algorithm utilized to decrease filling pressures and optimize stroke volume and cardiac output is safe and larger studies are needed to better understand how management affects outcomes.

The treatment of diastolic heart failure can be framed in three goals. The first goal is to reduce symptoms, this is the most applicable to the perioperative period. Symptoms of diastolic heart failure are caused by an increase in LV diastolic pressures.
Reduce Filling Pressures
1) Decreasing the LV volume will decrease pulmonary venous pressure and LV diastolic pressure. a) Mild vasodilatation i) General anesthesia ii) Low dose nitrates. b) Managing fluids i) Judicious fluid administration ii) Diuretics can be useful in reducing pulmonary congestion and LV volume. c) Blunting the neurohumoral systems, such as the renal angiotensin aldosterone system i) ACE inhibitors ii) AT₁ receptor antagonists iii) Aldosterone antagonists
Repeated LV filling pressure and cardiac output assessments using echocardiography throughout the perioperative period assists in management choices.
2) Maintaining synchronized atrial contraction and avoiding tachycardia a) Tachycardia is poorly tolerated because it increases myocardial oxygen demand and decreases coronary perfusion time. This can promote diastolic dysfunction caused by ischemic disease, especially in patients with LV hypertrophy. A shortened diastole may cause incomplete relaxation causing an increase in diastolic pressure relative to volume.
Lastly, diastolic dysfunction causes a flat or even negative relaxation velocity versus heart rate relationship, so that as heart rate increases, relaxation rate does not increase, or may even decrease, which can then cause diastolic pressures to increase. i) Beta blockers ii) Calcium channel blockers iii) Perioperative pain control is especially important as well to avoid associated tachycardia.
The other two goals include targeting the pathologic disease that caused the diastolic heart dysfunction and target the underlying mechanisms altered by the disease process. These goals are for long term therapy and difficult to achieve perioperatively.
Perioperative approach to a patient having either a cardiac or noncardiac procedure is similar. A good preoperative history is important, evaluate for new or ongoing symptoms of heart failure. It is most useful to have a preoperative echocardiography exam. You don’t know if you don’t look. If the patient has new symptoms, a preoperative TTE is crucial. The decision must then be made whether to proceed with the procedure or optimize the patient’s function. If the echo is not obtained until the patient is under general anesthesia, it is much more difficult to make those decisions.

Patients at risk for increased LV filling pressure should be assessed after induction. Using the ASE algorithm a patient’s baseline status should be determined. Mitral inflow data including peak E wave velocity, peak A wave velocity, E wave deceleration time, and E/A ratio should be obtained using pulse wave Doppler at the mitral valve leaflet tips. Propagation velocity data using color Doppler m-mode should be determined. Pulse wave Doppler utilized to find tissue Doppler(e’) at the septal and lateral annulus of the mitral valve. Pulse wave Doppler in the pulmonary vein to find peak S wave, peak D wave, peak Ar wave, and Ar duration. Mitral A duration is found using pulse wave Doppler at the mitral annulus. On a TTE, the IVC diameter and percentage of collapse on sniff test is recommended as well as, hepatic vein flow. The following algorithm from Nagueh et al should be utilized.
Estimation of Filling Pressures in Patients with Depressed EF
Mitral E/A
E/A≥ 1 and < 2, or
E/A<1 and E ≤ 50 cm/s E/A <1 and E >50 cm/s
E/e’ (avg e’) <8; E/Vp <1.4;
S/D>1; Ar – A <0 ms;
Valsalva Δ E/A <0.5; PAS <30 mmHg; IVRT/T (E-e’) >2
E/A ≥ 2, DT <150 ms
E/e’ (avg e’) >15; E/Vp ≥2.5;
S/D <1; Ar-A≥ 30ms;
Valsalva Δ E/A ≥ 0.5; PAS
>35 mmHg; IVRT/T (E-e’) <2
Normal
LAP
Normal
LAP
↑LAP ↑LAP
Estimation of Filling Pressures in Patients with Normal EF
E/e’
E/e’≤ 8 E/e’ 9-14
LA volume <34 ml/m²;
Ar-A < 0 ms; Valsalva Δ
E/A <0.5; PAS <30 mmHG; IVRT/T (E-e’) >2
E/e(avg)’ ≥ 13
LA Volume ≥34 ml/m²; Ar –
A ≥ 30 ms; Valsalva Δ E/A ≥
0.5; PAS > 35 mmHg;
IVRT/T (E-e’) <2
Normal LAP Normal LAP
↑LAP ↑LAP

Initial assessment includes a patient’s stroke volume and cardiac output, PASP, PADP, RAP estimate. No fluid resuscitation should begin until this data is obtained. Patient’s LV filling pressure should be optimized using the above strategies including limiting fluid and utilizing diuretics if needed, vasodilatation, perioperative ACEi use continued, maintaining atrial contraction, a slow heart rate, and optimizing cardiac output. Each of these parameters should be reassessed at regular intervals approximately 2-3 times per hour. Maximizing cardiac output ensures vital organ perfusion and should be documented each time the echocardiographic data is obtained. Finding each patient’s best cardiac output may take time and pharmacologic assistance. The appropriate mean blood pressure where optimum cardiac output is achieved is an important goal for managing each anesthetic. Decreasing LV filling pressure with fluid and pharmacologic management is also an anesthetic priority for each procedure.
References:
Fahad, A. et al. Diastolic Heart Failure: A Concise Review. J Clin Med Res. 2013; 5(5):327-334
Flu, WJ., et al. Prognostic Implications of Asymptomatic Left Ventricular Dysfunction in Patients
Undergoing Vascular Surgery. Anes. 2010; 112(6):1316-1324
Hammill, B., et al. Impact of Heart Failure on Patients Undergoing Major Noncardiac Surgery. Anes.2008;
108(4):559-567
Nagueh, SF., et al. Doppler estimation of left ventricular filling pressures in patient with hypertrophic cardiomyopathy. Circulation. 1999;99(2):254-261
Nagueh, S., et al. Echocardiographic Evaluation of Hemodynamics in Patients with Decompensated
Systolic Heart Failure. Circ Cardiovasc Imaging. 2011; 4:220-227
Rakowski H., et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus of Diastolic Dysfunction by Echocardiography. J Am Soc Echocariogr. 1996;9(5)736-760
Shillcutt, S. et al. Echocardiography-Based Hemodynamic Management of Left Ventricular Diastolic
Dysfunction: A Feasibility and Safety Study. Echocardiography. Accepted for publication January 2014
Son, DW., et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardio. 1997;79(7):921-928
Zile, M., et al. New Concepts in Diastolic Dysfunction and Diastolic Heart Failure: Part II. Circulation.
2002; 105:1053-1058.