The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography

doi:10.1016/S0894-7317(97)70062-2

Journal of the American Society of Echocardiography

Volume 10, Issue 3, April 1997, Pages 246-270

https://doi.org/10.1016/S0894-7317(97)70062-2 Get rights and content

Abstract

Left ventricular diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. An impaired relaxation pattern identifies patients with early stages of heart disease, and appropriate therapy may avert progression and functional disability. Pseudonormalization is a transitional phase between abnormal relaxation and restrictive physiology and signifies increased filling pressure and decreased compliance. In this phase, reducing preload, optimizing afterload, and treating the underlying disease are clinically helpful. A restrictive physiology pattern identifies advanced, usually symptomatic disease with a poor prognosis. Therapeutic intervention is directed toward normalizing loading conditions and improving the restrictive filling pattern, although this may not be feasible in certain heart diseases. Finally, many patients have left ventricular filling patterns that appear indeterminate or mixed. In these cases, clinical information, left atrial and left ventricular size, pulmonary venous flow velocity, and alteration of preload help assess diastolic function and estimate diastolic filling pressures. (J Am Soc Echocardiogr 1997;10:246-70.)

Section snippets

Echocardiographic Evaluation of Diastolic Function

Normal diastolic function allows adequate ventricular filling during rest and exercise without abnormal increase in diastolic pressures. Adequate diastolic filling ensures normal stroke volume according to the Frank-Starling mechanism. LV filling consists of a series of hemodynamic events (Figure 1) that are affected by multiple intrinsic and extrinsic factors.

. Schematic drawing of LV (solid black line) and LA (gray line) pressures along with mitral flow velocity pattern in normal ventricle

Normal Patterns

The rate of myocardial relaxation and compliance change with aging so that different diastolic filling patterns are expected for different age groups17, 18 (Figure 5; Table 1).

. A, Schematic drawing of expected normal mitral inflow (upper panel) and pulmonary venous flow velocity pattern (lower panel) in normal young, middle-aged, and older subjects. In young, normal subjects, E velocity predominates and PV systolic (PVs) and diastolic flow velocity (PVd) are nearly equal. However, with aging, E

Impaired Myocardial Relaxation Pattern

There are two distinctly abnormal LV diastolic filling patterns: (1) abnormal relaxation pattern (independent of aging) and (2) restrictive (or decreased compliance) pattern. The initial abnormality of diastolic filling in nearly all heart diseases is slowed or impaired myocardial relaxation (Figure 5, B) exceeding that expected with aging. Typical examples of heart diseases that produce impaired relaxation include LV hypertrophy, hypertrophic cardiomyopathy, myocardial ischemia/infarction,20,

Estimation of LV Filling Pressures

Because changes in LA and LV filling pressures produce alterations in mitral and pulmonary venous flow velocities, analysis of these velocities might assist in the noninvasive estimation of LV diastolic pressures (Figure 1). Numerous studies have shown that as filling pressures increase mitral variables become more restrictive, with a higher E/A ratio and shortened IVRT and DT.4, 6, 26, 27, 35, 36 However, the mitral velocity pattern at a similar filling pressure varies significantly among

Systematic Interpretation of LV Diastolic Filling Pattern

Analysis of diastolic filling pattern by mitral flow velocity must take into account changes with aging and a wide 95% confidence limit for normal values.15, 17, 38 It is reasonable to assume that a normal-looking filling pattern represents normal diastolic function if a person has no cardiac symptoms and structural abnormalities on two-dimensional echocardiography. Therefore before diastolic functional assessment, the patient's cardiac structural and functional status should be analyzed,

Pitfalls And Limitations

When there is tachycardia with a shortened diastolic filling period, atrial contraction may occur before the early filling is completed. The A velocity will be higher than it would be if the heart rate were slower. An abnormally long or short PR interval influences the mitral inflow velocities. If a PR interval is abnormally prolonged, it produces an effect similar to that of tachycardia. When a PR interval is abnormally short, the A velocity is abbreviated as a result of the abrupt rise in LV

Clinical Applications

Clinically, there are two specific tasks to be accomplished with the analysis of LV diastolic filling pattern. The first task is to assess diastolic filling status (LV filling pressures, LV compliance, and relaxation abnormality) in patients with known heart disease so that optimal treatment strategies can be devised to achieve more favorable loading conditions and filling dynamics, hence better clinical outcome. It is possible to understand the patient's prognosis better based on the

Treatment Strategy For Diastolic Dysfunction Based On Doppler Evaluation Of Diastolic Filling Pattern

Assessment of ventricular filling by Doppler echocardiography provides a useful guide to the treatment of patients with diastolic dysfunction. If heart failure is caused primarily by systolic dysfunction, mitral and pulmonary venous flow Doppler velocities usually show restrictive physiology or pseudonormalized filling pattern because of elevated filling pressure in decompensated stage. This represents the most common clinical situation of heart failure, usually in patients with a significant

Summary

LV diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. Based on two-dimensional and Doppler echocardiographic evaluation, the following grading system for diastolic dysfunction is proposed: grade 1, impaired relaxation pattern; grade 2, pseudonormalized pattern; grade 3, reversible

Acknowledgements

We appreciate Mrs. Jami Spitzer's excellent help in the preparation of the manuscript.

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^☆: From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, the Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, and the Department of Clinical Physiology, University of Linköping.

^☆☆: Reprint requests: Jae K. Oh, MD, Mayo Clinic, 200 First St. S.W., East 16B, Rochester, MN 55905.

^★: 27/1/78006

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The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography☆,☆☆,★

Abstract

Section snippets

Echocardiographic Evaluation of Diastolic Function

Normal Patterns

Impaired Myocardial Relaxation Pattern

Estimation of LV Filling Pressures

Systematic Interpretation of LV Diastolic Filling Pattern

Pitfalls And Limitations

Clinical Applications

Treatment Strategy For Diastolic Dysfunction Based On Doppler Evaluation Of Diastolic Filling Pattern

Summary

Acknowledgements

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