Review article
A practical approach to the echocardiographic evaluation of diastolic function

https://doi.org/10.1016/j.echo.2003.08.012Get rights and content

Abstract

A number of recent community-based epidemiologic studies suggest that 40% to 50% of the cases of heart failure have preserved left ventricular systolic function. Although diastolic heart failure is often not well clinically recognized, it is associated with marked increases in morbidity and all-cause mortality. Doppler echocardiography has emerged as the principal clinical tool for the assessment of left ventricular diastolic function. Doppler mitral inflow velocity-derived variables remain the cornerstone of the evaluation of diastolic function. Pulmonary venous Doppler flow indices and mitral inflow measurements with Valsalva's maneuver are important adjuncts for differentiating normal and pseudonormal mitral inflow patterns. Unfortunately, these Doppler flow variables are significantly influenced by loading conditions and, therefore, the results from these standard techniques can be inconclusive. Recently, color M-mode and Doppler tissue imaging have emerged as new modalities that are less affected by preload and, thus, provide a strong complementary role in the assessment of diastolic function. This review will discuss the diastolic properties of the left ventricle, Doppler echocardiographic evaluation, and grading of diastolic dysfunction.

Section snippets

Diastolic properties of the LV

Diastole of the cardiac cycle has traditionally been divided into 4 phases: isovolumic relaxation; early rapid filling; diastasis; and atrial contraction (Figure 1). The isovolumic relaxation time is a continuum of the systolic cardiac cycle and is, therefore, dependent on systolic function in addition to relaxation of the LV. The early diastolic filling phase is dependent on both LV relaxation and chamber compliance. The slow diastolic filling phase, or diastasis, is dependent on heart rate

Mitral valve inflow

The LV filling patterns are assessed using pulsed wave Doppler mitral flow velocity recordings.16 The 4 useful variables from mitral flow interrogation are peak early diastolic transmitral flow velocity (E), peak late diastolic transmitral flow velocity (A), early filling deceleration time (DT), and A-wave duration (Adur). Figure 2 shows a schematic representation of the mitral inflow variables in normal diastolic function and various stages of diastolic dysfunction.

Normal mitral flow velocity

Evaluation and grading of diastolic dysfunction

Assessment of LV diastolic function requires a meticulous and systematic approach. The initial evaluation begins with echocardiographic observation of standard M-mode and 2-dimensional anatomic imaging. Anatomic evaluation of LA diameter and volume, LV mass, LV relative wall thickness, and LV systolic function should be the first step in the evaluation of diastolic dysfunction.14, 36 Mitral inflow interrogation is the cornerstone of initial physiologic evaluation of diastolic function (Figure 4

Summary

Routine evaluation of diastolic dysfunction should be done on every patient presenting with congestive HF. Echocardiography has emerged as a highly versatile and accurate tool for the evaluation of diastolic dysfunction. A meticulous and systemic approach should begin with anatomic evaluation of the heart followed by the interrogation of mitral valve inflow and PV flow parameters. The Valsalva maneuver can be a useful adjunct to the mitral valve inflow interrogation. Newer imaging modalities

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