This document discusses diastolic function and its evaluation. It begins by describing the four phases of diastolic function: isovolumic relaxation, early rapid filling, diastasis, and late filling due to atrial contraction. It then discusses factors that influence diastolic function like systolic function and ventricular relaxation rate. Key parameters of diastolic function are described such as ventricular relaxation, compliance, diastolic pressures, and filling patterns. Methods for evaluating diastolic function using Doppler echocardiography of mitral inflow and pulmonary venous flow are presented. Stages of diastolic dysfunction are defined based on mitral inflow patterns.

1. DIASTOLIC FUNCTION
DR. LE HUU DUNG
HUE UNIVERSITY OF MEDICINE AND PHARMACY

2. DIASTOLIC FUNCTION
 Isovolumic relaxation
 The early rapid
diastolic filling phase
 Diastasis
 Late diastolic filling
due to atrial
contraction

3.  Isovolumic relaxation
 The early rapid diastolic
filling phase
 Diastasis
 Late diastolic filling due
to atrial contraction
DIASTOLIC FUNCTION

4. Factors influence
 Ventricular systolic function
 AV valve function
 Rate of ventricular relaxation (compliance or
stiffness)
 Atrial and ventricular muscle
 Atrial systolic function
 Loading or volume conditions of the two chambers
 Intrathoracic pressure changes with respiration
 Heart rate and rhythm
DIASTOLIC FUNCTION

5. PARAMETERS OF DIASTOLIC FUNCTION
1. Ventricular relaxation
2. Myocardial compliance and Chamber Compliance
3. Left Ventricular end diastolic pressure (LV-EDP)
4. Ventricular Diastolic filling
5. Atrial Pressures and Filling

6.  Occurs during IVR and early diastolic filling
 Active process involving utilization of energy of the
myocardium.
The measure of Ventricular Relaxation include the
following:
1. Isovolumic relaxation time (IVRT)
2. The maximum rate of pressure decline (- dP/dt)
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR RELAXATION

7. Impaired LV relaxation
 Reduced dP/dt
 prolonged time
constant of relaxation.
The Doppler:
 Prolonged (IVRT)
 Reduced E velocity
 Increased A velocity.
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR RELAXATION

8. -dP
dt
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR RELAXATION

9. PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR RELAXATION

10.  Compliance: Ratio of change in volume to change in
pressure (dV/dP).
 Stiffness: Inverse of compliance: the ratio of change in
pressure to change in volume (dP/dV)
Myocardial: myocardium
 Compliance
Chamber: Entire chamber
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR COMPLIANCE

11. Reduced diastolic
compliance:
 Pressure-volume
relationship of the LV.
 LV volume increases in
diastole, pressure rises
rapidly, resulting in an initial
high LA-LV pressure
gradient with a rapid
decrease in the filling
gradient during diastole.
Doppler
 Decreased IVRT,
 Steep deceleration slope
 Reduced A velocity.
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR COMPLIANCE

12.  Chamber compliance is influenced by:
1. Ventricular size and shape
2. Characteristics of the myocardium
3. Extrinsic factors:
a. pericardium
b. right ventricular volume
c. pleural pressure
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR COMPLIANCE

13. PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR COMPLIANCE

14. Used in patient management.
 LV end-diastolic pressure (LV EDP): ventricular
pressure after filling is complete
 Mean left atrial pressure (LAP): average pressure in
the LA during diastole
Clinically LAP is estimated by the pulmonary capillary
wedge pressure (PCWP)
 Single time point in the cardiac catheterization
laboratory
 Many time points with Swan-Ganz catheter
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR DIASTOLIC PRESSURES

15.  Clinically available measure related to diastolic function
is the time course of ventricular filling.
 Can be measured using
1. Angiography
2. Computed tomography (Cat Scab)
3. Magnetic Resonance Imaging (MRI)
4. Doppler Echocardiaography
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR DIASTOLIC FILLING (VOLUME) CURVES

16. Factors that affect Diastolic filling
Early filling
• Ventricular Diastolic Function
• Changes in the pressure difference between the ventricle
and atrium due to changes in preload.
• Changes in Transmitral volume flow rate (increased in
mitral regurgitation).
• Change in left atrial pressure.
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR DIASTOLIC FILLING (VOLUME) CURVES

17. Factors that affect Diastolic filling
Late filling
• Ventricular Diastolic function
• Cardiac rhythm
• Atrial contractile function
• Ventricular end-diastolic pressure
• Heart rate
• Time of atrial Contraction
The utility of ventricular diastolic filling patterns for
assessing diastolic function is valid only in the absence of
obstruction at the atrioventricular valve level (mitral
stenosis).
PARAMETERS OF DIASTOLIC FUNCTION
VENTRICULAR DIASTOLIC FILLING (VOLUME) CURVES

18. Right atrial filling
 Small reversal of flow following atrial contraction (a
wave)
 Systolic phase (which is effectively “diastole” for the
atrium) when blood flows from the superior and
inferior vena cava into the atrium
 Small reversal of flow at end-systole (v wave)
 Diastolic filling phase when the atrium serves as a
conduit for flow from the systemic venous return to
the RV
PARAMETERS OF DIASTOLIC FUNCTION
ATRIAL PRESSURES AND FILLING CURVES

19. PARAMETERS OF DIASTOLIC FUNCTION
ATRIAL PRESSURES AND FILLING CURVES

20. LA filling:
 Small reversal of flow following atrial contraction (a
wave)
 Systolic filling phase
 Blunting of flow or brief reversal at end-systole (v
wave)
 Diastolic filling phase
PARAMETERS OF DIASTOLIC FUNCTION
ATRIAL PRESSURES AND FILLING CURVES

21. EVALUATION OF LV DIASTOLIC FUNCTION
 Mitral Inflow +/- Valsalva
 Pulmonary Venous Flow
 Tissue Doppler
 Color M-mode

22. apical 4-chamber view
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

23. cm/s
E velocity
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

24. cm/s
A velocity
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

25. cm/s
IVRT
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

26. cm/s
A dur
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

27. cm/s
Deceleration time
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

28. cm/s
E velocity
A velocity
IVRT
A dur
Deceleration time
EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

29. EVALUATION OF LV DIASTOLIC FUNCTION
MITRAL VALVE INFLOW

30. EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

31. cm/s S velocity
EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

32. cm/s
D velocity
EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

33. cm/s
AR velocity
EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

34. cm/s
AR dur
EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

35. cm/s
D velocity
S velocity
AR velocity
AR dur
EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

36. EVALUATION OF LV DIASTOLIC FUNCTION
PULMONARY VENOUS FLOW

37. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT
 Respiration
 Heart rate
 Age
 PR interval

38. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

39. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

40. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

41. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

42. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT
Atrial arrhythmia showing the effect of a shorter
diastolic interval on the E/A pattern

43. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT
Nondiastolic physiolgic factors
 Preload
 Volume flow rate
 LV systolic function
 Atrial contractile function

44. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

45. EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT
MR

46. Af or AF
EVALUATION OF LV DIASTOLIC FUNCTION
FACTORS THAT EFFECT

47. DIASTOLIC DYSFUNCTION

48. DIASTOLIC DYSFUNCTION
STAGE I
E/A < 1.0
Stage
I

49. DIASTOLIC DYSFUNCTION
STAGE II VERSUS NORMAL
1.0 < E/A < 2.0
• AR < 0.35
• AR dur < A dur
• No E/A reversal
• AR > 0.35
• ARdur > A dur + 30 ms
• E/A reversal
Valsalva
PV inflow
Valsalva
PV inflow
Normal Stage II

50. DIASTOLIC DYSFUNCTION
STAGE III VERSUS STAGE IV
E/A > 2.0
• E/A reversal
Valsalva Valsalva
Stage III Stage IV
• No E/A reversal