The document discusses methods for evaluating left ventricular diastolic function using echocardiography. It describes the four phases of diastole, parameters used to assess diastolic function including mitral inflow patterns, mitral annular tissue Doppler, pulmonary vein flow, left atrial size and the Tei index. Grades of diastolic dysfunction and approaches from ASE/EAE and Mayo Clinic are summarized. Continuous wave Doppler of aortic regurgitation is also presented as a noninvasive method to evaluate left ventricular relaxation.

1. Echo Teaching: Evaluation
of LV Diastolic Function
23 Sep 2015
Koh Choong Hou
Supervisor: Lim Choon Pin

2. Scope
• Physiology of diastole
• Methods used to assess diastolic dysfunction
• Quiz

3. Definitions
• Traditional definition of diastole (in ancient Greek
language the term διαστολε means expansion):
includes the part of the cardiac cycle starting at
the AoV closure - when LV pressure falls below
aortic pressure - and finishing at the mitral valve
(MV) closure
• Normal LV diastolic function may be clinically
defined as the capacity of the LV to receive a LV
filling volume able in its turn to guarantee an
adequate stroke volume, operating at a low
pressure regimen.
EAE Textbook of Echocardiography 2013

4. Why is Diastolic Function
Important?
• Assess degree of diastolic impairment
• Assess left sided filling pressures – LA
filling pressures

5. 4 Phases of Diastole
• Isovolumic Relaxation. Between end of LV systolic ejection
(AoV closure) and MV opening. LV pressure continues to fall
while maintaining constant LV volume. Mainly attributed by
active LV relaxation.
EAE Textbook of Echocardiography 2013

6. 4 Phases of Diastole
• LV Rapid Filling. LV pressures falls below LA pressure and MV
opens. Blood has an acceleration which achieves a maximal
velocity (proportional to AV gradient), and stops when
pressures equalise. Due to interaction between LV suction
(active relaxation) and viscoelastic properties of myocardium
(compliance)
EAE Textbook of Echocardiography 2013

7. 4 Phases of Diastole
• Diastasis. LA and LV pressures almost equal. LV filling
maintained by pulmonary veins inflow (LA = passive conduit)
relationship with LV filling pressure. Mainly a function of LV
compliance
EAE Textbook of Echocardiography 2013

8. 4 Phases of Diastole
• Atrial Systole. Due to LA contraction, ends with MV closure.
Mainly influenced by LV compliance, but also by pericardial
resistance, atrial force and AV synchrony (PR interval)
EAE Textbook of Echocardiography 2013

9. Diastolic Dysfunction
Grades
• Grade 1 = impaired relaxation pattern
with normal filling pressure (1a = impaired
relaxation pattern with increased filling
pressure)
• Grade 2 = pseudonormalized pattern
• Grade 3 = reversible restrictive pattern
• Grade 4 = irreversible restrictive pattern
Assessment of diastolic function and diastolic heart failure. The Echo Manual, 3rd edition.

10. Stages of Diastolic Dysfunction

11. ASE/EAE “Practical Approach”
15 parameters
Mayo “Quick Screen”
4 parameters
Recommendations for the Evaluation of LV
Diastolic Function by Echocardiography
(JASE 2009, Vol 22, 107 – 133)
37 parameters
(excluding strain, twist, Tei, stress)

12. Basic Diastolic Function
Indices / Parameters
• Mitral Inflow
§ E/A
§ DT
• Mitral Annular E’
§ E/E’
• IVRT
• Pulmonary Vein Doppler
§ Ar-A duration
• Propagation Velocity
(Vp)
• LA size

13. Mitral Inflow Patterns

15. Mitral Inflow
• As age increases, E velocity and E/A ratio
decrease, while DT and A velocity increase
• Factors affecting MV inflow:
§ HR and rhythm
§ PR interval (AV synchrony)
§ Cardiac output
§ Mitral annular size
§ LA function and compliance
1-3mm sample volume placed between MV leaflets tips

16. Quiz

17. Quiz

18. Quiz

19. Mitral Annular E’
• Sample volume at/or within 1cm of septal / lateral
insertion sites of mitral leaflets, and adjusted as
required to cover the longitudinal excursion of the
mitral annulus
• Septal E’ 8-10cm/s
• Lateral E’ velocity usually 25% higher

20. IVRT
To measure IVRT (i.e., the interval from aortic valve closure to mitral valve opening), a 3 to 4-mm sample volume is placed
at the mitral leaflet tips. Next, the transducer beam is angulated toward the LV outflow tract until aortic valve closure app
ears above and below the baseline. An alternative technique is to use continuous wave Doppler echocardiography to reco
rd aortic and mitral flow simultaneously.

21. M-Mode MV Leaflets

22. Bonus Question

23. Flow Propagation (Vp)
• Apical 4-chamber view, using color
flow imaging with a narrow color
sector
• The M-mode scan line is placed
through the center of the LV inflow
blood column from the mitral valve to
the apex
• Color flow baseline is shifted to lower
the Nyquist limit so that the central
highest velocity jet is blue
• Vp measured as slope of 1st alising
velocity during early filling, measured
from MV plane to 4cm distally into LV
cavity

24. E/Vp
• Should other Doppler indices appear inconclusive,
Vp can provide useful information for the
prediction of LV filling pressures
• E/Vp ≥ 2.5 predicts PCWP 15 mm Hg with
reasonable accuracy

25. Rivas-Gotz C, Manolios M, Thohan V, Nagueh SF. Impact of left ventricular ejection fraction on estimation of left ventricul
ar filling pressures using tissue Doppler and flow propagation velocity. Am J Cardiol 2003;91:780-4.

26. • Pulmonary venous inflow velocities are
influenced by age
• Normal young subjects aged ︎40 years
usually have prominent D velocities,
reflecting their mitral E waves.
• With increasing age, the S/D ratio
increases.
• In normal subjects, Ar velocities can
increase with age but usually do not
exceed 35 cm/s. Higher values suggest
increased LVEDP
Pulmonary Vein Flow
A 2-mm to 3-mm sample volume is placed ︎0.5 cm into the pulmonary
vein for optimal recording of the spectral waveforms

27. Ar-A duration

28. • LA volume index =34ml/m2 is
an independent predictor of:
Death, Heart failure, Atrial
fibrillation, Ischemic stroke
• Causes of LA enlargement:
Anemia and other high-output
states; AF/AFL; Mitral valve
disease in the absence of
diastolic dysfunction

29. Myocardial Performance (Tei)
Index

30. AR CW Doppler
Noninvasive Assessment of Left Ventricular Relaxation Using Continuous-Wave Doppler Aortic Regurgitant Velocity Curve. Kazuhiro Y. Circulation
Volume 91(1):192-200 January 1, 1995
T -the time interval between
the onset of aortic
regurgitation and the
regurgitant velocity
corresponding to 1/2 of the
maximal velocity
P=4V2
V- is aortic regurgitation
velocity in meters per second
at 20 ms after the onset of
regurgitation

31. ΔP/Δt-AR correlated with catheter-derived
−dP/dtmax (r=.92, P.01)

32. A, Plot showing relation between catheter-derived −dP/dtmax and Doppler-derived ΔP/Δt-AR. Dashed line is a line
of identity, and solid line is a regression line.
B, Mean vs the difference of catheter-derived −dP/dtmax minus Doppler-derived ΔP/Δt-AR. Solid line indicates me
an difference, and dashed lines are 2 SD of mean difference.

33. Mayo Quick Screen
• LV Size / Function
• LA Volume
• E/A, DT
• E/e’