Echocardiographic evaluation of left ventricular diastolic function
- Sherif F Nagueh, MD, FACC, FAHA, FASE
Sherif F Nagueh, MD, FACC, FAHA, FASE
- Professor of Medicine
- Weill Cornell Medical College
Left ventricular (LV) diastolic function can be characterized by invasive and noninvasive methods. Invasive measures of diastolic function include the peak instantaneous rate of LV pressure decline (-dP/dt), the time constant of LV relaxation (tau), and the stiffness modulus. Although echocardiography does not directly measure these parameters, echocardiography is the most practical routine clinical approach for evaluating LV diastolic function given clinical and experimental evidence supporting its use as well as its safety, versatility, and portability. (See "Pathophysiology of heart failure with preserved ejection fraction".)
Diastole is conventionally divided into the following phases: isovolumetric relaxation (both aortic and mitral valves are closed and LV pressure is declining), early LV filling with opening of the mitral valve, a mid-diastolic phase (often noted in patients with bradycardia), and late or atrial filling with left atrial (LA) contraction. In normal hearts, predominant LV filling occurs in early diastole. With impaired LV relaxation, LV filling shifts to late diastole and becomes dependent on LA systolic function. This accounts for the significant clinical deterioration that is seen in patients with diastolic dysfunction (such as hypertrophic cardiomyopathy) in the presence of atrial fibrillation.
Diastolic dysfunction by echocardiography is one of the criteria for the diagnosis of heart failure with preserved ejection fraction (HFpEF) . This topic summarizes available echocardiographic methods for assessment of LV diastolic function. Recommendations in this topic are generally in agreement with the American Society of Echocardiography recommendations for the evaluation of LV diastolic function by echocardiography .
Diagnosis, management, and prognosis of HFpEF are discussed separately. (See "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
DIAGNOSIS AND EVALUATION
When to suspect diastolic dysfunction — Left ventricular (LV) diastolic dysfunction should be suspected in patients with known or suspected heart failure (eg, patients with possible cardiogenic dyspnea) as well as in asymptomatic patients with hypertension. LV diastolic dysfunction can cause symptoms of dyspnea and reduced exercise tolerance in patients with heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Thus, assessment of diastolic function is an integral component of the echocardiographic examination in patients referred with a diagnosis of dyspnea or heart failure. Evaluation of diastolic function in asymptomatic patients with hypertension is also reasonable, as echocardiographic findings of diastolic dysfunction and its progression or lack thereof have been shown to predict clinical events of death and heart failure in observational and community studies. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Asymptomatic diastolic dysfunction'.)
- Paulus WJ, Tschöpe C, Sanderson JE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007; 28:2539.
- Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2016; 29:277.
- Redfield MM, Jacobsen SJ, Burnett JC Jr, et al. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289:194.
- Appleton CP, Jensen JL, Hatle LK, Oh JK. Doppler evaluation of left and right ventricular diastolic function: a technical guide for obtaining optimal flow velocity recordings. J Am Soc Echocardiogr 1997; 10:271.
- Møller JE, Søndergaard E, Poulsen SH, Egstrup K. Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study. J Am Coll Cardiol 2000; 36:1841.
- Appleton CP, Hatle LK, Popp RL. Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coll Cardiol 1988; 12:426.
- Appleton CP. Hemodynamic determinants of Doppler pulmonary venous flow velocity components: new insights from studies in lightly sedated normal dogs. J Am Coll Cardiol 1997; 30:1562.
- Smiseth OA, Thompson CR, Lohavanichbutr K, et al. The pulmonary venous systolic flow pulse--its origin and relationship to left atrial pressure. J Am Coll Cardiol 1999; 34:802.
- Klein AL, Tajik AJ. Doppler assessment of pulmonary venous flow in healthy subjects and in patients with heart disease. J Am Soc Echocardiogr 1991; 4:379.
- Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol 1993; 21:1687.
- Appleton CP, Galloway JM, Gonzalez MS, et al. Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease. Additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction. J Am Coll Cardiol 1993; 22:1972.
- Kuecherer HF, Muhiudeen IA, Kusumoto FM, et al. Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow. Circulation 1990; 82:1127.
- Yamamuro A, Yoshida K, Hozumi T, et al. Noninvasive evaluation of pulmonary capillary wedge pressure in patients with acute myocardial infarction by deceleration time of pulmonary venous flow velocity in diastole. J Am Coll Cardiol 1999; 34:90.
- Chirillo F, Brunazzi MC, Barbiero M, et al. Estimating mean pulmonary wedge pressure in patients with chronic atrial fibrillation from transthoracic Doppler indexes of mitral and pulmonary venous flow velocity. J Am Coll Cardiol 1997; 30:19.
- Nagueh SF, Sun H, Kopelen HA, et al. Hemodynamic determinants of the mitral annulus diastolic velocities by tissue Doppler. J Am Coll Cardiol 2001; 37:278.
- Sohn DW, Chai IH, Lee DJ, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997; 30:474.
- Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation 2000; 102:1788.
- Nagueh SF, Middleton KJ, Kopelen HA, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997; 30:1527.
- Dokainish H, Zoghbi WA, Lakkis NM, et al. Optimal noninvasive assessment of left ventricular filling pressures: a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters. Circulation 2004; 109:2432.
- Kasner M, Westermann D, Steendijk P, et al. Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation 2007; 116:637.
- Nagueh SF, Mikati I, Kopelen HA, et al. Doppler estimation of left ventricular filling pressure in sinus tachycardia. A new application of tissue doppler imaging. Circulation 1998; 98:1644.
- Sohn DW, Song JM, Zo JH, et al. Mitral annulus velocity in the evaluation of left ventricular diastolic function in atrial fibrillation. J Am Soc Echocardiogr 1999; 12:927.
- Ha JW, Oh JK, Pellikka PA, et al. Diastolic stress echocardiography: a novel noninvasive diagnostic test for diastolic dysfunction using supine bicycle exercise Doppler echocardiography. J Am Soc Echocardiogr 2005; 18:63.
- Diwan A, McCulloch M, Lawrie GM, et al. Doppler estimation of left ventricular filling pressures in patients with mitral valve disease. Circulation 2005; 111:3281.
- Ha JW, Oh JK, Ling LH, et al. Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis. Circulation 2001; 104:976.
- Nagueh SF, Bhatt R, Vivo RP, et al. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging 2011; 4:220.
- Mullens W, Borowski AG, Curtin RJ, et al. Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure. Circulation 2009; 119:62.
- Popovic ZB, Puntawangkoon C, Verhaert D, et al. Impact of longitudinal cardiac rotation on mitral and tricuspid atrioventricular annular diastolic motion. Circ Cardiovasc Imaging 2010; 3:368.
- D'Souza KA, Mooney DJ, Russell AE, et al. Abnormal septal motion affects early diastolic velocities at the septal and lateral mitral annulus, and impacts on estimation of the pulmonary capillary wedge pressure. J Am Soc Echocardiogr 2005; 18:445.
- Takatsuji H, Mikami T, Urasawa K, et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol 1996; 27:365.
- Garcia MJ, Ares MA, Asher C, et al. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure. J Am Coll Cardiol 1997; 29:448.
- Rivas-Gotz C, Manolios M, Thohan V, Nagueh SF. Impact of left ventricular ejection fraction on estimation of left ventricular filling pressures using tissue Doppler and flow propagation velocity. Am J Cardiol 2003; 91:780.
- Schwammenthal E, Popescu BA, Popescu AC, et al. Association of left ventricular filling parameters assessed by pulsed wave Doppler and color M-mode Doppler echocardiography with left ventricular pathology, pulmonary congestion, and left ventricular end-diastolic pressure. Am J Cardiol 2004; 94:488.
- Ohte N, Narita H, Akita S, et al. Striking effect of left ventricular systolic performance on propagation velocity of left ventricular early diastolic filling flow. J Am Soc Echocardiogr 2001; 14:1070.
- Matyal R, Hess PE, Subramaniam B, et al. Perioperative diastolic dysfunction during vascular surgery and its association with postoperative outcome. J Vasc Surg 2009; 50:70.
- Quiñones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 2002; 15:167.
- DIAGNOSIS AND EVALUATION
- When to suspect diastolic dysfunction
- Approach to diagnosis and evaluation
- - Initial clinical and echocardiographic assessment
- - Echocardiographic diagnosis of diastolic dysfunction
- - Limitations and caveats
- GRADING DIASTOLIC DYSFUNCTION
- ESTIMATION OF LEFT ATRIAL PRESSURE
- INDICATORS OF DIASTOLIC FUNCTION
- Summary of indicators
- Doppler mitral inflow velocity
- Pulmonary venous flow
- Tissue Doppler imaging
- Color flow mapping
- Alternate approach
- SUMMARY AND RECOMMENDATIONS