Assessment of Diastolic

Function
by Echocardiography
Roxanne Jeen L. Fornolles

Physiology of Diastole
Isovolumic
Relaxation
Rapid Filling
Diastasis
Atrial systole

Determinants of
Diastolic Function
Major parameters:
1. Active myocardial relaxation- is an active
process involving the use of ATP and calcium
in the myocardium
2. Ventricular compliance-ratio of change in
volume to change in pressure (Dv/Dp), and
stiffness is the reverse compliance(dp/dv).
2 components: intrinsic myocardial and chamber

3. Left atrial (including atrial

function),pulmonary vein, and mitral valve
characteristics
4. Heart rate

Definition of Diastolic Dysfunction

Different Imaging Modalities:

Echocardiographic Evaluation
of Diastolic Function

Doppler Techniques in Assessment of Diastolic

Filling Patterns:

Transmitral Flow Assessment

The following are the variables derived from mitral
flow interrogation:

Peak early diastolic transmitral flow velocity (E)

Peak late diastolic transmitral flow velocity (A)
Early filling deceleration time (DT)
A wave duration
Normal individuals: rapidly accelerating E wave, relatively
rapid deceleration, A wave significantly smaller than E
wave
o Normal aging: slowing of left ventricular relaxation

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Pulmonary Venous Flow
PV flow velocity provide an integrated approach with
mitral inflow in the evaluation of diastolic dysfunction.
4 useful variables from the PV flow interrogation: peak
systolic PV flow velocity (S), peak diastolic PV flow (D),
peak PV atrial reversal flow velocity (AR),and AR
duration
Pulmonary vein AR and Ardur provides incremental
value in assessing diastolic function
An AR velocity greater than 35cm/s and an Ardur at
least 30 msec longer than the mitral inflow A wave
duration is predictive of a left ventricular end diastolic
pressure greater than 15 mmhg.

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Mitral Inflow at Peak Vasalva Maneuver
The strain phase of the Vasalva maneuver is a
simple approach used to decrease LA pressure .
During this phase, E wave velocity normally
decreases by 20% with a smaller decrease in A
velocity.
In patients with pseudonormal mitral inflow
patterns, vasalva strain lowers LA pressure and
unmasks the underlying impaired LV function.

Stages of Diastolic Function

Stages of Diastolic Function

Normal Diastolic Function

Normal Compliance
E/A >1
Pulmonary Venous Inflow-Codominant
TDI- e >a E/e<15
e>8

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Impaired Relaxation
Abnormal Relaxation- Delayed
Normal Compliance- LVEDP<15mmHg
E velocity stays the same
A velocity increases E/A<1
TDI- a>e
E/e<15

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Pseudonormal
Abnormal Relaxation-Delayed
Decreased Compliance-LVEDP 15-25
mmHg
E velocity elevated- 100 cm/s
A velocity decreases- E/A>1
Pulmonary Venous InflowDiastolic Dominant
TDI- E/e >15

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Restricitve
Abnormal Relaxation- Delayed
Decreased ComplianceLVED>25mmHg
E velocity elevated- 150 cm/s
A velocity decreases- E/A >2
Pulmonary Venous InflowDiastolic Dominant
TDI- E/e >15

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Grade 3 vs. Grade 4

Reversible restrictive?

Vasalva

Other Echocardiographic
Techniques:
Tissue Doppler Imaging for Evaluation of
Diastolic Function
Techniques:
Using pulsed Doppler techniques we can:
Obtain high quality Doppler signals
Measure, mean and instantaneous local acceleration
Obtain quantitative wall motion information

Doppler imaging of the myocardium:

Enables rapid visual qualitative assessment of wall dynamics
Provides a good spatial resolution to differentiate between
velocity profiles of subendocardial and subepicardial layers
Allows simultaneous analysis of various myocardial regions.

In the assessment of diastolic function, velocities typically

are measured at the annuli or myocardium in the
longitudinal axis to minimize the effect of cardiac
translation.

Strain Rate Imaging in Evaluation of

Diastolic Function:
Strain and strain rate are measures of myocardial
mechanical properties.
Myocardial strain is a dimensionless index of
change in myocardial length in response to
applied force and is expressed as fractional or
percentage change.
SR is the time derivative of strain with unit per
second.
By convention, myocardial lengthening or
thinning gives a positive strain value and
shortening or thickening gives a negative value.

Strain Rate Imaging in

Evaluation of Diastolic Function:
Limitations of Strain Imaging:
Only deformation of the Ultrasound
beam is measured
Angle errors affect SR measurements
heavily
SR data are calculated from a small
difference of values thus magnify the
noise inherent in the velocity data.

Normal Values of Myocardial

Strain and Strain Rate
Isolated myocardial fibers shorten by
approximately 15% after excitation.
Typical values for normal systolic
longitudinal strain: 196% peak
systolic strain rate: 1.270.39 s1.
Typical values for normal systolic
radial strain: 414.4% , SR :2.30.3 s1

Assessment of Diastolic Function

by Strain Echocardiography
Assessment of transmitral and pulmonary vein blood
flow is utilized to detect global changes in LV filling.
On the other hand, myocardial velocity profiles
measure local wall motion and have the potential of
identifying local changes induced by filling.
E-wave changes in myocardial diastolic parameters
will usually mirror the changes in global filling
detected in the transmitral and pulmonary vein flow.
Regional abnormalities in myocardial diastolic motion
may be detectable despite mitral and pulmonary vein
velocities being normal.

Assessment of Diastolic Function by

Strain Echocardiography
Assessment of transmitral and pulmonary
vein blood flow is utilized to detect global
changes in LV filling.
Myocardial velocity profiles measure local
wall motion and have the potential of
identifying local changes induced by filling.

Color M-Mode
Doppler

Is a pulsed Doppler technique in which mean

velocities are color encoded and displayed in
time and depth along the entire scan line .
Acquisition is made in the four-chamber
view. To visualize the direction of the
inflowing blood, a large color box is placed
from the mitral valve to the apex.
The scan line should ideally go through the
center of the mitral valve and along the
central part of the blood column.

Color M-Mode
Doppler

Clinical Utility of Diastolic Function

Assessment:
Myocardial Diseases
Dilated Cardiomyopathy: when systolic dysfunction is
present, the elevated end-systolic volume results in a
shift along the pressure volume curve to a steeper
segment.
Cardiac amyloidosis: associated with abnormal LV and
RV diastolic function
HCM: patients often have a pattern of LV diastolic
filling consistent with impaired relaxation

Left Ventricular Hypertrophy

Ischemic Cardiac Disease
Pericardial Disease

Clinical Utility of Diastolic Function

Assessment:
Myocardial Diseases
Dilated Cardiomyopathy: when systolic dysfunction is
present, the elevated end-systolic volume results in a
shift along the pressure volume curve to a steeper
segment.
Cardiac amyloidosis: associated with abnormal LV and
RV diastolic function
HCM: patients often have a pattern of LV diastolic
filling consistent with impaired relaxation

Left Ventricular Hypertrophy

Ischemic Cardiac Disease
Pericardial Disease

Emerging Techniques in
Assessment of Diastolic Function
Torsion Echocardiography: Emergence of
Speckle Tracking
LV torsion (or twist) plays an important role with
respect to LV ejection and filling.
During the cardiac cycle, there is a systolic twist and
an early diastolic untwist of the LV about its long axis
due to oppositely directed apical and basal rotations.
As viewed from the LV apex, systolic apical rotation
is counterclockwise and basal rotation, clockwise. LV
rotation is sensitive to changes in both regional and
global LV function.
127-1

Thank You!