Assessment of Diastolic Function

Diastolic dysfunction is responsible for one third of cases of heart failure alone and rest two third of cases in combination with systolic dysfunction. Diastolic dysfunction can be assessed by Doppler echocardiography (basics of diastolic dysfunction would be covered in this section)

Doppler Echocardiographic Indices of Diastolic Function:

1) Mitral inflow velocity = (Ewave, A = wave E/A ratio)

2) Mitral= Ewave deceleration time

3) Isovolumetric relaxation time (IVRT)

4) Pulmonary vdin systolic and diastolic velocity (S,D,S/D ratio)

5) ' Pulmonary vain atrial systolic reversal (PVa)

6) Difference between PVa and mitral a wave duration

7) Tissue Doppl$r at mitral annulus

Transducer positidn: Place the pulsed sample at the level of tips of the mitral leaflets in their fully open diastolic position. The ultrasound beam need to be parallel with the direction of blood flow.

Position of pulse sample for taking mitral flow velocity to evaluate
diastolic function. The pulse sample is placed at tip of mitral leaflets in
fully open diastolic position

Where to record Doppler of mitral and pulmonary venous flow velocity

Mitral Flow Velotity

The normal flow pattern cross-mitral valve is a tall E wave where is due to early rapid filling and small A-wave which is due to atrial contraction. E/A ratio >1.Basics of Echocardiography and Cardiac Doppler

Pulmonary Vein Flow Velocity
Transducer Position

Position of pulse sample in pulmonary view. The pulse sample is place
1-2 cm in right upper pulmonary vein in four chamber view

The pulse sample is placed 1-2 cm into the right upper pulmonary vein in 4 chamber vein.

Pulmonary vein Doppler recordings show 4 distinct velocity components. Two systolic velocities (PVs' AND PVs2),diastolic velocity (PVd) and atrial flow reversal (Pva.).

In normal filling PVs2 2 PVd.

Schematic representation of pulmonary vein
Doppler

Diastolic dysbction can be graded as follows according to diastolic filling pattern:

Grade I-impaired relaxationFundamentals of Echocardiography

Grade 11-Pseudonormal

Grade TIT-Reversible restrictive pattern

Grade IV-Irreversible restrictive pattern

During grade I diastolic dysfunction E-wave is reduced with a shallow deceleration slope an4 A-wave becomes more tall and sharp and the
isovolumetric relaxatilon time gets prolonged. When the LA pressure increases as in failure the elevated pressure opens the mitral valve earlier in diastolic (short IVRT) and sharp drop in gradient occur because of increased LVEDP. The E-wave becomes tall with steep deceleration slop, A-wave amplitude is diminished. This is called restrictive pattern on mitral trace. There may be a phase in transition where E to A ratio and IVRT drops back to normal so called psuedonormalization. Value of identifying such a defect can make considerable change in managemdnt.

A relaxation abnormhlity (A > E) indicated a possible benefit with B blockers despite presence or absence of LV systolic dysfunction. Restrictive pattern. (E>>> A) neccesitates use of preload and afterload reduction-NTG, diuretic and ACE inhibitors. These patients are likely to deteriorate with B blockers. The restrictive pattern indicates worse prognosis. [Fig. 1.25 (a), (b) and (c)]

(Pulse wave Doppler across mitral valve for assessing diastolic function)The classification of diastolic dysfunction and its main characteristics are tabulated below. (Table)