Elsevier

Cardiology Clinics

Volume 18, Issue 3, 1 August 2000, Pages 513-546
Cardiology Clinics

THE ECHO-DOPPLER EVALUATION OF LEFT VENTRICULAR DIASTOLIC FUNCTION: A Current Perspective

https://doi.org/10.1016/S0733-8651(05)70159-4Get rights and content

The role of left ventricular (LV) diastolic function in health and disease is still incompletely understood and underappreciated by most primary care physicians and many cardiologists. This is not surprising because diastole is a complex phenomenon with many determinants that are difficult to individually study, and has several phases that encompass the relaxation and then filling of the ventricle.6, 38, 42, 65 Physical examination, electrocardiogram (ECG), and chest radiographs are unreliable in making the diagnosis of LV diastolic dysfunction in most individuals, and invasive measurements of cardiac pressures, rates of LV relaxation, and LV compliance are costly, clinically impracticable as they carry increased risk, and require special catheters and software analysis programs.66

This situation changed with the development of echocardiography. Because of its noninvasive nature, large numbers of normal individuals and patients were studied and different LV filling patterns were described, first with M-mode echocardiography35, 36, 43 and later using pulsed-wave (PW) Doppler technique interrogating mitral inflow.45, 46, 53, 73, 110, 112 Validation of these mitral filling patterns against radionuclide and angiographic techniques soon followed;96, 104 however, enthusiasm for relating LV filling patterns to diastolic function was dampened by reports that the velocity and proportion of early and late diastolic filling and their peak velocities were affected by preload,16, 106 afterload,77 and heart rate.4, 77

In 1988, hemodynamic pressure measurements were related to individual LV filling patterns, independent of disease state.9 Three basic abnormal filling patterns were described and were soon found to have clinical significance and prognostic value regardless of cardiac disease type.7, 56, 84, 90, 117, 124 The field of diastology using echo-Doppler evaluation was born20 and steady progress continued. Today this LV diastolic evaluation includes interrogation of mitral and pulmonary venous flow velocities, the rate of mitral inflow velocity by color Doppler flow propagation, and the evaluation of mitral annular motion by tissue Doppler imaging (TDI). In addition, manipulation of preload and afterload assesses how sensitive abnormal LV filling patterns are to changes in loading conditions.21, 47, 92 Although all echo-Doppler indices remain imperfect and much remains to be learned, the aggregate sum of this information remains our best and most practical way to assess LV diastolic function, and to objectively follow serial changes after medical intervention or with disease progression.

To begin to use echo-Doppler information for patient evaluation and management requires a basic understanding of cardiac physiology, particularly LV diastolic properties and LV filling patterns, and reproducible high-quality Doppler flow velocity recording.10 The routine performance of a diastolic function examination on every patient referred for echocardiography is recommended for acquiring experience to eliminate technical and interpretive pitfalls. This article explains a practical way for approaching the echo-Doppler analysis of LV diastolic function, and how the information obtained may be used clinically to aid patient diagnosis and therapy.

Section snippets

Definition

Abnormal diastolic function is a disorder of LV filling. As systolic function effects LV relaxation and often LV compliance, all patients with a decrease in LV ejection fraction have diastolic abnormalities. Many patients with symptoms of congestive heart failure (CHF) or reduced exercise capacity, however, have a normal LV ejection fraction or isolated LV diastolic dysfunction as the etiology of their cardiac problem. A definition for LV diastolic dysfunction includes: 1) an inability to fill

A Historical Perspective

One of the first attempts to explain ventricular filling was provided by Galen in 100 BC, who proposed that the heart is filled by dilation of the right ventricle. Centuries later, in 1628, William Harvey recognized the heart was the central pump in a circulatory system containing arteries and veins. This discovery was followed by recognition that most cases of CHF were caused by damage or weakening of the heart muscle and a decrease in LV pumping function. Diastole was largely ignored as

Mitral Flow Velocity Variables

As shown in Figure 5, LV filling patterns are assessed using PW Doppler mitral flow velocity recordings and variables. Left ventricular isovolumic relaxation time (IVRT) is the time interval from aortic valve closure to mitral valve opening. Longer IVRT values (>100 ms) are associated with impaired LV relaxation and normal filling pressures. This lengthening of the IVRT interval is the earliest change seen with diastolic dysfunction, and is sensitive to slowing of the rate of LV relaxation. A

PULMONARY VENOUS FLOW VELOCITY VARIABLES

Within a short time after mitral flow velocity patterns were correlated with hemodynamics, it became apparent that pulmonary venous flow velocity obtained using transthoracic PW Doppler technique could be helpful in assessing LV filling patterns.9, 59 As with mitral flow velocity, pulmonary venous flow velocity changes with normal aging and disease states (see Fig. 8). With experience, high-quality PW Doppler transthoracic recordings can be obtained in approximately 85% to 90% of patients.49

M-mode and Two-dimensional Echocardiography

There is considerable information about LV diastolic function and filling pressures available from M-mode and two-dimensional (2D) cardiac ultrasound recordings. Left ventricular hypertrophy slows LV relaxation independent of other cardiac abnormalities and results in an impaired relaxation filling pattern. In the absence of mitral regurgitation or arrhythmias, LA enlargement and hypocontractility (compared with the right atrium) usually indicate elevated filling pressures and are typically

PERFORMING A PRACTICAL ECHO-DOPPLER EVALUATION OF LEFT VENTRICULAR DIASTOLIC FUNCTION

The assessment of LV diastolic function requires high quality echo-Doppler images and recordings of mitral and pulmonary venous flow velocity. Although beyond the scope of this article, a practical guide for optimizing these recordings and avoiding pitfalls is available.10

Organizing an echo-Doppler assessment of LV diastolic function into a standard routine helps the sonographer and the physician improve their interpretive skills.17, 83, 93 Our laboratories start with standard M-mode and 2D

INTERPRETATION OF RIGHT VENTRICULAR DIASTOLIC FUNCTION

The same Doppler analysis used for mitral flow velocity can be applied to tricuspid inflow and right ventricular filling. Because inspiration increases right ventricular filling, changes in tricuspid flow velocity are seen throughout the respiratory cycle, whereas on the left side of the heart, Doppler mitral variables vary only about 5%.4 This increase in inspiratory right ventricular filling can be used, in conjunction with hepatic and superior vena cava flow velocities, to assess the

LIMITATIONS

The greatest limitation to the echo-Doppler assessment of LV diastolic dysfunction is the experience to discern from the information available which of the key diastolic properties (LV relaxation or compliance) are most abnormal, how these are related to LV systolic function, and how both interact to affect the overall LV filling pattern. When first learning to interpret LV diastolic function using echo-Doppler techniques there is a tendency to try to make all variables fit into one abnormal LV

ACKNOWLEDGMENTS

The authors thank Diane F. Brown for her expert secretarial help during the preparation of this article.

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    Address reprint requests to Christopher P. Appleton, MD, Division of Cardiovascular Diseases 3–A, Mayo Clinic Scottsdale, 13400 E Shea Boulevard, Scottsdale, AZ 85259, e-mail: [email protected]

    Supported in part by grants from the American Heart Association, Scottsdale, Arizona (CPA), Ohio Affiliates, Cleveland Ohio (MSF, MJG), and the National Aeronautics Space Administration and National Institutes of Health (JDT).

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