THE ECHO-DOPPLER EVALUATION OF LEFT VENTRICULAR DIASTOLIC FUNCTION: A Current Perspective
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.
References (125)
Doppler assessment of left ventricular diastolic function: The refinements continue [editorial comment]
J Am Coll Cardiol
(1993)Hemodynamic determinants of Doppler pulmonary venous flow velocity components: New insights from studies in lightly sedated normal dogs
J Am Coll Cardiol
(1997)- et al.
Diastolic mitral regurgitation with atrioventricular conduction abnormalities: Relation of mitral flow velocity to transmitral pressure gradients in conscious dogs
J Am Coll Cardiol
(1991) - 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) - et al.
Cardiac tamponade and pericardial effusion: Respiratory variation in transvalvular flow velocities studied by Doppler echocardiography
J Am Coll Cardiol
(1988) - et al.
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) - et al.
Doppler evaluation of left and right ventricular diastolic function: A technical guide for obtaining optimal flow velocity recordings
J Am Soc Echocardiogr
(1997) - et al.
Quantitative Doppler tissue imaging for assessment of regional myocardial velocities during transient ischemia and reperfusion
Am Heart J
(1996) - et al.
Transesophageal echo-Doppler echocardiographic assessment of pulmonary venous flow patterns
J Am Soc Echocardiogr
(1991) - et al.
Left ventricular flow propagation during early filling is related to wall relaxation: A color M-mode Doppler analysis
J Am Coll Cardiol
(1992)
Preload dependence of Doppler-derived indexes of left ventricular diastolic function in humans
J Am Coll Cardiol
A practical guide to assessment of ventricular diastolic function using Doppler echocardiography
J Am Coll Cardiol
50th anniversary historical article: The hemodynamic basis of diastology
J Am Coll Cardiol
Use of Valsalva maneuver to unmask left ventricular diastolic function abnormalities by Doppler echocardiography in patients with coronary artery disease or systemic hypertension
Am J Cardiol
Analysis of mitral inertance: A factor critical for early transmitral filling
J Am Soc Echocardiogr
Diastolic compliance of the left ventricle in man
Am J Cardiol
An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure
J Am Coll Cardiol
Differentiation of constrictive pericarditis from restrictive cardiomyopathy: Assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging
J Am Coll Cardiol
Myocardial wall velocity assessment by pulsed Doppler tissue imaging: Characteristic findings in normal subjects
Am Heart J
Color M-mode Doppler flow propagation velocity is a preload insensitive index of left ventricular relaxation: Animal and human validation
J Am Coll Cardiol
New Doppler echocardiographic applications for the study of diastolic function
J Am Coll Cardiol
Doppler-derived mitral decceleration time of early filling as a strong predictor of pulmonary wedge pressure in postinfarction patients with left ventricular dysfunction
J Am Coll Cardiol
Mitral annular descent velocity by tissue Doppler echocardiography as an index of global left ventricular function
Am J Cardiol
Automated method for characterization of diastolic transmitral Doppler velocity contours: Late atrial filling
Ultrasound Med Biol
Automated method for characterization of diastolic transmitral Doppler velocity contours: Early rapid filling
Ultrasound Med Biol
Left ventricular relaxation and filling pattern in different forms of left ventricular hypertrophy: An echocardiographic study
Am J Cardiol
Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: A simultaneous catheterization and Doppler echocardiographic study
J Am Coll Cardiol
Short deceleration time of mitral inflow E velocity: Prognostic implication with atrial fibrillation versus sinus rhythm
J Am Soc Echocardiogr
Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique
J Am Soc Echocardiogr
Quantitative evaluation of the segmental left ventricular response to dobutamine stress by tissue Doppler echocardiography
Am J Cardiol
Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: Failure of the Frank-Starling mechanism
J Am Coll Cardiol
Effects of age on left ventricular dimensions and filling dynamics in 117 normal persons
Mayo Clin Proc
Comprehensive Doppler assessment of right ventricular diastolic function in cardiac amyloidosis
J Am Coll Cardiol
Serial Doppler echocardiographic follow-up of left ventricular diastolic function in cardiac amyloidosis
J Am Coll Cardiol
Doppler assessment of pulmonary venous flow in healthy subjects and patients with heart disease
J Am Soc Echocardiogr
Clinical evaluation of left ventricular diastolic performance
Prog Cardiovasc Dis
Variation of flow propagation velocity with age
J Am Soc Echocardiogr
Augmentation of atrial contribution to left ventricular inflow with aging as assessed by intracardiac Doppler flowmetry
Am J Cardiol
New method for evaluating left ventricular wall motion by color-coded tissue Doppler imaging: In vitro and in vivo studies
J Am Coll Cardiol
Doppler tissue imaging: A noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures
J Am Coll Cardiol
Assessment of diastolic function of the heart: Background and current applications of Doppler echocardiography: Part II. Clinical studies
Mayo Clin Proc
“Diastology”: Beyond E and A
J Am Coll Cardiol
Mechanism of hemodynamic improvement by dual-chamber pacing for severe left ventricular dysfunction: An acute Doppler and catheterization hemodynamic study
J Am Coll Cardiol
Effect of dual-chamber pacing on systolic and diastolic function in patients with hypertrophic cardiomyopathy. Acute Doppler echocardiographic and catheterization hemodynamic study [see comments]
J Am Coll Cardiol
Assessment of diastolic function of the heart: Background and current applications of Doppler echocardiography: Part I. Physiologic and pathophysiologic features
Mayo Clin Proc
Failure of calcium channel blockers to improve ventricular relaxation in humans
J Am Coll Cardiol
The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography
J Am Soc Echocardiogr
Restrictive LV diastolic filling identifies patients with heart failure after acute myocardial infarction
J Am Soc Echocardiogr
Detection of left ventricular regional relaxation abnormalities and asynchrony in patients with hypertrophic cardiomyopathy with the use of tissue Doppler imaging
Am Heart J
Pulsed tissue Doppler imaging of left ventricular systolic and diastolic wall motion velocities to evaluate differences between long and short axes in healthy subjects
J Am Soc Echocardiogr
Cited by (154)
FFANet—Full frequency attention net for automatic diastolic function assessment
2023, Biomedical Signal Processing and ControlPrognostic value of echocardiography for heart failure and death in adults with chronic kidney disease
2022, American Heart JournalThe effects of activity, body weight, sex and age on echocardiographic values in English setter dogs
2021, Journal of Veterinary CardiologyTwo-Dimensional and Doppler Evaluation of Left Ventricular Filling, Including Pulmonary Venous Flow Velocity
2020, Diastology: Clinical Approach to Heart Failure with Preserved Ejection FractionHow myofilament strain and strain rate lead the dance of the cardiac cycle
2019, Archives of Biochemistry and BiophysicsCitation Excerpt :A large strain and strain rate of the myocardium is associated with a large atrioventricular pressure gradient [42,43]. Strain and strain rates also reveal abnormal stiffness and relaxation (viscosity) in the left ventricle [4,5,44]. Strain rates during early filling (tissue Doppler e’) are reduced in patients with impaired relaxation [4,5].
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).