Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography

There are many myocardial and non-myocardial conditions that cause heart failure with normal left ventricular ejection fraction (LVEF). Among them, diastolic heart failure (heart failure due to diastolic dysfunction) is the most common cause of heart failure with normal LVEF. Diastolic heart failure easily can be diagnosed by comprehensive two-dimensional and Doppler echocardiography, which can demonstrate abnormal myocardial relaxation, decreased compliance, and increased filling pressure in the setting of normal LV dimensions and preserved LVEF. Therefore, diastolic heart failure should always be considered when LVEF is normal on two-dimensional echocardiography in patients with clinical evidence of heart failure. The diagnosis can be confirmed if Doppler echocardiography and myocardial tissue imaging provide evidence for impaired myocardial relaxation (i.e., decreased longitudinal velocity of the mitral annulus during early diastole and decreased propagation velocity mitral inflow), decreased compliance (shortened mitral A-wave duration and mitral deceleration time), and increased filling pressure (shortened isovolumic relaxation time and an increased ratio between early diastolic mitral and mitral annular velocities). Early identification of diastolic dysfunction in asymptomatic patients by the use of echocardiography may provide an opportunity to manage the underlying etiology to prevent progression to diastolic heart failure.     

Echokardiographische Diagnostik der diastolischen Herzinsuffizienz

BACKGROUND: Left ventricular diastolic dysfunction can be diagnosed if clinical signs of heart failure and normal ejection fraction are found. Beside clinical signs of heart failure and criteria from catheterization studies like abnormal left ventricular relaxation, filling and/or compliance echocardiography provides valuable parameters for the assessment of diastolic dysfunction. ECHOCARDIOGRAPHIC DEGREES OF SEVERITY: By the use of various parameters diastolic dysfunction can be differentiated into four degrees of severity, which are of great prognostic importance. If more than one echocardiographic parameter is used, sensitivity for the assessment of diastolic dysfunction becomes nearly 100%. Conventional parameters include isovolumetric relaxation time (IVRT) measured by pulsed Doppler, the ratio of rapid filling and atrial filling velocity (E/A), deceleration time of rapid mitral inflow as well as the ratio of systolic and diastolic pulmonary venous flow velocities. In patients with signs of diastolic heart failure and a normal E/A ratio pulmonary venous flow pattern can help to unmask "pseudonormalization" as the transition from abnormal relaxation to restriction. These parameters, however, are preload-dependent and do not provide intrinsic left ventricular properties. Even in atrial fibrillation, left ventricular filling pressure can be assessed. NEW METHODS: Two novel approaches, color Doppler M-mode of left ventricular inflow and tissue Doppler of the mitral annulus, are relatively preload-independent and allow direct estimation of relaxation and filling pressure. By the means of real-time 3-D echocardiography we developed a new method for the non-invasive assessment of rapid filling rate (PFR), thereby completing the echocardiographic approaches to determine diastolic dysfunction. CONCLUSION: The broad spectrum of approaches available today makes echocardiography the first choice for the assessment of diastolic dysfunction.     

Plasma B-type natriuretic peptide levels in systolic heart failure: importance of left ventricular diastolic function and right ventricular systolic function

OBJECTIVES: This study was designed to characterize the importance of echocardiographic indexes, including newer indexes of diastolic function, as determinants of plasma B-type natriuretic peptide (BNP) levels in patients with systolic heart failure (SHF). BACKGROUND: Plasma BNP levels have utility for diagnosing and managing heart failure. However, there is significant heterogeneity in BNP levels that is not explained by left ventricular size and function alone. METHODS: In 106 patients with symptomatic SHF (left ventricular ejection fraction [LVEF] <0.35), we measured plasma BNP levels and performed comprehensive echocardiography with assessment of left ventricular diastolic function, including color M-mode (CMM) and tissue Doppler imaging (TDI), and of right ventricular (RV) function. RESULTS: Median plasma BNP levels were elevated and increased with greater severity of diastolic dysfunction. We found significant correlations (p < 0.001 for all) between BNP and indexes of myocardial relaxation (early diastolic velocity: r = -0.26), compliance (deceleration time: r = -0.55), and filling pressure (early transmitral to early annular diastolic velocity ratio: r = 0.51; early transmitral flow to the velocity of early left ventricular flow propagation ratio: r = 0.41). In multivariate analysis, overall diastolic stage, LVEF, RV systolic dysfunction, mitral regurgitation (MR) severity, age and creatinine clearance were independent predictors of BNP levels (model fit r = 0.8, p < 0.001). CONCLUSIONS: Plasma BNP levels are significantly related to newer diastolic indexes measured from TDI and CMM in SHF. Heterogeneity of BNP levels in patients with SHF reflects the severity of diastolic abnormality, RV dysfunction, and MR in addition to LVEF, age, and renal function. These findings may explain the powerful relationship of BNP to symptoms and prognosis in SHF.     

Contributors of characteristic mitral flow velocity pattern in congestive heart failure--from clinical observations back to experimental validations.

Mitral flow velocity pattern in patients with left ventricular (LV) diastolic dysfunction usually includes decreased peak early diastolic filling velocity (E), slowed deceleration of the early diastolic filling wave and increased peak filling velocity at atrial contraction (A). However, the abnormal mitral flow velocity pattern can be normalized in the presence of concomitant congestive heart failure. In such cases E can be equal to or even higher than normal, its deceleration is normal or faster than normal value, and A can be normal or lower than normal value. Clinical observations in patients with severe heart failure showed that the mitral flow velocity pattern changes with vasodilating therapy, reflecting the changes in the left atrial (LA) to LV pressure difference rather than those in the absolute LA pressure or LV pressure alone. This was validated in the canine study in which levels of LV dysfunction were made by the injection of microspheres into the left coronary artery to study the interrelation among the mitral flow velocity pattern and LA and LV pressures. In this experiment, the changes in the mitral flow velocity pattern could not be explained by the changes in LA or LV pressure alone but was better explained by the changes in the LA to LV pressure difference. Not only LA-LV crossover pressure but also LA compliance seem to be important as determinants of LA pressure level in diastole. In addition to LV relaxation rate, incompleteness of relaxation, elastic recoil and LV passive elastic properties, extracardiac constraint is also considered to be an important determinant of the level of the LV diastolic pressure and hence of the mitral flow velocity pattern at least in the presence of congestive heart failure. Thus, mitral flow velocity pattern is determined by the interaction of LA and LV pressures, both of which are affected by chamber properties as well as loading conditions.     

Diastology: 2020-A practical guide

Left ventricular (LV) diastolic function can be most conveniently assessed by echocardiography which provides reliable assessments of LV structure and function. Most patients with structural heart disease have variable degrees of myocardial dysfunction. LV structural changes as pathologic hypertrophy and systolic functional abnormalities as depressed LV long-axis systolic function are associated with diastolic dysfunction. The recognition of structural abnormalities and abnormal LV long-axis function as indices of diastolic dysfunction is an important difference between 2016 and 2009 guidelines. In addition, there are other Doppler findings indicative of diastolic dysfunction and abnormally elevated LV filling pressures. In the absence of clinical, 2D echocardiographic, and specific Doppler indices of diastolic dysfunction, mitral annulus early diastolic velocity (e’), left atrium (LA) maximum volume index, peak velocity of tricuspid regurgitation jet by continuous-wave Doppler, and ratio of mitral inflow early diastolic velocity to e’ velocity can be used to draw inferences about LV diastolic function. In the presence of diastolic dysfunction, mean LA pressure and grade of diastolic dysfunction should be determined. When LA pressure at rest is normal, it is reasonable to proceed to diastolic stress testing in an attempt to identify patients with dyspnea due to heart failure. There are specific algorithms recommended in patients with atrial fibrillation, moderate or severe mitral annular calcification, and noncardiac pulmonary hypertension.     

Assessment of ventricular diastolic function.

A large number of patients suspected of having congestive heart failure have normal left ventricular systolic function and may, therefore, have primary diastolic heart failure. This diagnosis, however, should not be made unless there is also objective evidence of diastolic dysfunction, ie, signs of abnormal left ventricular relaxation and/or diastolic distensibility. The most useful noninvasive diagnostic approaches are the measurement of transmitral and pulmonary venous flow velocities by pulsed wave Doppler, and mitral annulus velocities by tissue Doppler echocardiography. In some patients, the assessment of intraventricular flow propagation by colour M-mode Doppler echocardiography provides additional information. Diastolic heart failure is most often due to coronary artery disease and/or hypertension; therefore, other noninvasive or invasive tests are needed to define the etiology of myocardial dysfunction. However, in the few patients who have constrictive pericarditis, the Doppler echocardiographic assessment of diastolic filling provides the most important clues to the etiology of the disease. Doppler echocardiographic assessment of left ventricular filling may also be used to obtain semiquantitative estimates of left ventricular diastolic pressure. Furthermore, left ventricular filling patterns, in particular, the deceleration time of early transmitral filling, are powerful predictors of patient prognosis. It is probably not cost effective to perform a comprehensive assessment of diastolic filling in every patient undergoing an echocardiographic examination. However, in selected patients, the assessment of diastolic filling provides information that is important for patient management.     

Improvements in left ventricular diastolic function after cardiac resynchronization therapy are coupled to response in systolic performance.

OBJECTIVES: To determine the short-term effects of cardiac resynchronization therapy (CRT) on measurements of left ventricular (LV) diastolic function in patients with severe heart failure. BACKGROUND: Cardiac resynchronization therapy improves systolic performance; however, the effects on diastolic function by load-dependent pulsed-wave Doppler transmitral indices has been variable. METHODS: Fifty patients with severe heart failure were evaluated by two-dimensional Doppler echocardiography immediately prior to and 4 +/- 1 month after CRT. Measurements included LV volumes and ejection fraction (EF), pulsed-wave Doppler (PWD)-derived transmitral filling indices (E- and A-wave velocities, E/A ratio, deceleration time [DT], diastolic filling time [DFT], and isovolumic relaxation time). Tissue Doppler imaging was used for measurements of systolic and diastolic (Em) velocities at four mitral annular sites; mitral E-wave/Em ratio was calculated to estimate LV filling pressure. Color M-mode flow propagation velocities were also obtained. RESULTS: After CRT, LV volumes decreased significantly (p < 0.001) and LVEF increased >5% in 28 of 50 patients (56%) and were accompanied by reduction in PWD mitral E-wave velocity and E/A ratio (both p < 0.01), increased DT and DFT (both p < 0.01), and lower filling pressures (i.e., E-wave/Em septal; p < 0.01). Patients with LVEF response < or =5% after CRT had no significant changes in measurements of diastolic function; LV relaxation (i.e., Em velocities) worsened in this group. CONCLUSIONS: In heart failure patients receiving CRT, improvement in LV diastolic function is coupled to the improvement in LV systolic function.     

Diastolic abnormalities in young asymptomatic diabetic patients assessed by pulsed Doppler echocardiography

Indexes of left ventricular diastolic filling were measured by pulsed Doppler echocardiography in 21 insulin-dependent diabetic patients and 21 control subjects without clinical evidence of heart disease. No patient had chest pain or electrocardiographic changes during exercise testing. The mean age of patients was 32 years. All patients had a normal ejection fraction. Six (29%) of the 21 diabetic patients had evidence of diastolic dysfunction as assessed by the presence of at least two abnormal variables of mitral inflow velocity. The ratio of peak early to peak late (atrial) filling velocity was significantly decreased in diabetic compared with control subjects (1.24 +/- 0.21 versus 1.66 +/- 0.30, p. less than 0.001). Atrial filling velocity was significantly increased in diabetic patients (74.3 +/- 16.7 versus 60.3 +/- 12.2 cm/s, p less than 0.004), whereas early filling velocity was reduced by a nearly significant degree (88.8 +/- 12.6 versus 98.5 +/- 18.8 cm/s, p less than 0.057). The atrial contribution to stroke volume as assessed by area under the late diastolic filling envelope compared to total diastolic area was also significantly increased in diabetic compared with control subjects (35 versus 27%, p less than 0.001). Left ventricular diastolic filling abnormalities in diabetic patients did not correlate with duration of diabetes, retinopathy, nephropathy or peripheral neuropathy. These data suggest that approximately one-third of such patients have subclinical myocardial dysfunction unrelated to accelerated atherosclerosis. Doppler echocardiography may offer a reliable noninvasive means to assess diastolic function and to follow up diabetic patients serially for any deterioration in cardiac status before the appearance of clinical symptoms.     

Relaxation and diastolic filling of the left ventricle

The cardiac cycle, as revisited by modern authors, consists of 3 fundamental phases: contraction, which includes isovolumic contraction and first part of ejection; relaxation which begins with left ventricular peak pressure, continues with second part of ejection and isovolumic relaxation, and ends together with ventricular rapid filling (i.e. as filling rate has decreased by 50 p. cent); finally compliance or slow filling which lasts until atrial systole. The LV diastolic dysfunction refers to filling abnormalities which are related to either relaxation abnormalities or compliance troubles or both. The mechanisms of these abnormalities are biochemical (deficiency in cyclic AMP resulting in calcium handling dysregulation) and mechanical: right ventricular filling, pericardial restraint, coronary arteries perfusion, myocardial inertial forces, myocardial visco-elastic properties, ventricular wall elasticity (depending itself on its thickness and its collagen content). The methods of analysis of LV filling are: left ventriculography, gamma angiography, digitized M-Mode echography and, mainly, Doppler echocardiography. This technique allows 2 types of mitral flow abnormalities to be distinguished: 1) the abnormal relaxation which combines an increased isovolumic relaxation time, an increased deceleration time and a diminished E/A ratio, but this pattern may be "normalized" by an increase in filling pressure; 2) the restriction to filling which results in an increased E/A ratio, a diminished deceleration time and, sometimes, a diastolic mitral regurgitation. The effects of drugs on LV diastolic function are difficult to assess: a beneficial result may be due either to a direct effect on the myocardium or to an improvement in load conditions, heart rate or contractility.     

Left ventricular filling measured by Doppler echocar diography during dynamic exercise in patients with myocardial infarction

Summary To assess left ventricular diastolic properties in response to dynamic exercise, mitral inflow velocity integrals were measured by pulsed-wave Doppler echocardiography in ten patients with myocardial infarction and in ten normal subjects, and simultaneous left ventricular pressure was obtained with micromanometry in the patients. Early filling velocity integrals were maintained in the patients during exercise. Late filling velocity integrals were not augmented during exercise in the patients, but were increased in the normal subjects. In the patients, there was an increase in mitral valve opening pressure, left ventricular end-diastolic pressure, and the time constant of left ventricular isovolumic pressure decay. The lowest diastolic pressure and the number of time constants that had elapsed before the lowest diastolic pressure remained unchanged. These results show that in patients with myocardial infarction, early filling is maintained by an increase in driving pressure during exercise, despite incomplete relaxation. Augmentation of late filling, seen in normal subjects, is impaired in patients with myocardial infarction, probably due to an increase in left ventricular stiffness.     

Left Ventricular Diastolic Function in the Elderly

Previous studies using pulsed Doppler echocardiography have demonstrated a pattern of abnormal left ventricular relaxation associated with increasing age. Specifically, aging is associated with decreased peak velocity of early diastolic mitral inflow, increased peak velocity of late diastolic inflow, increased isovolumic relaxation time, and early diastolic deceleration time. Abnormal relaxation can progress to significantly elevated left atrial pressure—characterized by increased early peak velocity and shortened isovolumic relaxation time and deceleration time—as part of the disease processes. Left ventricular diastolic dysfunction is highly prevalent, occurring in one half to two thirds of elderly patients with congestive heart failure, in association with normal systolic function. Left ventricular hypertrophy, which is commonly related to systemic arterial hypertension, and ischemic heart disease are the two major causes of abnormal left ventricular diastolic function in the elderly. Recently, newer echocardiographic techniques have been described that allow more accurate evaluation of left ventricular diastolic function. Treatments for left ventricular diastolic dysfunction should focus on the underlying disease etiology as well as on the derangement in left ventricular diastolic function. Although calcium channel blockers and angiotensin—converting enzyme inhibitors have been used clinically to treat diastolic dysfunction, their effects on prognosis remain unproven.     

Heart failure due to abnormal filling function of the heart

Symptoms of heart failure can be caused by the diastolic dysfunction even in patients with normal ejection fraction, and this condition has been called diastolic heart failure. After Kitabatake and his associates first used echo-Doppler to characterize the transmitral flow velocity in various disease states in 1982, there have been remarkable advances in the evaluation of diastolic function with Doppler echocardiography. Types of diastolic dysfunction can be classified into relaxation abnormality, pseudonormal, reversible restrictive physiology, and irreversible restrictive physiology. Classifying the patients into these types, in addition to the reliable estimation of left ventricular filling pressure with Doppler echocardiography, enables us to adjust treatment in individual patients and to get information about the prognosis. The main hemodynamic abnormality in patients with diastolic dysfunction is the abnormal filling function of the heart. Therefore, if we expand the scope of diastolic heart failure, patients with constrictive pericarditis can also be categorized into diastolic heart failure. The purpose of this review is to refine our knowledge in the concept of diastolic dysfunction and to update the methods used in its' evaluation.     

Evolving changes in Doppler mitral flow velocity pattern in rats with hypertensive hypertrophy

OBJECTIVES

The aim of our study was to explore evolving changes in a mitral flow velocity pattern (MFVP) and its hemodynamic and pathological correlates in hypertensive rats in an isolated diastolic heart failure model.

BACKGROUND

Development of left ventricular (LV) hypertrophy and concomitant diastolic dysfunction cause heart failure in hypertensive hearts even with normal systolic function; however, associated evolving change in MFVP is still unclear.

METHODS

Mitral flow velocity pattern was recorded every 2 weeks from 7 to 19 weeks in six hypertensive rats. Hemodynamic and pathological correlates of Doppler mitral flow indexes were examined as an additional part of the study using the hypertensive rats at the age of 13 weeks (compensatory stage, N = 7) and at 19 weeks (heart failure stage, N = 8).

RESULTS

Initial development of pressure overload LV hypertrophy resulted in a decrease in early diastolic filling wave (E), a reciprocal increase in the filling wave due to atrial contraction (A) and prolongation of deceleration time of E wave (relaxation abnormality pattern). These changes were associated with an increase in tau, an index of LV relaxation, but without a change in LV end-diastolic pressure. Transition to congestive heart failure caused an increase in E, a decrease in A and shortening of deceleration time. These changes were not associated with further increase in tau but with elevation of LV end-diastolic pressure, reflecting marked LV hypertrophy and myocardial fibrosis.

CONCLUSIONS

Development of pressure overload LV hypertrophy is associated with evolving changes in MFVP from normal to relaxation abnormality pattern and, in turn, to pseudonormalized to restrictive pattern. Analysis of MFVP may be useful to follow not only functional but also constitutional changes of the myocardium in hypertensive hearts.     

Tissue Doppler imaging identifies myocardial dysfunction in adults with Marfan syndrome

BACKGROUND: Successful prevention of aortic complications has lead to improved survival of Marfan syndrome (MFS). With increasing age, however, ventricular arrhythmia and heart failure are emerging as life-threatening manifestations of myocardial dysfunction. HYPOTHESIS: We sought to investigate whether echocardiography with tissue Doppler imaging (TDI) identifies myocardial dysfunction in adults with MFS. METHODS: We performed two-dimensional (2-D) and Doppler echocardiography with TDI in 141 individuals with suspected MFS and competent heart valves, including 28 persons with MFS who had not undergone surgery and 86 healthy controls without inherited connective tissue disorders. RESULTS: Demographic profile, 2-D, mitral and pulmonary venous flow indices, and left ventricular ejection fractions were similar in both groups. Conversely, isovolumic relaxation time (p < 0.001) and deceleration time of E velocity (p = 0.005) were longer, and atrial reversal velocities (p = 0.02), and systolic and early diastolic TD velocities were slower in MFS than in controls (p = 0.01). Multiple linear regression analysis excluded association of reduced systolic and early diastolic TD velocities with mitral valve prolapse or other clinical or echocardiographic features of MFS. CONCLUSIONS: Our study identifies reduced systolic and early diastolic TD velocities in adults with MFS. Further studies are mandatory to elucidate whether TD velocities predict arrhythmia and heart failure in MFS.     

Analysis of the early transmitral Doppler velocity curve: effect of primary physiologic changes and compensatory preload adjustment

Left ventricular filling (as assessed by Doppler echocardiography) has previously been shown to depend in a complex fashion on ventricular diastolic function (compliance and relaxation) as well as other variables, such as atrial pressure and compliance, ventricular systolic function and mitral valve impedance. To study the effect of isolated physiologic alterations on individual Doppler indexes, a mathematic model of mitral flow was analyzed. By varying one physiologic variable at a time, it was shown that mitral velocity acceleration is affected directly by atrial pressure and inversely by the ventricular relaxation time constant, with relatively little impact of chamber compliance. Deceleration rate was directly influenced by mitral valve area, atrial pressure and ventricular systolic dysfunction and inversely affected by atrial and ventricular compliance relations, with little impact of relaxation unless it was so delayed as to be incomplete during deceleration. Peak velocity was directly affected most strongly by initial left atrial pressure, and lowered somewhat by prolonged relaxation, low atrial and ventricular compliance and systolic dysfunction. Strikingly different filling patterns emerged when the primary physiologic alterations were accompanied by simultaneous compensatory changes in atrial pressure designed to maintain stroke volume constant. Low ventricular compliance with preload compensation produced characteristic E waves with very short acceleration and deceleration times and high peak velocity. Thus, mathematic analysis of ventricular filling helps to explain the physical and physiologic basis for the transmitral velocity curve.     

Left ventricular diastolic filling abnormalities identified by Doppler echocardiography in asymptomatic patients with sickle cell anemia

To determine whether left ventricular diastolic abnormalities are an early feature of sickle cell anemia, indexes of diastolic filling were obtained with pulsed Doppler echocardiography in 30 consecutive patients with this disease (mean age 29 years; range 19 to 39) who had not experienced symptoms of heart failure and had normal left ventricular systolic function. Data were compared with those in 30 normal control subjects of similar ages. Seventeen (57%) of the 30 patients with sickle cell anemia had evidence of abnormal left ventricular diastolic filling. Six of these 17 patients had a Doppler pattern consistent with "restrictive" filling, characterized by reduced early diastolic deceleration time (less than 110 ms) or an increased rate of decline of early flow velocity (EF slope greater than 7.4 m/s2), or both, as well as decreased late diastolic velocity-time integral (2.6 +/- 0.7 vs. 3.4 +/- 0.8 cm in normal subjects; p less than 0.05). Another 11 patients showed a Doppler waveform consistent with impaired relaxation, characterized by prolonged deceleration time (greater than 166 ms) or reduced EF slope (less than 3.8 m/s2), as well as increased late diastolic velocity-time integral (4.0 +/- 0.5 vs. 3.4 +/- 0.8 cm in normal subjects; p = 0.03). This Doppler echocardiographic analysis demonstrates that left ventricular diastolic filling patterns are altered in patients with sickle cell anemia and that these diastolic abnormalities may be present in the absence of symptoms of heart failure. These abnormal patterns suggest an intrinsic myocardial abnormality in patients with sickle anemia and may prove to be early markers of cardiac disease.     

Beurteilung der diastolischen Herzinsuffizienz

Diastolic heart failure, also known as heart failure with preserved left ventricular ejection fraction (HF-pEF), is responsible for approximately 50 % of all heart failure cases. According to current guidelines the diagnosis HF-pEF requires three criteria: (1) signs or symptoms of heart failure, (2) presence of a normal left ventricular ejection fraction and (3) evidence of diastolic dysfunction. Echocardiography is the diagnostic modality of choice, especially after ruling out other causes of dyspnea, such as pulmonary diseases, heart rhythm disturbances and volume overload. Important echocardiographic parameters for the assessment of diastolic function are atrial dimensions, myocardial mass, mitral inflow pattern, pulmonary vein flow, propagation velocity of mitral inflow and the tissue Doppler of the mitral annulus. Nevertheless, a complete echocardiographic examination should be performed in every patient with heart failure. In general, diastolic dysfunction is frequently associated with increased atrial diameter and left ventricular hypertrophy. In advanced stages pulmonary hypertension can be present. A robust method for evaluation of systolic function in patients with diastolic dysfunction is crucial. The mitral inflow pattern provides various parameters to describe diastolic function (E/A ratio, deceleration time, isovolumetric relaxation time). In case of difficulties to separate a normal from a pseudonormal mitral inflow pattern the Valsalva maneuver can be used. Another valuable parameter for this differentiation is the duration of the backward flow in the pulmonary veins in contrast to forward flow over the mitral valve. Tachycardia or atrial fibrillation is a major problem for grading of diastolic function; however, in patients with atrial fibrillation E/e’ is a well-established parameter. In summary, this review provides a detailed overview and discussion of the established and newer echocardiography techniques for the evaluation of diastolic function and provides an algorithm for the assessment of diastolic dysfunction in everyday routine.     

Heart Failure With Normal Left Ventricular Ejection Fraction: What is the Evidence?

Heart failure with a normal ejection fraction (HFNEF) is a common clinical problem with many unsolved questions regarding pathophysiology, diagnosis, and therapy. Although the term diastolic heart failure has been abandoned, diastolic left ventricular (LV) dysfunction together with combined systolic ventricular and arterial stiffening are considered to be the main pathophysiologic mechanisms in HFNEF. Current guidelines define HFNEF by symptoms or signs of heart failure in the presence of LV ejection fraction of more than 50%, but with additional evidence of LV diastolic dysfunction. Definite diagnosis of HFNEF requires exclusion of valvular heart disease, constrictive pericarditis, and several noncardiac diseases. Echocardiographic assessment of the tissue Doppler-derived filling index E/E′, which is the ratio of the peak early mitral valve flow velocity to the peak early diastolic mitral annular velocity, should improve the noninvasive estimation of filling pressures in suspected HFNEF. Elevated plasma levels of natriuretic peptides may confirm HFNEF if tissue Doppler echocardiography is inconclusive. Treatment of HFNEF is symptom oriented and mainly based on pathophysiologic assumptions such as heart rate reduction, blood pressure control, and maintenance of sinus rhythm. In contrast to heart failure with reduced ejection fraction, large-scale randomized controlled drug trials for HFNEF are scarce and could not demonstrate mortality reduction so far.     

Doppler echocardiography in dilated and restrictive cardiomyopathies

Dilated cardiomyopathy is characterized by systolic dysfunction and cardiac enlargement of unknown origin. Various Doppler modalities are useful to detect and quantitate atrioventricular regurgitation, which is common and contributes to clinical symptoms. Pulsed Doppler assessment of mitral and tricuspid inflow velocities shows a spectrum of findings indicative of abnormal diastolic function and hemodynamic status. When mitral regurgitation is more than moderate and heart failure is severe, the ratio between early inflow E wave to atrial inflow A wave peak velocities is increased. Mitral deceleration time may be short. When mitral regurgitation is trivial and left atrial pressure is not increased, abnormal relaxation may be detected as a low E:A ratio. Mitral deceleration time and isovolumic relaxation time are prolonged. In restrictive cardiomyopathy, there is an abrupt limitation in early ventricular filling due to abnormal compliance of endocardial or endomyocardial origin. Mitral and tricuspid inflow velocities show normal to increased early peak velocity, rapid deceleration time, low peak atrial velocity, and an increased E:A ratio. Differentiation between restriction and constriction might be possible by the demonstration in pericardial constriction of inspiratory decreases in mitral early inflow peak velocities and in prolongation of isovolumic relaxation time, with reciprocal changes on tricuspid inflow velocity profiles. In constriction, these respiratory variations are caused by the ventricular limitation to accommodate changes in venous return due to the pericardial shell. Doppler abnormalities and two-dimensional echocardiographic assessment of ventricular and atrial size and ejection fraction provide the practicing physician with valuable diagnostic information.     

Filling patterns in left ventricular hypertrophy: A combined acoustic quantification and Doppler study

Objectives. The purpose of this study was to evaluate the potential of acoustic quantification compared with Doppler echocardiography for assessment of left ventricular diastolic dysfunction.Background. Diastolic dysfunction usually accompanies left ventricular hypertrophy. Although Doppler echocardiography is widely used, it has known limitations in the diagnosis of diastolic abnormalities. The ventricular area-change waveform obtained with acoustic quantification technology may provide an alternative to assess diastolic dysfunction.Methods. Potential acoustic quantification variables (peak rate of area change and mean slope of area change rate during rapid filling, amount of relative area change during rapid filling and atrial contraction) were obtained and compared with widely used Doppler indexes of ventricular filling (isovolumetric relaxation time, pressure half-time, peak early diastolic velocity/peak late diastolic velocity ratio, rapid filling, atrial contribution to filling) ia 16 healthy volunteers and 30 patients with left ventricular hypertrophy.Results. Criteria for abnormal relaxation were present in 68% of patients by acoustic quantification and in 64% of patients by Doppler echocardiography. However, abnormal relaxation was identified in 89% of patients by one or both methods. Acoustic quantification indicated abnormal relaxation in the presence of completely normalized Doppler patterns and in patients with mitral regurgitation or abnormal rhythm with unreliable Doppler patterns.Conclusions. Acoustic quantification potentially presents a new way to assess diastolic dysfunction. This technique may be regarded as complementary to Doppler echocardiography. The combined use of the methods may improve the diagnosis of left ventricular relaxation abnormalities.