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.     

Doppler echocardiographic-guided diagnosis and therapy of heart failure

Abnormalities of diastolic function play a major role in producing the signs and symptoms of heart failure. In patients with heart failure and reduced left ventricular systolic function, concomitant diastolic dysfunction is invariably present. In addition, it is now well established that as many as 40% to 50% of patients with well-documented episodes of heart failure have preserved systolic function. Doppler echocardiography provides one of the most useful clinical tools for assessing left ventricular diastolic function and can provide diagnostic and prognostic information. The Doppler assessment of diastolic function should be part of the routine echocardiographic evaluation of patients suspected of having heart failure. This review focuses on the use of Doppler echocardiographic techniques to assess diastolic function. The Doppler patterns of diastolic filling observed and their progression over time in patients with myocardial disease are described and related to changes in the physiology of diastolic filling. In addition, Doppler echocardiographic-guided treatment strategies for heart failure are discussed.     

The utility of newly derived Doppler echocardiographic variables in the diagnosis and management of patients with heart failure

Doppler echocardiography, because of its noninvasive nature, is an ideal tool to evaluate patients with heart failure (HF), offering the potential to improve early identification and management of these patients. Although traditional Doppler indices have allowed characterization of diastolic filling abnormalities associated with various HF states, important limitations are recognized. More refined Doppler techniques such as analysis of color M-mode flow propagation velocity, tissue Doppler imaging, and strain parameters can add to the ability of the noninvasive laboratory to improve the identification and management of this group of patients. These newer techniques as well as the traditional Doppler assessment of transmitral left ventricular inflow and pulmonary venous inflow velocities are reviewed as methods to improve the diagnosis and management of patients with HF.     

Assessment of diastolic dysfunction after acute myocardial infarction using Doppler echocardiography

Doppler echocardiography (DE) is becoming a powerful noninvasive tool for assessing left ventricular diastolic dysfunction after myocardial infarction (MI). Transmitral inflow DE measurements of early and late filling velocities, early to late ratio and early deceleration time correlate well with left ventricular filling pressure. Three abnormal filling patterns (impaired relaxation, pseudonormalization and restrictive) develop after MI, depending on infarct size. Pulmonary venous inflow DE contributes important additional diagnostic data and, when combined with transmitral DE, avoids potential confusion due to the pseudonormal pattern that develops in the presence of high left atrial pressure and impaired relaxation. Several studies indicate that these DE patterns correlate with progressively increasing functional impairment, and the restrictive transmitral pattern predicts heart failure and death among MI survivors. Further studies are needed to evaluate the effects of therapy on the DE patterns of diastolic dysfunction after MI.     

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.     

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.     

The role of Doppler echocardiography in the assessment of left ventricular diastolic function

The role of Doppler echocardiography of transmitral filling velocities in the assessment of diastolic function in man has not been adequately defined. It is now appreciated that multiple interacting factors such as loading conditions influence the transmitral velocity profile independent of intrinsic left ventricular diastolic function. Extrapolating the status of diastolic function from the transmitral velocity profile is complicated by these factors. The load dependence of ventricular filling has tempered the initial enthusiasm for the clinical application of the Doppler technique. In the present review, studies examining invasive parameters of diastolic function and Doppler indices of diastolic filling are discussed to gain greater insight and understanding of the role of Doppler echocardiography in the noninvasive assessment of diastolic function. These studies have demonstrated a relatively consistent influence of left ventricular relaxation, chamber stiffness, and left atrial pressure on the transmitral velocity filling profile. Impairment of relaxation impedes early filling and may result in a compensatory increase in atrial contribution to filling. An independent decrease in left atrial pressure from altered loading conditions may also reduce filling in early diastole. Increased left ventricular chamber stiffness (i.e., noncompliant left ventricle) impairs atrial contribution to filling and may enhance early filling. Theoretically, reduced left atrial contractility may decrease atrial contribution to filling. Pulmonic vein flow demonstrating increased retrograde flow during atrial systole helps to exclude impaired left atrial contractility. An increased left atrial pressure from altered loading conditions may also augment early filling. Therefore, an invasive or clinical assessment of left atrial pressure as being increased, decreased, or normal greatly aids in the interpretation of the transmitral filling velocity profile when inferences on the status of diastolic function are being made. Diastolic dysfunction is likely when a given pattern of filling cannot be explained on the basis of left atrial pressure. In situations where reasonable estimates on the status of left atrial pressure cannot be done, striking alterations in the transmitral velocity filling profile may be useful.     

Is 'diastolic heart failure' a diagnosis of exclusion? Echocardiographic parameters of diastolic dysfunction in patients with heart failure and normal systolic function

Background: Diastolic heart failure (DHF) is reported to account for 30–50% of heart failure presentations, but its prevalence in the absence of overt coronary disease is unclear. Diastolic heart failure is usually defined by exclusion (heart failure with normal left ventricular (LV) systolic function), and few studies have sought a specific diagnosis of diastolic dysfunction. The objective of the present study was to determine the prevalence of isolated DHF and characterise LV diastolic function in patients without clinical evidence of coronary disease, who were referred for LV function assessment.

Methods: Among 938 consecutive patients referred for assessment of LV function, diastolic dysfunction was sought in patients with clinical heart failure, normal systolic function, and no valvular or coronary disease. The evaluation was based on measurement of early (E) and late (A) transmitral velocities and E wave deceleration time (DT). Pulmonary vein systolic, diastolic and atrial reversal velocities were used to differentiate pseudonormal filling in patients with normal E/A and DT.

Results: Normal LV systolic function was present in 331 patients (35%), of whom 53 (6%) met criteria for a clinical diagnosis of DHF. Diastolic dysfunction was confirmed by echocardiography in 38 patients (72% of clinical DHF patients), of whom 27 had impaired LV relaxation, 10 had pseudonormal filling, and one had restrictive filling. Diastolic function was normal in 13 and indeterminate in two patients. Pseudonormal or restrictive LV filling were more prevalent in patients with acute heart failure (7/20, P < 0.05).

Conclusions: Carefully defined, isolated DHF is uncommon, but most of these patients demonstrate echocardiographic evidence of diastolic dysfunction.     

Echocardiographic assessment of left ventricular diastolic function and filling pressure in atrial fibrillation

Diastolic dysfunction has been linked to 2 epidemics: atrial fibrillation (AF) and heart failure. The presence and severity of diastolic dysfunction are associated with an increased risk for first AF and first heart failure in patients with sinus rhythm. Furthermore, the risk for heart failure is markedly increased once AF develops. The evaluation of diastolic function once AF has developed remains a clinical challenge. The conventional use of Doppler echocardiography for the assessment and grading of diastolic dysfunction relies heavily on evaluating the relation of ventricular and atrial flow characteristics. The mechanical impairment of the left atrium and the variable cycle lengths in AF render the evaluation of diastolic function difficult. A few Doppler echocardiographic methods have been proved clinically useful for the estimation of diastolic left ventricular filling pressures in AF, but these appear to be underutilized. Several innovative methods are emerging that promise to provide greater precision in diastolic function assessment, but their clinical utility in AF remains to be established. In conclusion, this review provides an up-to-date discussion of the evaluation of diastolic function assessment in AF and how it may be important in the clinical management of patients with AF.     

Assessment and impact of diastolic function by echocardiography in elderly patients

Doppler echocardiography is the gold standard for assessment of diastolic dysfunction, which is increasingly recognised as a cause of heart failure, especially in the elderly. Using a combination of Doppler echocardiography techniques, it is possible to identify grades of diastolic dysfunction, estimate left ventricular filling pressures and establish the chronicity of diastolic dysfunction. These physiologically-derived measures have been widely validated against invasive measurements of left heart pressures and have been shown to be prognostically valuable in a wide range of clinical settings. This review explores the mechanisms, and approaches to the assessment of diastolic dysfunction in the elderly. The challenge for clinicians is to identify pathophysiological changes from those associated with normal ageing. When used in combination, and taking age into account, Doppler echocardiographic parameters are helpful in the assessment of dyspnoea in older patients and provide prognostic insights.     

Modern evaluation of left ventricular diastolic function using Doppler echocardiography

The evaluation of left ventricular (LV) diastolic function is an essential component of the echocardiographic examination for dyspneic patients with impaired or preserved LV systolic function. Doppler echocardiography in combination with two-dimensional echocardiographic findings can assist the diagnosis of underlying cardiac dysfunction, give an estimate of LV filling pressures, guide heart failure treatment, and provide important prognostic information. This article reviews the essentials of modern Doppler assessment of diastolic function and highlights recent updates, areas of controversy, and future applications.     

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.     

"Pure" diastolic dysfunction is associated with long-axis systolic dysfunction. Implications for the diagnosis and classification of heart failure

AIMS: To investigate regional systolic function of the left ventricle, to test the hypothesis that "pure" diastolic dysfunction (impaired global diastolic filling, with a preserved ejection fraction > or = 50%) is associated with longitudinal systolic dysfunction. METHODS AND RESULTS: One hundred thirty subjects (31 patients with asymptomatic diastolic dysfunction, 30 with diastolic heart failure, 30 with systolic heart failure; and 39 age-matched normal volunteers) were studied by conventional and tissue Doppler echocardiography. Global diastolic function was assessed using the flow propagation velocity, and by estimating left ventricular filling pressure from the ratio of transmitral E and mitral annular E(TDE) velocities (E/E(TDE)); and global systolic function by measurement of ejection fraction. Radial and longitudinal functions were assessed separately from posterior wall and mitral annular velocities. Global and radial systolic function were similar in patients with "pure" diastolic dysfunction and normal subjects, but patients with either asymptomatic diastolic dysfunction or diastolic heart failure had impaired longitudinal systolic function (mean velocities: 8.0+/-1.2 and 7.7+/-1.5 cm/s, respectively, versus 10.1+/-1.5 cm/s in controls; p<0.001). In subjects with normal ejection fraction, global diastolic function correlated with longitudinal systolic function (r=0.56 for flow propagation velocity, and r=-0.53 for E/E(TDE) ratio, both p<0.001), but not with global systolic function. CONCLUSION: Worsening global diastolic dysfunction of the left ventricle is associated with a progressive decline in longitudinal systolic function. Diastolic heart failure as conventionally diagnosed is associated with regional, subendocardial systolic dysfunction that can be revealed by tissue Doppler of long-axis shortening. Diagnostic algorithms and definitions of heart failure need to be revised.     

The usefulness of tissue doppler imaging in the determination of left ventricular diastolic filling pressure. Comparison with other techniques

The further examination of left ventricular diastolic function (LVDF) is important in terms of early diagnosis, therapy and follow-up of heart failure. Although cardiac catheterization is considered as the most accurate method in the evaluation of diastolic function, since it is invasive, noninvasive methods are preferred. This study was undertaken to examine whether mitral annular velocities assessed by pulsed tissue Doppler imaging (PTDI) were associated with invasive measures of diastolic LV pressure and whether additional information was gained over traditional transmitral and pulmonary venous flow velocity parameters. Doppler examination was performed in 102 patients referred to our clinic for cardiac catheterization. Doppler signals from the mitral inflow, pulmonary venous inflow, and PTDI of the mitral annulus were obtained. Mean left ventricular diastolic pressure (M-LVDP) was measured.The relationship between echocardiographic parameters and M-LVDP was investigated.A significant correlation was observed between M-LVDP and E/septal Em (r = 0.52, p < 0.000), E/lateral Em (r = 0.45, p < 0.0001), E/posterior Em (r = 0.46, p < 0.0001) E/anterior Em (r = 0.49, p < 0.0001), E/mean Em (r = 0.49, p < 0.0001), PVadur - MVadur (r = 0.51, p < 0.0001). The best echocardiographic parameters correlating with M-LVDP were E/septal Em and PVa-dur - MVa-dur. In conclusion, PTDI could be used in the assessment of LVDP. However, the combination of transmitral flow and pulmonary venous flow velocities with annular velocity can be proposed as the best method for assessing LV filling pressure that combines the influence of transmitral driving pressure and myocardial relaxation.     

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.     

Left ventricular diastolic function in children measured by Doppler echocardiography: normal values and relation with growth.

OBJECTIVES--To determine normal values for variables of left ventricular diastolic function in children measured by Doppler echocardiography and their relations to body surface area (BSA). BACKGROUND--There is increasing interest in echocardiographic assessment of left ventricular diastolic function in children but normal data for children are limited. METHODS--Assessment of left ventricular diastolic function was performed in 130 normal participants (aged from 2.4 months to 19.6 years) from their transmitral flow patterns obtained by pulsed wave Doppler echocardiography. RESULTS--Centile charts for commonly used left ventricular diastolic functional variables plotted against BSA are presented. Peak early diastolic filling velocity and atrial phase filling velocity integral were independent of BSA. Although most other filling indices showed strong relations with BSA, some had more curvilinear relations with BSA due to additional interactions with heart rate. The increase in left ventricular filling with growth is largely achieved by an increase in the early "passive" contribution to filling. The slower heart rates of older children are associated with lower atrial phase filling velocities but increased filling time, so the atrial contribution to filling remains relatively constant. CONCLUSIONS--Normal values of many left ventricular diastolic function variables change with growth in children and cannot be extrapolated from adult data. The data presented are suitable for use in size matched matched comparative studies of left ventricular function in children. Careful standardisation of echocardiographic protocols is necessary to ensure the validity of any comparisons.     

Doppler echocardiographic evaluation of left ventricular diastolic function in acute hypothyroidism

OBJECTIVE Left ventricular diastolic dysfunction Is an important cause of symptomatic heart failure. Previous studies suggest that thyroid dysfunction affects left ventricular diastolic function but the underlying mechanisms remain controversial. The study was undertaken to assess the influence of acute hypothyroidism on left ventricular diastolic function and to elucidate possible underlying mechanisms by means of Doppler echocardiography in a group of athyreotic patients, whose thyroid state depended only on external thyroid hormone supply and could therefore easily be controlled. PATIENTS Eleven patients (5 men, 6 women, aged 20-55 years), who had had total thyroidectomy, were investigated during mild hyperthyroidism and during acute hypothyroidism. Additionally, 11 healthy control subjects aged 25-51 years were included in the study. DESIGN M-mode echocardiography of the left ventricle and pulsed-wave Doppler echocardiography of the trans-mitral flow velocity pattern were carried out. RESULTS Acute hypothyroidism produced a decrease of left ventricular end-diastolic diameter from 48 ± 5 to 46 ± 5 mm (mean ± SD P < 0.05), of peak velocity of early diastolic filling from 0.52 ± 0.10 to 0.42 ± 0.05 m/s (P < 0.05), of peak velocity of late diastolic filling from 0.42 ± 0.10 to 0.36 ± 0.09 m/s (P < 0.05), and a decreased time-velocity integral of early diastolic filling (6 2 ± 1 8 vs 5.1 ± 0.7 cm, P < 0.05). The other M-mode and Doppler echocardiographic parameters did not differ between the hyperthyroid and the hypothyroid states. CONCLUSIONS The observed changes of the transmitral flow velocity pattern during acute hypothyroidism can be attributed to a reduction of pre-load. There is no direct evidence that acute hypothyroidism affects the intrinsic diastolic properties of the left ventricle.     

Tissue Doppler velocities of mitral annulus and NT-proBNP in patients with heart failure

BACKGROUND: It has been shown that pulsed wave tissue Doppler velocities of mitral annulus correlate well with left ventricular (LV) diastolic and systolic functions. It is not yet clear whether these velocities can be used to estimate left ventricular dysfunction in an unselected population of patients with clinical signs and symptoms of heart failure (HF). AIM: To determine whether LV mitral annulus velocities measured by tissue Doppler imaging (TDI) correlate with plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with HF. METHODS AND RESULTS: Early diastolic (E(m)) and systolic (S(m)) TDI velocities of septal and lateral mitral annulus were measured in 50 patients with HF together with other conventional echocardiographic parameters, and compared with plasma NT-proBNP levels. Significant correlations were found between NT-proBNP level and E(m) velocity (r=-0.79), S(m) velocity (r=-0.43), early transmitral to E(m) velocity ratio (r=0.38), LV end diastolic diameter (r=0.29), LV ejection fraction (r=-0.44) and tricuspid regurgitant velocity (r=0.31). In multiple regression model (R(2)=0.733), the E(m) velocity was the most important predictor of NT-proBNP level. CONCLUSIONS: Early diastolic mitral annulus velocity measured by TDI correlates strongly with plasma NT-proBNP levels, and provides a simple, accurate and reproducible echocardiographic index of heart failure.