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ASE/EACVI Diastolic Guidelines: Strength and Limitations

Case Study A 56-year-old obese woman with exertional dyspnea was referred for evaluation of suspected heart failure with preserved ejection fraction (HFpEF). She had a past medical history of Crohn Crohn’s disease, hypothyroidism, and asthma. She had been medically treated for hypertension for several years. Over the last several years, she was hospitalized several times with pneumonia and exacerbations of asthma. Between these admissions, she was…

Diastology Stress Test

Case Study A 71-year-old man presents with exertional dyspnea progressing over several months. He has known diabetes mellitus and hypertension, both well controlled on medications. Chest x-ray and electrocardiogram (ECG) are unremarkable. His resting transthoracic echocardiogram shows normal-size cardiac chambers and left ventricular (LV) ejection fraction of 70%. Mitral inflow shows reduced early (E) to late (A) diastolic filling ratio and prolonged deceleration time of E…

Diastolic Echocardiographic Examination

Case Study 1 A 68-year-old female presents with Class II heart failure. Her echocardiogram (see figure) showed normal left ventricular (LV) systolic function with the LV ejection fraction (EF) estimated at 67% by the Simpson’s biplane method (A). There was no significant valvular heart disease. Diastolic function parameters include the transmitral inflow profile (B), septal and lateral mitral annular velocities (C), the peak tricuspid regurgitant (TR)…

Evaluation of Diastolic Function by Radionuclide Techniques

Case Study A 73-year-old man with a history of longstanding hypertension, diabetes mellitus, paroxysmal atrial fibrillation, and coronary artery disease (CAD) presents with progressive shortness of breath and exertional fatigue. Physical examination is notable for prominent apical impulse and a blood pressure of 140/90 mmHg. A transthoracic echocardiogram reported normal systolic function and concentric hypertrophy without significant valvular disease or regional wall motion abnormalities. An ischemic…

Evaluation of Diastolic Function by Cardiac Magnetic Resonance Imaging

Case Study A 62-year-old male was admitted to the hospital with progressive dyspnea on exertion and presyncope. His workup in the emergency room included a troponin T, which was found to be mildly elevated. Further evaluation thus far has included an unrevealing coronary angiogram. Transthoracic echocardiogram (TTE) showed normal left ventricular ejection fraction (LV EF) of 65% with moderate LV hypertrophy and a moderate pericardial effusion.…

Evaluation of Right Ventricular Diastolic Function

Case Study A 63-year-old man presented with acute onset of shortness of breath. Body surface area (BSA) is 2.04 m 2 with body mass at 199 lb. An echocardiogram was obtained as a stat test. Blood pressure (BP) was 105/65 mmHg, with heart rate at 95 bpm. Parasternal views show normal left ventricular (LV) size and function. In all of the required views, the right ventricle…

Evaluation of Intracardiac Filling Pressures

Case Study A 69-year-old woman presents with a 2-month history of dyspnea that has progressed to a NYHA Class III, occurring with minimal exertion. Fig. 13.1 shows a four-chamber view at end systole and a continuous wave (CW) Doppler recording of tricuspid regurgitation (TR) enhanced by saline contrast. Fig. 13.2 shows a pulse wave (PW) Doppler recording of the transmitral velocity (MV) and tissue Doppler recording…

Assessment of Left Atrial Size and Function

Case Study 1 A 68-year-old woman was transferred to the emergency room with paroxysmal nocturnal dyspnea. She had comorbidities with obesity, hypertension, and glucose intolerance and had been treated with calcium channel and angiotensin-II receptor blockers. On admission, her oxygen saturation was 90%, blood pressure 186/102 mmHg, and heart rate 102 bpm with regular rhythm. The point-of-care echocardiography revealed mildly reduced left ventricular (LV) systolic function…

Color M-mode Doppler

Introduction Pulsed-wave Doppler velocities of mitral inflow are the most commonly used indices of diastolic function. Their application is nevertheless limited by their load dependency. Flow propagation (Vp) using color M mode Doppler has been proposed as a complementary technique to evaluate left ventricular (LV) relaxation. Color M mode Doppler echocardiography provides a spatiotemporal map of blood distribution within the heart, with a typical temporal resolution…

Evaluation of Diastolic Function by Tissue Doppler, Strain, and Torsion Analysis

Introduction Early Doppler echocardiographic indices of left ventricular (LV) diastolic function have studied the mechanics of left atrial (LA) and ventricular filling. These filling indices have been proven to be useful in providing prognostic information in heart failure patients. However, filling indices have limited accuracy predicting intrinsic parameters of diastolic function due to the confounding effects of extrinsic loading conditions and intrinsic cardiac performance. Tissue Doppler…

Two-Dimensional and Doppler Evaluation of Left Ventricular Filling, Including Pulmonary Venous Flow Velocity

Abbreviations 2-D two-dimensional (echo) A-fib atrial fibrillation A-wave flow velocity due to atrial contraction BPM beats per minute CMM color M-mode (Doppler) CV cardiovascular CW Doppler continuous wave Doppler (technique) DHF diastolic heart failure E-wave ventricular inflow velocity in early diastole HF heart failure HFpEF heart failure with preserved ejection fraction HFrEF heart failure with reduced ejection fraction HT hypertension HV hepatic vein IR impaired relaxation…

Invasive Hemodynamic Assessment in Heart Failure With Preserved Ejection Fraction

Introduction Assessment of left ventricular (LV) systolic and diastolic function is fundamental to understanding cardiovascular pathophysiology and guiding accurate diagnosis, especially for patients with heart failure (HF). Invasive hemodynamic assessment was the standard for almost all patients in the 1950s to 1970s, but subsequently waned with development of echocardiography and a shift in the catheterization laboratory from diagnostics to intervention (percutaneous coronary intervention). Noninvasive imaging has…

General Principles, Clinical Definition, Epidemiology, and Pathophysiology

Case Study A 63-year-old woman has the following past medical history: 1. Coronary artery disease (drug-eluting stents placed in the right carotid artery [RCA] 3 years prior) 2. Hypertension diagnosed 20 years prior 3. Obesity with a body mass index (BMI) of 39 kg/m 2 4. Type 2 diabetes mellitus with an A1C of 8.2% She presents with complaints of dyspnea on exertion, which has worsened…

Ventricular–Arterial Interaction in Patients With Heart Failure and a Preserved Ejection Fraction

Case Study A 79-year-old obese male (body mass index 33 kg/m 2 ) with prior history of coronary bypass grafting, hypertension, and diabetes presented with New York Heart Association functional class III dyspnea progressive over 1 year. Vitals included a blood pressure of 162/90 mmHg and heart rate of 55 bpm. Jugular venous pressure and cardiac auscultation was normal, and there was no edema. Stress echocardiogram…

Physical Determinants of Diastolic Flow

Comprehensive assessment of ventricular diastolic function is a complex process. Full elucidation generally requires invasive measurements, such as left ventricular end-diastolic pressure (EDP), the time constant of isovolumic left ventricular (LV) relaxation (τ), the pressure-volume (P-V) relationship of the ventricle at end diastole, and mean left atrial pressure. Such invasive measurements are inappropriate for routine clinical purposes and thus diastolic function is generally assessed using Doppler…

Left Atrial Function: Basic Physiology

Case Study DL is a 75-year-old white male with a history of hypertension who presented with a 6-month history of reduced exercise tolerance, dyspnea on exertion, and occasional palpitations. The patient was scheduled for an exercise test but was noted to be in atrial fibrillation (AF). His physical examination was normal except for a blood pressure of 150/98 mmHg and an irregularly irregular pulse at 73…

Role of the Pericardium in Diastolic Dysfunction

Introduction Pericardial diseases are often underdiagnosed and confused with other pathologic entities such as chronic liver diseases, heart failure, and restrictive cardiomyopathies especially in the setting of complicated pericarditis with evolution to constrictive pericarditis. The main reasons for these misunderstandings are related to both the rarity of the diseases and the lack of specific skills and knowledge of pericardial diseases, which are often considered the “Cinderella…

Pathophysiology of Heart Failure With a Preserved Ejection Fraction: Measurements and Mechanisms Causing Abnormal Diastolic Function

Introduction Heart failure (HF) can be defined physiologically as an inability of the heart to provide sufficient forward output to meet the perfusion and oxygenation requirements of the tissues at rest and during exercise while maintaining normal diastolic filling pressures. Patients with chronic HF can be divided into two broad groups: heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).…

Molecular, Gene, and Cellular Mechanism

Although heart failure (HF) has been traditionally affiliated with reduced contractile function and dilation of the left ventricle (LV) resulting in reduced ejection fraction (HFrEF), nearly half of HF patients have an ejection fraction that is normal. These patients present with abnormal LV relaxation, diastolic distensibility, or diastolic stiffness. The number of patients hospitalized and the mortality risk for patients with heart failure with preserved ejection…

ANSWERS

ANSWERS TO THE ASSESSMENT QUESTIONS: Chapter 1: 1) E 2) C 3) A Chapter 2: •Ruptured papillary muscle—Carpentier Type II •Restricted posterior leaflet—Carpentier Type IIIb Chapter 3: 1) E. Class 1 indications (see Fig. 3.1) according to the ACC/AHA guidelines for treatment of primary mitral regurgitation include symptoms and LV dysfunction (defined as ejection fraction (EF) ≤60% or left ventricular end systolic diameter (LVESD) ≥40 mm)…