Links To And Excerpts From Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography

In this post I link to and excerpt from Recommendations for the Evaluation of Left
Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging [PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Am Soc Echocardiogr 2016;29:277-314.

For details on how to obtain the doppler views discussed in the article above and in this post please 2019 Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography [PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Am Soc Echocardiogr. 2019 Jan;32(1):1-64. doi: 10.1016/j.echo.2018.06.004. Epub 2018 Oct 1.

In the 2019 article above, please see the detailed discussion in VIII. SPECTRAL DOPPLER IMAGING MEASUREMENTS on pp. 39 – 45 and review Table 6 on pp. 39 -42.

Here are the key points on Doppler from the above 2019 article:

Key Points #4

Doppler Imaging and Measurements

1. For routine CDI of valvular insufficiency and forward
flow, use a consistent scale setting of 50 to 70 cm/sec.
Maintain optimal gain settings.

2. CDI scale velocity should be adjusted for specialized circumstances to best display color flow, particularly in
low-flow states.

3. Spectral PW and CW Doppler measurements should be
made at the modal (densest) margin of the flow signal.
Do not overgain. Do not measure weak, ill-defined signals beyond the modal velocity.

4. Obtain spectral Doppler signals as parallel as possible to
flow. CDI interrogation may help orientation.

5. Flow signals may be acquired (e.g., tricuspid regurgitation) from multiple anatomic sites. Use the highest
quality and highest velocity signals for final measurements. Edit out velocity data from poor-quality and
lower velocity signals for the final reported velocity.
Do not report Doppler flow signals of poor definition
or marginal quality.
 Use CDI and pulsed Doppler mapping to characterize
the origin of unusual signals within chambers or blood

Here are excerpts from the 2016 article:


2D = Two-dimensional
AR = Aortic regurgitation
ASE = American Society of
AV = Atrioventricular
CW = Continuous-wave
DT = Deceleration time
EACVI = European
Association of Cardiovascular
EF = Ejection fraction
GLS = Global longitudinal
HCM = Hypertrophic
HFpEF = Heart failure with
preserved ejection fraction
HFrEF = Heart failure with
reduced ejection fraction
IVRT = Isovolumic relaxation
LA = Left atrial
LAP = Left atrial pressure
LV = Left ventricular
LVEDP = Left ventricular
end-diastolic pressure
LVEF = Left ventricular
ejection fraction
MAC = Mitral annular
MR = Mitral regurgitation
PASP = Pulmonary artery
systolic pressure
PCWP = Pulmonary capillary
wedge pressure
RV = Right ventricular
STE = Speckle-tracking
TR = Tricuspid regurgitation
Vp = Flow propagation

Echocardiographic assessment of left ventricular (LV) diastolic function is an integral part of the routine evaluation of patients
presenting with symptoms of dyspnea or heart failure.

The 2009 American Society of Echocardiography (ASE) and European Association of Echocardiography (now European
Association of Cardiovascular Imaging [EACVI]) guidelines for
diastolic function assessment were comprehensive, including
several two-dimensional (2D) and Doppler parameters to
grade diastolic dysfunction and to estimate LV filling pressures.1

The primary goal of this update is to simplify the approach and thus increase the utility of the guidelines in daily clinical practice.

LV diastolic dysfunction is usually the result of impaired LV relaxation with or without reduced restoring forces (and early diastolic suction), and increased LV chamber stiffness, which increase cardiac filling pressures.

[Most] important, LV filling pressure should be estimated  because elevated LV diastolic pressure in the absence of increased LV end-diastolic volume is strong evidence in favor of well-developed diastolic dysfunction.

In the majority of clinical studies, LV filling pressures and diastolic function grade can be determined reliably by a few
simple echocardiographic parameters with a high feasibility.

This update places more emphasis on applying the most useful reproducible, and feasible 2D and Doppler measurements from
the 2009 guidelines.

Before applying the guidelines, it is essential to consider what the term LV filling pressures refers to. The term LV filling pressures can refer to mean pulmonary capillary wedge pressure (PCWP) (which is an indirect estimate of LV diastolic pressures), mean left atrial (LA) pressure (LAP), LV pre-A pressure, mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP). The different LV and LA diastolic pressures mentioned above (Figure 1) have different correlates with Doppler signals.

For example, in the early stages of diastolic dysfunction, LVEDP is the only abnormally elevated pressure because of a large atrial pressure wave, while mean PCWP and LAP remain normal.

With tachycardia and/or increased LV afterload, mean PCWP and LAP increase which provides the basis for the diastolic stress test.*

*Please see Diastolic Stress Test: Invasive and Noninvasive Testing [PubMed Abstract]. JACC: Cardiovascular Imaging Volume 13, Issue 1, Part 2, January 2020, Pages 272-282.

Although the current recommendations are focused on echocardiographic techniques, it should be noted that both
nuclear scans and cardiac magnetic resonance can be used to evaluate LV filling rates and volumes.

Tables 1 and 2 summarize the technical aspects, hemodynamic determinants, and clinical applications including limitations of each of the Doppler and 2D parameters.

Table 1

Table 2

Doppler signals that occur at end diastole correlate best with LVEDP. These include mitral peak A velocity at tips level, A-wave duration at the annulus, A velocity deceleration time
(DT), pulmonary vein peak Ar velocity, Ar velocity duration, Ar-A duration, and tissue Doppler–derived mitral annular a’ velocity.

Mitral peak E wave velocity, E/A ratio, E velocity DT, E/e0 ratio, pulmonary vein systolic-to-diastolic velocity ratio, and peak velocity of tricuspid regurgitation (TR) by continuous-wave (CW) Doppler relate best with earlier occurring LV diastolic pressures (mean PCWP, pre-A pressure, and mean LV diastolic pressure).


Key Points

1. The four recommended variables for identifying diastolic dysfunction and their abnormal cutoff values are annular e’ velocity: septal e’ < 7 cm/sec, lateral e’ < 10 cm/sec, average E/e’ ratio > 14, LA volume index > 34 mL/m2 , and peak TR velocity
> 2.8 m/sec.

2. LV diastolic function is normal if more than half of the available variables do not meet the cutoff values for identifying abnormal function. LV diastolic dysfunction is present if more than half of the available parameters meet these cutoff values. The study is inconclusive if half of the parameters do not meet the cutoff values.


The key variables recommended for assessment of LV diastolic
function grade include mitral flow velocities, mitral annular e0 velocity, E/e0 ratio, peak velocity of TR jet, and LA maximum volume index (Figure 8B)

Supplementary methods are pulmonary vein velocities and as a means to identify mild reduction in systolic function, LV GLS by speckle-tracking echocardiography (STE). Because patients with reduced LVEFs also have impaired diastolic function (examples shown in Figures 9–11 for heart failure with reduced EF [HFrEF]), the evaluation has a different focus than in patients with normal LVEF ( ≥ 50%) (examples shown in Figures 12–15 for HFpEF).

The main reason for evaluating diastolic function in patients with reduced EFs is to estimate LV filling pressure.

Given the presence of situations in which LAP and LVEDP are different and because LAP is the pressure that relates better with mean cPCWP and thus pulmonary congestion symptoms at the time of the echocardiographic examination, the algorithm is presented with the premise of estimating mean LAP.

The approach starts with mitral inflow velocities and is applied in the absence of atrial fibrillation (AF), significant mitral valve disease (at least moderate mitral annular calcification [MAC], any mitral stenosis or mitral regurgitation [MR] of more than moderate severity, mitral valve repair or prosthetic mitral valve), LV assist devices, left bundle branch block, and ventricular paced rhythm.

The proposed algorithm is based on expert consensus and
has not been validated. Because diastolic dysfunction is a result
of underlying myocardial disease in patients with reduced or
preserved LVEF, a rather similar approach can be considered in
these populations

Key Points

1. In patients with reduced LVEFs, transmitral inflow pattern is usually sufficient to identify patients with increased LAP and DT of mitral E velocity is an important predictor of outcome.

2. In patients with preserved LVEFs, several parameters, including 2D variables, are often needed to estimate LAP.

3. In patients with depressed EFs and in patients with normal EFs and myocardial disease, if E/A ratio is ≤ 0.8 along with a peak E velocity of ≤ 50 cm/sec, then mean LAP is either normal or low and patient has grade I diastolic dysfunction.

4. In patients with depressed EFs and in patients with normal EFs and myocardial disease, if E/A ratio is ≥ 2, LA mean pressure is elevated and grade III diastolic dysfunction is present. DT is usually short in patients with HFrEF and restrictive filling pattern (<160 msec). However, in patients with HFpEF, DT can be normal despite elevated LV filling pressures.

5. In patients with depressed EFs and in patients with normal EFs and myocardial disease, E/A ratio ≤ 0.8 along with a peak E velocity of >50 cm/sec, or an E/A ratio > 0.8 but < 2, additional parameters are needed. These include peak TR velocity, E/e0 ratio and LA maximum volume index. Their cutoff values to conclude elevated LAP are peak velocity of TR jet >2.8 m/sec, average E/e0 ratio>14, and LA maximum volume index > 34 mL/m2. If more than half or all of the variables meet the cutoff values, then LAP is elevated and grade II diastolic dysfunction is present. If only one of three available variables meets the cutoff value, then LAP is normal and grade I diastolic dysfunction is present. In case of 50% discordance or with only one available variable, findings
are inconclusive to estimate LAP.

6. In patients with depressed LVEFs, pulmonary vein S/D ratio may be used if one of the three main parameters is not available. A ratio < 1 is consistent with increased LAP.


Although several invasive parameters of LV diastolic function such as the time constant of LV relaxation (t) or LV chamber stiffness may be inferred or derived from Doppler echocardiographic findings, the association between invasive and noninvasive parameters is not perfect.

Furthermore to date, there is no specific targeted treatment for these [above] abnormalities that has proved useful in clinical trials.

In comparison, specific comments on the status of LV filling pressures are more helpful to the referring physician in terms of narrowing a differential diagnosis. The conclusion could be one of three options: normal, elevated or cannot be determined (Table 5 shows examples from several laboratories on reporting findings about LV diastolic function). The writing group believes it is important to include this conclusion when feasible, particularly in patients referred with symptoms of dyspnea or diagnosis of ‘‘heart failure.’’

Place Table 5 here?

Furthermore, right heart catheterization may be needed in difficult cases to determine if PCWP is elevated or if there is a discrepancy between right ventricular (RV) and LV filling pressures indicating the presence of pulmonary vascular disease.

Key Points

1. Conclusions on LV diastolic function should be included routinely in reports when feasible, particularly in patients referred with symptoms of dyspnea or diagnosis of heart failure.

2. The report should comment on LV filling pressures and the grade of LV diastolic dysfunction. If available, comparison with previous studies is encouraged to detect and comment on changes in diastolic function grade over time.


The following sections discuss the pathophysiology of disorders with abnormal cardiac structure, valve disease and atrial arrhythmias, which modify the relationship between indices of diastolic function and LV filling pressure (Table 6).

In some of the disorders the algorithm outlined above has significant limitations. PASP estimated from the TR jet, however, is a valid index of LAP in all conditions mentioned, provided there is no evidence of pulmonary vascular or parenchymal disease.

In the absence of AF or atrial flutter, mitral valve disease or heart transplantation, an increased LA volume with a
normal appearing right atrial size is a robust indicator of elevated LAP.

One significant limitation to this [the above] marker is if heart failure therapy has resulted in normalization of pressures with persistent LA dilatation. In this setting, the presence of increased TR velocity > 2.8 m/sec is suggestive of elevated LAP.



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