1	Echocardiographic Assessment of Left Ventricular Diastolic Function Yoram Agmon MD Department of Cardiology Rambam Medical Center Technion – Israel Institute of Technology HAIFA
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3	LV Relaxation / Elastic Recoil Early Diastole
4	LV Compliance (Mid)-Late Diastole
5	Operative Chamber Compliance
6	Mitral Inflow
7	LV Diastolic Dysfunction Pathophysiology
8	Elevated LV Filling Pressures 2° LV Compliance ¯
9	Normal vs Pseudo-normal LV Filling
10	LV Filling Pressures End-Diastolic vs Mean Diastolic / LAP
11	LV vs LA Filling Pressures
12	Evaluation of LV Diastolic Filling Rules of Thumb Look at the patient Look at the ventricle (LV systolic function) Look at the atrium (LA) Mitral inflow Additional techniques – when necessary Estimate PA pressure Beware of caveats Reporting diastolic function
13	I. Look at the Patient Clinical Assessment Diastolic function / LV filling pressures are frequently obvious clinically Very healthy Very sick
14	I. Look at the Patient Effect of Age, HR, BP on Mitral Inflow
15	Common Wrong Statement “E < A (mitral inflow), a manifestation of LV diastolic dysfunction” E < A – may be normal for age (wide range) E < A – may be normal for a relatively young patient in the presence of relatively rapid HR E/A < 0.5 – usually LV diastolic dysfunction DT - supportive of Dx Mild (abnormal relaxation pattern)
16	Mitral Inflow U-Type Relationship – Health / Disease
17	The Dilemma Normal or Pseudo-normal ?
18	Common Dilemma U-Shape – E/A ratio, DT, PV S/D ratio
19	II. Look at the Ventricle LV systolic function LV hypertrophy Suspect LV diastolic dysfunction Not necessarily advanced diastolic dysfunction ! LV filling pressures – may be normal !
20	Mitral Inflow & LV Filling Pressures Abnormal LV Systolic Function
21	Mitral Inflow & LV Filling Pressures Abnormal vs Normal LV Systolic Fx
22	Value of Mitral Inflow Estimation of LV Diastolic Function
23	LV Systolic Function Relation to Diastolic Function Marker of diastolic dysfunction Systolic dysfunction ® LV volumes End-systolic volume ® Elastic recoil ¯ End-diastolic volume ® LV operative compliance ¯
24	LV Systolic Fx vs E/A Ratio
25	Systolic Fx & LV Diastolic Fx Practical Considerations What is “preserved” LV systolic function ? Global LVEF >50% / >45% / 40% ? Regional wall motion abnormalities ? Effect of age Young pts ® ~ normal global LV filling despite mild-moderate LV systolic dysFx
26	III. Look at the LA LA Size Sensitive marker of LV filling pressures LAP / LVDP ® LA size Limitations: Measurement of LA size (dimension / volume) ? Normal age-related values Effects of acute D loading (diuresis; AMI)
27	LA Size – Non-U-Shaped
28	IV. Assess PA pressure Normal PA pressure Advanced diastolic dysfunction – less likely Elevated PA pressure Rule-out diastolic dysfunction (as cause of diastolic dysfunction)
29	V. Additional Techniques When Necessary Pulmonary venous flow Mean diastolic / end-diastolic parameters Less load-dependent techniques Tissue Doppler Color M-mode – flow propagation Loading manipulations Valsalva maneuver
30	Pulmonary Venous Flow
31	Pulmonary Venous Flow Natural Hx of Diastolic Dysfunction
32	LVEDP Parameters PV AR_dur minus mitral A_dur > 30 ms PV AR_vel > 45 cm/s ® LVEDP
33	PV Flow Pattern vs LVEDP Abnormal vs Normal LV Systolic Fx
34	LVEDP and ~ Normal Mean LVDP
35	Less Load-Dependent Parameters Mitral Annular Diastolic Velocities (TD)
36	e’ (TD) Marker of LV Relaxation
37	TD – Caveats Annular velocity measurements Septal ? Lateral ? Average ? Effect of segmental WMAs ? Velocities ¯ on affected side Compensatory on other side ? Average velocities ?
38	Less Load-Dependent Parameters LV Inflow Propagation (Color M-mode)
39	LV Inflow Propagation
40	Hemodynamics Normal vs Abnormal LV Relaxation
41	Hemodynamics vs CMM Normal vs Abnormal LV
42	Normal vs Pseudo-nl LV Filling
43	Estimation of LV Filling Pressures TD / CMM e’, FPV » LV relaxation LV diastolic dysFx ® LV relaxation ¯ ® e’, FPV ¯ LV filling pressures ® E ® E / e’ ® E / FPV
44	Estimation of LV Filling Pressures Values TD E / e’ septal ³ 15 (8-15 = borderline) E / e’ lateral ³ 10 CMM E / FPV ³ 1.5
45	E / e’ vs LV Filling Pressures Normal vs Abnormal LV Systolic Fx
46	Preload Manipulation
47	Preload Manipulation Valsalva – “Classic” Response
48	Valsalva – Interpretation Look at the A wave
49	Valsalva – Caveats Limited feasibility Patients (uncontrolled maneuver) Operators Effect on HR () E & A fusion Variable diagnostic criteria
50	E/A Ratio – Cutoff for Pseudo-nl ?
51	E/A Ratio Cutoff for Definition of Pseudo-normal E/A > 1.0 – inadequate cutoff (elderly pts) Alternative cutoff Normal age-related range of E/A ratio Normal vs pseudo-normal (elevated filling pressures) For most pts with HF (elderly) – E/A > 0.7 Border between pseudo-normal & restrictive Clinically less important (both – “advanced DDFx”) > 1.5-2.0 or DT < 140 ms (SR) = restrictive
52	VI. Beware of Caveats Problematic subgroups Normal systolic function Young patients Diastolic “reserve” Use validated criteria Remember Real life – doesn’t always work by the book Conclusive assessment – not always feasible
53	VII. Reporting Diastolic Dysfunction “Tajik’s Classification”