Lecture Notes: Diastolic Function Evaluation

Overview

• Evaluation of diastolic function is a complex topic but can be simplified with a few rules.
• Understanding these rules helps in the assessment of 90-95% of patients.

Key Rules for Evaluation

Rule 1: Normal Diastolic Function

• Condition:
  • Echo is normal.
  • Patient is below 45 years old.
  • E-wave is taller than A-wave.
• Conclusion:
  • Patient has normal diastolic function.
  • No further action required.

Rule 2: Impaired Relaxation

• Condition:
  • A-wave is taller than E-wave (E/A ratio < 1).
• Conclusion:
  • Patient has impaired relaxation.
  • Filling pressure is usually normal or mildly elevated.
• Assessment:
  • Perform Tissue Doppler Imaging.
  • E/e' ratio > 12-15 indicates elevated filling pressure.

Rule 3: Pseudonormal Filling

• Condition:
  • Abnormal echo (hypertensive heart disease, LV hypertrophy, reduced LV function).
  • Patient is above 65 years old.
  • E-wave is taller than A-wave (E/A ratio > 1).
• Conclusion:
  • Pseudonormal filling pattern.
  • Elevated left ventricular filling pressure likely.
• Assessment:
  • Check deceleration time or E/e' ratio.
  • Use 2D image for left atrium enlargement.

Rule 4: Restrictive Filling Pattern

• Condition:
  • E velocity > 2x A velocity (E/A ratio > 2).
• Conclusion:
  • Restrictive filling pattern.
  • Significantly elevated left atrial or ventricular filling pressures.
• Exception:
  • Young, healthy adults may show a supernormal diastolic function (high E-wave).
  • Perform Valsalva maneuver to distinguish supernormal from restrictive patterns.

Practical Application

Example 1: Impaired Relaxation

• Observation:
  • A-wave taller than E-wave.
• Measurements:
  • E-wave velocity: ~0.8
  • e' (tissue Doppler): 0.5
  • E/e' ratio: 16 (indicating elevated filling pressure).

Example 2: Pseudonormal Pattern

• Observation:
  • E/A ratio > 1 (E-wave taller than A-wave).
• Measurements:
  • A-wave velocity: ~0.8
  • e' velocity: ~0.6-0.7
  • E/e' ratio: > 12-13 (indicating diastolic dysfunction).
  • Severe left ventricular hypertrophy observed via 2D imaging.
• Valsalva Maneuver:
  • Reveals relaxation pattern, demasking pseudonormal pattern.

Conclusion

• Simplified rules aid in the practical assessment of diastolic function.
• Emphasizing practical and straightforward methods ensure they are used effectively.