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Jul 30, 2012

Echo assessment of Diastolic heart dysfunction simplified approach


Diastolic heart failure which forms 50% of heart failure patients, its evaluation by echo is unpopular, this article is for induction of  its evaluation during routine echocardiographic examination. Unlike systolic evaluation where eyeballing would give a fair estimation of cardiac function, diastolic examination needs bit more of involvement both from echocardiographer and also patient (Valsalva maneuver).

Diastolic evaluation consists of.
  • In 2D echo evaluation, increased size of atria and hypertrophied LV give, clue to diastolic dysfunction.
  • Transmitral gradient is determined by LA and LV pressure difference and also relaxation properties of LV.
  • Deacceleration time is time taken by early rapid filling to zero from its peak. In diastolic dysfunction this ratio is altered.
  • Mitrale inflow velocities normally ‘A’ wave of atrial contraction is smaller than ‘E’ wave of early rapid filling. In diastolic dysfunction this ratio is altered.
  • Tissue Doppler imaging for mitrale annuals relaxation e’ also altered in diastolic dysfunction. Ratio of E/e’ is considered load independent measurement of diastolic dysfunction.

Diastolic heart dysfunction is graded by severity from Grade 1 to Grade 4, interestingly echo findings of diastolic dysfunction do not manifest as single directional changes, for example in Grade 2 we get pseudonormalization of E/A ratio and increased deacceleration time of Grade 1 is reversed due to increased atrial pressure.

In normal healthy individuals E/A ratio is more than 1, some times young people, this ratio may go more than 2 mimicking Grade 3 (restrictive pattern).

  1. Grade 1 (Mild diastolic dysfunction) early rapid filling is impaired and compensated by increased, late atrial filling of ventricles is and deceleration time increased and E/A decreased (atrial pressure is not increased)
  2. Grade 2, (Moderate diastolic dysfunction) is associated with mild to moderate increased atrial pressure, so in this declaration time normalizes or decreases and early rapid filling is increased leading to pseudonormalization of E/A ratio. (strain phase valsalva reverse to Grade 1 due decreased LA filling)
  3. Grade 3 (Reversible restrictive pattern) further increase left atrial pressure E wave peak more than normal and deacceleration time further reduces (strain phase valsalva reverse to Grade 2 due decreased LA filling)
  4. Grade 4 (Irreversible restrictive pattern) further increase left atrial pressure E wave peak much more than normal and deacceleration time further reduces more  (strain phase valsalva does not reverse to Grade 2 due decreased LA filling)

Parameter
Normal
Grade 1
Grade 2
Grade 3
Grade 4
E/A ratio
More than 1
Less than 1
less than 1
More than 2
More than 2
Deacceleration Time (DTI)
160 to 240 milli sec
More than 240 milli secs
160-240 milli secs
Less than 160
Less than 160
Septal e’
More than equal to 10 cm/sec
Less than 7 cm/sec
Less than 7
Less than 7
Less than 7
E/e’
Less than 8
Equal or more than 8-15
More than 15
More than15
More than15
Valsalva manuvar (strain phase)


E/A Revert to grade 1
E/A Revert to grade 2
Does not Revert


Echo assessment of Diastolic heart dysfunction

I am embedding a well narrated video from Dr Thomas Binder just see this video to get better grip of diastolic dysfunction