1/9/2018

Diastolic Function Assessment

Practical Ways to Incorporate into Every Echo

Jae K. Oh, MD
Echo Hawaii 2018
©2018 MFMER | 3712003-1

Learning Objectives
My presentation will help you to
• Appreciate the importance of myocardial relaxation for satisfactory
diastolic function
• Assess and Grade diastolic function
• Estimate LV filling pressure noninvasively
• Incorporate Diastolic Function assessment into every Echo
• Apply Diastolic Function Assessment in
• Diagnosis of HFpEF
• Exercise Diastolic Test
• Restrictive CM vs Constriction

©2018 MFMER | 3712003-2

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Cardiac Function
Systole and Diastole (διαστολή)

διαστολή: Greek word for dilation

Filling Pumping

Normal diastolic function allows adequate filling of the heart

without excessive increase in diastolic filling pressure at rest and
with stress ©2018 MFMER | 3712003-3

Diastolic Filling with Relaxation

©2018 MFMER | 3712003-4

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Diastolic Filling Patterns

Transmitral Gradient vs Mitral Inflow

1/9/2018
©2018 MFMER | 3712003-5

LV Relaxation by Cath and Echo

 (tau) vs e’ (mitral annulus velocity)
120

100
y=-6.80x + 85.68
tau (msec)

80
r=0.70
60 P<0.001

40

20

0
0 2 4 6 8 10 12
e’ (cm/sec)

Firstenberg et al: J Appl Physiol 90:299, 2001, Nagueh et al: JACC 1997
Oki et al: AJC 1997 , Sohn et al:JACC 1997, Ommen et al: Circ 2000
©2018 MFMER | 3712003-6

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Which of following patients has the most advanced

diastolic dysfunction (or impaired relaxation)?

1 2 3

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Myocardial Relaxation (e’)

e’ = 12 cm/sec e’ = 7 cm/sec e’= 3 cm/sec

©2018 MFMER | 3712003-8

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Evaluation of Diastolic Function

Mitral Inflow and Annulus Velocity
Normal Ab Relax Pseudo Restrictive
Grade 1 Grade 2 Grade 3
Mitral flow

Preload dependent
Mitral annulus
velocity

Preload independent
Sohn et al: JACC, 1997 CP1254003-30
©2018 MFMER | 3712003-9

Estimation of LV Filling Pressures

E/e’ (Medial MV annulus)
40
35 EF >50%
EF <50%
LV filling pressure

30
25
20
15
10
5
0
E/E <8 E/E 8-15 E/E >15

Ommen SR et al: Circulation 102:1788, 2000

©2018 MFMER | 3712003-10

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Four Major Parameters in Diastology

Normal values

Four Major Diagnostic Parameters

Normal Values
1. E’ velocity ≥ 7(med), 10 (lat) cm/s
2. E/e’ ≤ 14 (Ave), 15(Med)
3. TR velocity ≤ 2.8 m/sec
4. LAVI ≤ 34 mL/m2

JASE and EJ CV Imaging April 2016

©2018 MFMER | 3712003-11

New Criteria for Diastolic Function Assessment

In pts with normal LVEF≥ 50%

1 – Septal e’ velocity ≥7 cm/s or

lateral e′ velocity ≥10 cm/s
2 – Average E/e′ ≤14 , 15 (Med)
3 – TR velocity ≤2.8 m/s
4 – LA volume index ≤34 mL/m2

≥ 3 Normal 2 and 2 ≥ 3 Abnormal

Normal diastolic function Indeterminate Diastolic dysfunction

©2018 MFMER | 3712003-12

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71 year old woman with HR 45 BPM &

LAVI = 39 mL/m2

E/e’ NL < 14
E’ NL > 7
LAVI Enlarged
TR NL < 2.8
Lateral e’ = 10 cm/sec Medial e’ = 9 cm/sec
LVOT TVI = 30 cm

E/e’ = 9 E/e’ = 10

©2018 MFMER | 3712003-13

ӿ E’
ӿ E/e’ 67 year old man with HF
ӿ LAVI
ӿ TR vel.

E= 100 A = 30 cm/sec e’ = 5 cm/sec

E/A = 3.3 E/e’ = 20

©2018 MFMER | 3712003-14

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Mitral inflow
E/A ≤0.8 + E <50 E/A ≤0.8 + E >50 cm/s E/A ≥2
cm/s or
E/A >0.8-<2

3 criteria to be evaluated*

1 – Average E/e′ >14 2 of 3 or

2 of 3
2 – TR velocity >2.8 m/s 3 of 3
negative
3 – LA volume index >34 mL/m2 positive

When only 2 criteria are available

1 positive and
2 negative 2 positive
1 negative

Normal LAP Cannot determine LAP and  LAP  LAP

Grade I diastolic diastolic dysfunction Grade II diastolic Grade III diastolic
dysfunction grade* dysfunction dysfunction

If symptomatic consider
CAD or proceed to
In patients with depressed LVEF
diastolic stress test or normal EF with diastolic dysfunction

©2018 MFMER | 3712003-15

67 year old man with HF

GR 3 Diastolic Dysfunction with Severe Increase in Filling Pressure

E= 100 A = 30 cm/sec e’ = 5 cm/sec

E/A = 3.3 E/e’ = 20

©2018 MFMER | 3712003-16

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67 yo man with ischemic CM and HF

Gr. 1 dysfunction = normal filling pressure

E= 45 cm/sec A= 90 cm/sec
E=45 cm/s A= 90 cm/s
E/A = 0.5
E/A = 0.5

Grade 1 Dysfunction
E/A ≤ 0.8
E <50 cm/sec

©2018 MFMER | 3712003-17

67 year old man with ischemic CM and HF

E= 45 cm/s E/A = 0.5 Medial e’ = 4 cm/s

E/e’= 12

2 months before
E= 120 cm/sec E/A =1.0 TR Vel = 3 m/sec
E/e’ = 30

©2018 MFMER | 3712003-18

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Ischemic Cardiomyopathy Echo Predictor

STICH Trial (N=1511)

Best survival with E/A 0.5-0.8

©2018 MFMER | 3712003-19

Case # 2 ARS
Grade the diastolic function of
23 YO male with HCM
1. Grade 1
2. Grade 2
3. Grade 3
4. Possibly normal

E = 70 cm/s A= 30 cm/s
E/A = 2.3

©2018 MFMER | 3712003-20

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E = 70 cm/s

23 yo with HCM

Medial e’ = 8 cm/sec E/e’ = 9 Lateral e’ = 10 cm/sec E/e’ = 7

Can he have a normal diastolic function ?

©2018 MFMER | 3712003-21

23 yo man with HCM

LAVI 29 mL/m2

TR = 2 m/sec IVRT = 120 msec

©2018 MFMER | 3712003-22

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Valsalva in 23 yo HCM
Normal filling pressure

E/A= 2.3 E/A = 2.0

©2018 MFMER | 3712003-23

Mitral inflow

E/A ≤0.8 + E <50 E/A ≤0.8 + E >50 cm/s E/A ≥2

cm/s or
E/A >0.8-<2

3 criteria to be evaluated*

1 – Average E/e′ >14 2 of 3 or

e’ < 7 cm/s
2 of 3
2 – TR velocity >2.8 m/s 3 of 3
negative
3 – LA volume index >34 mL/m2 positive

When only 2 criteria are available

1 positive and
2 negative 2 positive
1 negative

Normal LAP Cannot determine LAP and  LAP  LAP

Grade I diastolic diastolic dysfunction Grade II diastolic Grade III diastolic
dysfunction grade* dysfunction dysfunction

If symptomatic consider
CAD or proceed to
When LVEF is reduced or Diastolic Function is
diastolic stress test abnormal

©2018 MFMER | 3712003-24

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Prognosis of a patient after AMI

E’ = 8 cm/s

TR = 2 m/sec
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Anterior Wall Myocardial Infarction

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An elderly man with exertional dyspnea

HFpEF
E= 80 A=80

E’ = 5 cm/sec TR = 2.9 cm/s

E/e’ = 16

©2018 MFMER | 3712003-27

Diastolic function assessment in patients with

mitral annulus calcification

E= 100 cm/sec

Lat e’= 4 cm/s Med e’ = 3 cm/s

TR = 2.4 m/sec

©2018 MFMER | 3712003-28

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Mitral annulus e’ velocity vs MAC

Mean age 73 years
Group 1 Group 2 Group 3
n=79 n=38 n=38
Variable no MAC mild MAC mod-severe MAC P for trend
Agatston Score 0 1-119 >119
Septal e’ 5.96±1.82 5.15±1.56 5.05±1.93 0.01
Lateral e’ 7.37±2.44 6.89±2.71 6.28±1.81 0.01
Average e’ 6.63±2 6.02±1.79 5.67±1.69 0.01
E/avg e’ ratio 13±4.93 15±8.95 18±8.26 <0.001

LV diastolic parameters are altered in the presence of MAC. This could be due to
direct effects of MAC or might reflect truly reduced diastolic function. Interpretation
of diastolic parameters in patients with MAC should be performed
with caution.

Codolosa et al: Am J Cardiol 2016;117:847-852

©2018 MFMER | 3712003-29

Proposed Clinical Algorithm for Estimation

of Left Ventricular Filling Pressure in
Subjects With Mitral Annular Calcification
Initial Cohort (n=50): Total Cohort (n=71):
Sensitivity: 81% Mitral E/A Sensitivity: 85%
Specificity: 100% Specificity: 95%
<0.8 0.8-1.8 >1.8

Normal LVFP IVRT High LVFP

Initial: 8/9 (89%) 10/10 (100%)

Total 12/13 (92%) 11/11 (100%)
80 ms <80 ms

Normal LVFP High LVFP

4/9 (44%) 16/16 (100%)

9/14 (64%) 23/24 (96%)

Abudiab et al: Am Coll Cardiol Img, 2017

©2018 MFMER | 3712003-30

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Atrial Fib. And Mitral Regurgitation

Medial e’ = 8 cm/s E= 90 cm/s E/e’=11

TR = 2.5 m/sec ©2018 MFMER | 3712003-31

Atrial Fib. And Mitral Regurgitation with exercise

E= 90 cm/s E= 130 cm/s and DT 120 msec

Medial e’ = 8 cm/s Medial e’ = 9 cm/s

TR = 2.5 m/sec TR = 3.2 m/sec ©2018 MFMER | 3712003-32

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Diastolic Function in A. Fib

• DT < 160 msec (with reduced EF)
• DT < 130 msec poor survival (Hurley, Oh)
• Other measurements
• E acceleration > 1900 cm/sec2
• IVRT ≤ 65 msec
• E/e’ ≥ 11
• IVRT/ T E-e’
• TR velocity

©2018 MFMER | 3712003-33

E=120

E/e’ =20
E’= 6

JASE 1999

©2018 MFMER | 3712003-34

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An elderly patient with worsening dyspnea

©2018 MFMER | 3712003-35

Take-home message Part 1

• Abnormal LV relaxation is one of the first manifestation of diastolic

dysfunction
• Mitral annulus e’ velocity is a clinically reliable parameter for LV
relaxation
• Diastolic function and filling pressure can be assessed by simple
Echo-Doppler parameters at rest and with exercise
• E/e’ ≥ 15 is specific for increased filling pressure

©2018 MFMER | 3712003-36

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Thanks for listening!

oh.jae@mayo.edu

©2018 MFMER | 3712003-37

Mitral Regurgitation and Diastolic Function

E= 80 cm/s

E’ = 6 cm/s
E/e’ = 13
©2018 MFMER | 3712003-38

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Mitral Regurgitation and Diastolic Function

©2018 MFMER | 3712003-39

Assessment of Diastolic Filling

Before and after TAVR

Baseline Normal Filling Pressure Post TAVR with PVAR

Increase in FP

©2018 MFMER | 3712003-40

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89 year old with TAVR

4 year follow-up

©2018 MFMER | 3712003-41

Stages of Heart Failure

2013/14 HF Guideline

A B C D
At high risk for Structural Heart Structural Heart Refractory Heart
HF W/O SHD or Disease W/O Disease W/ Failure
symptoms symptoms or signs symptoms or signs

©2018 MFMER | 3712003-42

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Distribution of Values of LV Moprhofunctional Parameters

for Stage B Heart Failure Categorization

Strain > -18% (n=11)

E/eʹ >13
n=40
Strain  -18% (n=29)
Moderate-to-severe LVH
n=123 Strain > -18% (n=11)
E/eʹ <13
n=83
Strain  -18% (n=60)

Strain > -18% (n=13)

E/eʹ >13
n=71
Strain  -18% (n=58)
No or mild LVH
n=387 Strain > -49% (n=13)
E/eʹ <13
n=316
Strain  -18% (n=267)

Kosmala W et al: JACC 65:257-266, 2015

©2018 MFMER | 3712003-43

Mitral A duration is shorter than PV AR

Increased LVEDP

©2011 MFMER |
slide-44
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45
40 r=0.68
EDP 35 P<0.001
(mm Hg) 30
Doppler 25
20
Determination 15
of LVEDP 10
5
0
-100 -50 0 50 100
Mitral flow velocity LV pressure
PVad-Ad (ms)

Rossvoll and Hatle:

25 mm Hg JACC, 1993
0.5

Ma=100 ms
0.5 PVa=165 ms LVEDP can be increased with normal mean LV
Pulmonary vein
diastolic pressure
CP1057136-18
©2018 MFMER | 3712003-45

LEVDP Elevation with normal filling pressure

©2018 MFMER | 3712003-46

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“L” Wave
Delayed Relaxation + Increased Filling Pressure

©2018 MFMER | 3712003-47

Mid-diastolic mitral flow (L)

Delayed relaxation
0.15

m/s

0.15

0.80

m/s

Frommelt et al: JASE 16:176, 2003 CP1100934-2

©2018 MFMER | 3712003-48

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95 year old woman

©2018 MFMER | 3712003-49

95 year old woman

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©2018 MFMER | 3712003-51

Normal “L” wave

©2018 MFMER | 3712003-52

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