SPECIAL ARTICLE
A Practical Approach to Echocardiographic Assessment of Perioperative
Diastolic Dysfunction
Feroze Mahmood, MD,* Jayant Jainandunsing, MD,† and Robina Matyal, MD*
The Doppler assessment of diastolic dysfunction (DD) is
not part of a standard comprehensive intraoperative echo-
cardiographic examination. Although the reasons may be
many, the lack of a simplified algorithm for the assessment
of DD specific to the perioperative arena, the implications of
this diagnosis on clinical care, and the absence of therapeu-
tic options are some of the commonly cited reasons. In this
article, the authors address these possible reasons for the
lack of routine application of Doppler indices to assess peri-
operative DD. The authors have chosen to highlight some of
the most common conceptual questions, which often have
been raised by anesthesiologists, and attempted to suggest
answers. Drawing from their experience and data, the au-
thors propose a simplified algorithm for the application of
P REOPERATIVE CONGESTIVE HEART FAILURE (CHF) is
a major predictor of postoperative outcome.1 Despite the
assumption of a systolic etiology, almost 50% of episodes of
CHF can be attributed to diastolic dysfunction (DD).2 Knowl-
edge of the prognostic value of CHF in preoperative risk
stratification is well known, but the role of DD in its etiology
has not been incorporated in clinical decision making. The
outcome value of perioperative DD (symptomatic and asymp-
tomatic) has been shown in cardiac and vascular surgeries and
more recently in the intensive care units.3-6 With an increase in
the geriatric population and associated comorbidities, the preva-
lence of DD in the perioperative arena is likely to increase sub-
stantially in the near future.7-10 Of the 17 million ambulatory
surgical procedures performed in 2009 in patients !65 years old,
with a male-to-female ratio of 1:1.33 and a prevalence of 35%, the
frequency of occurrence of DD would have been 1 of every 5
patients.11-13 Therefore, the presence of DD and its impact on
preoperative risk stratification and postoperative outcome could
have significant implications on health care expenditure.14 An
age-related increase in prevalence also has been associated with an
increase in all-cause mortality secondary to DD.13,15
The Doppler assessment of DD is not part of a standard com-
prehensive intraoperative echocardiographic examination. Al-
though the reasons may be many, the lack of a simplified algo-
rithm for the assessment of DD specific to the perioperative arena,
the implications of this diagnosis on clinical care, and the absence
of therapeutic options are commonly cited challenges.11,12,16-18 The
technical aspects of perioperative assessment of DD also have
been reviewed comprehensively.5,19 The recently published Amer-
ican Society of Echocardiography (ASE) guidelines for Doppler
assessment of left ventricular (LV) DD have not addressed the
perioperative application of the Doppler modalities.20 The pro-
posed classification schemes consist of a generalized approach to
grade DD and are suitable for epidemiologic studies but may not
Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 6 (December), 2012: pp 1115-1123
Doppler to assess and diagnose DD with an individualized
and a mechanistic approach. The proposed algorithm is
from within the premise of the published guidelines and
attempts to simplify the perioperative approach. The au-
thors hope this approach will be simple enough for routine
application to affect therapy and a tangible change in out-
come. The authors suggest that knowledge of left atrial size
is valuable as a marker for persistently increased left ven-
tricular end-diastolic pressure and its possible role in risk
stratification.
© 2012 Elsevier Inc. All rights reserved.
KEY WORDS: diastolic dysfunction, perioperative
be applicable to specific patients.1,20,21 The dynamic intraoperative
hemodynamic environment also may be unsuitable for the appli-
cation of such complex time-consuming algorithms.19 It may be
more prudent to use a more individualized approach to answer
mechanistic questions in specific situations.1,20,22,23 The lack of
such a simplified algorithm also could explain the ambivalence of
anesthesiologists toward incorporating Doppler assessment of LV
filling as part of an echocardiographic examination. Therefore, in
perioperative circumstances, the error may not be in the modalities
but in their application. Considering these challenges, in this
article the authors address the possible reasons for the lack of
routine application of Doppler indices to assess perioperative DD.
The authors have chosen to highlight some of the most commonly
raised conceptual questions and limitations and to suggest possible
solutions. Drawing from their experience and the available data,
the authors propose a simplified algorithm for application of
Doppler to assess and diagnose DD with an individualized and a
mechanistic approach. The proposed algorithm is from within the
premise of the published guidelines and attempts to simplify
the decision tree to suit the perioperative circumstances.20 The
authors hope this approach will be practical enough for routine
application and affect clinical care and eventually a tangible
change in outcome. The authors also suggest the value of
*Harvard Medical School, Beth Israel Deaconess Medical Center,
Boston MA; and †Department of Anesthesiology and Pain Medicine,
University Medical Center Groningen, University of Groningen, Gro-
ningen, The Netherlands.
Address reprint requests to Feroze Mahmood, MD, Harvard Medical
School, Beth Israel Deaconess Medical Center, Deaconess 1, CC-540,
Boston, MA 02215. E-mail: fmahmood@bidmc.harvard.edu
© 2012 Elsevier Inc. All rights reserved.
1053-0770/2606-0025$36.00/0
http://dx.doi.org/10.1053/j.jvca.2012.07.012
1115
1116
Fig 1. Difference between physiologic and clinical diastole. Phys-
iologically, diastole starts before opening of the mitral valve. IVRT,
isovolumetric relaxation time. (Color version of figure is available
online.)
knowledge of left atrial (LA) size as a marker for persistently
increased LV end-diastolic pressure (LVEDP) and its possible
role in risk stratification.
Fig 2. Doppler representation of clinical diastole: (1) transmitral pulse-wave Doppler; (2) transmitral flow propagation velocity (Vp); (3)
Doppler tissue imaging with E= and A= waves. A, transmitral wave corresponding to atrial systole; A=, mitral annular peak velocity, atrial systole;
E, transmitral wave corresponding with the rapid filling phase; E=, mitral annular peak velocity, rapid filling phase.
MAHMOOD, JAINANDUNSING AND MATYAL
WHAT IS DIASTOLE?
Conventionally, diastole extends from aortic valve closure to
mitral valve closure during the cardiac cycle. The physiologic,
biochemical, and clinical events that constitute this phase of the
cardiac cycle follow a different timeline. Biochemical diastole
is initiated when calcium ion (Ca2") uptake into the sarcoplas-
mic reticulum and mitochondria starts and coincides with the
release of actin-myosin bonds, a process initiated later during
systole.24,25 Physiologically, diastole starts with the initiation of
the isovolumetric relaxation time (#pressure/#time [dP/dt]) in
the later part of clinical systole and extends to the early part of
clinical diastole (Fig 1).26,27 Clinical diastole starts with the
opening of the mitral valve and initiation of the rapid filling
phase (Fig 1). The current Doppler filling modalities adequately
analyze “clinical diastole,” ie, after mitral valve opening. The
classification schemes based on these Doppler filling patterns
also are limited in that they do not differentiate clinical from
physiologic diastole (Fig 2).19,20 Therefore, isovolumetric re-
laxation time, which is an energy-consumptive part of the
cardiac cycle, ie, physiologic diastole, is not measured rou-
tinely and considered part of conventional systole. Also, this
information is not incorporated in the assessment of diastolic
function.
ARE DIASTOLIC DYSFUNCTION AND DIASTOLIC HEART
FAILURE SYNONYMOUS TERMS?
Clinically, it is also important to differentiate DD from
diastolic HF (DHF). These are not synonymous terms. Echo-
cardiographic evidence of a continuum of LV filling abnormal-
ities (impaired relaxation to restrictive filling) is termed DD.28
ASSESSMENT OF PERIOPERATIVE DIASTOLIC DYSFUNCTION
It is a clinical state, recognized echocardiographically, in which
LV relaxation abnormalities result in elevated LA pressure
initially and increased LVEDP in later stages. In contrast, DHF
is a clinical state characterized by symptoms of HF (shortness
of breath) with echocardiographically preserved LV systolic
function and increased LVEDP.19,29 Depending on the objec-
tivity of the estimation of the LVEDP, HF symptoms with
preserved ejection fraction are classified as definitive, possible,
or probable DHF.19,30 Not all patients with DD have DHF,
whereas all patients with DHF have DD.
WHAT IS PSEUDONORMALIZATION?
Pseudonormalization is an intermediate stage in the progres-
sion of DD. Impaired relaxation results in a gradual increase in
LA pressure owing to inadequate filling during the rapid filling
phase. During this stage, increased LA pressure and not the
active relaxation becomes the driving force of LV filling,
giving rise to an ambiguous Doppler profile (Fig 3). Typically,
because of increased LA pressure, an impaired relaxation trans-
mitral filling pattern transitions into a “normal”-appearing pat-
tern (Fig 3). All Doppler modalities are susceptible to pseudo-
normalization to a certain extent, and pulse-wave Doppler
(PWD) is more susceptible than transmitral flow propagation
velocity and Doppler tissue imaging.20,31 Therefore, the Dop-
pler-derived LV filling profile during the impaired relaxation
stage depends on whether the LA pressure is increased (Fig
3).19 Physiologic maneuvers to decrease LA pressure (Valsalva
maneuver) are required and often performed in the outpatient
cardiology clinic to echocardiographically “unmask” the un-
derlying impaired relaxation abnormality (Fig 4).31 Typically
during a Valsalva maneuver, there is a decrease in “E”-wave
peak velocity, an increase in “A”-wave velocity, and prolon-
gation of the deceleration time (Fig 4). Because of the nature of
the surgery (cardiac and vascular), most patients undergoing
elective intraoperative transesophageal echocardiographic ex-
aminations may have some degree of DD and are in the
pseudonormal stage of progression.32-35 Therefore, in addition
to the dynamic changes in loading conditions, the intermediate
nature of the LV filling abnormality makes it even more chal-
lenging to interrogate LV filling comprehensively. There is no
standardized method of performing a Valsalva maneuver. The
associated hemodynamic instability with increased intratho-
racic pressure and its value in differentiating stages of diastolic
function makes its value in the perioperative assessment of DD
questionable (Fig 4).20,36 Hence, a maneuver routinely used in
the outpatient cardiology clinic for refining the assessment of
DD is of limited intraoperative use.
ARE THERE ANY PSEUDO-ABNORMAL
FILLING PATTERNS?
Although not stated explicitly, it is implied that the phrase
“changes in loading conditions” refers to an increase of LA
pressure with progressive impairment of LV relaxation. There-
fore, because of LA pressure increases, it is physiologically
possible for abnormal LV filling to assume a “normal” appear-
ance surreptitiously. However, a further decrease in LA pres-
sure beyond the normal value does not necessarily result in a
“pseudo-abnormal” filling pattern.19 Hence, a “normal”-appear-
1117
ing LV filling pattern may require more corroborative evidence
to be classified as a “true normal”; abnormal LV filling is
always a “true abnormal.” Hence, the real clinical challenge in
knowing whether a normal pattern is a “true normal” or a
“pseudonormal” pattern.
IS DIASTOLIC DYSFUNCTION A MISNOMER?
The progression of LV filling abnormalities is a continuum
from impaired relaxation in the early stages to decreased compli-
ance in the advanced stage. The term diastolic dysfunction is
therefore an overinclusive term because it does not specify the
point in the continuum of progressive LV filling abnormalities that
describes the condition of a particular patient. The ASE guidelines
also recommend an approach geared to diagnose specifically im-
paired relaxation or decreased compliance (Figs 5 and 6).20 Each
of the Doppler indices has been evaluated in the context of its
value as a direct or a surrogate marker of relaxation or compliance
of the left ventricle (Figs 5 and 6). This approach is intuitively
simpler and addresses mechanistic issues with possible therapeutic
implications, which are discussed later in this article.
ARE THE PUBLISHED GUIDELINES FOR ASSESSMENT
OF DD TOO RESTRICTIVE?
The wide variability of the Doppler indices in patients with
DD has been acknowledged.19,20,37 Owing to the unique intra-
operative circumstances, an approach based on assigning se-
verity grades is less helpful than knowledge of the specific
filling abnormality.19 Based on the criteria for the grading of
DD, ie, multiple Doppler indices, a patient’s severity grade can
be changed with minor variations in hemodynamics and Dop-
pler-derived values.20,38 The restrictive nature of a verbatim
application of the published guidelines in the perioperative
setting has been shown.6,19,34 Simplified algorithms with high
reproducibility have been shown to be better predictors of
outcome than the approach to grade DD.6,34
ARE THE PUBLISHED GUIDELINES APPLICABLE IN THE
PERIOPERATIVE ARENA?
The traditional preoperative risk stratification includes a history
of CHF as a predictor of an adverse outcome, with a presumption
of systolic etiology.16,18 It has been established that the presence of
asymptomatic DD is also a marker of increased all-cause morbid-
ity and mortality.22 Logically, the presence of DD (symptomatic
and asymptomatic) should be used routinely as a risk stratification
index.10 By including advanced age as a risk factor, at least
impaired LV relaxation may be factored indirectly in the pro-
cess.13,39 However, advanced age and DD are not synonymous and
DD can occur in younger groups.
The evolution of Doppler has simplified the assessment of
diastolic function.27 It started using the PWD assessment of LV
filling to the use of more sophisticated techniques, eg, propa-
gation velocity and Doppler tissue imaging.10,21,27,31 It is now
known that a patient’s hydration status, position, and ventila-
tion (spontaneous v controlled) can affect LV filling.19 The LV
filling parameters also are known to change with anesthetic
agents.19 It is intuitive that the dynamic intraoperative circum-
stances possibly can make a Doppler assessment based on
awake-state hemodynamics unreliable. The most recent guide-
1118 MAHMOOD, JAINANDUNSING AND MATYAL

Fig 3. Continuum of dia-

stolic dysfunction from nor-
mal to impaired relaxation
with increased left atrial pres-
sure (LAP). The pulse-wave
Doppler profile of left ventric-
ular filling during the impaired
relaxation phase depends on
the LAP. DT, deceleration
time; LA, left atrium; LV, left
ventricle. (Color version of fig-
ure is available online.)

lines have provided a generalized conceptual framework,
whereas the specific methodology needs to be customized to
best suit the intraoperative circumstances.20
ARE THERE ANY CLINICAL IMPLICATIONS OF A
SIMPLIFIED APPROACH?
Knowledge of the specific LV filling abnormalities (impaired
relaxation or decreased compliance) can have possible thera-
peutic implications (Fig 7).19,37 During the impaired relaxation
phase, LV filling can be optimized by an increase of LA
pressure, ie, it is a preload-tolerant stage. Prolonging diastole
by heart rate control can have a similar beneficial effect on LV
filling by prolonging the rapid filling phase. Patients in the
decreased compliance stage have an increased LA pressure at
baseline, ie, preload intolerant, thus requiring a careful periop-
erative fluid management and the judicious use of diuretics.

Fig 4. Physiologic basis of a

“pseudonormal” left ventricular
filling pattern and the rationale
for left atrial (LA) pressure de-
crease (Valsalva) maneuvers to
“unmask” the relaxation abnor-
malities. Progressive left ventric-
ular relaxation is counterbal-
anced by an increased left atrial
pressure. A decrease in left atrial
pressure leads to a decrease in
peak E wave velocity and prolon-
gation of the deceleration time.
(Color version of figure is avail-
able online.)
ASSESSMENT OF PERIOPERATIVE DIASTOLIC DYSFUNCTION 1119

Fig 5. Direct and surrogate measurements of left ventricular (LV) relaxation. A, transmitral wave corresponding to atrial systole; A=, lateral
mitral annular peak velocity, atrial systole; AI, aortic insufficiency; CFD, color-flow Doppler; CWD, continuous-wave Doppler; DT, deceleration
time; DTG, deep transgastric; DTI, Doppler tissue imaging; E, transmitral wave corresponding with the rapid filling phase; E=, lateral mitral
annular peak velocity, rapid filling phase; IVRT, isovolumetric relaxation time; Lat, lateral; LVEDP, left ventricular end-diastolic pressure; LVOT,
left ventricular outflow tract; MR, mitral regurgitation; PHT, pressure half-time; PT, Pressure half-time; PWD, pulse-wave Doppler; Tau, left
ventricular relaxation time constant; Vp, propagation velocity; VTI, velocity time integral. (Color version of figure is available online.)

Also, they may require a higher aortic pressure to increase the
coronary perfusion pressure owing to an increased LVEDP.
The appreciation of these fine differences between the stages of
DD can further optimize perioperative management and possi-
bly improve outcome. Therefore, knowledge of the particular
stage of DD has clinical implications with the potential to
modify therapy.
WHAT IS A SIMPLIFIED APPROACH?
A practical approach for the assessment of perioperative DD
should be simple, quick, and less dependent on loading condi-
tions and reliably diagnose a specific LV filling abnormality, ie,
impaired relaxation or decreased compliance. Ideally, there
should be no manipulation/calculation steps after acquisition. A
simplified approach can have perioperative implications re-
garding hemodynamic management decisions (Fig 8). Drawing
from their experience and the available evidence, the authors
propose a simplified echocardiographic approach to the peri-
operative assessment of DD based on the ASE guidelines.20
The proposed scheme is within the framework of the guidelines
and based on the diagnosis of a specific abnormality, ie, im-
paired relaxation or decreased compliance.
Based on the ASE guidelines,20 the simplified approach is
based on the following principles.
1. Doppler tissue-derived peak mitral annular velocities are the
least load dependent of all Doppler-derived modalities.
2. Doppler indices of LV filling differ in their sensitivity
and specificity to assess LV relaxation and compliance.
3. There can be a “pseudonormal” LV filling pattern, but
there is no “pseudoabnormal” LV filling pattern, ie, an
abnormal value is always a true abnormal value.
4. Normal values need to be corroborated with a normal LA
size.
5. Decreased compliance is assessed in the context of
systolic function.
Step 1
Lateral mitral annular peak velocity (E=) should be obtained
during apnea and corrected for age. An average of 3 velocities
should be taken as the final value for each modality. For
patients with wall motion abnormalities, an average of the
septal and lateral mitral annuli should be performed.
A peak E= velocity of $10 cm/s establishes impaired relaxation
of the left ventricle. Although there may be cutoff values for
1120 MAHMOOD, JAINANDUNSING AND MATYAL

Fig 6. Direct and surrogate measurements of left ventricular (LV) compliance. (A) A decrease in left ventricular compliance is represented in
pressure volume curve changes and changes in the ratio of the transmitral wave corresponding to the rapid filling phase to the transmitral wave
corresponding to atrial systole. However, simultaneous recordings can be performed only in the setting of a cardiac catheterization laboratory.
(B) Deceleration time (DT) decreases with increased left ventricular stiffness. The pressure between the left atrium and left ventricle equalizes
more rapidly compared with a more compliant ventricle. (C) The A-wave transit time (AWTT) after left atrial contraction. A pressure wave is
generated that reflects at the apex of the left ventricle toward the aorta. It can be detected as a wave before ejection. The A-wave transit time
is measured from the start of the A wave to the start of the transmitted wave; this interval relates to left ventricular stiffness. LVOT, left
ventricular outflow tract. (Color version of figure is available online.)

different age groups, an E= value of $10 cm/s for the lateral
annulus would be most inclusive and diagnose impaired relaxation
in age groups most likely to have this abnormality.20 After having
established impaired relaxation as an abnormality, the presence of
concomitant decreased compliance needs to be diagnosed.
Step 2
A peak transmitral E-wave velocity with PWD should be ob-
tained. The assessment of decreased compliance or an increased
LA pressure needs to be performed in the context of a patient’s
systolic function (Fig 8). A ratio of E= to transmitral E-wave peak
velocity reliably establishes an increased LA pressure.
When the age-corrected peak Doppler tissue imaging E=
velocity is within the normal range, corroborative evidence
should be obtained to confirm this finding as a “true normal”
value and pseudonormalization should be excluded (Fig 8). The
advantages of this simplified approach are obvious. The entire
assessment can be completed quickly in 2 steps. The algorithm
is based on peak E= velocity, which is the least load dependent
of all the Doppler modalities. Most ultrasound machines have
presets that calculate the E/E= ratio automatically, making this
assessment a 1-step process.
THE FUTURE—LEFT ATRIAL SIZE?
The left atrium increases when the LVEDP is increased
persistently; hence, it has been suggested that LA size can be
considered a barometer of the LVEDP.40 Although Doppler
indices of LV filling can change dynamically, LA size is a
marker of persistently increased LVEDP. The association of
LA size with DD is analogous to the association of hemoglobin
A1c with diabetes mellitus.40 Although glucose levels can
change acutely, hemoglobin A1c represents long-term glyce-
mic control. Similarly, LV filling patters can change dynami-
cally; LA size represents a long-term LV filling pattern.40-42
Although insulin is the most important determinant of blood
glucose, it is not the only one; LV relaxation properties are the
most important but not the only determinant of LV filling. LA
size indexed to the body surface area also has been shown to be
a marker of all-cause morbidity and mortality.43,44 The knowl-
edge of preoperative LA size can provide a context to the
intraoperative assessment of DD. For example, a normal-ap-
pearing PWD LV filling pattern in the presence of an enlarged
left atrium in the absence of other causes implies pseudonor-
malization. Intraoperative assessment of DD has been associ-
ASSESSMENT OF PERIOPERATIVE DIASTOLIC DYSFUNCTION 1121

Fig 7. Physiologic differ-

ences between impaired relax-
ation and decreased compliance
and proposed therapeutic op-
tions. CHF, congestive heart fail-
ure; LA, left atrial. (Color version
of figure is available online.)

ated with postoperative outcome in cardiac and noncardiac
surgeries. Now is the time to take it a step further and extend
this knowledge to the preoperative risk stratification. Because
LA size cannot be measured reliably with transesophageal
echocardiography,45 it would be interesting to see if preopera-
tive LA size measured with transthoracic echocardiography
could be used as a risk stratification index for cardiac and
high-risk noncardiac surgeries.
CONCLUSIONS
The assessment of DD is a constantly evolving process. The
availability of sophisticated Doppler indices has facilitated the

Fig 8. Proposed diastolic dysfunction algorithm based on the ASE guidelines. Step 1: Left atrial (LA) volumes should be obtained with
transthoracic echocardiography before surgery. Lateral mitral annular peak velocity (E=) and transmitral pulse-wave Doppler-derived peak
velocity (E) are obtained or calculated after induction. Impaired relaxation is established with lateral mitral annular Doppler tissue imaging. E=
<10 cm/s is the cutoff value for impaired relaxation. Step 2(a): After establishing impaired relaxation, the presence of concomitant decreased
compliance needs to be diagnosed. The assessment of decreased compliance or an increased left atrial pressure needs to be performed in the
context of patient’s systolic function. Step 2(b): When the age-corrected peak Doppler tissue imaging E= velocity is within the normal range,
corroborative evidence should be obtained to confirm this finding as a “true normal” value and exclude pseudonormalization. Left atrial volume
measurement and propagation velocity (Vp) will aid in distinguishing pseudonormalization from true normal. This algorithm, derived from
within the published guidelines, has the possibility to differentiate patients with impaired relaxation from those with decreased compliance,
allowing care providers to act accordingly. EF, ejection fraction. (Color version of figure is available online.)
1122
understanding of normal and abnormal LV filling patterns. The
increasing awareness of the prognostic value of DD among
echocardiographers is a welcome change.19,46,47 The simplifi-
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