Diastolic dysfunction assessment (echocardiography)

According to the American Society of Echocardiography and the European Association of Cardiovascular Imaging, diastolic dysfunction assessment on echocardiography is divided into two different groups based on left ventricular systolic function. 

Normal left ventricular systolic function

There are four criteria should be evaluated:

1. average E/e’ >14
2. septal e’ velocity <7 cm/s or lateral e’ velocity <10 cm/s
3. tricuspid regurgitation (TR) velocity >2.8 m/s
4. left atrium (LA) volume index >34 mL/m²

If >50% of these criteria were positive then diastolic dysfunction is evident ¹.

Depressed left ventricular systolic function

Firstly, mitral inflow should be assessed using pulsed-wave Doppler:

1. if E/A ≤0.8 + E ≤50 cm/s: Normal filling pressure with grade I diastolic dysfunction ¹
2. E/A ≥2: elevated left atrial pressure (LAP) with grade III diastolic dysfunction ¹
3. if E/A ≤0.8 + E >50 cm/s or E/A > 0.8 - <2: then there are three criteria should be evaluated:
   • average E/e’ >14
   • tricuspid regurgitation (TR) velocity >2.8 m/s
   • left atrium (LA) volume index >34 mL/m²

If two were negative: normal left atrial pressure (LAP) and grade I diastolic dysfunction ¹. If two were positive: elevated left atrial pressure (LAP) with grade III diastolic dysfunction ¹.

However, the dilemma is with the estimation of the left ventricular filling pressures in patients with specific cardiovascular diseases such as arrhythmias and valve diseases. An approach is presented below. 

Mitral regurgitation

Chronic mitral regurgitation leads to volume overload, which accompanies with dilated left ventricule/atrium. Moderate and severe MR causes peak E velocity (pulsed Doppler mitral inflow) and a decrease in pulmonary venous systolic velocity (S wave velocity).

An increased E/e’ ratio has a direct significant relation with elevated left atrial pressure (LAP) in patients with depressed left ventricular systolic function.  However, in patients with normal left ventricular systolic function E/e’ does not appear to be useful ².

Assessment of left ventricular filling pressures in mitral regurgitation ^1,3:

1. Ar-A (>30 ms)
2. IVRT (<60 ms)
3. IVRT/TE-e’ (<5.6) predict LV filling pressures in patients with MR and normal EF
4. average E/e’ (>14) only in patients with depressed EF

Mitral stenosis

Typically, patients with mitral stenosis have normal or even reduced left ventricular diastolic pressures, except for the rare occurrence of coexisting myocardial disease. However, short IVRT and higher peak E-wave velocity predict elevated left atrial pressure (LAP).

E/e’ ratio is not useful in mitral stenosis, although some studies suggest that tissue Doppler of the mitral annulus may provide a potential diagnostic role for the assessment of the left ventricular diastolic function in patients with mitral stenosis ⁴.

Assessment of left ventricular filling pressures in mitral stenosis ¹:

1. IVRT (<60 ms)
2. IVRT/TE-e’ (<4.2)
3. mitral A velocity (>1.5 m/sec)

Aortic regurgitation

The aortic regurgitation jet could interfere with the recording of the mitral inflow velocities (pulsed-wave Doppler). Yet, these criteria support the presence of increased left ventricular filling pressure in patients with aortic regurgitation ^1,5:

1. the presence of left atrium enlargement
2. average E/e’ ratio >14
3. tricuspid regurgitation (TR) peak velocity >2.8 m/sec

Aortic stenosis

The guidelines in patients without valvular heart disease can be applied to patients with aortic stenosis. This excludes patients with heavy mitral annulus calcification (moderate to severe mitral annulus calcification may decrease mitral orifice area, leading to increased diastolic transmitral velocities, while lateral e’ may be decreased due to restriction of the posterior mitral leaflet excursion leading to an increase in E/e’ ratio) ¹.

Atrial fibrillation

Assessment of left ventricular diastolic function is limited due to the variability in cycle length. However, measurements that can be applied include peak acceleration rate of mitral E velocity, IVRT, DT of pulmonary venous diastolic velocity, E/mitral Vp, and E/e’ ratio ⁶.

Assessment of left ventricular filling pressures in atrial fibrillation ¹:

1. septal E/e’ ratio (>11)
2. IVRT (<65 ms)
3. E/Vp ratio (>1.4)
4. peak acceleration rate of mitral E velocity (>1,900 cm/sec²)
5. DT of pulmonary venous diastolic velocity (<220 ms)