Assessment of Left-Ventricular

Diastolic Function
Mateo Uribe
Medical Student

Objectives
Define Diastolic dysfunction and its relevance to
anesthesia and critical care

Understand pathophysiology of diastolic heart

failure

Understand evaluation methods

Diastolic dysfunction
Inability of the heart to Fill at normal Atrial pressures
A mechanical problem of
delayed relaxation And/Or decreased compliance

Pressure/Volume Curve.
Slope = Elastance
Inverse of compliance
Decreased compliance
More pressure to
generate same volume

Diastolic dysfunction vs.

Diastolic heart failure.

Why is important
Heart Failure
#1 cause of hospitalization in pt over 65 yo. (Age)
1 million admissions/year
15 billion dollars
1yr Re-admission of 50%

Half have HFPEF

Prone hemodynamic instability
Probably worse outcomes
Decompensation in the perioperative period
1 . Bernard F, Denault A, Babin D, et al. Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary
bypass. AnesthAnalg. 2001;92(2):291-298.
Priebe HJ . The aged cardiovascular risk patient. Br ] Anaesth. 2000;85(5):763-778.

Diastolic physiology

Diastole comprises
1.
2.
3.
4.

Isovolumetric filling
Rapid filling
Diastasis
Atrial contraction

Diastolic phase
1. Isovolumetric Relaxation
Best time to assess diastolic function.
90 to 120 mseg
Inactivation of contractile forces by active re-entry of Ca+
+ into SR
(Translation: Relaxation consumes energy!!!)
What can cause a disturbed relaxation then?

2. Rapid filling
80 % of the filling
180-200 mseg
Relaxation persists and recoil of the ventricule

Sucking of blood

Diastolic phase
3. Diastasis
5% of the filling (Very little to matter)
Passive blood flow
(Little because is after equalization)
Pressures start to rise

4. Atrial contraction
20-25 % of filling
Contribution highly dependant on Ventricule
compliance

New cardiac cycle division

Contraction (Active)
Isovolumetric contraction
First half of ejection

Relaxation (Active)
Second half of ejection
Isovolumetric relaxation
Most rapid filling

Filling
Diastasis
Atrial contraction

Diastolic dysfunction
pathophysiology
Increased resistance to
filling
Upward shift of PV

curve (Less compliance)

(More increase of
pressure per unit of
volume)

Increased pressure
S&S of Congestion
Decrease in Ventricular
filling and Stroke
Volume

Diastolic dysfunction
Mechanisms
Primary
myocardial
disease

Secondary
hypertrophy

Coronary
artery
disease

Extrinsic
constrain

Calcium
handling

Matrix
remodelling

Afterload

Dilation

Invasive Measures of
Diastolic function
Relaxation

Peak dP/dt
(Invasive)

Maximum rate (speed) of

Pressure decline

Aortic pressure
LV pressure
Duration of Isovolumic

relaxation period (IVRT)

Relaxation time constant

(Math derivation)

Compliance

(PV Graph)

Compliance and stiffness are

unique to every ventricle

Modulus of chamber
stiffness (Kc)

The change in stiffness

(dP/dV) with an
increase in pressure

Modulus of myocardial
stiffness (Km)
Strain

Stress

Echocardiographic Measures of
Diastolic function
Ejection Fraction
Systolic+Diastolic
Pure diastolic

2D Chamber
dimensions
PW Doppler
Mitral inflow
Pulmonary venous flow

Caveats:
Doppler parameters are
dependant on:
Load
Heart rate
Studies done in
TEE
Spont. Breathing

Color M Mode
Tissue doppler

Trans-Mitral Inflow
Transmitral velocity

assessed by doppler
Reflects LV ventricule
volume change

Velocity is determined by
Pressure gradient
LA Pressure (pushing)
LV Pressure decrease
(pulling)

Trans-mitral 4 phases
(Analog to diastole)

1. IVRT
2. DT Deceleration time of E
3.
4.

velocity
Diastasis
A-dur

Parameters measures in
Trans-mitral outflow
IVRT

Time for LVP to decrease

below LAP

Peak E
Velocity

Peak velocity at Rapid

filling phase

DT

Time for LVP to equalize

with LAP

Peak A
Velocity

Peak velocity at atrial

contraction time

Atrial
systole
time

Time for LAP to equalize

with LVP

Factors that affect

Trans-mitral flow
Respiration

Preload

Heart rate

Volume flow rate

Age

LV systolic function

PR interval

Atrial contractile function

Relaxation

Compliance

Factors are not independent

Changes of relaxation and compliance vs changes because of elevated pressures

Factors that affect

Trans-mitral flow
Respiration

Atrial
Function

Hear Rate

Relaxation

Compliance
Systolic
Function

Age

Loading

Mitral velocity profile

Aging
Profile changes with age: Alteration of
Young:
Vigorous rate of
relaxation
LV filling

myocardial fibers

Old:
Decreased relaxation
Decreased LV recoil
Slower filling

80% in early diastole

Good compliance
High Peak E
High E/A ratios
Short DT ?????

Prolonged IVRT
Prolonged DT
More dependent on Atrial
contraction (35-40%)
A Peak increases

Mitral velocity profile

Aging

Loading conditions
Effect on Mitral flow

Heart rate
Effect on Mitral flow

Abnormal Trans-mitral patterns

Diastolic dysfunction

Grade I

Impaired relaxation
AP still not changed
Relaxation is Slow

Prolonged IVRT
Prolonged DT
Low peak E
Increased peak A

E/A ratio < 1

Grade II
Pseudonormal
Altered compliance
Increased pressures

Normal IVRT
Normal DT
Normal E/A ratio

Grade III

Restrictive filling
IIIa Reversible
IIIb Irreversible

Short IVRT
Short DT
High E
Little A

Pulmonary venous flow

1. Peak systolic flow velocity S Velocity
2. Peak diastolic flow velocity D Velocity
3. Peak atrial reversal flow velocity AR velocity
4. AR wave duration AR-dur
5. Difference between AR-dur and mitral A-dur
6. Deceleration time of D wave

Good
but not that good

Pulmonary venous flow

Abnormal Patterns
Grade 1 diastolic dysfunction
Decreased PV diastolic
S >> D
Grade 2 diastolic dysfunction
(Increased atrial pressure)
Diastolic waves prominent
Systolic waves blunted
D>S

Grade 3 diastolic dysfunction

Diastolic waves prominent
Systolic waves Even more blunted
D >> S

Mitral annulus
Tissue doppler
During diastole, myocardial fibers
Lengthen from apex to base
Expand radially
Measure of Lengthening and shortening speed

Benefit
Less dependent on loading conditions
Differentiate Grade II and III

Curve
Similar to transmitral flow
Inverted
Less speed

Diastolic dysfunction
Findings on Tissue doppler
E Wave Peak < 8
E/A ratio reversal

Does the pt have

increased filling pressure?
Compare E/E ratio
> 12 15 filling pressure is elevated
E/E is correlated to PCWP
Nagueh Formula
PCWP= (1.24 * E/E)+1.09

Pulmonary venous flow AR Velocity > 35 cm/s

AR greater than TM-A by 30 msec
E/Vp ratio > 1.5

Color M Doppler
Information from multiple PW Doppler
From Mitral annulus to apex

Vp

Flow propagation on early diastole

Normal Diastolic function
Vp > 55 cm/S

Less dependent on
Loading
Conditions

Summary

Summary

Diastolic Function
Anesthesia Setting
Perioperative setting = Hemodynamic fluctuations
Loading conditions

Changes in intrathoracic
pressures

Be careful!

Unmask Subclinical diastolic dysfunction

Decompensate a diagnosed dysfunction

Prognostic
factor
Indicator for preload

TEE

Excellent tool in the OR

Mitral annulus TDI
Vp
Conventional doppler indices