Journal of Echocardiography

, Volume 8, Issue 3, pp 65–79 | Cite as

Diastology 2010: clinical approach to diastolic heart failure

Review Article

Abstract

The role of echocardiography in the evaluation of left ventricular diastolic function is increasingly important in both systolic and diastolic heart failure. In routine clinical practice, the diastolic dysfunction associated with diastolic heart failure can mainly be evaluated by Doppler echocardiography. In order to use echocardiographic techniques for this purpose, one should recognize the definition, terminology, epidemiology, and pathophysiology of diastolic dysfunction and diastolic heart failure. There are various echocardiographic parameters for this purpose, including transmitral flow velocity, pulmonary venous flow velocity, mitral annular velocity, flow propagation velocity, left atrial size, strain, strain rate, twist, and so on. However, no single Doppler echocardiographic index has yielded a robust criterion for diastolic dysfunction and elevated left ventricular filling pressure. Thus, multiple indices are required to increase the sensitivity of the diagnosis. Clinicians who take care of heart failure patients should continue to make critical use of a current Doppler echocardiographic evaluation and utilize this information to improve survival and quality of life in these patients.

Keywords

Diastole Heart failure Echocardiography Tissue Doppler LV filling pressures Prognosis 

Abbreviations

HF

Heart failure

LV

Left ventricle, left ventricular

EF

Ejection fraction

LA

Left atrial

RFP

Restrictive filling pattern

E

Peak early diastolic transmitral flow velocity

A

Atrial systolic transmitral flow velocity

DT

Deceleration time of the early diastolic flow velocity wave

PVS1

First systolic pulmonary venous flow velocity

PVS2

Second systolic pulmonary venous flow velocity

PVD

Diastolic pulmonary venous flow velocity

PVC

Pulmonary venous flow velocity at mitral valve closure

AR

Atrial reversal pulmonary venous flow velocity

e′

Early diastolic mitral annular velocity

a′

Atrial systolic mitral annular velocity

TE-e′

Time interval between the onset of the early diastolic transmitral flow velocity and that of the early diastolic mitral annular velocity

Vp

The slope of the flow propagation velocity

References

  1. 1.
    Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure. Part I: diagnosis, prognosis, and measurements of diastolic function. Circulation. 2002;105:1387–93.CrossRefPubMedGoogle Scholar
  2. 2.
    Aurigemma GP, Zile MR, Gaasch WH. Contractile behavior of the left ventricle in diastolic heart failure: with emphasis on regional systolic function. Circulation. 2006;113:296–304.CrossRefPubMedGoogle Scholar
  3. 3.
    Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to update the 2001 guidelines for the evaluation and management of heart failure). J Am Coll Cardiol. 2005;46:e1–82.CrossRefPubMedGoogle Scholar
  4. 4.
    Yamada H, Goh PP, Sun JP, Odabashian J, Garcia MJ, Thomas JD, et al. Prevalence of left ventricular diastolic dysfunction by Doppler echocardiography: clinical application of the Canadian consensus guidelines. J Am Soc Echocardiogr. 2002;15:1238–44.CrossRefPubMedGoogle Scholar
  5. 5.
    Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA. 2003;289:194–202.CrossRefPubMedGoogle Scholar
  7. 7.
    Fischer M, Baessler A, Hense HW, Hengstenberg C, Muscholl M, Holmer S, et al. Prevalence of left ventricular diastolic dysfunction in the community. Results from a Doppler echocardiographic-based survey of a population sample. Eur Heart J. 2003;24:320–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999;33:1948–55.CrossRefPubMedGoogle Scholar
  9. 9.
    Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med. 2006;355:260–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Meta-analysis Research Group in Echocardiography (MeRGE) Heart Failure Collaborators. Independence of restrictive filling pattern and LV ejection fraction with mortality in heart failure: an individual patient meta-analysis. Eur J Heart Fail. 2008;10:786–92.Google Scholar
  11. 11.
    Kitzman DW, Gardin JM, Gottdiener JS, Arnold A, Boineau R, Aurigemma G, et al. Importance of heart failure with preserved systolic function in patients > or = 65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol. 2001;87:413–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Aurigemma GP. Diastolic heart failure—a common and lethal condition by any name. N Engl J Med. 2006;355:308–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiographic applications for the study of diastolic function. J Am Coll Cardiol. 1998;32:865–75.CrossRefPubMedGoogle Scholar
  14. 14.
    Bursi F, Weston SA, Redfield MM, Jacobsen SJ, Pakhomov S, Nkomo VT, et al. Systolic and diastolic heart failure in the community. JAMA. 2006;296:2209–16.CrossRefPubMedGoogle Scholar
  15. 15.
    Pozzoli M, Traversi E, Cioffi G, Stenner R, Sanarico M, Tavazzi L. Loading manipulations improve the prognostic value of Doppler evaluation of mitral flow in patients with chronic heart failure. Circulation. 1997;95:1222–30.PubMedGoogle Scholar
  16. 16.
    Dumesnil JG, Pibarot P. Doppler assessment of diastolic function at rest and during exercise: distinguishing myth from reality. J Am Soc Echocardiogr. 2009;22:350–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Tabata T, Thomas JD, Klein AL. Pulmonary venous flow by doppler echocardiography: revisited 12 years later. J Am Coll Cardiol. 2003;41:1243–50.CrossRefPubMedGoogle Scholar
  18. 18.
    Iuchi A, Oki T, Fukuda N, Tabata T, Manabe K, Kageji Y, et al. Changes in transmitral and pulmonary venous flow velocity patterns after cardioversion of atrial fibrillation. Am Heart J. 1996;131:270–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Keren G, Sonnenblick EH, LeJemtel TH. Mitral anulus motion. Relation to pulmonary venous and transmitral flows in normal subjects and in patients with dilated cardiomyopathy. Circulation. 1988;78:621–9.PubMedGoogle Scholar
  20. 20.
    Klein AL, Obarski TP, Stewart WJ, Casale PN, Pearce GL, Husbands K, et al. Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity. J Am Coll Cardiol. 1991;18:518–26.CrossRefPubMedGoogle Scholar
  21. 21.
    Tanimoto M, Pai RG. Effect of isolated left atrial enlargement on mitral annular size and valve competence. Am J Cardiol. 1996;77:769–74.CrossRefPubMedGoogle Scholar
  22. 22.
    Tice FD, Heinle SK, Harrison JK, Bashore TM, Lieberman EB, Wilson JS, et al. Transesophageal echocardiographic assessment of reversal of systolic pulmonary venous flow in mitral stenosis. Am J Cardiol. 1995;75:58–60.CrossRefPubMedGoogle Scholar
  23. 23.
    Kisanuki A, Shibata K, Otsuji Y, Kuroiwa R, Murayama T, Matsushita R, et al. Pulmonary venous flow patterns assessed by transesophageal pulsed Doppler echocardiography in left atrial myxoma. Am J Cardiol. 1993;72:1089–93.CrossRefPubMedGoogle Scholar
  24. 24.
    Yamamoto K, Nishimura RA, Burnett JC Jr, Redfield MM. Assessment of left ventricular end-diastolic pressure by Doppler echocardiography: contribution of duration of pulmonary venous versus mitral flow velocity curves at atrial contraction. J Am Soc Echocardiogr. 1997;10:52–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Garcia MJ, Rodriguez L, Ares M, Griffin BP, Thomas JD, Klein AL. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol. 1996;27:108–14.CrossRefPubMedGoogle Scholar
  26. 26.
    Oki T, Tabata T, Yamada H, Wakatsuki T, Shinohara H, Nishikado A, et al. Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular relaxation. Am J Cardiol. 1997;79:921–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Oki T, Tabata T, Yamada H, Manabe K, Fukuda K, Abe M, et al. Difference in systolic motion velocity of the left ventricular posterior wall in patients with asymmetric septal hypertrophy and prior anteroseptal myocardial infarction. Evaluation by pulsed tissue Doppler imaging. Jpn Heart J. 1998;39:163–72.PubMedGoogle Scholar
  28. 28.
    Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol. 1997;30:1527–33.CrossRefPubMedGoogle Scholar
  29. 29.
    Park HS, Naik SD, Aronow WS, Visintainer PF, Das M, McClung JA, et al. Differences of lateral and septal mitral annulus velocity by tissue Doppler imaging in the evaluation of left ventricular diastolic function. Am J Cardiol. 2006;98:970–2.CrossRefPubMedGoogle Scholar
  30. 30.
    Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22:107–33.CrossRefPubMedGoogle Scholar
  31. 31.
    Onose Y, Oki T, Tabata T, Yamada H, Ito S. Assessment of the temporal relationship between left ventricular relaxation and filling during early diastole using pulsed Doppler echocardiography and tissue Doppler imaging. Jpn Circ J. 1999;63:209–15.CrossRefPubMedGoogle Scholar
  32. 32.
    Rivas-Gotz C, Khoury DS, Manolios M, Rao L, Kopelen HA, Nagueh SF. Time interval between onset of mitral inflow and onset of early diastolic velocity by tissue Doppler: a novel index of left ventricular relaxation: experimental studies and clinical application. J Am Coll Cardiol. 2003;42:1463–70.CrossRefPubMedGoogle Scholar
  33. 33.
    Diwan A, McCulloch M, Lawrie GM, Reardon MJ, Nagueh SF. Doppler estimation of left ventricular filling pressures in patients with mitral valve disease. Circulation. 2005;111:3281–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Garcia MJ, Ares MA, Asher C, Rodriguez L, Vandervoort P, Thomas JD. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure. J Am Coll Cardiol. 1997;29:448–54.CrossRefPubMedGoogle Scholar
  35. 35.
    Takatsuji H, Mikami T, Urasawa K, Teranishi J, Onozuka H, Takagi C, et al. A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography. J Am Coll Cardiol. 1996;27:365–71.CrossRefPubMedGoogle Scholar
  36. 36.
    Douglas PS. The left atrium: a biomarker of chronic diastolic dysfunction and cardiovascular disease risk. J Am Coll Cardiol. 2003;42:1206–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol. 2002;90:1284–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification. Eur J Echocardiogr. 2006;7:79–108.CrossRefPubMedGoogle Scholar
  39. 39.
    Wang J, Khoury DS, Yue Y, Torre-Amione G, Nagueh SF. Left ventricular untwisting rate by speckle tracking echocardiography. Circulation. 2007;116:2580–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Urheim S, Edvardsen T, Torp H, Angelsen B, Smiseth OA. Myocardial strain by Doppler echocardiography. Validation of a new method to quantify regional myocardial function. Circulation. 2000;102:1158–64.PubMedGoogle Scholar
  41. 41.
    Langeland S, D’Hooge J, Wouters PF, Leather HA, Claus P, Bijnens B, et al. Experimental validation of a new ultrasound method for the simultaneous assessment of radial and longitudinal myocardial deformation independent of insonation angle. Circulation. 2005;112:2157–62.CrossRefPubMedGoogle Scholar
  42. 42.
    Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol. 2006;47:789–93.CrossRefPubMedGoogle Scholar
  43. 43.
    Notomi Y, Setser RM, Shiota T, Martin-Miklovic MG, Weaver JA, Popovic ZB, et al. Assessment of left ventricular torsional deformation by Doppler tissue imaging: validation study with tagged magnetic resonance imaging. Circulation. 2005;111:1141–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Notomi Y, Popovic ZB, Yamada H, Wallick DW, Martin MG, Oryszak SJ, et al. Ventricular untwisting: a temporal link between left ventricular relaxation and suction. Am J Physiol Heart Circ Physiol. 2008;294:H505–13.CrossRefPubMedGoogle Scholar
  45. 45.
    Wang J, Khoury DS, Yue Y, Torre-Amione G, Nagueh SF. Preserved left ventricular twist and circumferential deformation, but depressed longitudinal and radial deformation in patients with diastolic heart failure. Eur Heart J. 2008;29:1283–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000;102:1788–94.PubMedGoogle Scholar
  47. 47.
    Rivas-Gotz C, Manolios M, Thohan V, Nagueh SF. Impact of left ventricular ejection fraction on estimation of left ventricular filling pressures using tissue Doppler and flow propagation velocity. Am J Cardiol. 2003;91:780–4.CrossRefPubMedGoogle Scholar
  48. 48.
    Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved trial. Lancet. 2003;362:777–81.CrossRefPubMedGoogle Scholar
  49. 49.
    Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, Zile MR, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359:2456–67.CrossRefPubMedGoogle Scholar
  50. 50.
    Paulus WJ, van Ballegoij JJ. Treatment of heart failure with normal ejection fraction: an inconvenient truth! J Am Coll Cardiol. 2010;55:526–37.CrossRefPubMedGoogle Scholar
  51. 51.
    Little WC, Oh JK. Echocardiographic evaluation of diastolic function can be used to guide clinical care. Circulation. 2009;120:802–9.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2010

Authors and Affiliations

  1. 1.Department of Cardiovascular Medicine, Institute of Health Bioscience ResearchThe University of Tokushima Graduate School of MedicineTokushimaJapan
  2. 2.Department of Cardiovascular Imaging, Heart and Vascular InstituteCleveland ClinicClevelandUSA

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