Diastolic dysfunction
Can it be diagnosed by Doppler echocardiography?
Mathew S. Maurer, MD*,
Daniel Spevack, MD ,
Daniel Burkhoff, MD, PhD* and
Itzhak Kronzon, MD, FACC,*
* Department of Medicine, College of Physicians and Surgeons
Department of Medicine, New York University School of Medicine, New York, New York
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Figure 1 Nonlinearity of end-diastolic pressure-volume relationship (EDPVR). Terms used are depicted, including ventricular stiffness (slope of EDPVR at a given volume [dP/dV]), compliance (mathematical reciprocal of stiffness), and chamber capacitance (volume at a specific filling pressure). LV = left ventricle.
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Figure 2 (A) Changes in the passive component of diastole (i.e., shift of end-diastolic pressure-volume relationship [EDPVR]). A leftward/upward-shifted EDPVR (decreased ventricular capacitance) results in a need for increased filling pressure to achieve filling volumes necessary for the heart to generate a normal stroke volume and blood pressure. Conversely, a rightward/downward-shifted EDPVR (increased ventricular capacitance) occurs in all forms of dilated cardiomyopathy and is commonly referred to as "ventricular remodeling." (B) The EDPVR provides the lower boundary for the instantaneous pressure-volume loop. At low filling pressures (black loop), the filling phase of the loop (arrow) may coincide with EDPVR. At high filling pressures (red), however, the filling phase (arrow) may be elevated significantly abovethe EDPVR, even when tau is normal. This is a response of any normal heart and does not necessarily indicate diastolic dysfunction. LV = left ventricle.
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Figure 3 Echocardiographic Doppler grades of diastolic function based on mitral inflow patterns (30). Impaired relaxation (grade 1) results from impairments in active relaxation (prolonged tau) but is not associated with a change in mean left atrial pressure. Further grades of diastolic dysfunction by echocardiographic Doppler (grades 2 [pseudonormal] and 3 [restrictive]) are associated with an increased mean left atrial pressure. However, as depicted by the representative pressure-volume loops (bottom right), there is no shift in the end-diastolic pressure (EDP)-volume relationship, indicating that changes in Doppler filling patterns can be independent of alterations in the intrinsic passive diastolic properties of the left ventricle (LV). These curves are readily obtainable from a time-varying elastance-based simulation of the cardiovascular system. LVP = left ventricular pressure; LVV = left ventricular volume.
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Figure 4 Transmitral flow velocity patterns in a patient with elevated left ventricular filling pressure. (A) Baseline. (B) During Valsalva maneuver. Decreases in venous return result in marked changes in the filling pattern, reflecting the fact that these parameters are determined primarily by loading conditions and not intrinsic passive diastolic properties of the left ventricle (33).
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Figure 5 Hypothetical end-diastolic pressure-volume relationships for normal subjects (red) and two groups with heart failure and normal ejection fraction (HFNEF): subjects with idiopathic hypertrophic cardiomyopathy (HCM+HFNEF, green) and subjects with hypertensive hypertrophy (HTN+HFNEF, blue). The concept is based on results of preliminary studies (12,13). Curves were constructed using a standard equation (EDP = ßEDV ) (21).
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