Diastolic Heart Failure Can Be Diagnosed by Comprehensive Two-Dimensional and Doppler Echocardiography
Jae K. Oh, MD*,*,
Liv Hatle, MD*,
A. Jamil Tajik, MD* and
William C. Little, MD
* Mayo Clinic College of Medicine, Rochester, Minnesota
Cardiology Section, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Figure 1 Pulsed-wave Doppler recordings of mitral inflow velocities from predominant relaxation abnormality (left), normal or pseudonormal (center), and restrictive (right) filling patterns. Abnormal relaxation is the earliest diastolic abnormality with characteristic reduction in early diastolic velocity (E) and prolongation of deceleration time (DT). Usually, filling pressure is not elevated as long as there is adequate diastolic filling time. As diastolic filling pressure increases, E velocity increases, duration of late diastolic velocity (A) becomes truncated (right), and DT becomes shortened. When filling pressure is markedly elevated, there may be diastolic mitral regurgitation (arrow in the right figure). Reproduced with permission from Oh JK, Seward JB, Tajik AJ, editors. Echo Manual. 2nd edition. Philadelphia, PA: Lippincott, Williams, and Wilkins, 1999.
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Figure 2 Pulsed-wave Doppler recording of mitral inflow velocity (top) demonstrating a mid-diastolic flow (arrow) due to markedly delayed myocardial relaxation. Tissue Doppler imaging (bottom) shows mid-diastolic velocity (arrow) from the septal mitral annulus. E = early diastolic velocity; A = late diastolic velocity due to atrial contraction; S = peak systolic velocity of the mitral annulus, S is also markedly reduced.
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Figure 3 (A) End-diastolic pressure and volume relationship (EDPVR) curve. Modified from Mauer et al. (1). The EDPVR is shifted left-upward for diastolic dysfunction or diastolic heart failure and is shifted right-downward for remodeled heart. Inserted in the figure are mitral inflow and mitral septal annulus velocity recording for normal, diastolic dysfunction, and remodeling groups. Mitral inflow velocity may appear similar in all three groups, but myocardial relaxation (hence, mitral annulus early diastolic velocity) is almost always reduced in patients with diastolic dysfunction or remodeling. Patients with diastolic dysfunction or remodeling may not be distinguished by mitral inflow and mitral annulus velocities, but the distinction is obvious when interpreted with two-dimensional echocardiography, as shown in (B). Top panel shows three mitral inflow velocity recordings from normal subject (center), a patient with diastolic heart failure (left), and a patient with left ventricular (LV) remodeling after myocardial infarction (right). In the first two, it is difficult to tell their diastolic function or filling pressures by mitral inflow velocity pattern alone. On the right, both deceleration time and atrial flow duration were shortened indicating marked elevation of LV diastolic pressure. The middle panel shows tissue Doppler velocity recording from the septal corner of respective individuals with mitral inflow velocities shown on the top panel. In the middle column, mitral annulus early diastolic velocity (Ea) is normal (11 cm/s), indicating that myocardial relaxation is normal with normal filling pressure (E/Ea = 80/11 = <8). In the left column, Ea is markedly reduced to 5 cm/s with E/Ea of 20 (=100/5). On the right, Ea is delayed and fused with late diastolic velocity occurring after biphasic isovolumic velocities. On the basis of mitral inflow velocity and tissue Doppler mitral annulus velocity, the patients in the left and right column were found to have increased filling pressure and abnormal relaxation of LV. However, their underlying reason for increased filling pressure is not clear without structural information, shown at the bottom. Two-dimensional echo shows completely normal cardiac structures for normal subject at the center, abnormal heart (increased wall thickness and enlarged left atrium), but normal LV size and ejection fraction (in real time) in the left typical of diastolic heart failure with leftward/upward-shifted EDPVR and abnormal heart (enlarged LV size and reduced ejection fraction in real time) on the right typical of remodeling with rightward/downward-shifted EDPVR.
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