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4.6 Diastolic function in clinical practice


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Is it really worth the effort to look at diastolic function? Some believe that it adds little and is of no major clinical importance. True, in many settings one does not gain much from a detailed analysis of diastolic function. However, there are numerous situations in which it is helpful. It permits the investigator to understand the pathophysiology, draw conclusions with respect to treatment, and determine the prognosis of the patient. In this section we discuss specific clinical settings in which knowledge of diastolic function and filling pressures is helpful.

Echocardiography permits no more than an indirect assessment of diastolic function. Factors such as volume status or stiffness of the ventricle cannot be measured directly. Thus, in clinical practice one encounters situations in which echocardiographic findings of diastolic function appear ambiguous or contradictory.

4.6.1 Physiologic versus pathological hypertension (also see Chapter 3)

Patients with a pathological form of left ventricular hypertrophy (hypertension) will almost always demonstrate some type of diastolic dysfunction (usually grade I or II). In contrast, physiological forms of LVH, such as those in athletes, will be marked by normal or even supernormal diastolic function. The example below shows such a patient: a 34-year-old male professional tennis player with LVH (septal thickness of 15 mm). The Doppler image shows normal filling and also a low E/e´ ratio. Thus, the LVH is definitely not caused by hypertension or some other pathology, but simply by high-intensity training. Note that the left atrium is also normal in size.

LVH_Athlete_2D
2D image: apical view showing a septal thickness of 15 mm
LVH_ Athlete_Doppler
Mitral valve inflow signal with an E/A ratio of 1.4
LVH_Athlete_TDI
The e´ velocity is 0.1cm/s and the E/e´ ratio 7, denoting normal filling pressures

4.6.2 The patient with reduced left ventricular function

The degree of diastolic dysfunction and filling pressures are more closely correlated with symptoms than the ejection fraction. Patients with severely reduced left ventricular function may have almost normal filling pressures. As filling pressure indicates the degree of pulmonary congestion, it more strongly reflects symptoms of heart failure and provides additional information in respect of prognosis, especially when it is not possible to quantify pulmonary pressure because no tricuspid regurgitant signal is present.

Here are three patients with dilated cardiomyopathy and severely reduced function. The patients have different degrees of diastolic dysfunction.


Patient 1 has a relaxation pattern (E/e´ ratio = 9):
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Patient 2 has pseudonormal filling (E/e´ ratio 14):
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Patient 3 has a restrictive pattern (E/e´ ratio = 19):
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Clearly, patient 3 has the worst prognosis and also had more severe dyspnea (NYHA class III-IV) than patient 1 (NYHA II) or patient 2 (NYHA II-III).

To a certain degree this information may help in deciding how to treat such patients. Patients with hypertension and those with heart failure but normal filling pressures will usually not benefit from “additional” diuretics. Monitoring diastolic dysfunction may help to monitor the effects of treatment. Under optimal treatment patients may revert from severe to less severe forms of diastolic dysfunction.

4.6.3 Heart failure with a “normal” ejection fraction

This is a woman with hypertensive heart disease who had NYHA class II-III dyspnea. Significantly, she had a normal ejection fraction (57%) but pseudonormal filling and an E/A ratio of 1.7. In addition, her E/e´ ratio was 16. The patient clearly has elevated filling pressure. Based on these findings one may establish the diagnosis of HFNEF. As a side note: although her ejection fraction was normal the patient already has reduced longitudinal function (her global peak systolic strain was −10.5%).

ventricular hypertrophy
Severe left ventricular hypertrophy
HFNEF
Pseudonormal filling in a patient with HFNEF; the E/A ratio is 1.7

A rise in filling pressure usually precedes left ventricular failure. This information may be relevant especially in patients with aortic regurgitation. Those with advanced forms of diastolic dysfunction might already be candidates for surgery and should therefore be monitored closely.

4.6.4 Sequelae of valvular heart disease

4.6.5 Optimization of AV delay in patients with a pacemaker

The Doppler signal of mitral inflow may also be used to optimize diastolic filling in patients with AV sequential pacing. Here is an example of a patient with dilated cardiomyopathy in whom a pacemaker / ICD was implanted because of sinus bradycardia. Note that an AV delay of 60 ms results in early termination of the A-wave. The ventricle contracts at the same time as the atrium. This is an unfavorable condition and greatly impairs filling. Prolongation of the AV delay to 280 ms solves the problem. Now diastolic filling is optimized. An E-wave as well as an A-wave are seen on the Doppler tracing.

patient with a DDD pacemaker
“Pretermination of the A-wave (left) in a patient with a DDD pacemaker. Prolongation of AV delay (left) improves filling. The A-wave is now visible.