Left Ventricular Diastolic Function - Decision Support

Abstract heart illustration

Evaluation of left ventricular diastolic function is a part of echocardiography which has been adjusted several times with the introduction of new methods and it is still associated with a not neglectable inter-rater variability. 

Regardless the choice of method, to evaluate diastolic function and filling pressures a combination of Doppler echocardiographic variables has to be considered. Present guidelines (Nagueh) provide support but do not address all the challenges. The important aspect of age-dependency for normality of many of the used variables during assessment is not clearly dealt with by the guidelines.

We have constructed a reference table pooled from several earlier publications, but mainly based on the paper published by Munagala et al. With this new reference table of age-dependent normal values we have created this automated decision support which categorizes the variables as “low-normal-high” related to age. The possible and reasonable combination of the categorized variables results in a classification of “normal” function or grade I-III dysfunction. The assessment starts with E/A ratio and pulmonary venous flow, accompanied by E/e’ (mean of septal and lateral) and left atrial area or volume. Implausible or clearly contradictory combinations results in “manual control”.

If “manual control” is required we recommend checking the variables and the quality of measurements, and adding tricuspid regurgitation velocity, E-deceleration time, IVRT etc. In some cases, this will provide a reasonable classification, in others it has to be accepted that a classification is not possible.

 Our intention has been to provide a decision support which is a usable assistance in evaluating diastolic function/filling pressure in individuals with known cardiac disease or patients with symptoms of possible cardiac origin (as in algorithm “B” in the guidelines).

Welcome to try this decision support and please feel free to contact us for feed-back! 

Decision supportShow/Hide content

About the studyShow/Hide content

Fig 1 Diastolic Function Algorythm

Glossary

LAA Left atrial area
LAV Left atrial volume
i Indexed for body surface area
E (m/s) Early diastolic mitral flow velocity
A (m/s) Late diastolic mitral flow velocity
PVs (m/s) Pulmonary vein systolic flow velocity
PVd (m/s) Pulmonary vein diastolic flow velocity
e’ S (cm/s) Early diastolic septal myocardial velocity
e’ L (cm/s) Early diastolic lateral myocardial velocity
E/A Ratio of early- to late diastolic mitral flow velocity
E/e´ Ratio of early diastolic mitral flow velocity to early diastolic myocardial velocity

ReferencesShow/Hide content

  1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing G, American Society of Echocardiography's G, Standards C, and European Association of E. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18: 1440-1463. https://www.onlinejase.com/article/S0894-7317(14)00745-7/fulltext

  2. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF, 3rd, Dokainish H, Edvardsen T, Flachskampf FA, Gillebert TC, Klein AL, Lancellotti P, Marino P, Oh JK, Alexandru Popescu B, Waggoner AD, Houston T, Oslo N, Phoenix A, Nashville T, Hamilton OC, Uppsala S, Ghent, Liege B, Cleveland O, Novara I, Rochester M, Bucharest R, and St. Louis M. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2016; doi:10.1093/ehjci/jew082 http://asecho.org/wordpress/wp-content/uploads/2016/03/2016_LVDiastolicFunction.pdf

  3. Munagala VK, Jacobsen SJ, Mahoney DW, Rodeheffer RJ, Bailey KR, and Redfield MM. Association of newer diastolic function parameters with age in healthy subjects: a population-based study. J Am Soc Echocardiogr 2003;16: 1049-1056. https://www.onlinejase.com/article/S0894-7317(03)00516-9/fulltext

  4. Caballero L, Kou S, Dulgheru R, Gonjilashvili N, Athanassopoulos GD, Barone D, Baroni M, Cardim N, Gomez de Diego JJ, Oliva MJ, Hagendorff A, Hristova K, Lopez T, Magne J, Martinez C, de la Morena G, Popescu BA, Penicka M, Ozyigit T, Rodrigo Carbonero JD, Salustri A, Van De Veire N, Von Bardeleben RS, Vinereanu D, Voigt JU, Zamorano JL, Bernard A, Donal E, Lang RM, Badano LP, and Lancellotti P. Echocardiographic reference ranges for normal cardiac Doppler data: results from the NORRE Study. Eur Heart J Cardiovasc Imaging 2015;16: 1031-1041. https://www.semanticscholar.org/paper/Echocardiographic-reference-ranges-for-normal-data%3A-Caballero-Kou/723ff1d3ded0574a471fecd38556859f75b146d0

  5. Gentile F, Mantero A, Lippolis A, Ornaghi M, Azzollini M, Barbier P, Beretta L, Casazza F, Corno R, Faletra F, Giagnoni E, Gualtierotti C, Lombroso S, Mattioli R, Morabito A, Pepi M, Todd S, and Pezzano A. Pulmonary venous flow velocity patterns in 143 normal subjects aged 20 to 80 years old. An echo 2D colour Doppler cooperative study. Eur Heart J 1997;18: 148-164. https://watermark.silverchair.com/18-1-148.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAcAwggG8BgkqhkiG9w0BBwagggGtMIIBqQIBADCCAaIGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMf-HePZMdAyjRNxtBAgEQgIIBc7ACANimgLoHrZJcCNDxSuac5BvwfPquLfrfCbWu-HoNwQI03GqyJ78TeNub7gQDkLjBOAcK_2MoAa5XSAlD5SZhJ1O7bJb4dG2R4Y1nNTQiHefNkq7z0B9yVXaifRyMPYBJ0CSea92Co9XTzTJSbwzn3XMwj_-5Urjwg0St7401QWRzDF16wRn189rENCVxCzdenz8tUhoWGH3lOSHAoAiJTXaY0wvmIW7gRLvCgk1FvifufA6wiA3IzhcxNXS2JQJg_ZcikMlpSXi3WE66zI9ONhgvwu_jxK8XFu1-5u_JB7OqRtw3zp8WYa-z3fRHe57VVH-_Iq0HY3iLj8mcLNZNrBBzzKWpwaDPaeBxaqZ7D3xcF-Ncp__mvq3tew49vy41B_JshCFtXcArkXZ9E2BS9g0s3xGvQJ98KDhgmy7np1_IXmryJNeJzFimFOZBa41KwwXX8zkERqv3UoxH5CoHmDig3m7e7_W3X4hntcNOrS9V

  6. Dalen H, Thorstensen A, Aase SA, Ingul CB, Torp H, Vatten LJ, and Stoylen A. Segmental and global longitudinal strain and strain rate based on echocardiography of 1266 healthy individuals: the HUNT study in Norway. Eur J Echocardiogr 2010;11: 176-183, 2010. https://www.ncbi.nlm.nih.gov/pubmed/19946115
 

ContactShow/Hide content

OrganisationShow/Hide content