1. Diastology
Patrick Feng, PGY1

2. Outline Definition Clinical significance Technique Measurements
Analysis
Pearls
Pitfalls
References

3. Definition Measurement of diastolic function with echocardiography
Relaxation
Compliance
First described by Kitabatake. A, et al (1982). Jpn Circ J
Determined transmitral blood flow with pulse Doppler to describe diastolic behavior
Jpn Circ J. 1982 Jan;46(1):

4. Clinical Significance
Heart failure is a large burden on society
CHF affects 5.7 million in US
Costs $34.4 billion/year
50% of CHF is diastolic
Incidence of diastolic HF increases per decade
/j.ajem
/ejechocard/jep007

5. Benefits of Diastology
Improves diagnosis of acute LV HF
Better accuracy compared to BNP and Boston Criteria
Worse outcomes in several disease states
Post-MI
Sepsis
Afib
ESRD
Cardiomyopathy
Nazerian. P, et al (2010). Academic Emergency Medicine
Diastology vs Boston Criteria vs BNP in diagnosis of HF?
Method
145 Pts with dyspnea
4 EPs with 4 hrs of echo training from cardiologists scanned for diastolic heart function
Gold standard for HF dx was all clinical data besides BNP and echo
Results
Improved sensitivity (82%) and specificity (90%) of in diagnosing HF with diastology compared to reduced EF
Improved accuracy of diagnosing HF with diastology (75%) compared to BNP and positive Boston Criteria (both 49%)
doi: /j.echo
/eurheartj/ehr351.

6. Technique Probe: Phased Array View: Apical 4 Chamber Measurements
Mitral valve inflow
Tissue Doppler imaging

7. Measurements LA size Mitral value annulus movement Mitral valve inflow
Qualitative
Quantitative
LA size
Mitral value annulus movement
Mitral valve inflow
Tissue Doppler imaging
Pulmonary vein flow
Mitral inflow propagation
Isovolumetric relaxation time
Nagueh, S., et al, (2009). Journal of the American Society of Echocardiography
Qualitative
LA size
Mitral value annulus movement
Other Quantitative
Pulsed wave mitral valve inflow
Tissue Doppler imaging
Pulmonary vein flow
Mitral inflow propagation
Isovolumetric relaxation time

8. Measurements in the ED LA size Mitral value annulus movement
Qualitative
Quantitative
LA size
Mitral value annulus movement
Mitral valve inflow
Tissue Doppler imaging
Pulmonary vein flow
Mitral inflow propagation
Isovolumetric relaxation time
Evaluate qualitatively before deciding whether to take quantitative measurements
Bess. R, et al (2006). Echocardiography
Why MVI and TDI?
Method
One sonographer (>20 yrs experience) scanned 80 pts
Five cardiologists interpret diastology echos
Data
Success rate = at least 4/5 cardiologists have same interpretation
Time to record
Results
Highest recording success rate (MVI = 99, TDI = 100%)
Shortest times to record (MVI = / sec, TDI = / sec)

9. Measurements in the ED LA size Mitral value annulus movement
Qualitative
Quantitative
LA size
Mitral value annulus movement
Pulsed wave mitral valve inflow
Tissue Doppler imaging
Pulmonary vein flow
Mitral inflow propagation
Isovolumetric relaxation time
Take these measurements in the ED since they can be obtained quickly and accurately
Bess. R, et al (2006). Echocardiography
Why MVI and TDI?
Method
One sonographer (>20 yrs experience) scanned 80 pts
Five cardiologists interpret diastology echos
Data
Success rate = at least 4/5 cardiologists have same interpretation
Time to record
Results
Highest recording success rate (MVI = 99, TDI = 100%)
Shortest times to record (MVI = / sec, TDI = / sec)

10. Measurements in the ED
Can Emergency Physicians diagnose and classify diastolic dysfunction?
Methods
EPs trained 3 hrs on MVI and TDI
62 patients, 52% with diastolic dysfunction
Compared interpretation with 3 Cardiologists
Results
EPs can diagnose diastolic dysfunction
Sensitivity 92% (60-100)
Specificity 69% (50-82)
EPs have moderate agreement with cardiologists on severity of diastolic dysfunction
K = 0.45
Weighted K = 0.52
Ehrman, R. et al (2015). American Journal of Emergency Medicine

11. Qualitative - Mitral Valve Inflow

12. Qualitative - Mitral Valve Inflow
Ultrasound Podcast

13. Qualitative - Mitral Valve Inflow
E/A < 0.8
E/A < 1.5
E/A > 2
Flow from LA to LV occurs in 2 phases
E: LV relaxation
A: atrial kick
In normal heart, E > A

14. Qualitative - Tissue Doppler Imaging
Ultrasound Podcast

15. Qualitative - Tissue Doppler Imaging
e’ > 8 cm/s
e’ < 8 cm/s
e’ < 8 cm/s
e’ < 8 cm/s

16. Grading Diastolic Dysfunction

17. Grading Diastolic Dysfunction
Perform TDI
e’ < 8
Perform MVI
A > E
E < 100
Grade III/IV: Restrictive
Normal Diastolic Function
Grade I: Impaired
Grade II: Pseudonormal

18. Grading Diastolic Dysfunction
Pts can move between Grades I - III
Grade IV is irreversible

19. E/e’ = LVEDP and PCWP E/e’ < 10 E/e’ < 10 E/e’ > 10

20. Preload: IVC vs Diastology
IVC shows preload to RV
Right heart failure
R MI PE
Pulmonary hypertension
Diastology shows preload to LV

21. IVC vs Diastology Right sided heart failure Right sided MI PE
Increased Preload to RV
Increased Preload to LV
Right sided heart failure
Right sided MI PE
Pulmonary Hypertension
Left sided heart failure
Chronic hypertension
Aortic stenosis
Right heart failure
R MI PE
Pulmonary hypertension

22. Pearls Determine etiology of common clinical presentations
Determine response to treatment
Prognosis for various pathologies
Guide use of fluids or pressors

23. Pitfalls Highly operator dependent
Pathology can interfere with diastology measurements
Irregular rates/rhythms
Tachycardia
Afib
Cardiomyopathys
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy

24. References
Diastology archives. (2016, September 30). Retrieved October 3, 2016, from Ultrasound Podcast,
Bess RL, Khan S, Rosman HS, Cohen GI, Allebban Z, Gardin JM. Technical aspects of diastology: why mitral inflow and tissue Doppler imaging are the preferred parameters?. Echocardiography ;23(4):332-9.
Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012;33(7):
Nazerian P, Vanni S, Zanobetti M, et al. Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide. Acad Emerg Med. 2010;17(1):18-26.
Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10(2):
Kitabatake A, Inoue M, Asao M, et al. Transmitral blood flow reflecting diastolic behavior of the left ventricle in health and disease--a study by pulsed Doppler technique. Jpn Circ J ;46(1):