1. DIASTOLIC DYSFUNCTION and DIASTOLIC HEART FAILURE
Original slides courtesy of Drs. David O’Halloran and Craig Walsh
2008
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Definitions
Diastolic dysfunction:
normal venous return during rest or exercise results in abnormal increase in LV diastolic pressure
Diastolic heart failure:
Congestive heart failure with a normal LV ejection fraction and evidence of diastolic dysfunction
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HOW COMMON IS IT?
2.2% of over 45s have symptomatic CHF
In patients with heart failure
1/3 of those have DD
½ of those >70 have DD
28% of over 45s have some degree of diastolic dysfunction
More common in women
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4 phases of diastole
1. Isovolumic relaxation
2. Rapid filling
3. Diastasis
4. Atrial contraction
Now is the time
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DURING DIASTOLE…
LV “untwists” – the elastic recoil will “suck” blood into the LV
Occurs during early diastole
Energy dependent
During later diastole
Cardiomyocytes are relaxed
Minimal resistance to filling
Left atrial (and hence wedge) pressures are low
2008
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6. HOW DO PATIENTS PRESENT?
Similar to patients with systolic HF
Dyspnea
Reduced exercise tolerance
Fatigue
Diminished quality of life
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WHAT CAUSES IT?
Chronic hypertension and LVH
Ischemic heart disease
Aortic stenosis
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Amyloid
Sarcoid
Hemochromatosis
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HOW DOES ECHO HELP?
LV morphology.
Evaluate for Aortic stenosis
Assess other causes
Diastolic function
LV inflow
Tissue Doppler
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9. Diastolic Dysfunction Two-dimensional Echo
Dilated
Cardiomyopathy
Restrictive
Cardiomyopathy
Normal
Eccentric
LVH
Concentric
LVH
Atrial enlargement
Atrial enlargement
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10. Mitral Inflow Velocity
LV relaxation
LV stiffness/LA pressure
Transmitral Pressure Gradient
Mitral Inflow Velocity
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11. Mitral Valve Inflow Velocity Pulse Wave Doppler SignalLA AC MO
PW Doppler
IVRT
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12. Mitral Valve Inflow Velocity Pulse Wave Doppler SignalLA E AC MO
PW Doppler
IVRT
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13. Mitral Valve Inflow Velocity Pulse Wave Doppler SignalLA E AC MO
PW Doppler
IVRT DT
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14. Mitral Valve Inflow Velocity Pulse Wave Doppler SignalLA E A AC MO
PW Doppler
IVRT DT
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15. Mitral Valve Inflow Velocity Pulse Wave Doppler SignalLA E A AC MO MC
PW Doppler
IVRT DT
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16. Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure
 Myocardial Relaxation
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17. Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure
IVRT
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18. Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure
IVRT
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19. Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure
DT
IVRT
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20. Mild Diastolic Dysfunction Delayed Relaxation - Normal LA Pressure
E/A E
IVRT
DT
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21.  Myocardial Relaxation
Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure
Normal
Pseudonormalization
 Myocardial Relaxation
and
 LA Pressure
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Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure
Normal
Pseudonormalization
IVRT
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Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure
Normal
Pseudonormalization E
IVRT
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Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure
Normal
Pseudonormalization E
DT
IVRT
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Moderate Diastolic Dysfunction Delayed Relaxation - Mildly Increased LA Pressure
Normal
Pseudonormalization
E/A E A
IVRT
DT
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26.  Myocardial Relaxation
Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure
Normal
Restriction
 Myocardial Relaxation
and
 LA Pressure
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Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure
Normal
Restriction
 IVRT
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Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure
Normal
Restriction
 E
 IVRT
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Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure
Normal
Restriction
 E
 IVRT
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 DT

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Severe Diastolic Dysfunction Delayed Relaxation - Markedly Increased LA Pressure
Normal
Restriction
 E/A
 E
 A
 IVRT
 DT
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31. Diastolic Dysfunction Summary of Mitral Inflow Parameters
MV Inflow
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32. Tissue Doppler Imaging Mitral Annular Motion
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33. Tissue Doppler Imaging Mitral Annular Motion
normal
Diastolic dysfunction
E < A
E > A
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WHAT’S WITH E/e’
Ratio of E wave on MV inflow to e’ on tissue Doppler
<8 – normal filling pressures
>15 – PCWP above 12mm Hg
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WHAT ABOUT TREATMENT?
Treatment is directed to the associated problems
Hypertension
LV hypertrophy
Ischemia
Maintaining slow sinus rhythm
Diuretics
Underlying cause (if known)
Sarcoid/amyloid/hemochromatosis
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36. PRINCIPLES OF TREATMENT
Unfortunately no good specific treatment for diastolic heart failure:
Control hypertension
ACE-I/ARB are 1st line since they cause regression of LVH and has mild benefit shown in the CHARM-PRESERVE trial.
Control ventricular rate
Allow longer time for filling.
Control pulmonary congestion
Mainstay is diuretics
Revascularize if appropriate
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PROGNOSIS
Annual mortality rate for patients with diastolic heart failure is 5-8%, compared with 10-15% for patients with systolic heart failure.
In men older than 70, mortality rates for systolic and diastolic heart failure is almost equal.
Closely associated with presence of comorbidities such as ischemic heart disease.
2008
Zoll Firm Lecture Series