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Diastolic challenges

In collaboration with the Romanian Working Group on Echocardiography

  • How to evaluate: general recommendations, presented by B A Popescu (Bucharest, RO)  
  • The patient with valvular stenosis, presented by J E Moller (Odense M, DK)  
  • The patient with valvular regurgitation, presented by S Nagueh (Houston, US)  
  • The patient with atrial fibrillation, presented by A M Iliesiu (Bucharest, RO)

The session on Friday December the 9th was titled Diastolic Challenges and was presented in collaboration with the Romanian Working Group on Echocardiography. Dr. Popescu reviewed the ASE/EAE diastolic function guidelines, highlighting the applications and limitations of each of the parameters including mitral inflow, pulmonary venous flow, and tissue Doppler velocities. He stressed the utility of the Valsalva manoeuvre and the need to look at the change in E/A ratio as well as the mitral late diastolic velocity (A velocity).  The 2 different approaches based on left ventricular (LV) ejection fraction (EF) were presented and the need for a comprehensive approach was emphasised.

Dr. Moller’s presentation addressed the assessment of diastolic function in patients with aortic stenosis.  He reviewed the existing literature and noted that left atrial volume in patients with aortic stenosis is related to the structural changes as the decrease in aortic valve area and the extent of LV hypertrophy. Likewise, he noted that E/e’ ratio can be used not only to estimate LV filling pressures, but also to predict outcome in this population.

The next speaker discussed the available methods to assess diastolic function and estimate filling pressures in patients with mitral regurgitation (MR). In patients with significant MR and depressed EF, both mitral E velocity deceleration time (DT) and E/e’ ratio relate well to filling pressures and predict outcome. However, they have limited accuracy in MR patients with normal EF. In the latter group, estimating pulmonary artery systolic pressure (using the TR peak velocity from multiple windows) and measuring the Ar-A duration (Ar refers to the atrial reversal velocity recorded from the pulmonary veins) can be helpful. Likewise, measurements of isovolumetric relaxation time and the time delay between the onset of mitral E velocity and the onset of mitral annulus e’ velocity can be applied to estimate LV filling pressures in patients with mitral valve disease and normal EF.

Dr. Iliesiu discussed the available parameters in patients with atrial fibrillation. She showed the results from 10 studies that looked at this question. She noted that in patients with atrial fibrillation and depressed EF, DT relates well with mean wedge pressure, but not in those with normal EF, which is similar to the situation in patients with sinus rhythm.  Other useful parameters include peak acceleration rate of the mitral inflow velocity, IVRT, E/Vp (Vp refers to early diastolic propagation velocity by colour M-mode), and pulmonary venous flow.  For the latter parameter, the DT of the pulmonary diastolic velocity is helpful in predicting filling pressures with a cutoff of 220 ms. She also discussed a study where septal e’ velocity <8 cm/s was capable of identifying patients with prolonged relaxation time constant and where septal E/e’ ratio of 11 identified atrial fibrillation patients with increased filling pressures.


In summary, this session was a showcase of how to assess diastolic function using established and novel tools in technically challenging but not uncommon clinical scenarios.




Diastolic challenges

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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