Guest Writer:  Michael Owen

Last week we discussed the algorithm for determining the presence of diastolic function in patients with normal ejection fraction (EF). This week, we are going to discuss determining the presence of diastolic function in patients with depressed EF or pathologic left ventricular hypertrophy (LVH) with preserved EF.

LEFT VENTRICLE EJECTION FRACTION

In order to determine the patients ejection fraction, the ASE suggest using the bi-plane volumetric method. You can check out CardioServ’s blog here that explains how to perform this measurement! ASE’s 2015 guidelines explain the cut-off values for LVEF:

LEFT VENTRICULAR HYPERTROPHY

The guidelines for this algorithm pathway also includes patients who have left ventricular hypertrophy (LVH) with a preserved ejection fraction. You can check out CardioServ’s blog here that covers how to determine the presence of LVH!

ALGORITHM 2: DEPRESSED LVEF OR LVH WITH PRESERVED LVEF

With this patient population we will place a heavier emphasis on the mitral E/A ratio. For this algorithm, we will be evaluating the following parameters:

1. Mitral E/A Ratio
2. Average E/e’ Ratio
3. Tricuspid Regurgitation (TR) Velocity
4. Left Atrial (LA) Volume Index

You can check out our blog here to review how to acquire these measurements!

MITRAL E/A RATIO

Let’s begin with the first step of the chart. There are three columns that dictate which grade of dysfunction you will eventually arrive at. First, evaluate where your E/A ratio falls.

To keep things simple, let’s look at the first and third options

• If your E/A ratio falls into the first option, you automatically have Grade I Dysfunction with Normal LAP.
• If your E/A ratio falls in the third option, you automatically have Grade III Dysfunction with Increased LAP.

Here is where things get a little tricky: When your E/A ratio falls into the second category, there appears to be a slew of possibilities but it is actually quite simple. Let’s return to the above mentioned parameters that will be utilized after you move past E/A ratios and have landed into the second category.

DETERMINE DIASTOLIC FUNCTION PARAMETERS

Let’s recall the values associated with the parameters used for evaluating diastolic function:

ALL 3 PARAMETERS OBTAINED

First, let’s assume you have properly obtained all 3 of these measurements. If this is the case, then:

• If only one of these is positive, you have Grade I Dysfunction with Normal LAP.
• If two or more are positive, you have Grade II Dysfunction with Increased LAP.

ONLY 2 PARAMETERS OBTAINED

Now, let’s assume that you did not have all three of the above mentioned parameters but rather only 2.

• If they are both negative, you have Grade I Dysfunction with Normal LAP.
• If one is positive and one is negative, you Cannot Determine LAP and Grade of Dysfunction.
• If they are both positive, you have Grade II Dysfunction with Increased LAP.

ONLY 1 PARAMETER OBTAINED

Lastly, if you only have one of the three measurements obtained, the pulmonary vein S/D ratio can conclude there is elevated LAP if the ratio is <1. As a reminder, this is to only be applied in patients with depressed EF.

ADDITIONAL NOTE

Anytime you arrive at Grade I Dysfunction with Normal LAP and the patient is symptomatic, you MUST consider coronary artery disease (CAD) or proceed to diastolic stress testing.

SUMMARY

We have now covered 2 algorithms for evaluation of diastolic function over the past two weeks. These workflow charts cover patients with normal ejection fraction, depressed ejection fraction and LVH with preserved ejection fraction. Next week we will cover how to evaluate diastolic function in patients with present abnormalities.

Michael Owen RDCS, RVT

Connect with Michael:  LinkedIn, iEchoToday

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If you need additional information on how to obtain correct diastolic measurements check out CardioServ’s recent blog on Correct Techniques to Acquire Diastology Measurements. This article reviews how-to obtain:

• MV inflow
  • Peak E-Wave Velocity (cm/s)
  • Peak A-Wave Velocity (cm/s)
  • A-Duration (msec)
  • E/A Ratio
  • Deceleration Time (msec)
• Pulmonary Veins
  • S-Wave (cm/sec)
  • D-Wave (cm/sec)
  • AR Duration (msec)
  • S/D Ratio
• LA Volume
• LV EF
• TR Velocity