Algorithm for Diagnosing Diastolic Dysfunction With Doppler Echocardiography
A stepwise approach using E/A and E/e′ to diagnose diastolic dysfunction. Proper assessment is dependent on an accurate acquisition of transmitral flow and tissue Doppler imaging. A LAVI of >28 ml/m2 (as opposed to a cutoff of >34 ml/m2) is used in the algorithm presented to indicate an increased LA size, because obesity is a risk factor for diastolic dysfunction; thus, LAVI can underestimate LA enlargement in these individuals (due to indexing to body size). *Although grading of diastolic dysfunction is not possible in these cases, the LVFP can still be estimated using surrogate markers, such as the estimated pulmonary artery systolic pressure or the end-diastolic pulmonary regurgitation gradient (as long as pulmonary arterial hypertension is not present). In older patients with normal sinus rhythm, systolic blunting of the pulmonary vein flow can be a sign of increased LA pressure. **It is not always possible to assign a diastolic dysfunction grade. In cases where equivocal data exists (e.g., an E/A ratio >0.8, reduced e' velocity, indeterminate range E/e', and normal LAVI), one can simply state that, “diastolic dysfunction is most likely present,” without assigning a specific grade of diastolic dysfunction. In other cases, the e' velocity may be normal, but LA volume may be increased and an E/A ratio of >1, which can be seen in cases of increased cardiac output or athlete's heart. In these cases, one can simply state, “diastolic function is most likely normal.” A = late (atrial) transmitral flow velocity; AV = atrioventricular; DT = deceleration time; E = early diastolic transmitral flow velocity; e′ = early diastolic mitral annular velocity; LA = left atrial; LAVI = left atrial volume index; LVFP = left ventricular filling pressure; LVEF = left ventricular ejection fraction; MAC = mitral annular calcification; MR = mitral regurgitation; NYHA = New York Heart Association.