Heart failure with preserved ejection fraction - unwinding the diagnosis mystique

Abstract

A precise diagnosis of diastolic dysfunction is often difficult and requires invasive techniques to determine left ventricular volume, relaxation, and compliance properties. At this current point of time there is no single non-invasive index available to adequately reflect diastolic function, perhaps because of the numerous factors that can alter diastolic function. In most clinical settings, diastolic function is estimated using Doppler echocardiography. Cardiac magnetic resonance imaging (CMRI) is yet another emerging modality for diastolic function analysis. Here we present a comprehensive review of the various parameters used to assess diastolic function as part of diagnosis of clinical syndrome "Heart failure with preserved ejection fraction (HFPEF)".

Keywords: Diastolic dysfunction; HFNEF; HFPEF; echocardiography.

Figure 3

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of HFPEF by the Heart Failure and Echocardiography Associations of the European Society of Cardiology [12]. LVEDVI: left ventricular end-diastolic volume index; mPCW: mean pulmonary capillary wedge pressure; LVEDP: left ventricular end-diastolic pressure; τ: time constant of left ventricular relaxation; b: constant of left ventricular chamber stiffness; TD: tissue Doppler; E: early mitral valve flow velocity; e’: early myocardial velocity at mitral annulus; NT-proBNP: N-terminal-pro brain natriuretic peptide; BNP: brain natriuretic peptide; E/A: ratio of early (E) to late (A) mitral valve flow velocity; DT: deceleration time; LVMI: left ventricular mass index; LAVI: left atrial volume index; Ard: duration of reverse pulmonary vein atrial systole flow; Ad: duration of mitral valve atrial wave flow.

Figure 1

Biplane methods to calculate LA volume (A) Biplane area length, A1 = left atrial (LA) area, 4-chamber view; A2 = LA area, 2-chamber view; L1 and L2: length from midplane of mitral annulus to superior LA, L = LA length, L1 or L2 whichever is shorter; (B) Biplane Simpson’s where the volume of the LA is calculated as the sum of the volume of each individual disc.

Figure 4

Diagnostic algorithm for the estimation of LV filling pressures [21,29]. LA: left atrium; Val: Valsalva; e’: early myocardial velocity at mitral annulus; E: early mitral valve inflow velocity; A: late mitral valve inflow velocity; DT: deceleration time of E velocity; IVRT: isovolumic relaxation; Ar-A: peak pulmonary venous atrial reversal velocity duration; PAS: pulmonary artery pressure; S: peak systolic pulmonary venous velocity; D: peak anterograde diastolic pulmonary venous velocity; LAP: left atrial pressure.

Figure 2

Scheme for grading diastolic dysfunction [21,29]. Av: Average; LA: left atrium; Val: Valsalva; e’: early myocardial velocity at mitral annulus; E: early mitral valve inflow velocity; A: late mitral valve inflow velocity; DT: deceleration time of E velocity; Ar-A: peak pulmonary venous atrial reversal velocity duration.