Diastolic dysfunction of the left ventricle – a practical approach for an anaesthetist

Figures

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  FIGURE 1. Assessment of mitral inflow in pulsed wave (PW) examination. In the diastolic phase, blood flows from the left atrium to the left ventricle through the open mitral valve. In cases of sinus rhythm and effective contraction of the left atrium, the inflow is of a two-phase nature. The first early wave (E wave) is associated with the pressure difference between the atrium and the ventricle, and the second wave (A [atrium] wave) – with atrial contraction and pushing of additional blood volume in its final phase

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  FIGURE 2. Evaluation of left ventricular muscle deformation in a tissue Doppler echocardiography. In the tissue Doppler imaging study, the record of muscle movement speed (and not of blood, as in the classic Doppler!) reflects the movement of the medial and lateral parts of the mitral ring during the diastole. The higher the muscle speed (e’), the better the preserved left ventricular diastolic function

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  FIGURE 3. Left ventricular filling pressure assessment, E/e’ parameter. E/e’ – the ratio of the early influx wave (E) velocity and the corresponding velocity of the left ventricular muscle (measured in the medial or lateral part of the mitral ring) (e’). E/e’ parameter best correlates with left ventricular filling pressures. Values greater than 14, as in this case, correspond to the increased filling pressure of the left ventricle

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  FIGURE 4. Left ventricular filling pressure assessment, reverse gradient through a tricuspid valve. The maximum tricuspid regurgitation velocity (TRV) determined in a continuous Doppler, e.g. in a four-chamber projection, correlates with the systolic pressure in the pulmonary artery. TRV values less than 2.8 m s−1 indicate a low probability of pulmonary hypertension

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  FIGURE 5. Assessment of the dimensions and volume of the left atrium. Remodelling, or increased volume, of the left atrium is the consequence of diastolic dysfunction and increased pressures therein. We consider it significant if the left atrium surface area in the four-chamber apical projection exceeds 20 cm2 and the volume indexed to the body surface is greater than 34 mL m−2. Most modern cameras measure the volume of the left atrium automatically, basing on three measurements: surface area in a four-chamber projection, surface area in a dual-chamber projection and the upper-lower dimension. The volume is calculated according to the formula:LA objętość=83π×A1×A2L;LAVI=LA objętośćBSA where A1 is the atrium area in the four-chamber projection, A2 – in the dual chamber projection and L – the upper-lower dimension of the atrium LA – left atrium, LAVI – left atrial volume index, BSA – body surface area

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  FIGURE 6. Diagnostic algorithm of diastolic dysfunction in patients with normal left ventricular ejection fraction. The above algorithm is discussed in the text TRV – tricuspid regurgitation velocity, LAVI – left atrial volume index, E/e’ – the ratio of the velocity of the early influx wave (E) to the corresponding velocity of the left ventricular muscle (measured in the medial or lateral part of the mitral ring) (e’)

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  FIGURE 7. Mechanisms leading to exacerbation of diastolic heart failure. Exacerbation of diastolic heart failure may occur as a result of hemodynamic changes in the patient, e.g. during removal of the endotracheal tube (stimulation of the sympathetic nervous system, cough reflex, change in end-expiratory pressure). As a result of deterioration of left ventricular muscle compliance, pressure in the left atrium increases, which can result in pulmonary oedema