1. Correct Answer: D. TR jet velocity >2.8 m/s and E/e′ >14

Rationale: Based on the 2016 American Society of Echocardiography (ASE) guidelines, grading of diastolic dysfunction in patients with reduced LVEF is dependent on the following variables. First, the E/A ratio will give the first data point to make a determination if there is abnormal diastolic dysfunction. With an E/A ratio of <0.8, grade I diastolic dysfunction can be diagnosed. When the E/A ratio is normal with values >0.8 and <2, then determining between normal and pseudonormal (grade II diastolic dysfunction) takes a few more variables into consideration. The three variables that can be used are the E/e′ ratio (>14), LA maximum VI (>34 mL/m²), and TR jet velocity (>2.8 m/s). If two of three or all three of these variables are positive (at or above values listed), it implies an elevated LA pressure and grade II diastolic dysfunction.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

2. Correct Answer: C. Grade III

Rationale: This patient’s E/A ratio is 2.59 (E/A ≥ 2) in the setting of reduced systolic function. Hence, based on the 2016 ASE guidelines, LA pressure is elevated and a diagnosis of grade III diastolic dysfunction or restrictive filling pattern can be made.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

2. Otto CM. Chapter 7: Ventricular diastolic filling and function. In: Delores Meloni, eds. Textbook of Clinical Echocardiography. Elsevier Saunders; 2013. Print.

3. Correct Answer: A. Normal

Rationale: In patients with normal systolic function and without cardiac disease, four criteria can be looked at to determine the presence of diastolic dysfunction. These include E/e′ >14, LA maximum VI of >34 mL/m², TR jet velocity of >2.8 m/s, and a septal e′ velocity of <7 cm/s or a lateral e′ velocity of <10 cm/s. If less than 50% of these criteria are met, then normal diastolic function is present. If 50% of these criteria are met, then the presence of diastolic dysfunction is indeterminate and should not be documented. If greater than 50% of the criteria are satisfied, then diastolic dysfunction is present. In this patient only one among the four criteria are met (lateral e′ =7.7 cm/s), suggesting normal diastolic function.

1. Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017 Apr 18;69(15):1937-1948.

2. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

4. Correct Answer: B. Mitral deceleration time (DT) of <160 ms

Rationale: Atrial fibrillation creates challenges in the diagnosis of diastolic dysfunction due to the fact that many of these patients have preexisting congestive heart failure and enlarged LA. Along with these changes, measurement of E/A ratio can be difficult due to the lack of an A-wave secondary to loss of atrial contraction in atrial fibrillation. There are some parameters that can be measured to ascertain diastolic function in these patients despite these pitfalls. These include a peak acceleration time of mitral E velocity >1900 cm/s², mitral DT of <160 ms, E/e′ ratio of >11, and IVRT of <65 ms.

1. Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017 Apr 18;69(15):1937-1948.

2. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

5. Correct Answer: B. Elevated LV end-diastolic pressure

Rationale: Of the listed answers, only the mitral DT of <160 ms (131.9 ms in this question) has been shown to be a reliable indicator of elevated LV filling pressures and diastolic dysfunction in patients with reduced EF and atrial fibrillation. The mitral DT is shown by the delta T in the upper left of the image but can also be calculated using the pressure half-time or PHT. The equation for this is: DT = 38/0.29 = 131 ms. Other parameters that have been shown to be associated with elevated filling pressures in patients with atrial fibrillation include peak acceleration time of mitral E velocity >1900 cm/s², E/e′ ratio of >11, and IVRT of <65 ms. Variations in mitral inflow velocity cannot be used to identify tamponade physiology in the presence of atrial fibrillation.

1. Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017 Apr 18;69(15):1937-1948.

2. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

6. Correct Answer: D. Indeterminate, cannot document

Rationale: In a patient with normal LV function, four parameters can be evaluated to assess diastolic function. These include an average E/e′ >14, septal e′ velocity of <7 cm/s or a lateral e′ velocity <10 cm/s, TR jet velocity >2.8 m/s, and LAVI >34 mL/m². If less than 50% of these criteria are met, then normal diastolic function is present. If 50% of these criteria are met, then the presence of diastolic dysfunction is indeterminate and should not be documented. If greater than 50% of the criteria are satisfied, then diastolic dysfunction is present. In this case, two out of four criteria are met and therefore diastolic function cannot be determined.

1. Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017 Apr 18;69(15):1937-1948.

2. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

7. Correct Answer: C. Grade III, restrictive filling pattern

Rationale: Patients with heart transplantation pose a special circumstance in regard to evaluating diastolic dysfunction. It is common for patients to have a restrictive filling pattern on echocardiography in the first few weeks following transplantation despite normal EF. Most times, the filling pressures are normal in these patients as the donors are typically young, healthy people at the time of donation. Elevated TR jet velocities can still be a surrogate marker of elevated left-sided filling pressure in this patient population. Diastolic dysfunction findings typically resolve over time with many patients having normal measurements after 1 year following transplant.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

8. Correct Answer: B. Grade I

Rationale: In this patient with normal systolic function and myocardial disease, the two parameters noted on the examination of E/A ratio and mitral E velocity are consistent with grade I diastolic dysfunction. Based on most recent guidelines, if values of E/A are less than or equal to 0.8 and E is less than or equal to 50 cm/s, the patient likely has normal LAP with grade I diastolic dysfunction. If the E/A ratio is less than or equal to 0.8 and E is greater than 50 cm/s or the E/A ratio is between 0.9 and 1.9, further information in terms of E/e′, TR velocity, and LAVI is needed to quantify diastolic function more accurately. If the E/A ratio is greater than or equal to 2, then grade III diastolic dysfunction is present along with elevated LAP.

1. Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol. 2017 Apr 18;69(15):1937-1948.

2. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.

9. Correct Answer: C. IVRT of 46 ms

Rationale: Differentiation between constrictive pericarditis and restrictive cardiomyopathy can be performed utilizing echocardiography, and differences in tissue Doppler velocities, IVRT, DT, and LAVI can be used to differentiate between the two. In the above scenario, the most specific finding to differentiate between constrictive pericarditis and restrictive cardiomyopathy is the drastically shortened IVRT of 46 ms. Other ancillary findings that discern between the two entities are an E/e′ of >15, mitral DT of <160 ms, and an LAVI of >48 mL/m². Figure 21.10 shows the IVRT in an LV outflow tract measurement with pulse wave. IVRT is normally between 70 and 90 ms.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277-314.