Aggeli, Constantina

Tousoulis, Dimitris

Tsiamis, Eleftherios

Hellenic Journal of Cardiology

Elsevier - Publisher Connector 

Hellenic Journal of Cardiology (2016) 57, 99e100Available online at www.sciencedirect.com
ScienceDirect
journal homepage: http: / /www.journals .elsevier .com/
hel lenic- journal-of-cardiology/EDITORIALLeft ventricular diastolic dysfunction: An old,
known entity in a technologically modern eraSo
ht
11
licKEYWORDS
Left ventricular
diastolic dysfunction;
Arterial hypertension;
Preserved left
ventricular ejection
fraction;
Left ventricular
hypertrophyPeer review under responsibility
ciety.
tp://dx.doi.org/10.1016/j.hjc.2016
09-9666/ª 2016 Hellenic Cardiologi
ense (http://creativecommons.org/Left ventricular diastolic dysfunction (LVDD) manifests early
and is a common pathophysiological pathway leading to
many cardiovascular diseases.1 Diastolic dysfunction can
present in a spectrum of diverse patterns, ranging from a
simple delay of ventricular relaxation without significant
hemodynamic changes, to pulmonary venous congestion due
to ventricular diastolic pressure elevationwith displacement
of the upper, left pressure-volume loop (Figure 1). Cardiac
catheterization provides data on the left side of the heart,
the right side of the heart, systemic and pulmonary arterial
pressures, vascular resistances, cardiac output, and ejection
fraction. These data are often used as markers of cardiac
preload, afterload, and global function, although each of
these parameters reflects additional complex interactions
between the heart and loading conditions. Hemodynamic
evaluation has long been considered to be the “gold-stan-
dard” method for characterizing load, contractility, dias-
tole, and, ventricular-arterial interactions, but has not been
adopted for clinical practice. Attaining a working under-
standing of each of these elements remains paramount to
properly interpreting hemodynamic changes in patients who
have heart failurewith preserved ejection fraction (HF-PEF).
However, it is worth noting that recently, conventional and
newer echocardiographic methods2e6 have been used toof Hellenic Cardiological
.04.001
cal Society. Publishing services by
licenses/by-nc-nd/4.0/).accurately evaluate patients with HF-PEF (Table 1).
Recently, Kasner et al.4 reported that the quotient of
simultaneously measured E/E’ and LV end-diastolic volumes
using TDI and 3DE allows a simple determination of LV stiff-
ness in the clinical routine. The combination of left ven-
tricular dysfunction and coronary artery disease in
hypertensive patients usually aggravates LV diastolic pa-
rameters, as Vlasseros et al.5 have published.
Any type of heart disease that leads to myocardial
structural alteration and/or pericardial effusion can cause
LVDD. Sometimes this structural abnormality is macro-
scopically evident as LV hypertrophy, whereas in other
cases, diastolic dysfunction is linked to abnormalities of
the cellular mechanisms of myocyte relaxation and is
caused by hypoxia and/or ischemia. Diastolic dysfunction is
a dominant feature in many HF-PEF patients, and many
factors contribute to diastolic dysfunction, including both
vascular and myocardial stiffening. Diffuse stiffening that
occurs throughout the cardiovascular system because of
aging or comorbidities interferes with the forces that
normally develop during systole to produce ventricular
suction and thus reduces early diastolic filling. Left ven-
tricular diastolic dysfunction may be related to changes in
the extracellular matrix or changes that are intrinsic to
myocyte stiffness, microvascular dysfunction, and meta-
bolic abnormalities.
Left ventricular hypertrophy is the most common path-
ological condition that induces LVDD and is associated with
a poor cardiovascular prognosis. Furthermore there has
been no direct comparison of the LVDD characteristics be-
tween patients with and without LVH. Therefore, Kattel
et al.7 hypothesized that mild to moderate LVDD with LVH
carries a higher risk for developing severe LVDD and dia-
stolic heart failure than LVDD without LVH. The authors
studied 2 LVDD groups, a group with mild to moderate LVDD
with LVH (LVH group) and a group with mild to moderate
LVDD without LVH (non-LVH group), to determine the
echocardiographic differences between the two groups.
The authors compared two major echocardiographic char-
acteristics, the left ventricular filling pressure (FP) and theElsevier B.V. This is an open access article under the CC BY-NC-ND
100 EditorialTei-index (also known as the myocardial performance
index), between those 2 groups. Furthermore, they
assessed whether LVH had any additional effects on LVFigure 1 The black line depicts the curve in a normal person.
The curve (green) that is shifted up and to the left (red arrow)
indicates the effect of increased passive chamber stiffness.
Table 1 Conventional and newer echocardiographic pa-
rameters in the evaluation of the LV filling pressure.
Method
Transmitral inflow Normal>1
(E/A) Impaired relaxation <1
Restrictive>2
Presence of L wave Indicates advanced LV dysfunction
DT Normal 160e240 ms
Impaired relaxation >240ms
Pseudonormal 160e240 ms
Restrictive <160ms
Pulmonary
venous flow
S/D Normal >1
Tei index Normal <0.4
TDI Normal Lateral E’>10 cm/s
Normal Septal E’>8 cm/s
Normal Averaged E/E’ ratio<8
LA evaluation Normal Volume index<34 ml/m2
Speckle tracking
imaging
Normal LA strain>18%
E/E’SR-ST>93 surrogate marker
of elevated LV filling pressure
Impaired vortex
generation
Advanced diastolic dysfunctiondiastolic function and overall cardiac function in patients
with mild to moderate LVDD.
The study by Kattel et al. demonstrated that FP was
significantly higher when LVDD was accompanied by LVH.
Higher FP was also reflected by the significantly larger left
atrial size and greater left atrial volume index (ml/m2) in
the LVH group. In addition, a higher Tei-index was attrib-
uted solely to poorer LV diastolic function in the LVH group.
A limitation of this study is that the authors did not use
newer echocardiographic techniques, such as speckle
tracking imaging, that could detect earlier and more ac-
curate information regarding LVDD in hypertensive patients
without LVH.
Because of the potential for a poorer prognosis for pa-
tients with mild to moderate LVDD, it may be beneficial to
have closer monitoring and more aggressive hypertension
management when LVH co-exists.
References
1. Palmiero P, Zito A, Maiello M, et al. Left ventricular diastolic
function in hypertension: methodological considerations and
clinical implications. J Clin Med Res. 2015 Mar;7(3):137e144.
2. Kimura K, Takenaka K, Ebihana A, et al. Speckle tracking global
strain rate E/E’ Predicts LV filling pressure more accurately than
traditional tissue doppler E/E’. Echocardiography. 2012;29:
404e410.
3. Ha J, Ahn J, Moon J, et al. Triphasic mitral inflow velocity with
mid-diastolic flow: the presence of mid-diastolic mitral annular
velocity indicates advanced diastolic dysfunction. Eur J Echo-
cardiogr. 2006;7:16e21.
4. Kasner M, Sinning D, Burkoff D, Tschope C. Diastolic pressure-
volume quotient (DPVQ) as a novel echocardiographic index
for estimation of LV stiffness in HFpEF. Clin Res Cardiol. 2015;
104:955e963.
5. Vlasseros I, Katsi V, Vyssoulis G, et al. Aggravation of left ven-
tricular diastolic dysfunction in hypertensives with coronary
artery disease. Hypertens Res. 2013;36:885e888.
6. Martinez-Lepazpi P, Bermejo J, Benito Y, et al. Contribution of
the diastolic vortex ring to left ventricular filling. J Am Coll
Cardiol. 2014;64:1711e1721.
7. Kattel SH, Memon S, Saito K, Narula J, Saito Y. Effect of left
ventricular hypertrophy on mild to moderate left ventricular
diastolic dysfunction. Hell J Cardiol. 2016.
Constantina Aggeli*
Eleftherios Tsiamis
Dimitris Tousoulis
1st Cardiology Department, Hippokration Hospital,
Athens, Greece
*Corresponding author. Constantina Aggeli, First
Department of Cardiology, Hippokration Hospital, Athens
Medical School, 114 Vas. Sofias Ave, 115 27 Athens, Greece
E-mail address: dina.aggeli@gmail.com (C. Aggeli)


Left ventricular diastolic dysfunction: An old, known entity in a technologically modern era 

Constantina Aggeli

Eleftherios Tsiamis

Dimitris Tousoulis

Directory of Open Access Journals

Left ventricular diastolic dysfunction: An old, known entity in a technologically modern era

file:///data/core-remote/dit/data/elsevier/pdf/31f/aHR0cDovL2FwaS5lbHNldmllci5jb20vY29udGVudC9hcnRpY2xlL3BpaS9zMTEwOTk2NjYxNjMwMDI1Mg==.pdf

Left ventricular diastolic dysfunction: An old, known entity in a technologically modern era

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector

Directory of Open Access Journals

Elsevier - Publisher Connector