What is the echocardiographic approach to assess diastolic function in patients with valvular heart disease according to the British Society of Echocardiography (BSE) 2024 guidelines?

Echocardiographic Assessment of Diastolic Function in Valvular Heart Disease: BSE 2024 Guidelines

The British Society of Echocardiography (BSE) 2024 guidelines recommend a comprehensive and systematic approach to assess diastolic function in patients with valvular heart disease, integrating multiple parameters to accurately evaluate left ventricular filling pressures and relaxation abnormalities.

Core Diastolic Assessment Parameters

Primary Measurements

• Mitral Inflow Pattern:

  • E/A ratio (early to late diastolic filling velocity ratio)
  • E-wave deceleration time
  • Isovolumic relaxation time

• Tissue Doppler Imaging (TDI):

  • Mitral annular e' velocity (septal and lateral)
  • E/e' ratio (key indicator of LV filling pressures)
  • a' velocity

• Left Atrial Assessment:

  • LA maximum volume index (indexed to BSA)
  • LA function and reservoir strain

• Pulmonary Vein Flow:

  • Systolic (S) and diastolic (D) velocities
  • S/D ratio
  • Atrial reversal velocity and duration

Valvular Disease-Specific Considerations

Aortic Valve Disease

• In Aortic Stenosis:

  • Assess LV wall thickness and mass index
  • Evaluate for concentric remodeling pattern
  • Monitor for paradoxical low-flow, low-gradient states
  • Look for diastolic dysfunction as a marker of increased mortality 1

• In Aortic Regurgitation:

  • Evaluate LV volumes and dimensions
  • Assess for eccentric hypertrophy pattern
  • Monitor E/A ratio for pseudonormalization
  • Evaluate blood pressure control impact on diastolic function 1

Mitral Valve Disease

• In Mitral Stenosis:

  • Direct assessment of diastolic function is challenging
  • Focus on planimetry of valve area
  • Pressure half-time measurements
  • Mean gradient across the valve

• In Mitral Regurgitation:

  • Differentiate primary vs. secondary MR
  • Assess LV volumes and function
  • Evaluate LA size and function
  • Measure E/e' ratio with caution (may be misleading) 1

Grading Diastolic Dysfunction in Valvular Disease

Grade I (Impaired Relaxation)

• E/A ratio <0.8
• Deceleration time >200 ms
• e' velocity reduced
• E/e' ratio <10
• Normal LA size

Grade II (Pseudonormal)

• E/A ratio 0.8-2.0
• Deceleration time 160-200 ms
• e' velocity reduced
• E/e' ratio 10-14
• Enlarged LA

Grade III (Restrictive - Reversible)

• E/A ratio >2.0
• Deceleration time <160 ms
• e' velocity reduced
• E/e' ratio >14
• Significantly enlarged LA

Grade IV (Restrictive - Fixed)

• Same as Grade III but persists with Valsalva maneuver

Special Considerations and Pitfalls

Technical Challenges

• Tachycardia: E and A waves may fuse - use Valsalva maneuver to separate
• Atrial Fibrillation: Rely more on:
  • Deceleration time
  • e' velocity
  • E/e' ratio
  • LA size

Valve-Specific Pitfalls

• Mitral Annular Calcification: May affect tissue Doppler measurements - use multiple sites
• Prosthetic Valves: Limited utility of conventional parameters - focus on:
  • Pulmonary vein flow
  • LA size and function
  • Tricuspid regurgitation velocity 1

Dynamic Assessment

• Exercise Echocardiography: Valuable for:
  • Unmasking diastolic dysfunction
  • Assessing exercise-induced changes in valve gradients
  • Evaluating pulmonary pressures with exertion 1

Integration with Other Parameters

Structural Assessment

• LV mass and relative wall thickness
• LA volume and function
• RV size and function
• Pulmonary artery pressure estimation

Functional Assessment

• Global longitudinal strain (GLS) - early marker of subclinical dysfunction
• LA strain - correlates with LV filling pressures
• Valvular regurgitation quantification 2

Reporting Recommendations

The BSE 2024 guidelines emphasize a standardized reporting approach that includes:

1. Quantitative assessment of all diastolic parameters
2. Grading of diastolic dysfunction (I-IV)
3. Integration with valvular pathology assessment
4. Estimation of LV filling pressures
5. Comparison with previous studies when available

Clinical Application

The assessment of diastolic function in valvular heart disease provides critical information for:

• Timing of intervention decisions
• Risk stratification
• Monitoring disease progression
• Evaluating treatment response
• Guiding perioperative management

By systematically applying these BSE 2024 guidelines, clinicians can accurately assess diastolic function in patients with valvular heart disease, leading to improved patient outcomes and reduced morbidity and mortality.