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
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
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DOI：
10.1016/j.echo.2016.01.011
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发表时间：
2016-04-01
影响因子：
6.5
通讯作者：
Waggoner, Alan D.
中科院分区：
文献类型：
--
作者：
Nagueh, Sherif F.;Smiseth, Otto A.;Waggoner, Alan D.
超声心动图评估左心室（LV）舒张功能是对出现呼吸困难或心力衰竭症状的患者进行常规评估的一个组成部分。2009年美国超声心动图协会（ASE）和欧洲超声心动图协会（现为欧洲心血管成像协会[EACVI]）的舒张功能评估指南非常全面，包括几个二维（2D）和多普勒参数，用于对舒张功能障碍进行分级并估计LV充盈压。1尽管如此，人们认为指南中包含的许多参数使舒张功能评估过于复杂，因为一些读者将指南解释为强制要求文件中列出的所有参数在指定特定等级之前均应落在指定值范围内。本次更新的主要目标是简化方法，从而提高指南在日常临床实践中的实用性。左心室舒张功能障碍通常是左心室舒张功能受损的结果，伴有或不伴有恢复力降低（和舒张早期抽吸），以及左心室腔室僵硬度增加，这会增加心脏充盈压。因此，当对潜在舒张功能障碍患者进行超声心动图研究时，应寻找左室舒张功能受损、恢复力降低和舒张僵硬度增加的体征。更重要的是，应估计左心室充盈压，因为在左心室舒张末期容积未增加的情况下左心室舒张压升高是支持舒张功能障碍发展良好的有力证据。在大多数临床研究中，通过几个简单的超声心动图参数可以可靠地确定左室充盈压和舒张功能等级，具有较高的可行性。此外，技术的发展已经出现，提供了新的指标，似乎有前途的研究左心室舒张功能。本次更新更加强调应用2009年指南中最有用、可重复和可行的二维和多普勒测量。在应用指南之前，必须考虑术语LV充盈压指的是什么。术语LV充盈压可以指平均肺毛细血管楔压（PCWP）（其是LV舒张压的间接估计值）、平均左心房（LA）压（PEEP）、LV A前压、平均LV舒张压和LV舒张末期压（LVEDP）。上述不同的LV和LA舒张压（图1）与多普勒信号具有不同的相关性。例如，在舒张功能障碍的早期阶段，由于大的心房压力波，LVEDP是唯一的异常升高的压力，而平均PCWP和PCWP保持正常。随着心动过速和/或LV后负荷增加，平均PCWP和LAP增加，这为舒张应力测试提供了基础。因此，重要的是要清楚估计的是哪个压力，因为存在仅与LVEDP增加相关的多普勒变量与反映LVEDP和LVEDP两者增加的多普勒变量。尽管目前的建议主要集中在超声心动图技术上，但应该注意的是，核扫描和心脏磁共振均可用于评价LV充盈率和容量。值得注意的是，通过两种技术获得的测量值受LV舒张和LV充盈压的影响，并且与从二尖瓣流入速度获得的测量值和导数非常相似。
Echocardiographic assessment of left ventricular (LV) diastolic function is an integral part of the routine evaluation of patients presenting with symptoms of dyspnea or heart failure. The 2009 American Society of Echocardiography (ASE) and European Association of Echocardiography (now European Association of Cardiovascular Imaging [EACVI]) guidelines for diastolic function assessment were comprehensive, including several two-dimensional (2D) and Doppler parameters to grade diastolic dysfunction and to estimate LV filling pressures. 1 Notwithstanding, the inclusion of many parameters in the guidelines was perceived to render diastolic function assessment too complex, because several readers have interpreted the guidelines as mandating all the listed parameters in the document to fall within specified values before assigning a specific grade. The primary goal of this update is to simplify the approach and thus increase the utility of the guidelines in daily clinical practice. LV diastolic dysfunction is usually the result of impaired LV relaxation with or without reduced restoring forces (and early diastolic suction), and increased LV chamber stiffness, which increase cardiac filling pressures. Thus, when performing an echocardiographic study in patients with potential diastolic dysfunction, one should search for signs of impaired LV relaxation, reduced restoring forces and increased diastolic stiffness. More important, LV filling pressure should be estimated because elevated LV diastolic pressure in the absence of increased LV end-diastolic volume is strong evidence in favor of well-developed diastolic dysfunction. In the majority of clinical studies, LV filling pressures and diastolic function grade can be determined reliably by a few simple echocardiographic parameters with a high feasibility. In addition, technical developments have emerged that provide new indices that appear promising for studying LV diastolic function. This update places more emphasis on applying the most useful, reproducible, and feasible 2D and Doppler measurements from the 2009 guidelines. Before applying the guidelines, it is essential to consider what the term LV filling pressures refers to. The term LV filling pressures can refer to mean pulmonary capillary wedge pressure (PCWP)(which is an indirect estimate of LV diastolic pressures), mean left atrial (LA) pressure (LAP), LV pre-A pressure, mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP). The different LV and LA diastolic pressures mentioned above (Figure 1) have different correlates with Doppler signals. For example, in the early stages of diastolic dysfunction, LVEDP is the only abnormally elevated pressure because of a large atrial pressure wave, while mean PCWP and LAP remain normal. With tachycardia and/or increased LV afterload, mean PCWP and LAP increase which provides the basis for the diastolic stress test. Thus, it is important that one is clear on which pressure is being estimated as there are different Doppler variables that correlate with an increase in LVEDP only versus those that reflect an increase in both LAP and LVEDP. Although the current recommendations are focused on echocardiographic techniques, it should be noted that both nuclear scans and cardiac magnetic resonance can be used to evaluate LV filling rates and volumes. Notably, measurements derived by both techniques are affected by LV relaxation and LV filling pressures and are quite similar to measurements and derivatives obtained from mitral inflow velocities.