Written by Judith Buckland, MBA, RDCS, FASE

5 Steps to Identify Diastolic Dysfunction in Echo

How to measure diastolic dysfunction echocardiography

Last week we reviewed some common errors found when measuring diastolic function. This week we will review 5 steps to identify diastolic dysfunction in echo. Since the Intersocietal Accreditation Commission mandates both the assessment and reporting of diastolic function for echo accreditation, we thought it would be a good idea to review these measurements again. We understand that diastology can be complex, but this is a great starting point.

Before we can grade the severity of diastolic dysfunction, we first have to know if diastolic dysfunction is present. We have posted similar articles on diastology. This week we will address how to establish if diastolic dysfunction is present in a patient with a normal ejection fraction and no known cardiac disease.

Identify Diastolic Dysfunction: Step 1


correct way to perform Simpsons  LV biplane in echo

The algorithm we are going to use to determine the presence of diastolic dysfunction is specifically for patients with normal ejection fraction. Therefore, step 1 requires us to calculate the ejection fraction of our patient using the Bi-Plane Simpson’s method. You will need to measure the LV in both systole and diastole in the 4 chamber and 2 chamber view. For additional tips on how best to perform the Bi-plane Simpson’s method for LV volume and EF in echo, review our past blog.

Identify Diastolic Dysfunction: Step 2

Mitral Valve Inflow: E Wave

Next, perform an accurate PW of the MV inflow and obtain your peak E Wave velocity. This will be used to determine your average E/e’ measurement. Correct PW technique includes:

  • Apical 4 chamber
  • Pulsed-wave Doppler
  • Sample volume between mitral valve leaflet tips
  • Low wall-filter
  • E Wave: Early diastole (after T-wave on EKG)
MV inflow diastology echo

Identify Diastolic Dysfunction: Step 3


PW TDI Diastolic Function Measurement

Now onto step 3 – In the 4 chamber view, perform tissue Doppler (TDI) of the mitral valve on both the septal and lateral basal region. For common errors to avoid, check out last weeks blog. This data will provide:

  • Average E/e’ (Abnormal cut-off value > 14)*
  • Septal e’ velocity (cm/sec) (< 7 cm/s)
  • Lateral e’ velocity (cm/sec) (< 10 cm/s)

NOTE: The average E/e’ is calculated using the average value of both the septal and lateral TDI velocities.

Identify Diastolic Dysfunction: Step 4


Tricuspid Regurgitation Velocity

Step 4. It is necessary to know the max tricuspid regurgitation (TR) velocity when determining LV dysfunction. We have a past blog that covers the tricuspid valve and how to calculate the RVSP in echo. In regards to diastolgy assessment, we are looking at the max TR velocity. The abnormal range used in diastology assessment is a TR velocity > 2.8 m/s.

Diastolic Function in Echo: Step 5


Left Atrial Volume Index in echo

You’ve made it to the last step! The final measurement we must have in order to evaluate for diastolic dysfunction is the left atrial volume index (LAVI). This measurement is indexed to the patients BSA so be sure to enter the patients height and weight into your ultrasound machine in order to calculate the LA volume index.

For this measurement you will trace the LA in end-systole in both the 4 chamber and 2 chamber views. Be careful not to foreshorten your views. For more tips on correct echo left atrial volume measurements you can review past blogs. A cut-off value of > 34 mL/m2 is used as one of the parameters of assessment.

Now what?

Great…you know how to obtain the necessary echo measures to determine diastolic dysfunction … but now what? How do you apply these measurements to assess diastolic function?

In the case of a patient with a normal ejection fraction and no known heart disease (afib, mod-severe MR, etc.), use the following cut-off values to assess the number of abnormal parameters.

  • If you have none, or only one abnormal parameter the patient has NORMAL diastolic function
  • If you have three or more abnormal parameters, the patient has diastolic dysfunction
  • If you have only two abnormal parameters, the patient has indeterminate diastolic dysfunction
how to determine diastolic dysfunction with echo


You now have the basics of how to determine if your patient has diastolic dysfunction. In future weeks we will discuss how to further handle indeterminate diastolic dysfunction along with how to grade the severity of diastolic dysfunction.

Judith Buckland CardioServ

Judith Buckland, MBA, RDCS, FASE

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Luis Go
What do you do if there is no TR and no TR jet velocity to measure and 2 abnormalities present? Many Thnaks
Then it is indeterminate
Daniel Ward
Question re: calculating e/e’ average; Specifically, it appears there are 2 ways to calculate this value: 1) calculate e/e’ (septal), then calculate e/e’ (lateral) and then calculate the average of these 2 values. For example, given an e wave peak velocity = 90 cm/s, septal e’ = 6 cm/s and lateral e’ = 8 cm/s the arithmetic would be : 90/6 = 15, 90/8 =11.25 and then average (15+11.25) / 2 = 13.125. 2) Alternatively I could average the e’ values (8+6)/2 = 7, and then calculate 90/7 = 12.85. Which is the correct calculation? Thanks for your great articles!
The correct method is to average the e' values first
Dana R Parker
Excellent concise review of how to assess diastolic function of LV.
Anthony LaSala MD
Enjoyed the review on How to assess diastolic function of LV. I am "Old School". I teach early LV diastolic dysfunction as impaired LV filling. Seen early in patients with subclinical hypertensives. You see prolonged Isovolumetricic Relaxation (IVR). Period of time from the closure of AV to onset of LV filling. This period can be measured many ways. An easy way is from TDI where the time from the end of the S1 wave to onset of E1 is measured. In abnormal LV filling IVRT is in excess of 110ms. IVRT should be considered as the first and early indicator of diastolic dysfunction (impaired filling)in patients with so called "normal hearts" but subclinical hypertensive heart disease.
if E/A<0.8+E<50cm/s,can we comment as a mild diastolic dysfunction?
Cynthia Kaufman
How would you put this into the report?Thank you
Excellent work. Thanks for sharing with us
Dionissios Tsipas
The diastolic dysfunction in 5 steps! Very useful.
Lana pollard
I;am having trouble answering the Septal and Lateral e' because there are two parts. First off the question is if Septal and lateral are less than 7cm and 10cm? If they are less than its a Yes? If they are over 7cm and 10cm than it's a no? Also what do I do if one is over and one is under how do we apply that, with a yes or no because it's both.

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