New Insights Into Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction

Abstract

As the population ages, the incidence of patients presenting for surgical procedures with diastolic dysfunction and heart failure with preserved ejection fraction will rise. This review will discuss the most current and relevant information on the pathophysiology, treatment, and perioperative management of these patients.

Pulmonary Edema and Diastolic Heart Failure in the Perioperative Period

“…HFPEF is a well-described entity with prevalence ranging from 1.1 to 1.5% [ 3 ]. Studies have reported mixed results for perioperative risk in patients with HF and preserved LVEF [ 4 ].…”

Successful management of diastolic heart failure in a patient with restrictive cardiomyopathy following an anterior communicating artery aneurysm clipping

“…Diastolic heart failure is termed as HFpEF, and it is characterised by impairment in the distensibility of the myocardium, resulting in elevated ventricular diastolic pressures and thereby compromising the diastolic filling. [2,3] Post-operative diastolic dysfunction is hard to diagnose and often challenging to manage. [4] Due to lack of any definite clinical sign or specific test, diastolic failure is a diagnosis of exclusion and primarily depends on the combination of typical echocardiographic findings and elevated serum cardiac biomarkers.…”

“…The ACC/AHA 2013 Class 1 recommendation for Stage III HFpEF is to maintain systolic and diastolic pressure with no specific mention of any agent. [2] We selected milrinone, a selective phosphodiesterase-III inhibitor, because of the following reasons. (1) It promotes diastolic function with a concomitant reduction in pulmonary and systemic vascular resistance, without a considerable increase in heart rate and myocardial oxygen consumption [6] and (2) It is less arrhythmogenic than dobutamine and therefore proved to be the most favourable inotropic agent.…”

“…Echocardiographic findings are characterised by trans-mitral Doppler E/A >2 (early [E] to late [A] diastolic wave) and reduced early diastolic mitral annular tissue velocity (e') with a predominance of pulmonary venous 'D' wave amplitude. [2] Although not specific, NTpro-BNP is the most relevant biomarker, which has been shown to be predictive of diastolic dysfunction. [2] It is cleaved from the precursor hormone pro-BNP and released along with BNP, in response to the high ventricular tension.…”

Evolution, Practice, and Challenges of Cardiopulmonary Bypass

“…The last 2 articles are reviews of literature on diastolic dysfunction as it relates to the perioperative management of patients undergoing cardiac surgery. In “New Insights Into Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction,” 10 Dr Gelzinis focuses on the definition, symptoms, and diagnosis of diastolic heart failure and the perioperative management of patients with diastolic heart failure. The timing of this review is highly relevant.…”