R3 Lee, John

John Lee

Hi John

Apologies for the delay

Would like you to tackle the concept of diastolic heart failure in our patient  who is a 65 year old female with SLE and an infiltrative cardiomyopathy and presenting with dyspnea  She does have CAD but also has an infiltrative disease

So the question is does she have diastolic heart failure to account for her symptoms

Diastolic Heart Failure
Heart failure with preserved ejection fraction (HFpEF). 


  • Structural Abnormality
    • Thick Wall Small cavity
    • Enlarged Left Atrium
  • Physiology
    • Low Cardiac Output
    • Elevated End Diastolic Pressures

Many causes

  • Most common
  • We have established in our patient that
    • both her ventricles are thick walled
    • making infiltrative disease most likely
MRI with 4 chamber view from “black blood” T2 weighted imaging of a 65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI. Cardiac cath showed 2 vessel disease and she was referred for CABG. At surgery there were adhesions and the surgeon was unable to identify the coronaries as a result of the fibrosis. She was closed without surgery. She subsequently had a diagnostic MRI and endomyocardial biopsy which showed chloroquine related cardiomyopathy
Ashley Davidoff MD
  • Regarding other criteria
    • Is the cavity small?  and
    • What does her ejection fraction look like?
      • Systole to left and diastole to right
The images on the right are taken at peak systole and those on the left are peak diastole.  It would appear that volume in the cavity at peak systole on both views is about 1/2 the original volume suggesting  an EF of about 50%


Yes the LV cavity is small both by measurement and subjective assessment
  • Re EF (subjective)
    • the end systolic volume is small but is about 1/2 the volume  of the end diastolic volume
  • Re EF (objective)
    • Calculated EF was 60%
  • Re LAE?

    Both LA and RA look normal

Cardiac Output/Index

Calculated cardiac Index was 2.8 L/min/m2 ( normal range for CI is 2.5 to 4 L/min/m2.)

  • So she has some features of diastolic heart failure

    • Small LV cavity
    • Thick walled LV
    • CI lower limits normal
  • But
    • LA is normal in size
    • Calculated wedge pressure is normal


Next Zohaib Ahmad, Nulling the Myocardium