Impaired Relaxation

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Fig. 5. Measuring mitral valve inflow (see Technical Issues in Measuring MV Inflow section for explanation).

E-wave velocities tend to increase). Deceleration of mitral inflow is directly related to MV area and inversely related to ventricular compliance (as MV area or compliance decrease, E-wave deceleration time increases). Mitral inflow patterns are highly modulated by filling pressures and loading conditions, particularly LV preload. A rise in LA pressure is associated with an increase in peak E-wave velocity. Conversely, decreased LA pressure can be associated with a decrease in peak E-wave velocity as well as E-wave deceleration time, independently of the intrinsic relaxation properties of the LV. This dependence limits the clinical applicability of using MV inflow patterns to predict filling pressures and diastolic function (Fig. 6).

abnormal mitral inflow patterns

Impaired Relaxation

The Doppler pattern of impaired relaxation (Fig. 7) is characterized by E- to A-wave reversal (peak A-wave velocity > peak E-wave velocity, or E:A < 1) and prolongation of E-wave deceleration time more than 220 ms. This pattern may be seen more commonly in elderly patients and is not necessarily accompanied by patho-physiological changes, but it generally suggests early abnormalities of diastolic function if detected in patients less than 60 yr old. This pattern occurs because as LV relaxation becomes impaired or LV compliance decreases and LA pressure has not become abnormally elevated, there is greater impedance to blood flow from

Transmitral Flow

Fig. 6. Limitation of transmitral Doppler profile. Transmitral Doppler profiles showing normal and mild diastolic dysfunction profiles. The limitation of relying on transmitral flow patterns alone for the assessment of diastolic function is that a normal E:A-wave ratio can occur in patients with impaired relaxation and elevated filling pressure (right column). This ambiguity in the relationship of E:A ratio and the severity of diastolic dysfunction mandates the incorporation of other echocardiographic parameters to arrive at an accurate assessment of diastolic function. Doppler tissue imaging profiles are less influenced by loading conditions. Impaired relaxation and increased preload states of diastolic dysfunction are both associated with reduced E velocities.

Fig. 6. Limitation of transmitral Doppler profile. Transmitral Doppler profiles showing normal and mild diastolic dysfunction profiles. The limitation of relying on transmitral flow patterns alone for the assessment of diastolic function is that a normal E:A-wave ratio can occur in patients with impaired relaxation and elevated filling pressure (right column). This ambiguity in the relationship of E:A ratio and the severity of diastolic dysfunction mandates the incorporation of other echocardiographic parameters to arrive at an accurate assessment of diastolic function. Doppler tissue imaging profiles are less influenced by loading conditions. Impaired relaxation and increased preload states of diastolic dysfunction are both associated with reduced E velocities.

LA to LV, manifested as a diminution in peak E-wave velocity and a slowing of deceleration. Given the slowing

Diastolic ^ . Mild Moderate Severe

Function orma Dysfunction Dysfunction Dysfunction

impaired Relaxation

Restrictive Pattern t

Time (milliseconds)

Fig. 7. Transmitral Doppler flow patterns. Transmitral Doppler flow patterns showing normal filling, impaired relaxation (A-wave > E-wave), pseudonormal filling and restrictive filling (E-wave > A-wave; increased E-wave velocity and shortened E-wave deceleration time). These patterns form the basis of grading diastolic function from mild to severe (grade 1-4).

Table 3

Stages of Diastolic Dysfunction

Table 3

Stages of Diastolic Dysfunction

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