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Figure 3 (A) End-diastolic pressure and volume relationship (EDPVR) curve. Modified from Mauer et al. (1). The EDPVR is shifted left-upward for diastolic dysfunction or diastolic heart failure and is shifted right-downward for remodeled heart. Inserted in the figure are mitral inflow and mitral septal annulus velocity recording for normal, diastolic dysfunction, and remodeling groups. Mitral inflow velocity may appear similar in all three groups, but myocardial relaxation (hence, mitral annulus early diastolic velocity) is almost always reduced in patients with diastolic dysfunction or remodeling. Patients with diastolic dysfunction or remodeling may not be distinguished by mitral inflow and mitral annulus velocities, but the distinction is obvious when interpreted with two-dimensional echocardiography, as shown in (B). Top panel shows three mitral inflow velocity recordings from normal subject (center), a patient with diastolic heart failure (left), and a patient with left ventricular (LV) remodeling after myocardial infarction (right). In the first two, it is difficult to tell their diastolic function or filling pressures by mitral inflow velocity pattern alone. On the right, both deceleration time and atrial flow duration were shortened indicating marked elevation of LV diastolic pressure. The middle panel shows tissue Doppler velocity recording from the septal corner of respective individuals with mitral inflow velocities shown on the top panel. In the middle column, mitral annulus early diastolic velocity (Ea) is normal (11 cm/s), indicating that myocardial relaxation is normal with normal filling pressure (E/Ea = 80/11 = <8). In the left column, Ea is markedly reduced to 5 cm/s with E/Ea of 20 (=100/5). On the right, Ea is delayed and fused with late diastolic velocity occurring after biphasic isovolumic velocities. On the basis of mitral inflow velocity and tissue Doppler mitral annulus velocity, the patients in the left and right column were found to have increased filling pressure and abnormal relaxation of LV. However, their underlying reason for increased filling pressure is not clear without structural information, shown at the bottom. Two-dimensional echo shows completely normal cardiac structures for normal subject at the center, abnormal heart (increased wall thickness and enlarged left atrium), but normal LV size and ejection fraction (in real time) in the left typical of diastolic heart failure with leftward/upward-shifted EDPVR and abnormal heart (enlarged LV size and reduced ejection fraction in real time) on the right typical of remodeling with rightward/downward-shifted EDPVR.