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Figure 2 Diastolic Filling Parameters and the Prediction of Normal Versus Elevated Filling Pressure

(A) Prediction of normal versus elevated filling pressure. In patients with preserved and reduced left ventricular ejection fraction (LVEF), normal filling pressures are predicted by normal mitral inflow E-wave to tissue Doppler E’-wave ratio (E/E’) and mitral inflow E-wave to flow propagation ratio (E/Vp) values or intermediate values with normal left atrium (LA) size, normal pulmonary vein atrial reversal duration minus mitral inflow A-wave duration (ARdur – Adur), and a minimal change in the E/A wave ratio with Valsalva. Elevated filling pressures are predicted by elevated E/E’ and E/Vp values or intermediate values with elevated LA size, prolonged ARdur – Adur, a substantial change in the E to A valve with Valsalva, or a prolonged pulmonary vein D-wave deceleration time (DDT). (B) Degree of diastolic dysfunction. In patients with reduced LVEF, mitral inflow E/A, mitral inflow E-wave deceleration time (EDT), and isovolumic relaxation time (IVRT) parameters, confirmed by pulmonary vein S to D ratio (S/D), systolic fraction of pulmonary venous forward flow (SF), and DDT can further define filling dynamics by stratifying diastolic function into "abnormal relaxation" (normal filling pressures), "pseudonormal" (elevated filling pressures), and "restrictive" (very high filling pressures) categories. Valsalva E/A = change in mitral inflow E to A-wave ratio with Valsalva maneuver. (Modified from Nagueh SF, Zoghbi WA. Clinical Assessment of LV Diastolic Filling by Doppler Echocardiography. ACC Current Journal Review. 2001; July/Aug: 49).