Diastolic Function

Mitral Annular e′

Is there diastolic dysfunction?

Optional lateral e′

Use when septal e′ is unavailable or potentially unreliable

Mitral Inflow

What grade is it?

E/e′

Do they have elevated filling pressure?

TR Velocity

Is there PH?

Supportive LAP Markers

Optional. Select abnormal findings when primary markers are discordant.

Diastology Decision Tree

Reduced e′ velocity?

Septal ≤6 · lateral ≤7 · average ≤6.5 cm/s

Primary Measurements

Mitral annular tissue Doppler
Mitral inflow Doppler
E/e’
Right ventricular systolic pressure
Left atrial volume index
Left atrial strain
Pulmonary vein Doppler

Tissue Doppler- Do they have diastolic dysfunction?

Mitral annular motion reflects LV relaxation.

Septal e’ velocity < 6 cm/s is abnormal
Lateral e’ < 7 cm/s can also be used, but septal e’ is preferred and easier to measure
If e’ is normal, the patient almost certainly has normal diastolic function and you are essentially done with diastology
- This is by far the most important measurement

Tissue Doppler Velocities

s’ = LV systolic annular velocity
e’ = early diastolic annular velocity, reflecting LV relaxation
a’ = late diastolic annular velocity, reflecting atrial kick/late LV filling

How to Measure Medial e’

Measure the bright modal envelope
Avoid measuring artifact
Measure the e’ envelope nearest to the a’ wave
The preceding wave measured at 4 cm/s is isovolumetric relaxation and is not e’
In this example, e’ < 6 cm/s, consistent with impaired relaxation

Mitral Inflow Doppler- How severe is their diastolic dysfunction?

Measure using PW doppler at the mitral leaflet tips
If e' is abnormal, mitral inflow velocity helps grade the severity of diastolic dysfunction

Normal

E > A
E/A > 0.8
- LV relaxes, pressure decreases and pressure rushes from high to low pressure area composing the majority of LV filling (E wave) with small component from atrial kick (A wave)

Grade I: Impaired Relaxation

A > E
E/A < 0.8
Usually long deceleration time (> 240ms)
- LV is stiff so when MV opens, no longer low pressure in LV in early diastole so lower amplitude of E wave/slower deceleration time and more reliant on atrial kick to fill the LV but LAP normal

Grade II: Pseudonormal

E > A
E/A 0.8-2.0
e’ is abnormal, so you know the apparently normal E/A pattern is actually abnormal
- LV is stiff but LAP is high enough to push blood out into the ventricle in early diastole

Grade III: Restrictive Filling

E >> A
E/A > 2.0
Usually short deceleration time (< 160ms)
- LAP keeps climbing and get more rapid/early diastolic filling with very short deceleration time with very little atrial filling

Deceleration time

Measured from peak E wave to return to baseline
- Normal: 160-240ms
- Long DT > 240ms = impaired relaxation/grade I pattern
- Short DT < 160ms = restrictive filling / high LA pressure

Mitral Inflow: Diastolic Dysfunction Pattern

Normal Filling

Mitral inflow E wave exceeds A wave with a normal deceleration slope.

E/A ≈ 1–2

Grade 1 Impaired relaxation

Pattern Reduced early filling. E decreases and atrial contribution becomes dominant.

E/A ≤ 0.8

Grade 2 Pseudo-
normal

Pattern Increased LA pressure restores the apparent E/A relationship despite abnormal relaxation.

E/A 0.8–2

Grade 3 Restrictive

Pattern Marked early diastolic filling with a small A wave and rapid deceleration.

E/A ≥ 2

Normal mitral inflow

Normal early filling with preserved atrial contribution

1–2 E/A ratio

160–240 DT, ms

Normal LA pressure

Normal: early diastolic filling predominates, but the A wave remains substantial.

Normal filling Increasing dysfunction

E/e’ Ratio- What is their filling pressure?

E is taken from pulse wave Doppler mitral inflow
e’ is taken from tissue Doppler of the mitral annulus
- E/e’ > 15 indicates elevated filling pressures/PCWP
- Specific but not sensitive

RVSP- Do they have pulmonary hypertension?

Estimate RVSP using the TR peak velocity.

How to interpret

TR peak velocity > 2.8 m/s is abnormal
RVSP/sPAP > 25 mmHg is abnormal
About two-thirds of patients with high LA pressure have pulmonary hypertension
If they have pulmonary hypertension, it may be due to elevated LA pressure, though other confounders should be considered, such as COPD

Putting It All Together

Normal Diastolic Function

e’ > 7 cm/s
E/e’ < 15
TR velocity < 2.8 m/s

Grade I Diastolic Dysfunction

Medial e’ is abnormal, < 6 cm/s
E/e’ is normal
No pulmonary hypertension
E < A
Long deceleration time

Some patients fall between grade I and grade II. Diastology is often a spectrum.

Grade II/III Diastolic Dysfunction

e’ < 6 cm/s
E/e’ > 15
TR velocity > 2.8 m/s

Then use mitral inflow to distinguish:

Grade II: E/A < 2
Grade III: E/A >> 2

What If It Is Not Clear?

Use additional markers of chronic pressure load and LA function.

Left Atrial Enlargement

Normal LA size: no evidence of long-term pressure elevation
Enlarged LA: suggests chronic adverse pressure load
- LA enlargement alone does not tell you current filling pressures.

Left Atrial Volume Index

LAVI > 34 mL/m² is abnormal
Not a perfect measure
If LAVI is around 50 mL/m², this is almost certainly abnormal

Left Atrial Strain

Measure in the apical 4-chamber view
Trace the LA in systole when the LA is largest
Software generates the LA strain curve
Left atrial strain looks at the contractility/function of the LA.
- Normal LA strain > 35%
- Clearly abnormal LA strain < 20%

Pulmonary Vein Doppler

Normal flow into the left atrium should be systolic predominant.

S > D: likely normal LA pressure
D > S: likely abnormal LA pressure

L Wave

Extra wave in early/mid diastole that can indicate increased LV filling pressures

When not to try assessing diastology?

Mitral prosthesis or severe mitral annular calcification: immobile structure that won’t move and confound things
Mitral stenosis/regurg: LAP probably high but don’t use these measures
LVAD/transplant
AF
LBBB, tachycardia
PH with marked RV dysfunction (with a big RA/RV the shared mitral annulus often reflects RV function)