1. Correct Answer: C. Isovolumic relaxation time (IVRT)

Rationale: IVRT is the time from the beginning of diastole (aortic valve closure) to the beginning of rapid filling (E) phase of LV diastolic filling. Like many other indices of diastolic function, IVRT has a biphasic course as diastolic dysfunction progresses. Normal IVRT is 70 to 90 ms. Initially, as LV diastolic relaxation becomes impaired and delayed, IVRT lengthens and in grade I dysfunction IVRT is typically >90 ms. As diastolic dysfunction progresses LV filling comes to be dependent on the “push” of blood from the LA instead of the normal “pull” of an actively relaxing left ventricle. As LV filling pressure (i.e., mean LAP) rises, MV opens earlier in the cardiac cycle and IVRT shortens back into the normal range in grade II dysfunction. In grade III diastolic dysfunction (restrictive filling pattern) IVRT further shortens and falls below 70 ms. In this patient IVRT is 130 ms, which is consistent with grade I diastolic dysfunction. IVRT is not one of the main parameters for identification of diastolic dysfunction, but may nonetheless be useful in some cases. IVRT is measured by positioning the PWD sampling volume in between the mitral and aortic valves in the apical five-chamber view, so that the aortic ejection velocity and mitral inflow velocity can be measured from the same recording. The time interval from the cessation of aortic flow to the beginning of mitral flow is IVRT.

All other answer options involve parameters also used in assessment of diastolic function, but all the listed parameters are obtained from mitral inflow velocity recordings which are obtained in the A4 view by positioning the PWD sample volume in the left ventricle right at the tips of the mitral leaflets. In contrast, IVRT is obtained closer to the aorta, in order to catch both aortic ejection as well as the mitral inflow.

On spectral Doppler graphs velocity is plotted on the Y-axis and time on the X-axis. E-wave velocity is its height, not its duration (Figure 50.42).

Deceleration time refers to E-wave deceleration and is measured as shown in Figure 50.43.

A-wave duration measurement is shown in Figure 50.44.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016 Apr;29(4):277-314. doi:10.1016/j.echo.2016.01.011.

2. Oh JK. Assessment of diastolic function. In: Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

2. Correct Answer: C. Figure 50.3C

Rationale: All answer options offer a different spectral (PWD) graph of mitral inflow.

Answer A shows a restrictive pattern, grade III diastolic dysfunction. In this pattern E >> A. In this case, A-wave is essentially absent, despite the presence of atrial contraction.

Answer B shows a normal or pseudonormal (grade II) inflow pattern. Here E/A is > 0.8 but <2.0. Whether the pattern is normal or pseudonormal depends on clinical circumstances.

Answer D shows a relatively rare pattern featuring a third diastolic inflow wave—the L-wave. This is generally a sign of elevated filling pressures and can be seen in combination with grade II or grade III patterns. It is thought to always be abnormal.

The most important learning point of this question is that it is assumed that all patients with systolic dysfunction also have diastolic dysfunction. The truth of this statement has been debated, but it remains a useful general principle applicable to the absolute majority of patients. Assuming this is correct, no patient with systolic dysfunction can have a normal filling pattern regardless of volume status. If the normal pattern is excluded, then any E-predominant mitral inflow must represent pseudonormalization. The “best” or most normal filling pattern a patient with systolic CHF can hope to achieve is an A-dominant (grade I) pattern of mitral inflow.

1. Kerut EK, McIlwain EF, Plotnick GD. Handbook of Echo-Doppler Interpretation, 2nd ed. Futura, an imprint of Blackwell Publishing; 2004.

2. Oh JK, Hatle L, Tajik AJ, Little WC. Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography. J Am Coll Cardiol. 2006 Feb 7;47(3):500-506. doi:10.1016/j.jacc.2005.09.032. Epub 2006 Jan 18.

3. Sharon M. Kay, Sidney University. Purrrfect Echo chic @sharonmkay. Accessed April 23, 2021. http://twitter.com/sharonmkay/status/380264241267093504. Posted Sep 18, 2013.

3. Correct Answer: B. 1—normal, 2—normal, 3—elevated, 4—elevated, 5—normal

Rationale: Determination of diastolic function is complex and may depend on many echo-derived parameters. However, a three-step procedure is able to classify most patients correctly.

First, patients should be classified as having or not having LV systolic dysfunction. In the second step, in patients with normal systolic function, mitral inflow pattern will be able to place a patient on the continuum of diastolic function, albeit with some ambiguity. Finally, e′ velocity will allow for the final classification into diastolic function categories. Note that this is not an algorithm recommended in the latest ASE guidelines, but is an easier to understand, pathophysiology-based approach. (See also Figure 50.45.)

Differentiation between supra-normal and restrictive and between normal and pseudonormal patterns is made based on tissue Doppler parameters (e′ and E/e′).

Among patients with disordered diastolic function, transition from grade I to grade II is characterized by transition from normal to elevated LA pressure and from “pull” to “push” filling physiology.

1—LAP is normal. Patient has a restrictive (grade III) vs “supra-normal” pattern. LV diastolic fx is supra-normal (likely normal for her age), as evidenced by high e′. Therefore, she likely has a supra-normal filling pattern and normal LAP.

2—LAP is normal. Patient likely has grade I diastolic dysfunction. This pattern does not have a differential diagnosis and is always abnormal.

3—LAP is elevated. Patient likely has grade III diastolic dysfunction (restrictive filling pattern). The phenotype suggests that the patient is not fit and has multiple features predictive of diastolic dysfunction.

4—LAP is elevated. This E/A pattern is consistent with both pseudonormal and normal filling patterns. In this case normal diastolic function is ruled out by abnormally low e′, therefore this patient has grade II diastolic dysfunction.

5—LAP is normal. Patient has a normal vs pseudonormal filling pattern. Diastolic fx is normal as evidenced by normal e′, therefore this patient likely has a normal filling pattern and normal LAP.

1. Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

4. Correct Answer: C. The norms listed are for a healthy elderly population. When interpreting study results, it is important to remember that “supra-normal” values may be younger age-related and not related to any pathology.

Rationale: The norms listed are for a healthy elderly population. When interpreting study results, it is important to remember that “supra-normal” values may be younger age-related and not related to any pathology.

1. Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

5. Correct Answer: C. Between inverse, A-dominant (grade I), and pseudonormal (grade II)

Rationale: Up until and including grade I diastolic dysfunction the filling is thought to occur by active relaxation and suctioning effect of the left ventricle on the blood, that is, by “pull.” After that the left ventricle is rigid and filling occurs by the LA pushing blood into it. Consequently, LAP is typically normal up until pseudonormal (grade II) pattern develops.

1. Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

6. Correct Answer: B. Restrictive filling pattern

Rationale: As the apical four-chamber view shown in Figure 50.5, LV systolic function in this case is severely depressed. This automatically rules out diastolic CHF as a sole diagnosis. In fact, all patients with systolic dysfunction should be thought of as having abnormal diastolic function as well. Diagnosis of diastolic CHF, however, is reserved specifically for patients with a compatible clinical syndrome, abnormal diastolic function, and normal systolic function.

This patient has a history of cardiotoxic chemotherapy and radiation to the left chest, which almost inevitably includes the heart into the radiation field. Radiation is known to cause a variety of cardiac abnormalities, including accelerated coronary atherosclerosis, constrictive pericarditis, cardiomyopathy, and valvulopathies. In any patient with a history of radiation to the chest who presents with a syndrome of CHF, constrictive pericarditis must be kept in the differential. Even though echo diagnosis of constriction is complex, tissue Doppler of mitral annulus (Figure 50.7) offers a relatively simple assessment. In a normal heart, the lateral part of the mitral annulus, being part of the free wall, moves faster than the medial, and lateral e′ will be greater than medial. In contrast, in constrictive pericarditis, the lateral annulus is tethered to the pericardial sac, resulting in lateral e′ being less than medial, which is sometimes referred to as “annulus reversus.” In this case, e′_lateral > e′_medial, making constriction unlikely.

Filling pattern in this case shows E>>A. This pattern is called “restrictive filling” and indicates very elevated LA pressures. It can be seen in patients with either grade III diastolic dysfunction or systolic dysfunction. Restrictive filling is not to be confused with restrictive cardiomyopathy, which too may result in a restrictive filling pattern, but is a term reserved for a particular type of cardiomyopathy.

1. Oh JK. Assessment of diastolic function. In: Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

2. Rygiel K. Cardiotoxic effects of radiotherapy and strategies to reduce them in patients with breast cancer: an overview. J Cancer Res Ther. 2017 Apr-Jun;13(2):186-192. doi:10.4103/0973-1482.187303.

3. Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging. 2014 May;7(3):526-534. doi:10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.

7. Correct Answer: B. This patient still has elevated left filling pressures. He may benefit from further diuresis.

Rationale: This patient has a restrictive filling pattern (E>>A), suggestive of significantly elevated left-sided filling pressures. Though there is no guarantee that the patient will tolerate further diuresis, normal serum creatinine and normal RV filling pressures (as assessed by IVC and JVP) suggest that he is currently not “over-diuresed,” that is, there is no evidence that his cardiac output (and end-organ perfusion) have diminished after decrease in preload following diuretics. Consequently, it is not unreasonable to attempt further diuresis in this patient who is still symptomatic. Recall that the theoretical best inflow pattern in patients with decreased systolic function, who are presumed to always have diastolic dysfunction as well, is the “inverse” (E<A) corresponding to grade I diastolic dysfunction. There are certainly other ways of gauging LAP by ultrasound, the main one being lung ultrasound pattern. A pattern effectively rules out elevated LV filling pressures as a cause of dyspnea. In this patient, however, lung auscultation and ultrasound are noninformative, because of the coexisting parenchymal lung disease. There is no evidence of constriction and lateral e’ is greater than medial (i.e., annulus reversus is absent).

1. Oh JK. Assessment of diastolic function. In: Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019:168-201.

8. Correct Answer: A. This patient is clinically euvolemic and his left filling pressures are as good as they will ever get. He should receive only his usual maintenance diuretics. Etiology of his dyspnea is likely noncardiac.

Rationale: The patient has an inverse filling pattern characteristic of impaired diastolic relaxation (grade I diastolic dysfunction). This is the “best” filling pattern a patient with impaired systolic function can attain. Recall that systolic dysfunction always is presumed to imply the presence of diastolic dysfunction. Consequently, it is not possible for a patient with impaired systolic function to have normal filling, regardless of loading conditions. In fact, a “normal” filling pattern in this patient would indicate that it is in fact not normal but is “pseudonormal” and would suggest that in the absence of contraindications, further diuresis may be attempted. This patient’s LV filling pressures have now likely been optimized. As always, if tolerated, reduction of afterload in CHF is indicated.

Normal right filling pressure is zero, and therefore right atrial pressures (RAPs) in the range described in this case are not by themselves a contraindication to continuing diuresis.

Importantly, evidence of normal LV filling pressures suggests that other, noncardiac, etiologies should be sought in order to explain the patient’s dyspnea.

1. Oh JK. Assessment of diastolic function. In: Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019:Chapter 8. ISBN 9781496312198.

9. Correct Answer: B. At the tips of the MV in the left ventricle

Rationale: The sample volume of PWD has to be positioned at the tips of the MV leaflets in the left ventricle. Doppler interrogation line should be aligned with the direction of inflow into the left ventricle during diastole. (See also Figure 50.46.)

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016 Apr;29(4):277-314. doi:10.1016/j.echo.2016.01.011.

10. Correct Answer: D. Coexisting aortic regurgitation (AR)

Rationale: Imperfect alignment of the Doppler interrogation line with the flow will result in underestimation of the velocity, not its overestimation. Doppler shift can only estimate the component of the velocity parallel to the insonation beam. Recall that the Doppler equation contains a correction factor cosθ.

where c is the speed of sound in the tissue, Δf is Doppler shift, f_insonation is insonation frequency, and θ is the angle of insonation relative to the flow.

As the angle of insonation increases between 0 and 90°, the cosine of that angle decreases, and the estimated velocity will decrease. Consequently, assuming that the angle of insonation is zero (with its cosine being equal to 1) while in reality it is not, will underestimate the velocity.

Positioning Doppler sample volume in the LA is likely to underestimate the inflow velocities, because flow accelerates in the narrower tract.

Flow of MR and AS occurs in systole and will not affect measurements of diastolic mitral inflow. Both may result in high diastolic LV pressures, but that is a physiologic effect, not an error of measurement.

In contrast, flow of AR occurs in diastole, at the same time as normal mitral inflow. Because of the anatomic proximity of the LV in in- and outflow tracts, the jet of AR can be easily mixed with the mitral inflow, especially if the sample box is positioned too close to the LV outflow tract. Pressure gradient across a regurgitant aortic valve is much higher than across a normal open MV. From Bernoulli’s equation, high pressure gradient corresponds to high flow velocities, and, therefore, mitral inflow velocities may be significantly overestimated.

1. Kerut EK, McIlwain EF, Plotnick GD. Handbook of Echo-Doppler Interpretation. 2nd ed. Futura, an imprint of Blackwell Publishing; 2004. ISBN: 0-4051-1903-9.

11. Correct Answer: A. Continuous-wave Doppler (CWD) was used instead of PWD.

Rationale: Mitral inflow velocity tracing is obtained by PWD with the sample volume positioned at the tips of the MV leaflets within the left ventricle. PWD measures velocities of flow only within the space defined by the sample volume, usually denoted by two small parallel hatches on the interrogation line. PWD is thus the modality used to evaluate flow velocities at a particular point in space.

In this recording CWD was used instead. CWD measures all the velocities encountered along the interrogation line, and, therefore, does not have a sample volume. The fact that CWD rather than PWD is being used is indicated by a closed rhomboid shape on the interrogation line. Position of the rhomboid symbol along that line is of no relevance and does not change the fact that all points along the interrogation line are surveyed. To be sure, the rhombus is not a sample volume. (Note that the indicator of CWD modality may vary among devices by various manufacturers.)

There are two other ways to distinguish CWD from PWD. Because, as mentioned, all velocities along the interrogation line are detected, a wide spectrum of velocity values will be detected, and tracing’s envelope will be filled. In contrast, if the flow is laminar, PWD samples a limited range of velocities and the envelope will have an outline, but an empty middle. Finally, CWD designation can be seen along the left margin of the screen, identifying the modality used.

A potential issue with using CWD is that any simultaneously present flow will be mixed-in with the mitral inflow signal. For example, significant AR is expected to affect the measurements.

Inflow velocities can be done in several different apical views, but A4 is a standard preferred view, which was used in this case, as can be seen in the accompanied B-mode image.

Tissue Doppler records velocity of moving myocardium, not the blood and is not used for detection of mitral inflow velocities. Tissue movement velocities are one to two orders of magnitude slower than velocity of blood flow. It was not used in this case.

1. Kerut EK, McIlwain EF, Plotnick GD. Handbook of Echo-Doppler Interpretation. 2nd ed. Futura, an imprint of Blackwell Publishing; 2004. ISBN: 0-4051-1903-9.

12. Correct Answer: C. Grade II diastolic dysfunction

Rationale: According to the 2016 ASE guidelines, the first step in evaluation of diastolic function is assessment for the presence of myocardial pathology. This patient has several risk factors for myocardial disease (age, HTN, and obesity), but normal LV systolic function. In the absence of known myocardial disease, qualitative presence of diastolic dysfunction is confirmed based on the presence of three of four criteria in the guidelines, which are:

Note that presence or absence of myocardial disease should not be equated with the presence or absence of CHF. In fact, clinical history of coronary heart disease, hypertensive heart disease, or CHF is a sufficient ground to state that the patient has diastolic dysfunction. Presence of systolic dysfunction too is taken as evidence of coexisting diastolic dysfunction.

Other echo and Doppler parameters may indicate the presence of diastolic dysfunction, such as increased Ar-A duration, significant change in mitral inflow pattern with Valsalva maneuver, significant discrepancy between inflow patterns across mitral and tricuspid valves, and presence of L-wave on the spectral tracing of mitral inflow. These guidelines, among other things, were meant to increase specificity of assessment for diastolic dysfunction, at the expense of lower sensitivity. It remains to be seen how these changes in criteria play out clinically.

Once the presence of diastolic dysfunction has been ascertained (or at least its probability is thought to be high enough), the next step is quantification of diastolic dysfunction, with the main goal of identifying patients with increased, as opposed to normal, LV filling pressures.

The classification scheme shown in Figure 50.47 is based on the variability of diastolic mitral inflow velocity patterns shown in Figure 50.45 in Answer 3, but with some refinements:

1. The upper limit of normal E/A ratio is not 1 (E=A), but rather 0.8, meaning that E-wave does not have to be greater than A-wave, but still may not be less than A-wave by >20%.

2. A second criterion for normal inflow pattern is added: E-wave velocity cannot be too high (has to be ≤50 cm/s). Both the criteria must be met for the pattern to be normal (or pseudonormal).

3. Among patients with pseudonormal mitral inflow pattern, abnormal tissue Doppler velocity (E/e′ >14) does not automatically classify a patient as having grade II diastolic dysfunction and at least one additional criterion is required: either a dilated LA or presence of pulmonary hypertension (PHTN). If abnormally high E/e′ is the sole finding, the patient is classified as having grade I diastolic dysfunction. This distinction is important, because grade I implies normal LA pressure. In fact, these three criteria (high E/e′, large LA, PHTN) are treated as equally important. Diagnosis of grade II diastolic dysfunction requires presence of at least two of the three.

The flowchart provided in the ASE guidelines may be somewhat cumbersome to follow. A simplified flowchart of the same classification is given in Figure 50.48.

The patient in this question has E/A slightly over 0.8 (E/A = 0.83), which is characteristic of normal or, in the presence of myocardial disease, pseudonormal inflow pattern. His E/e′ is low, but he does fulfill the other two criteria listed in Figure 50.47, namely, TR V_max >2.8 m/s and LAVI >34 cc/m². Thus, this case would be classified as grade II diastolic dysfunction, with the implication that LA pressure is elevated. Note that the physiologic classification (Figure 50.45), which does not take LA size or PHTN into consideration, would yield a different result and classify this patient’s diastolic dysfunction as grade I, which implies normal mean LA pressure.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016 Apr;29(4):277-314. doi:10.1016/j.echo.2016.01.011.

13. Correct Answer: D. LA volume index (LAVI)

Rationale: LA size does not decrease despite decrease in LAP with diuretic therapy.

1. Greenstein YY, Mayo PH. Evaluation of left ventricular diastolic function by the intensivist. Chest. 2018 Mar;153(3):723-732. doi:10.1016/j.chest.2017.10.032. Epub 2017 Nov 4.

2. Oh JK, Miranda WR, Bird JG, Kane GC, Nagueh SF. The 2016 diastolic function guideline: is it already time to revisit or revise them? JACC Cardiovasc Imaging. 2020 Jan;13(1 Pt 2):327-335. doi:10.1016/j.jcmg.2019.12.004.

14. Correct Answer: B.

Rationale: Constrictive pericarditis is in the differential of severe diastolic dysfunction, that is, restrictive filling in a patient with a clinical picture consistent with CHF. Currently the most robust and validated diagnostic approach is that by the Mayo Clinic. It includes several parameters other than mitral annular diastolic velocity, such as clinical presence of CHF, plethoric IVC, abnormal respiratory septal movement (septal bounce), restrictive filling pattern, significant respiratory mitral inflow variation, and prominent hepatic vein expiratory diastolic flow reversals (expiratory end-diastolic reversal velocity/forward flow velocity ≥ 0.8). Reversal of normal relationship of e′ lateral > e′ medial is termed annulus reversus. Among patients with clinical CHF and plethoric IVC, annulus reversus had LR(-) of 0.3 and LR(+) = 5. This likelihood ratio by itself would not be sufficient to rule out constrictive pericarditis if a reasonable pretest probability existed. The patient in this case has an extremely low suspicion for constriction and lack of annulus reversus effectively rules it out. Lack of septal bounce is the most useful variable in ruling out constriction with LR = 0.1.

Answer A. IVRT is a time interval between the closure of the aortic valve and opening of the MV. In the course of diastolic dysfunction progression IVRT follows a biphasic course analogous to E/A pattern. Normal IVRT is 70 to 90 ms. Trained athletes frequently have supra-normal filling and their IVRT would be shorter than normal. As the LV diastolic relaxation becomes impaired and delayed (grade I diastolic dysfunction), IVRT lengthens to >90 ms, and often >110 ms. As diastolic dysfunction progresses to grade II, marked by transition from normal to elevated LV filling pressures (and from the “pull” to “push” physiology), IVRT shortens and falls back into the normal range. In grade III, that is, restrictive filling, IVRT progressively shortens and falls below the lower end of normal 70 ms. It follows that IVRT of 52.8 ms could represent either a supra-normal LV filling in an athlete or stage IV diastolic dysfunction. It would certainly be inappropriate to discount a possibility of this symptomatic patient having diastolic dysfunction based solely on low IVRT value. Importantly, IVRT is not a part of the general algorithm for diagnosis or grading of diastolic dysfunction, according to the 2016 ASE guidelines.

Answer B. E-DT is a time from the peak of the E-wave velocity to zero velocity (or extrapolation to baseline). Like IVRT, E-DT follows a biphasic course with increasing severity of diastolic dysfunction. Normal E-DT is 160 to 200 ms, but in a vigorously relaxing athletic heart E-DT will be shorter. In grade I diastolic dysfunction, as the suctioning force of the left ventricle decreases and becomes delayed, E-DT lengthens (>200 ms). Beginning with grade II diastolic dysfunction, as physiology of LV filling switches from “pull” to “push,” E-DT progressively shortens. A comparison to a car braking on sand, as compared to braking on ice, may be useful. On sand, the resistance is high and decrease in velocity is rapid. As the kinetic energy is rapidly dissipated, the car will come to a stop after only a short skidding distance. On the contrary, when driving on ice, the resistance is low, and the skidding distance will be long. Similarly, a compliant accommodating left ventricle will result in a slow decrease in inflow velocity, whereas hitting a “wall” of a stiff, highly noncompliant ventricle will result in a rapid drop in the velocity and short E-DT.

Note that it is not really the declaration time, but the rate of deceleration (slope) that has physiologic meaning. This is illustrated by the fact that in some cases of restrictive filling, when E-velocity is very high (>120 cm/s) it takes a long time for the atrium to empty and E-DT may be longer than 160 ms. The reason E-DT has been in use in cardiology, instead of the slope of deceleration, is largely historic: earlier machines lacked automatic tools to calculate slopes, whereas time intervals could be readily measured. It is thus clear that E-DT alone is insufficient to make diagnosis of diastolic dysfunction. E-DT is too not a part of the general algorithm for diagnosis or grading of diastolic dysfunction, according to the 2016 ASE guidelines.

Answer C. Peak velocity of tricuspid regurgitant flow (TR V_max) can be used to estimate systolic pulmonary arterial pressure (PAPs). According to the modified Bernoulli equation,

ΔP = 4 × V², where ΔP is peak systolic pressure gradient across the tricuspid valve and V=TR V_max, and

ΔP = P_RV – P_RA

In the absence of pulmonic stenosis, P_RV ø PAPs, and so PAPs – P_RA = 4 × V² and

PAPs = 4 × V² + P_RA

Note that because RAP estimates are very crude, they introduce a large error into the estimate. Consequently, TR velocity alone has been used as a surrogate for PAPs.

Normal peak tricuspid transvalvular pressure gradient is ≤30 mm Hg, which corresponds to peak velocity ≤2.8 m/s. In this case the TR V_max = 2.1, which is below the threshold (corresponding pressure gradient is 18 mm Hg, which is normal).

Answer D. In diastolic dysfunction E/e′ is increased and e′ is decreased, therefore answer D is incorrect.

1. Claessens PJ, Claessens CW, Claessens MM, Claessens MC, Claessens JE. Supernormal left ventricular diastolic function in triathletes. Tex Heart Inst J. 2001;28(2):102-110.

2. Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral “annulus reversus” to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009 May;10(3):372-375. doi:10.1093/ejechocard/jen258. Epub 2008 Oct 24.

3. Silbiger JJ. Pathophysiology and echocardiographic diagnosis of left ventricular diastolic dysfunction. J Am Soc Echocardiogr. 2019 Feb;32(2):216-232.e2. doi:10.1016/j.echo.2018.11.011.

4. Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging. 2014 May;7(3):526-534. doi:10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.

15. Correct Answer: A. Normal diastolic function

Rationale: Recall that assessment of diastolic function starts with the clinical context and echocardiographic evaluation for the presence of overt myocardial disease, in essence an estimation of probability of diastolic dysfunction. This patient has no historical clues to any preexisting cardiac disease and her B-mode echo images reveal normal LV size, thickness, and systolic function. Further, the patient does not fulfill any of the four criteria listed in the 2016 ASE guidelines (Figure 50.49). This patient has a normal diastolic function and an alternative explanation to her dyspnea on exertion must be sought, such as, for example, deconditioning.

1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016 Apr;29(4):277-314. doi:10.1016/j.echo.2016.01.011.

2. Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

16. Correct Answer: D. None of the above

Rationale: In standard notation blood flow spectral Doppler waves are labeled with Latin capital letters, such as E and A, as shown in Figure 50.50A. Tissue velocities are designated by addition of apostrophe to a (usually lower case) Latin letter, such as e′, a′, and s′. The waves of the MV movement are shown in Figure 50.50B. Note that both e′- and a′-wave are diastolic events. Systolic movement of the mitral (and tricuspid) annulus toward the apex is designated as s′.

1. Oh JK, Kane GC, Seward JB, Tajik AJ, eds. The Echo Manual. 4th ed. Wolters Kluwer; 2019.

17. Correct Answer: A. Evaluation for the presence of myocardial disease, such as decreased LV systolic function, LVH, and known diastolic dysfunction

Rationale: The 2016 ASE guidelines separate assessment of diastolic function into two steps. The first is to determine whether myocardial disease is present. “Myocardial disease” is a broad notion here. Importantly, it is NOT limited to CHF with reduced LV systolic function (heart failure with reduced ejection fraction [HFrEF]), but includes conditions such as LVH, and hypertensive heart disease, as well as qualitatively present diastolic dysfunction.

In the absence of other myocardial disease, qualitative assessment of diastolic function is based on four parameters:

1. Septal e′ <7 cm/s or lateral e′ <10 cm/s

2. Average E/e′ >14

3. TR velocity >2.8 m/s (equivalent to pressure gradient of >31.4 mm Hg)

4. LAVI >34 mL/m²

If >50% of the criteria are fulfilled (3 or 4)—diastolic dysfunction is present.

If <50% of the criteria are fulfilled (0 or 1)—diastolic dysfunction is absent.

If exactly 50% of the criteria are fulfilled (2)—diastolic function is indeterminate.

Severity of diastolic dysfunction, which in practicality boils down to estimation of mean LAP, is reserved for the subsequent step in the evaluation.

Note that inflow pattern is not part of the first step in that algorithm (Figure 50.47), but is the basis of the classification in step 2.