1. Correct Answer: B. Abnormal LV relaxation with normal LA pressure

Rationale: Abnormal LV relaxation pattern includes E/A ratio <1 (bigger A wave compared to E wave), prolonged LV isovolumic relaxation time (>100 ms), and E-wave deceleration time >250 ms.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

2. Correct Answer: E. Mitral annulus e′ (early diastolic) velocity with tissue Doppler imaging (TDI)

Rationale: Mitral inflow and pulmonary venous flow do not always exhibit the typical respiratory changes. The IVC is typically dilated in both patients with constrictive and restrictive cardiomyopathy. Atrial size will usually be increased in patients with restrictive cardiomyopathy, but constrictive pericarditis will also eventually result in (particularly right-sided) dilatation. TDI can provide important differentiating information. In restrictive cardiomyopathy, myocardial relaxation (e′) will be severely impaired, whereas patients with constriction usually have preserved annular vertical excursion. A septal e′ velocity ≥ 7 cm/s has been shown to be highly accurate in differentiating patients with constrictive pericarditis from those with restrictive cardiomyopathy. Since the lateral annular e′ velocity could be decreased if the constrictive process involves the lateral mitral annulus, the septal e′ velocity is considered more specific for this assessment.

1. Dal-Bianco JP, Sengupta, Khandheria BK. Role of echocardiography in the diagnosis of constrictive pericarditis. J Am Soc Echocardiogr. 2009;22(1):24-33.

3. Correct Answer: A. Peak AR >35 cm/s suggests elevated LV filling pressures.

Rationale: AR may increase with age, but AR >35 cm/s is usually consistent with elevated LV filling pressures, particularly at end diastole. The pulmonary D wave is related to LV relaxation. Young and healthy individuals can therefore exhibit large D waves indicating forceful elastic recoil of the left ventricle rather than high LA pressure. The pulmonary S wave is related to LV contractility, atrial function, atrial pressure, and MR. Mitral and pulmonary vein inflow patterns are not very reliable for assessment of LV filling pressures in patients with an overall normal systolic function. AR_dur – A_dur >30 ms is, therefore, a more robust marker of elevated LVEDP in this group of patients. Pulmonary venous atrial reversal can be obtained in more than 70% of patients. A commercially available contrast injection can help enhance the Doppler tracing.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

4. Correct Answer: C. Apical four-chamber view

Rationale: LA size is an important marker of the severity of LV diastolic dysfunction. An LA volume of 34 mL/m² (reflective of moderate or greater LA dilatation) has been shown to predict death and nonfatal cardiovascular events among patients without atrial fibrillation or valvular heart disease. The most accurate echocardiographic measurement of LA size is the LA volume from the transthoracic apical views.

1. Murata M, Iwanaga S, Ogawa S. A real-time three-dimensional echocardiographic quantitative analysis of left atrial function in left ventricular diastolic dysfunction. Am J Cardiol. 2008;102(8):1097-1102.

5. Correct Answer: B. Patient has diastolic dysfunction

Rationale: In a patient with normal EF, the following criteria can be used to determine if the patient has diastolic dysfunction:

If more than 50% of them are positive (i.e., three or more), then the patient has diastolic dysfunction. For making determinations in patients who have a preserved EF (Figure 35.15A) versus patients who have a depressed EF or myocardial disease (Figure 35.15B), please refer to Figure 35.15 for the algorithm delineated by the American Society of Echocardiography.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

6. Correct Answer: B. Elevated LA pressure with elevated EDP

Rationale: The rapid D-wave deceleration time <170 ms indicates high LA pressure. Also, the S wave is smaller than the D wave. The AR duration is 220 ms. This is due to increased duration of atrial systole having to pump against elevated LVEDP. Pulmonary vein AR duration greater than mitral A-wave duration is indicative of high LVEDP.

1. Buffle E, Kramarz J, Topilsky Y. Added value of pulmonary venous flow Doppler assessment in patients with preserved ejection fraction and its contribution to the diastolic grading paradigm. Eur Heart J Cardiovasc Imaging. 2015;16(11):1191-1197.

2. Morrissey C. Echo for diastology. Ann Card Anaesth. 2016;19(suppl S1):12-18.

7. Correct Answer: A. Impaired LV relaxation causes the mitral inflow E velocity to decrease with a longer deceleration time, representing a decreased early diastolic LV filling rate.

Rationale: In patients with impaired LV relaxation, the mitral inflow E velocity decreases with a longer deceleration time, reflecting a decreased early diastolic LV filling rate. To complement this change, A velocity through the mitral inflow increases.

1. Tabata T, Thomas JD, Klein AL. Pulmonary venous flow by doppler echocardiography: revisited 12 years later. J Am Coll Cardiol. 2003 Apr;41(8):1243-1250.

8. Correct Answer: E. All of the above

Rationale: In patients with a restrictive mitral inflow pattern (a deceleration time <150 ms), the pulmonary venous flow (PVF) shows a lower S2 and higher D velocities (severely blunted systolic flow) and increased atrial reversals (unless atrial systolic failure), suggesting decreased LV operating compliance. These echocardiographic findings are seen in patients with elevated LVEDP and elevated LA pressure. Dilated cardiomyopathy, restrictive cardiomyopathy, and ischemic cardiomyopathy cause diastolic dysfunction resulting in these echocardiographic findings. In patients with constrictive pericarditis, LV compliance is compromised by pericardial restriction resulting in similar echocardiographic features.

1. Tabata T, Thomas JD, Klein AL. Pulmonary venous flow by doppler echocardiography: revisited 12 years later. J Am Coll Cardiol. 2003 Apr;41(8):1243-1250.

9. Correct Answer: B. Passive relaxation of the left ventricle

Rationale: Independent determinants of e’ are LV relaxation, restoring forces, and lengthening load. Rate of relaxation reflects decay of active fiber force. Restoring forces that account for diastolic suction is similar to an elastic spring coming back from a recoil position. Lengthening load is the pressure in the left atrium at mitral valve opening, which “pushes” blood into the left ventricle and thereby lengthens the ventricle.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

10. Correct Answer: E. E wave = Rapid LV filling, A wave = Atrial contraction

Rationale: In a sinus heart rhythm, two waveforms are seen on the transmitral Doppler flow velocity profile. E wave represents rapid LV filling during the early part of diastole and A wave represents atrial contraction that occurs at the end.

1. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function. Circulation. 2002;105(11):1387-1393.

11. Correct Answer: E. Abnormal LV relaxation with normal LA pressure

Rationale: Young children have very compliant left ventricle, resulting in rapid early filling (mitral E wave) paralleled by an increase in D wave that might have rapid deceleration as well. As S1 is due to atrial relaxation, atrial fibrillation results in reduced S-wave amplitude. Systolic LA filling from MR will impede pulmonary vein flow in systole. High LA pressure renders the left atrium less compliant due to rightward shift of its pressure-volume curve and hence will impede atrial systolic filling, as the left atrium is a closed chamber receiving only pulmonary venous flow during systole. Abnormal LV relaxation reduces E- and D-wave amplitudes, resulting in an increase in S-wave amplitude in the absence of elevated LA pressure.

1. Daneshvar D, Wei J, Merz CNB. Diastolic dysfunction: improved understanding using emerging imaging techniques. Am Heart J. 2010;160(3):394-404.

12. Correct Answer: A. Less

Rationale: Increased pulmonary A-wave duration compared to mitral A-wave duration indicates high LVEDP. A difference in duration of more than 30 ms is very suggestive of high LVEDP.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

13. Correct Answer: A. LA relaxation

Rationale: The arrow denotes the systolic S1 wave, created by LA relaxation. Mitral annular descent and RV ejection generate the S2 wave, which follows the S1 wave. The mitral valve opening generates the diastolic D wave, which is synchronous with the mitral E wave.

1. Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol. 1993;21(7):1687-1696.

14. Correct Answer: E. Pulmonary artery pressure

Rationale: The amplitude is increased in the presence of a stiff left ventricle and reduced in LA mechanical failure. The pulmonary A wave may disappear with HRs in excess of 100/min, where flow may be entirely antegrade, and atrial contraction may produce a transient deceleration pulmonary flow without reversal. As velocity depends upon flow volume and cross-sectional area, a dilated pulmonary vein is likely to reduce the A-wave velocity and a collapsed vein in a dry patient can result in a giant A wave. Pulmonary artery pressure is least likely to have any significant effect on A-wave characteristics.

1. Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol. 1993;21(7):1687-1696.

15. Correct Answer: D. Loading conditions

Rationale: CMM echocardiography provides a way to assess the propagation velocity (Vp), which appears to be relatively independent of loading conditions and hence overcomes one of the main limitations of Doppler-based techniques. They are affected by cardiac output, LA size, LV compliance, and HR, just like other diastolic parameters. After the mitral valve opens in early diastole, there is a rapid component (phase 1), often followed by a slow component (phase 2). Finally, the last component in late diastole is associated with atrial contraction.

1. Rovner A, de las Fuentes L, Waggoner AD, Memon N, Chohan R, Dávila-Román VG. Characterization of left ventricular diastolic function in hypertension by use of Doppler tissue imaging and color M-mode techniques. J Am Soc Echocardiogr. 2006;19(7):872-879.

16. Correct Answer: C. Greater than 50 cm/s

Rationale: Normal mitral E-wave propagation velocity is >50 cm/s.

1. Vierendeels JA, Dick E, Verdonck PR. Hydrodynamics of color M-mode Doppler flow wave propagation velocity V (p): a computer study. J Am Soc Echocardiogr. 2002;15(3):219-224.

17. Correct Answer: C. Pulmonary vein S/D time velocity integral ratio

Rationale: High LA pressure results in short isovolumic relaxation time (IVRT), an increase in pulmonary vein AR-wave duration and amplitude, and reduced E-wave deceleration time. Mitral E/mitral annular Em ratio is a good indicator of LA pressure. The S-wave amplitude is diminished in high LA pressure due to increased LA operating stiffness during LV systole, when there is no LA emptying. Atrial mechanical failure results in diminution of pulmonary AR reversal and absence of atrial relaxation, which causes an LA suction effect and will result in diminution of S-wave amplitude.

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. Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1321-1360.

18. Correct Answer: A. Mean LA pressure of 10 mm Hg and LVEDP of 22 mm Hg

Rationale: Abnormal relaxation generally has normal LA pressure but an elevated LVEDP because of a combination of increased contribution of LV filling during atrial systole and possibly increased LV diastolic stiffness by the same process that caused abnormal LV relaxation. Very high mean LA pressures result in pseudonormal or restrictive LV filling patterns.

1. Hanrath P, Mathey DG, Bleifeld W. Left ventricular relaxation and filling pattern in different forms of left ventricular hypertrophy: an echocardiographic study. Am J Cardiol. 1980;45(1):15-23.

19. Correct Answer: A. Severe MR

Rationale: Presence of an A wave excludes atrial fibrillation. In mitral stenosis and prosthetic mitral valve, the E-wave deceleration will be slow. The inflow pattern shown here indicates high LA pressure typified by E/A ratio >2 and E-wave deceleration of <150 ms and is consistent with severe MR.

1. Olson JJ, Costa SP, Palac RT. Early mitral filling/diastolic mitral annular velocity ratio is not a reliable predictor of left ventricular filling pressure in the setting of severe mitral regurgitation. J Am Soc Echocardiogr. 2006;19(1):83-87.

20. Correct Answer: C. Short deceleration time associated with worsening prognosis

Rationale: Deceleration time ≤150 ms in patients with amyloidosis has been shown to correlate with a higher risk of cardiac death over an 18-month period nearly five times greater than those patients with a deceleration time >150 ms. Similarly, 1-year cardiac survival of patients with an increased E/A ratio (≥2.1) was less than that of patients with normal or decreased E/A ratio (<2.1).

1. Klein AL, Hatle LK, Taliercio CP, et al. Prognostic significance of Doppler measures of diastolic function in cardiac amyloidosis: a Doppler echocardiography study. Circulation. 1991;83:808-816.