REVIEW ARTICLE Diastolic Function: A Sonographer’s Approach to the Essential Echocardiographic Measurements of Left Ventricular Diastolic Function Gregory Gilman, BSN, RDCS, FASE, Tishri A. Nelson, BA, RDCS, William H. Hansen, MMS, RDCS, FASE, Bijoy K. Khandheria, MD, and Steve R. Ommen, MD, Rochester, Minnesota, and Scottsdale, Arizona Noninvasive assessment of left ventricular filling pres- sures by echocardiography has been validated by in- vasive hemodynamic studies and correlated with clin- ical findings. A comprehensive echocardiographic examination based on the referral diagnosis and pa- tient symptomatology routinely includes efforts to measure specific parameters of left ventricular dia- stolic function. We provide a step-by-step approach to goal-directed echocardiographic assessment of dia- stolic function. (J Am Soc Echocardiogr 2007;20: 199-209.) Echocardiographic assessment of diastolic function has advanced considerably from early research ef- forts that associated M-mode assessment of mitral valve (MV) motion with left ventricular (LV) filling pressures. 1-4 More recently, there have been sub- stantial advances in the noninvasive echocardio- graphic assessment of diastolic function, enabling the determination of LV filling pressures by using a comprehensive 2-dimensional (2D) and Doppler ex- amination. 5-8 A widening knowledge base and in- creased access to echocardiography have positioned the echocardiogram as the diagnostic modality of choice in the clinical treatment of patients with heart failure. 9 Imaging Views and Techniques The echocardiographic acquisition of diastolic pa- rameters is best accomplished when integrated within a standardized examination. Current state-of- the-art assessment of LV diastolic function is ac- quired from the apical tomographic imaging planes. Specifically, the sonographer presents api- cal 4-chamber, 2-chamber, and apical long-axis views that include the LV and the left atrium (LA). Every effort should be made to limit foreshortened imaging of the chambers to provide the reviewer with a visual assessment of the relative sizes of 2D parameters, and with accurate acquisition of Dopp- ler hemodynamic measurements. Table 1 presents normal LV diastolic Doppler filling values and Ta- ble 2 presents sex-based reference values for the LA. 10 Tables 3 and 4 present suggestions for optimi- zation of 2D imaging and Doppler acquisition during the diastolic assessment. An assessment of LV filling pressures using the data set presented in this article is possible by following the algorithm shown in Figure 1. METHODS AND RESULTS Assessment of LA Volume Increased indexed LA volumes, obtained at the end of LV systole, have been shown to have clinically signifi- cant correlation with chronically elevated LV filling pressures. 11,12 Apical 4- and 2-chamber views allow acquisition of the required measurements needed to calculate LA volumes either by Simpson vs rule or the area-length method. 10,13,14 Whereas LA volume deter- mination by Simpson vs rule is accomplished by using the onboard calculation software of the ultrasound machine, the area-length method can be derived using the following equation: 0.85 4-chamber area (cm 2 ) 2-chamber area (cm 2 )/shortest length (cm) (Figure 2). To avoid an overestimation of LA volume, measure- ments must avoid inclusion of the MV tenting area, the LA appendage, and the pulmonary veins (Figure 3). As with all echocardiographic imaging, accurate volumes require appropriate optimization of 2D images that are not foreshortened or rotated out of the proper plane. From the Divisions of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, and Scottsdale, Arizona (B.K.K.). Reprint requests: Bijoy K. Khandheria, MD, Division of Cardio- vascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259. 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2006.08.005 199
Transcript
REVIEW ARTICLE
Diastolic Function: A Sonographer’s Approachto the Essential EchocardiographicMeasurements of Left Ventricular
Diastolic FunctionGregory Gilman, BSN, RDCS, FASE, Tishri A. Nelson, BA, RDCS,William H. Hansen, MMS, RDCS, FASE, Bijoy K. Khandheria, MD,
and Steve R. Ommen, MD, Rochester, Minnesota, and Scottsdale, Arizona
Noninvasive assessment of left ventricular filling pres-sures by echocardiography has been validated by in-vasive hemodynamic studies and correlated with clin-ical findings. A comprehensive echocardiographicexamination based on the referral diagnosis and pa-
doi:10.1016/j.echo.2006.08.005
measure specific parameters of left ventricular dia-stolic function. We provide a step-by-step approach togoal-directed echocardiographic assessment of dia-stolic function. (J Am Soc Echocardiogr 2007;20:199-209.)
tient symptomatology routinely includes efforts to
Echocardiographic assessment of diastolic functionhas advanced considerably from early research ef-forts that associated M-mode assessment of mitralvalve (MV) motion with left ventricular (LV) fillingpressures.1-4 More recently, there have been sub-stantial advances in the noninvasive echocardio-graphic assessment of diastolic function, enablingthe determination of LV filling pressures by using acomprehensive 2-dimensional (2D) and Doppler ex-amination.5-8 A widening knowledge base and in-creased access to echocardiography have positionedthe echocardiogram as the diagnostic modality ofchoice in the clinical treatment of patients withheart failure.9
Imaging Views and Techniques
The echocardiographic acquisition of diastolic pa-rameters is best accomplished when integratedwithin a standardized examination. Current state-of-the-art assessment of LV diastolic function is ac-quired from the apical tomographic imagingplanes. Specifically, the sonographer presents api-cal 4-chamber, 2-chamber, and apical long-axisviews that include the LV and the left atrium (LA).Every effort should be made to limit foreshortenedimaging of the chambers to provide the reviewerwith a visual assessment of the relative sizes of 2D
From the Divisions of Cardiovascular Diseases, Mayo Clinic,Rochester, Minnesota, and Scottsdale, Arizona (B.K.K.).Reprint requests: Bijoy K. Khandheria, MD, Division of Cardio-vascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ85259.0894-7317/$32.00Copyright 2007 by the American Society of Echocardiography.
parameters, and with accurate acquisition of Dopp-ler hemodynamic measurements. Table 1 presentsnormal LV diastolic Doppler filling values and Ta-ble 2 presents sex-based reference values for theLA.10 Tables 3 and 4 present suggestions for optimi-zation of 2D imaging and Doppler acquisition duringthe diastolic assessment. An assessment of LV fillingpressures using the data set presented in this articleis possible by following the algorithm shown inFigure 1.
METHODS AND RESULTS
Assessment of LA Volume
Increased indexed LA volumes, obtained at the end ofLV systole, have been shown to have clinically signifi-cant correlation with chronically elevated LV fillingpressures.11,12 Apical 4- and 2-chamber views allowacquisition of the required measurements needed tocalculate LA volumes either by Simpson vs rule or thearea-length method.10,13,14 Whereas LA volume deter-mination by Simpson vs rule is accomplished by usingthe onboard calculation software of the ultrasoundmachine, the area-length method can be derived usingthe following equation: 0.85 � 4-chamber area (cm2) �2-chamber area (cm2 )/shortest length (cm) (Figure 2).To avoid an overestimation of LA volume, measure-ments must avoid inclusion of the MV tenting area, theLA appendage, and the pulmonary veins (Figure 3). Aswith all echocardiographic imaging, accurate volumesrequire appropriate optimization of 2D images that are
not foreshortened or rotated out of the proper plane.
199
Journal of the American Society of Echocardiography200 Gilman et al February 2007
Pulsed Wave Doppler Interrogation of MitralInflow Velocities
In patients with a regular in sinus rhythm and clinicallyinsignificant MV disease, Doppler measurements of the trans-mitral inflow velocities have been shown to correspond wellwith hemodynamic studies of LV filling pressures. 5
Accurate transmitral inflow assessment is predicated onthe placement of the Doppler cursor along a line parallelwith blood flow. This alignment is best accomplished byacquiring an apical 4-chamber view without apical fore-shortening. The flow into the LV may be directed slightlytoward the lateral wall, and optimization of the Dopplersignal is accomplished by having the patient in a slightlysupine position to obtain a more lateral imaging windowthat better aligns blood flow with cursor placement. Colorflow imaging enables minimization of the angle of Dopp-ler interrogation during placement of the sample volume.Figure 4 shows incorrect placement of the sample vol-ume, whereas Figure 5 shows correct placement of thesample volume. These measurements are best obtained
Table 1 Age-corrected normal values for mitral inflowand pulmonary venous inflow Doppler velocity profiles
Normal values*
Parameter Age 21-49 y Age > 50 y
Mitral valve inflow (N � 61) (N � 56)Peak E velocity 72 � 14 62 � 14Peak A velocity 40 � 10 59 � 14E/A ratio 1.9 � 6 1.1 � 0.3Deceleration time, ms 179 � 20 210 � 36IVRT, ms 76 � 11 90 � 7
A, Mitral A wave; D, diastolic; E, mitral E wave; IVRT, isovolumic relaxationtime; S, systolic.*Values are mean � SD.Modified from Anderson B. Echocardiography: the normal examination andechocardiographic measurements. Australia: MGA Graphics; 2000. Usedwith permission.
Table 2 Age- and sex-based values of left atrial volumeassessment
Reference
Parameter range, y
WomenLA ESV, mL 22-52LA ESV index 22 � 6*
MenLA ESV, mL 18-58LA ESV index 22 � 6*
LA ESV, Left atrial end-systolic volume.*Values are mean � SD.Data from Lang et al.10
during short durations of held end expiration.
After the image is optimized, the acquisition of themitral E wave (E), the mitral A wave (A), and inflowdeceleration time by pulsed wave Doppler interrogationof mitral inflow is accomplished by placing the samplevolume at the level of the mitral leaflet tips as imagedduring mid-diastole. A minimal sample volume (1-2 mm)provides optimal signal acquisition. The duration of themitral A wave for comparison with the duration of thepulmonary vein atrial reversal (discussed below) are bestacquired by moving the cursor into the annular plane ofthe MV and decreasing low-level filters.
During sinus rhythm, the initial transmitral flow com-ponent, or MV-E velocity, represents a combination ofmultiple complex features that can be summarized asreflecting both LV filling pressure and early relaxation.The second flow component, or MV-A velocity, reflectslate diastolic filling of the LV during atrial contraction(after LV relaxation), which occurs during the PR intervalof the electrocardiogram (Figure 6). The MV-A velocityand the comparison of the duration of MV-A with theduration of pulmonary venous atrial reversal reflect end-diastolic LV filling characteristics (Figure 7). The timebetween the completion of systole as indicated by aorticvalve closure and the onset of mitral flow represents aphase of the cardiac cycle with no change in volume. Thisinterval is referred to as the isovolumic relaxation time. Itcan be obtained by placing the continuous wave Dopplercursor between the LV outflow tract and the mitral inflowregions of the LV to reveal a closing click of the aorticvalve and onset of flow through the MV. In this manner,systolic and diastolic flow phenomena for the valves canbe acquired simultaneously (Figure 8).
Pulsed Wave Doppler Interrogation of MitralAnnular Velocities
During the cardiac cycle, diastolic motion at the atrioven-tricular interface or cruces has been shown to correlatewith ventricular filling.8,15 To assess this motion, thesonographer acquires a low-velocity pulsed Doppler sam-pling of the medial or lateral mitral annulus motion duringdiastole using a 5-mm gate-pulsed wave sample volume toyield an early mitral annulus diastolic velocity (E=) (Figure9). The E= itself correlates with invasive measures ofmyocardial relaxation and is relatively load independent. Itis most commonly combined with the MV-E pulsed waveDoppler velocity (MV-E velocity) into the MV-E velocity/E=, or E/E= (Figure 10). The E/E= is an indicator of LV fillingpressures. The use of E= may not be a true indicator ofventricular filling when there are wall-motion abnormali-ties in the basal septal or lateral LV wall segments,constriction, or previous cardiac surgery in this region (eg,valve replacement, annular reconstruction, or septal my-ectomy) and it should, therefore, be used as part of acomprehensive evaluation. Normal values for mitral annu-lus velocities derived by Doppler tissue imaging arepresented in Table 5.16,17
At this point in the examination, after all baseline LVfilling characteristics have been defined, the Valsalva
maneuver may be used. When used during acquisition of
Journal of the American Society of EchocardiographyVolume 20 Number 2 Gilman et al 201
the mitral inflow Doppler velocity signals, the Valsalvamaneuver has been found to effectively unload the heartand clarify any filling characteristics that occur because ofelevated LV filling pressure.19-21 An absolute decrease inthe mitral E-wave/A-wave (E/A) ratio of 0.5 can predict anelevation of LV filling pressure (specificity, 100%).8
Briefly, this maneuver is accomplished first by the cessa-tion of breathing at any point in the respiratory cyclewhen assessment of mitral inflow is optimized. Next, theparticipant exerts a firm contraction of the abdominalmuscles to force air against the closed glottis, therebyincreasing intrathoracic pressure. This action results in adecrease in both right ventricular and LV filling as a resultof an increased thoracic-to-extrathoracic pressure gradient.The mitral inflow pattern is observed for changes during live
Figure 1 Algorithm depicting assessment of left vhensive diastolic assessment. DT, Deceleration timearly filling wave to early mitral annulus velocityOmmen, et al7.
Table 3 Optimization of mitral inflow and mitral annular
Measurement View
Mitral inflow Ap 4, Ap LAXMV-E velocityMV-A velocityDeceleration timeMV-E velocity with Valsalva maneuverMV-A velocity with Valsalva maneuverDeceleration time with Valsalva maneuver
Ap 4, Apical 4-chamber; Ap LAX, apical long-axis; E=, early mitral annulusPW, pulsed wave.
Table 4 Optimization of apical 4- and 2-chamber left atria
Measurement View
LA ESVAp 4-chamberAp 2-chamber
Ap 4Ap 2
Obtvi
ObtTrac
in
Ap, Apical; ESV, volume at end left ventricular systole; LA, left atrial; P, pu
2D monitoring of the placement of the Doppler sample
volume. After the image has stabilized, the 2D update may beturned off to optimize the Doppler signal presentation.
Depending on the patient’s tolerance, the sonographershould encourage continuation of the Valsalva maneuver for15 seconds so that associated hemodynamic effects willmanifest in Doppler waveforms. Within an entirely digitizedlaboratory format, numerous waveform images may be ob-tained either as they occur or from the cine loop. Compar-ative examples of mitral inflow obtained during rest andresponse to Valsalva are provided in Figure 11 (normal) andFigure 12 (abnormal).
Pulsed Wave Doppler Interrogation of PulmonaryVenous Flow
Doppler measurements of the pulmonary venous veloci-
ular filling pressures using data set from compre-A, mitral inflow E/A ratio; E/E=, ratio of mitraljection fraction; LA, left atrial. (Modified from
er signal acquisition
Imaging tip
n Doppler interrogation along flow propagation using color flowaging
e PW sample volume (sized at 1 mm) at MV leaflet tipst Doppler filter to lowest settinghigher sweep speeds to measure time intervals and decelerationes; use shorter sweep speeds to assess respiratory variations in
w patternsn Doppler interrogation along line of annular descente PW Doppler sample volume (sized at 5 mm) where it will registerotion of annulusst Dopper scale and filter to lowest settings
; MV, mitral valve; MV-A, mitral valve A wave; MV-E, mitral valve E wave;
e acquisitions and measurements
Imaging tip
imized Ap reference view, then obtain measurements from zoomody of atriumorthogonal views of left atriumcurvature of atrium, avoiding errant volume measurements thatvein(s), LA appendage, or both
.
entrice; E/
; EF, e
lmonary
Doppl
Aligim
PlacAdjuUse
timflo
AligPlac
mAdju
diastolic
l imag
ain optew of bain twoe alongclude P
ties have been shown to correspond well with hemody-
Journal of the American Society of Echocardiography202 Gilman et al February 2007
namic studies of LV filling pressures in patients with aregular sinus rhythm, no evidence of first-degree atrioven-tricular block, no clinically significant MV stenosis orregurgitation, and no MV prosthesis.10,22,23 Within anoptimized view of the LA, enlarged from apical 4-chamberimaging, a color flow–guided, 3- to 5-mm gate-pulsedwave Doppler sample volume is placed 1 to 2 cm into thelumen of the right upper pulmonary vein (Figure 13).Reduction of the low-level filter and slight adjustments ofthe probe angle of interrogation are used to enhancevisualization of pulmonary venous flow. Doppler gain and
Figure 2 Apical 4-chamber (4-Ch) and 2-chamber viewsdemonstrating correct tracing and length measurements ofleft atrial (LA) endocardial border measured at end-ventric-ular systole when LA chamber is at greatest dimension.Note that trace excludes pulmonary veins and LA appendage.
Figure 3 Apical 4-chamber (4-Ch) and 2-chamber (2-Ch)views depicting correct and incorrect area tracings andlength measurements of left atrial (LA) endocardial borderfor calculation of LA volume. Note clinically significanterror in volume calculation caused by inclusion of pulmo-nary vein and LA appendage areas. BSA, Body surface area.
filter settings are optimized to facilitate the clearest de-
marcation of velocity profiles. Thus, the measurements offlow velocities and durations are enabled.
The measurements of pulmonary venous flow includethe atrial reversal velocity and atrial reversal duration andthe systolic and diastolic inflow velocities. When there isa biphasic systolic velocity pattern, the peak systolicvelocity is recorded. Using the electrocardiogram tracingas a guide to the electromechanical relationships of car-diac function, the echocardiographer can assess Dopplervelocities as events within carefully delineated cardiactimings (Figure 14). With an established impact of in-creased intrathoracic pressures on left-sided diastolic fill-ing in some patients, convention dictates that thesemeasurements be obtained during short durations of heldend expiration to minimize the effects of changes in
Figure 4 Apical pulsed wave interrogation of mitral inflowusing color flow Doppler guidance to demonstrate im-proper alignment with blood flow. Note lack of crisp modalvelocity profiles.
Figure 5 Optimized apical pulsed wave interrogation ofmitral inflow using color flow Doppler guidance (samepatient as in Figure 4). Note how proper alignment ofDoppler interrogation with direction of blood flow resultsin crisp modal velocity envelope that facilitates measure-ment of deceleration time and peak velocities.
intrathoracic pressures on intracardiac pressures.8 This
Journal of the American Society of EchocardiographyVolume 20 Number 2 Gilman et al 203
method affords optimization of the spectral Doppler dis-play. Values of differences between mitral A wave dura-tions and pulmonary venous atrial reversal durations aspredictors of elevated LV end-diastolic pressures are pre-
Figure 6 Apical pulsed wave interrogation of mitral inflowusing color flow Doppler guidance demonstrates mitralE wave (E), A wave (A), and deceleration time (D, dottedline). Arrow, Proper placement of sample volume at mitralleaflet tips and alignment of Doppler interrogation withblood flow.
Figure 7 Apical pulsed wave interrogation of mitral inflowusing color flow Doppler guidance demonstrates durationof mitral A wave (A) and corresponding measurement ofpulmonary vein atrial reversal duration (B). C, Singlearrow, Proper placement of Doppler sample volume nearannular plane of mitral valve and alignment of Dopplerinterrogation with direction of blood flow. (See Figure 13for pulmonary venous flow acquisition.)
sented in Table 6.
Diastolic Assessment of ConstrictivePericardial Disease
An important group of echocardiographic diagnoses thatrequire recognition of specific filling parameters resultsfrom pericardial disease. With substantial pericardial fluidor pericarditis, the normally compliant pericardium iseither distended (as in the former process) or diseased toa degree of noncompliance (as in the latter). Pericardialconstraint produces a dissociation of intracardiac andintrathoracic pressures that in turn produces a distinct andabnormal set of 2D and Doppler findings. The 2D findingconsistent with the presence of a dissociation of pressuresis a shifting of the ventricular septum toward the LVduring the inspiratory phase of respiration. This septalshift may be observed in the parasternal long- and short-axis imaging planes, and in the apical 4-chamber view(Figure 15). Thus, it is important to record the imageswith a respirometer to document the timing of the septalshift during the inspiratory phase of respiration.
Doppler evidence of pericardial disease can be demon-strated by interrogation of the mitral inflow and mitralannular velocity profiles.30 Figure 16 illustrates theblunted transmitral diastolic filling that occurs during theinspiratory phase of respiration and the exaggerated mitralannular velocities that occur because of pericardial con-
Figure 8 Measurement of apical continuous wave Dopplerinterrogation of isovolumic relaxation time (A), acquiredalong region of mitral-aortic intervalvular fibrosa.
straint. Annulus paradoxus has been shown to occur
Journal of the American Society of Echocardiography204 Gilman et al February 2007
when there is constriction with higher than expected E=velocities and resultant normalization of the MV-E/E= ratio.This normalization is not reflective of normal filling pres-sures; instead, it indicates the accentuated coronal motionof the annulus caused by constricted cardiac structureswith high filling pressures.31,32
DISCUSSION
Our step-by-step approach and image-optimizingsuggestions may be used to facilitate the essentialechocardiographic diastolic assessment. A list of the
Figure 9 Demonstration of apical 4-chamber tissue Dopp-ler acquisition by placement of sample volume at interven-tricular crux at end-ventricular systole so that crux movesthrough sample volume during diastolic portion of cardiaccycle. Examples of excessive Doppler gain (A), excessivefilter setting (C), and optimal Doppler gain and filtersettings (B) for waveform acquisition.
Figure 10 Apical pulsed wave interrogation of mitral in-flow using color flow Doppler guidance demonstratingearly filling (MV-E velocity), late filling (MV-A velocity),calculation of MV-E/A ratio, and tissue Doppler earlymitral annulus diastolic velocity (E=) with calculation ofMV-E/E= ratio. MV, mitral valve.
measurements and their corresponding views and
related imaging suggestions are provided in Tables 3and 4. The comprehensive echocardiogra m shouldinclude an assessment of diastolic function. Anacquisition of diastolic filling parameters, readilyobtainable in most patients, provides the reviewingechocardiographer with the necessary data to assessdiastolic function.33 Data interpretation is ultimatelythe responsibility of the reviewing echocardiologist.However, a sonographer who has an understandingof diastolic function is best qualified to produce acomprehensive diastolic examination that facilitatesaccurate interpretation.
Editing, proofreading, and reference verification were pro-vided by the Section of Scientific Publications, Mayo Clinic.
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SUPPLEMENTARY DATA
Supplementary data associated with this article canbe found, in the online version, at doi:10.1016/j.
lar velocity; Sm, peak systolic mitral annular velocity; NR, not reported.
ral annulus from apical 4- and 2-chamber views.cardiographic measurements. Australia: MGA Graphics; 2000. Used with
Figure 11 Apical pulsed wave interrogation of mitral in-flow (A) and mitral annular velocity (B) during resting stateof breathing (or held end expiration) and of mitral inflow(C) during Valsalva maneuver demonstrating MV-E/earlymitral annulus diastolic velocity (E=) ratio of 12 and noclinically significant change in mitral E/A ratio with ma-neuver. Note placement of sample volume at level of mitralleaflet tips aligned with direction of blood flow. (See Figure9 for tissue Doppler acquisition technique.) MV, mitral
Table 5 Normal values for mitral annulus velocities derived by D
Author (year) Patients, No. Sampling site
Sohn, et al (1997)18 59 Septal side Nagueh, et al (1997)19 34 Lateral side Farias, et al (1999)20 27 Average†
Am, Peak late diastolic mitral annular velocity; Em, peak early diastolic mitral annu*Values are mean � SD.†Obtained at basal lateral, septal, inferior, and anterior myocardial segments of mitModified from Anderson B. Echocardiography: the normal examination and echo
Journal of the American Society of EchocardiographyVolume 20 Number 2 Gilman et al 207
Figure 12 Apical pulsed wave interrogation of mitral inflow (A) and mitral annular velocity (B) duringresting state of breathing (or held end expiration) and of mitral inflow (C) during Valsalva maneuver.E/early mitral annulus diastolic velocity (E=) ratio is 23 and E/A ratio is reduced by 0.5. (See Figure 9 for
Figure 13 Apical pulsed wave interrogation of right upper pulmonary vein demonstrates proper place-
ment of pulsed wave sample volume 1 to 2 mm into pulmonary vein orifice.
Journal of the American Society of Echocardiography208 Gilman et al February 2007
Figure 14 Apical pulsed wave interrogation of right upper pulmonary vein (RUPV) with correspondingtime-velocity waveform demonstrates systolic (A) and diastolic (B) antegrade flow velocities and atrialreversal signal (D). C, Proper measurement of atrial reversal duration. (See Figure 9 for tissue Doppler
acquisition technique.) LA, Left atrium; MV, mitral valve.
Table 6 Value of difference between mitral A wave duration and pulmonary venous atrial reversal duration as a predictorof elevated left ventricular end-diastolic pressure
Author (year) Patients, No. PVa-A dur, ms LVEDP, mm Hg Sensitivity, % Specificity, %
Rossvoll, et al (1993)22 45 �0 �15 85 79Appleton, et al (1993)24 65 �20 �12 74 �95Cecconi, et al (1996)25 101 A dur/Pva � 0.9 �15
�20
7990
9690
Yamamoto, et al (1997)26 87 �0 �20 82 92Yamamoto, et al (1997)27 82 0 �15 73 83
25 46 970 �20 100 43
25 71 93O’Leary, et al (1998)28 186 �29 �18 90 86Sohn, et al (1999)29 43 �0 �20 67 85
LVEDP, Left ventricular end-diastolic pressure; PVa-A dur, pulmonary venous atrial reversal duration to mitral A velocity duration.
Modified from Anderson B. Echocardiography: the normal examination and echocardiographic measurements. Australia: MGA Graphics; 2000. Used withpermission.
Journal of the American Society of EchocardiographyVolume 20 Number 2 Gilman et al 209
Figure 15 Apical 4-chamber imaging demonstrates normal chamber size (A) during early diastole, and
right-to-left septal shift (arrows) during early diastole of following cardiac cycle with inspiration (B).
Figure 16 Apical pulsed wave interrogation of mitral in-flow and mitral annular velocities for patient with pericar-dial constriction. Note blunting of mitral inflow with firstbeat after onset of inspiration (A) compared with followingbeat (B) and early mitral annulus diastolic velocity of 0.17
