Evaluation of Diastolic Dysfunction

Mitral inflow shows how blood fills the LV.
Mitral annular TDI shows how the LV myocardium relaxes

The key insight is that mitral inflow changes dramatically with loading pressure, whereas mitral annular e′ remains a more direct marker of myocardial relaxation. The 2024 BSE diastolic function guidance makes the same central point: diastolic function must be assessed using multiple parameters because LV filling depends on relaxation, compliance, LA pressure, chamber interaction and loading conditions — not one Doppler trace alone

The top row: mitral inflow is “preload dependent”

The mitral inflow E and A waves are measured with pulsed-wave Doppler at the mitral leaflet tips

E wave = early passive LV filling

A wave = late filling caused by atrial contraction

In a young or normally relaxing LV, early suction is strong, so the E wave is taller than the A wave This gives a normal E/A pattern

When relaxation becomes impaired, the LV does not “spring open” efficiently. Early filling falls, so E becomes smaller, and the atrium has to contribute more at end-diastole, so A becomes larger. This is the classic impaired relaxation / Grade 1 pattern.

As disease progresses, the E wave rises again — not because relaxation has improved, but because LA pressure has increased. The raised LA pressure pushes blood into the LV more forcefully in early diastole, making the mitral inflow look “normal” again. This is pseudonormal filling / Grade 2

With more severe loss of compliance, LA pressure rises further, E becomes very tall, A becomes small, and the pattern becomes restrictive / Grade 3

Why pseudonormal is dangerous

In Grade 2, the mitral inflow may look deceptively similar to normal because E > A. But the physiology is completely different

In true normal filling, E is dominant because the LV relaxes well and sucks blood in at low pressure

In pseudonormal filling, E is dominant because the LA pressure is high and is forcing blood into a stiff, slowly relaxing LV

So the same-looking E/A pattern can mean two very different things:

• normal: good relaxation, low filling pressure

• pseudonormal: impaired relaxation, raised filling pressure

That is why mitral inflow alone is not enough

The bottom row: mitral annular velocity reveals the myocardium

The lower row shows tissue Doppler imaging of the mitral annulus:

e′ = early diastolic mitral annular velocity

a′ = annular motion during atrial contraction

This is the myocardial equivalent of E and A. It tells us how the annulus moves as the LV lengthens during diastole

In normal diastolic function, the annulus moves briskly in early diastole, so e′ is high and usually greater than a′

In impaired relaxation, e′ falls. This is the key teaching point: even when the mitral inflow E wave rises again because LA pressure is high, the myocardial relaxation velocity usually remains reduced. BSE specifically notes that with impaired LV diastolic function, e′ falls below a′, and although annular velocities are not completely load independent, they are much less load dependent than transmitral Doppler (because e′ can still be affected by loading, age, annular disease, regional dysfunction, mitral valve surgery, MAC, LBBB, pacing, pericardial disease and Doppler alignment. BSE highlights several of these limitations)

Mitral inflow tells ua the pressure gradient between LA and LV.
TDI e′ tells you whether the LV myocardium can relax.
When E rises but e′ stays low, suspect raised filling pressure

Where E/e′ fits

E is the transmitral pressure-driven filling signal

e′ is the myocardial relaxation signal

E/e′ tells you whether poor relaxation is occurring under high filling pressure

When E is high and e′ is low, the ratio rises. That means the LA is generating a high pressure to fill a poorly relaxing LV

BSE states that average E/e′ >14 is highly specific for raised LV filling pressure, while E/e′ <8 is specific for normal LV filling pressure. If only one annular site is valid, BSE gives septal E/e′ >15 or lateral E/e′ >13 as supportive thresholds.

Diastolic function should be interpreted with a structured approach, using relaxation markers, filling pressure markers, LA size/function, TR velocity, LV structure and the clinical setting

For a patient with preserved LVEF, the practical BSE-style interpretation should include:

Relaxation markers: e′, E/A pattern, deceleration time, possibly L wave

Filling pressure markers: E/e′, LA volume/index, TR velocity, pulmonary vein data if needed

Structural context: LVH, LA enlargement, valve disease, cardiomyopathy, age, rhythm and blood pressure.