Mitral Annulus Motion

Mitral annular tissue Doppler imaging (TDI): it looks at how fast the mitral annulus itself moves during systole and diastole

Core message:

The most important part is the e′ wave

e′ = early diastolic mitral annular velocity. It reflects how well the LV myocardium actively relaxes and recoils in early diastole. A good e′ means the ventricle is “springing open” normally. A low e′ means impaired relaxation, often due to ageing, LV hypertrophy, ischaemia, fibrosis, hypertension, or cardiomyopathy

In this infographic:

e′ > 7 cm/s suggests preserved septal annular relaxation and therefore diastolic function is more likely to be normal, especially if the other diastolic markers are also reassuring

e′ < 7 cm/s suggests impaired LV relaxation. It does not automatically mean raised filling pressure, but it means the LV relaxes slowly, so we must look further at E/e′, LA volume, TR velocity, mitral inflow, and clinical context

What the waves mean

S′ is the systolic annular velocity. It reflects longitudinal systolic contraction of the LV. A low S′ may suggest impaired longitudinal systolic function, even when EF looks preserved

e′ is the early diastolic relaxation wave. It occurs just after mitral valve opening, when the LV should rapidly relax and lengthen. This is the key wave for relaxation

a′ is the late diastolic annular velocity caused by atrial contraction. In impaired relaxation, e′ often falls and a′ becomes relatively more prominent, because the ventricle relies more on atrial contraction for late filling

A simple teaching phrase would be:

'e′ tells us how well the ventricle relaxes; E/e′ tells us whether that impaired relaxation is associated with raised filling pressure'

Useful teaching addition:

Septal e′ ≥ 7 cm/s = reassuring

Lateral e′ ≥ 10 cm/s = reassuring

Average E/e′ > 14 = supports raised LV filling pressure

TR Vmax > 2.8 m/s and LAVI > 34 mL/m² add supportive evidence

Clinical interpretation

A reduced e′ is often the earliest echo sign of diastolic dysfunction, especially in patients with hypertension, LVH, diabetes, ageing myocardium or ischaemic disease. But e′ mainly tells us about relaxation, not pressure

So:

Low e′ + normal E/e′ + normal LA size + normal TR velocity = impaired relaxation but filling pressure may still be normal

Low e′ + high E/e′ + enlarged LA + high TR velocity = impaired relaxation with likely raised filling pressure.