Doppler and tissue Doppler in left ventricular diastolic dysfunction
Doppler and tissue Doppler in left ventricular diastolic dysfunction: Tissue Doppler image with colour kinesis in the inset. E/E’ of the medial mitral annulus is shown as 19.1, indicating type II left ventricular diastolic dysfunction. In diastolic dysfunction, as the relaxation of the ventricle is impaired, the velocity of medial mitral annulus is reduced so that the E/E’ ratio is increased. E wave is measured prior to tissue Doppler imaging and stored (see image below) so that the software application displays the E/E’ as soon as the E’ is measured.
E/E’ below 8 is considered normal while ratio above 15 is considered a feature of left ventricular diastolic dysfunction . E/E’ has been correlated with left atrial pressure as well, which is in fact the left ventricular filling pressure, which increases in left ventricular diastolic dysfunction.
There are also limitations for E/E’ in the assessment of left ventricular diastolic dysfunction. These situations are decompensated advanced systolic heart failure with large left ventricle. Broad QRS with abnormal septal motion, significant mitral regurgitation and presence of cardiac resynchronization therapy are all confounding factors .
Though the E/E’ ratio is increased in this case, there is no E/A reversal which is the more commonly used indicator of left ventricular diastolic dysfunction. When the E/A ratio is used, there could be several grades of left ventricular diastolic dysfunction. First the E/A ratio equalizes, then there is reversal as the A wave becomes taller than the E wave. E wave is early diastolic and A wave occurs after atrial systole. In more severe diastolic dysfunction, as the left atrial pressure becomes very high, the E wave becomes much taller than the A wave, with a sharp deceleration slope. This pattern is known as a restrictive pattern.