basicIII.D-001
Name the four phases of diastole in order.
→ 1) Isovolumic relaxation. 2) Early rapid diastolic filling (E wave). 3) Diastasis. 4) Late filling from atrial contraction (A wave).
basicIII.D-002
Normal IVRT duration?
→ 50–100 ms. Prolonged (≥ 100 ms) with impaired relaxation; shortened (< 60 ms) with elevated filling pressures / severe diastolic dysfunction.
basicIII.D-003
State the four criteria in the ASE 2016 algorithm for elevated LV filling pressure in patients with NORMAL EF.
→ 1) E/e′ (average) > 14. 2) Septal e′ < 7 cm/s or lateral e′ < 10 cm/s. 3) TR peak velocity > 2.8 m/s. 4) LA volume index > 34 mL/m². Majority rules.
basicIII.D-004
How is diastolic function judged when 0, 2, or 3+ criteria are met in the Nagueh 2016 algorithm?
→ 0/4: normal diastolic function. 2/4: indeterminate — diastolic dysfunction present but grading ambiguous. 3+/4: elevated LV filling pressure (diastolic dysfunction).
basicIII.D-005
Grade I (impaired relaxation) diastolic dysfunction — key parameters.
→ E/A < 0.8, DT > 200 ms, IVRT ≥ 100 ms, e′ < 8, but E/e′ ≤ 8 and normal LA pressure (LVEDP not elevated). Grade I has abnormal relaxation but preserved filling pressure.
basicIII.D-006
Grade II ('pseudonormal') diastolic dysfunction — key parameters.
→ E/A 0.8–2.0, DT 150–200 ms, low e′ (< 8), E/e′ 9–14. Valsalva reduces E/A by ≥ 0.5. PV S < D. Represents impaired relaxation PLUS elevated LAP normalizing E/A appearance.
basicIII.D-007
Grade III (restrictive) diastolic dysfunction — key parameters.
→ E/A ≥ 2, DT < 150 ms, IVRT ≤ 60 ms, e′ < 5, E/e′ ≥ 15. PV D > S. Marked reduction in compliance with high LVEDP.
basicIII.D-008
What Valsalva finding distinguishes pseudonormal (Grade II) from truly normal filling?
→ With Valsalva (preload reduction), pseudonormal E/A drops by ≥ 0.5 (unmasks impaired relaxation as low E/A). Truly normal filling shows less change (ΔE/A < 0.5).
basicIII.D-009
Why is e′ (mitral annular tissue Doppler) considered preload-independent?
→ e′ reflects the intrinsic rate of myocardial lengthening during early diastole — a property of the myocardium itself — not the transmitral pressure gradient driving flow. Contrast with E, which is highly preload-dependent.
basicIII.D-010
Interpret a pulmonary vein Ar (atrial reversal) duration that exceeds the mitral A-wave duration by ≥ 30 ms.
→ Elevated LVEDP. When the LV is stiff, atrial contraction preferentially reverses more flow into the pulmonary veins than forward into the LV, giving a longer PVAr than mitral A duration.
basicIII.D-011
What is the significance of a mid-diastolic 'L wave' on mitral inflow Doppler?
→ A mid-diastolic flow signal between E and A that reflects markedly delayed relaxation with elevated filling pressures. Its presence automatically implies at least Grade II diastolic dysfunction.
basicIII.D-012
How does aging normally change the mitral E/A ratio?
→ E velocity decreases, DT prolongs, A velocity increases. E/A > 1 in young adults, ≈ 1 at age 50–60, < 1 in older adults. This is 'physiologic' impaired relaxation, not pathologic.
basicIII.D-013
How do you assess diastolic filling pressure in atrial fibrillation?
→ Cannot use A-wave. Use: DT (< 160 ms with reduced EF is specific), E acceleration rate > 1900 cm/s², IVRT ≤ 65 ms, E/e′ ≥ 11, and TR velocity.
basicIII.D-014
Why is E/e′ often unreliable in patients with LBBB or CRT? What alternatives should you use?
→ Dyssynchronous septal motion distorts septal e′. Use TR peak velocity, PV atrial reversal duration, and LA volume index instead.
basicIII.D-015
In HCM, which parameters are recommended for diastolic assessment?
→ E/e′ > 14, TR velocity > 2.8 m/s, LAVI > 34 mL/m², PV Ar−A duration ≥ 30 ms. Majority rules.
basicIII.D-016
When should diastolic function assessment be avoided?
→ Significant MR or AR (loading conditions overwhelm the signal), LVAD support, sinus tachycardia with E-A fusion, or absent atrial contraction (post-MAZE stunning, extensive atrial scar) though electrical p-wave present.
basicIII.D-017
Give three ways elevated LV filling pressure appears on pulmonary vein Doppler.
→ 1) S < D (pulmonary vein systolic-to-diastolic reversal). 2) Ar velocity ≥ 0.35 m/s. 3) Ar duration exceeds mitral A duration by ≥ 30 ms.
basicIII.D-018
How does severe LV systolic dysfunction alter mitral inflow?
→ With reduced compliance and elevated LAP, mitral inflow appears restrictive: high E velocity, short DT (< 150 ms), reduced A wave, high E/e′ (≥ 15). Behaves like Grade III diastolic dysfunction.
basicIII.D-019
State the septal and lateral e′ cutoffs used in the Nagueh 2016 algorithm.
→ Septal e′ < 7 cm/s OR lateral e′ < 10 cm/s. Average e′ used with E/e′ ratio.
basicIII.D-020
What is the normal LA volume index upper limit?
→ ≤ 34 mL/m². Values above this suggest chronic elevation of LA pressure.
basicIII.D-021
Give four non-diastolic-dysfunction causes of LA enlargement.
→ 1) Chronic AF. 2) Chronic mitral valve disease (MR/MS). 3) Athlete's heart (physiologic remodeling). 4) High-output states / anemia. Also: measurement error, hypertension, obesity.
basicIII.D-022
How does mitral annular calcification (MAC) affect diastolic assessment, and what do you use instead?
→ MAC distorts and blunts e′. Use IVRT and the second (non-e′) part of the algorithm; combine with TR velocity, LAVI, and PV Doppler.
basicIII.D-023
How does increased preload affect the mitral E, IVRT, and deceleration slope?
→ ↑ E velocity, ↓ IVRT, and a steeper deceleration slope (shorter DT). Pattern can mimic pseudonormal or restrictive filling.
basicIII.D-024
For a patient with reduced EF, what mitral inflow pattern indicates severe restriction and predicts poor prognosis?
→ E/A ≥ 2 with DT < 150 ms (restrictive filling). This pattern in HF portends worse prognosis; reversal to non-restrictive with therapy improves outcomes.
basicIII.D-025
State the normal septal and lateral e′ values in a healthy adult.
→ Septal e′ ≥ 7 cm/s (typically 8–14). Lateral e′ ≥ 10 cm/s (typically 12–20). Lateral is always higher than septal.
basicIII.D-026
How does a pseudonormal (Grade II) mitral inflow pattern respond to Valsalva strain?
→ Reduces both preload (drops E velocity) and unmasks impaired relaxation. E/A drops by ≥ 0.5, revealing a Grade I (impaired relaxation) pattern. Truly normal filling shows less change (< 0.5 drop in E/A).
basicIII.D-027
How does severe MR distort diastolic function assessment?
→ MR augments LA volume and E velocity, artificially inflating parameters. E/e′ is unreliable in significant MR. Do not use standard diastolic algorithms in patients with more than moderate MR.
basicIII.D-028
When is E/e′ unreliable as an estimate of LV filling pressure?
→ HCM, MAC, mitral surgery/repair, LBBB with CRT, significant MR/MS or AR, LVAD, prosthetic mitral valve, sinus tachycardia with E-A fusion, and severe LVH. Combine with TR velocity, LAVI, and PV Ar-A duration.
basicIII.D-029
State the septal-e′ and lateral-e′ cutoffs for abnormal diastolic function.
→ Septal e′ < 7 cm/s. Lateral e′ < 10 cm/s. Average e′ < 9 cm/s. Lateral e′ is normally higher than septal (typically by 4–6 cm/s).
basicIII.D-030
What is the effect of ATRIAL FIBRILLATION on E, A, and E/e′?
→ A wave is absent. E velocity varies beat to beat. Average measurements over ≥ 5 beats. Use DT (< 160 ms with reduced EF), E acceleration rate (> 1900 cm/s²), IVRT (≤ 65 ms), and E/e′ (≥ 11) to estimate elevated LAP.
basicIII.D-031
How does isovolumic relaxation time (IVRT) change with diastolic dysfunction?
→ Impaired relaxation (Grade I): IVRT PROLONGED (≥ 100 ms). Pseudonormal (Grade II): IVRT 60–100 ms (relatively normal). Restrictive (Grade III): IVRT SHORTENED (≤ 60 ms) due to rapid equalization.
basicIII.D-032
How does a positive pulmonary vein Ar-A duration difference (≥ 30 ms) indicate elevated LVEDP?
→ In a stiff LV, atrial contraction cannot push blood forward efficiently, so more flow goes retrograde into the pulmonary veins (longer Ar duration) than forward into the LV (shorter mitral A duration).
basicIII.D-033
What tissue Doppler pattern of the mitral annulus is characteristic of Grade III (restrictive) diastolic dysfunction?
→ Very low e′ (< 5 cm/s) with high E velocity → very high E/e′ (≥ 15). Reflects near-complete loss of relaxation with markedly elevated LAP.
basicIII.D-034
Which chronic condition classically presents with 'age-appropriate' Grade I diastolic dysfunction pattern?
→ Aging alone in a healthy older adult (age 60+): E/A < 1, prolonged DT and IVRT, but E/e′ normal and no LA enlargement. Not pathologic — a normal age-related pattern.
basicIII.D-035
How does exercise or diastolic stress test unmask elevated filling pressures?
→ HFpEF patients may have normal resting E/e′ but exercise-induced rise. Exercise E/e′ > 14 at peak stress or immediately post-exercise identifies HFpEF. Also look for TR velocity increase > 3.4 m/s.
