04/12/2025
Role of Pulse-Wave Doppler at the Mitral Valve Annulus (Mitral Inflow) in LV Diastolic Dysfunction
Pulse-wave Doppler across the mitral valve inflow is one of the cornerstone methods to evaluate left ventricular diastolic function. It provides information about LV relaxation, LV compliance, and filling pressures. The PW sample is placed at the tips of the mitral valve leaflets (not inside the annulus), but the measurement reflects the diastolic behavior of the mitral annulus–LV interface.
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What Mitral Inflow PW Doppler Measures
The mitral inflow Doppler provides the following main parameters:
1. E wave velocity
Represents early LV filling.
Mainly influenced by LV relaxation and the pressure gradient between the LA and LV.
2. A wave velocity
Represents atrial contraction–mediated filling.
Depends on atrial contractility and LV end-diastolic pressure.
3. E/A ratio
Gives a global impression of relaxation and filling pattern.
4. Deceleration time (DT)
Time for the E wave to return to baseline.
Reflects the rate of fall of LA–LV pressure gradient → therefore proportional to LV stiffness/compliance.
5. Isovolumetric relaxation time (IVRT)
Time between aortic valve closure and mitral valve opening.
Represents relaxation speed.
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How Mitral Inflow Reflects Different Stages of Diastolic Dysfunction
1. Normal Pattern
E > A
E/A around 1–2
DT normal (160–240 ms)
This indicates normal relaxation and compliance.
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2. Grade I Diastolic Dysfunction (Impaired Relaxation)
E is reduced
A is increased (compensatory stronger atrial kick)
E/A < 1
IVRT is prolonged
DT is prolonged
This pattern suggests the LV relaxes slowly but is still compliant. LA pressure is normal or low.
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3. Grade II (Pseudonormal Pattern)
Here, relaxation is impaired, but LA pressure is elevated, which restores E wave amplitude and makes the transmitral flow appear "normal".
E/A appears normal (between 1–2)
DT normal
IVRT normal
BUT the patient actually has diastolic dysfunction.
It mimics normal inflow, so additional parameters like TDI e′, E/e′, LA volume, and TR velocity are needed to unmask it.
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4. Grade III (Restrictive Filling)
Markedly increased E
Very small A
E/A > 2
Short deceleration time (< 160 ms)
This means markedly stiff LV, very high LA pressure, and poor prognosis.
Sometimes the pattern is reversible (improves with Valsalva) or fixed.
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Physiological Meaning of Mitral Inflow Abnormalities
Impaired Relaxation (Grade I)
The LV takes longer to relax → smaller early filling E wave.
More filling occurs during atrial contraction → increased A wave.
Pseudonormal (Grade II)
Relaxation still impaired.
LA pressure rises → drives more early filling → falsely normal E wave.
Restrictive (Grade III)
LV is very stiff and noncompliant.
A massive E wave because blood is pushed rapidly from a highly pressurized LA.
A wave becomes small because LV is already full and noncompliant.
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Limitations of Mitral Inflow PW Doppler Alone
Strongly influenced by age
Affected by HR, arrhythmias (AF), and MR
Cannot distinguish Grade II without tissue Doppler (e′)
Therefore, it is never used alone in the 2016 or 2025 ASE/ESC guidelines.
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How Mitral Inflow PW Doppler Integrates With Other Parameters
To determine filling pressures and diastolic grade, mitral inflow must be combined with:
Tissue Doppler e′ (septal/lateral)
E/e′ ratio (reflects LV filling pressures)
LA volume index
TR jet velocity
Together, they form the standard ASE algorithm.
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Special Notes
In Atrial Fibrillation
A wave disappears
Use average of 5 beats
Assess:
DT
E wave velocity
Isovolumetric relaxation surrogates
LA volume
TR velocity
E/e′ average (from multiple cycles)
In Significant Mitral Regurgitation
E wave is falsely elevated
E/A is unreliable
DT may shorten due to increased volume
→ Must rely more on TDI and LA size.
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Key Takeaway
Mitral inflow PW Doppler is the starting point of diastolic evaluation.
It informs you about LV relaxation, compliance, and filling pattern, and helps classify diastolic dysfunction into Grades I, II, and III—but must be interpreted with TDI and other parameters for accuracy.
