E Wave

The transmitral Doppler shows an E wave exceeding the A wave in velocity. This finding, by itself, in a patient with heart disease, is not very helpful, as it can represent either normal or “pseudonormal” filling. The former is associated with normal filling pressures, the latter with elevated filling pressures. Therefore, more data are necessary to evaluate filling pressures. These data are usually furnished by inspecting the pulmonary vein spectral Doppler, tissue Doppler of the mitral annulus, or, ideally, both. The duration of the transmitral A wave is 130 msec (Figure 7); the duration of the pulmonary vein diastolic A reversal velocity is roughly 200 msec (Figure 8); the A reversal velocity is high (roughly 50 cm/sec). When the pulmonary venous A duration exceeds the mitral A duration by more than 50 msec, it is indicative of an elevation of the LV end-diastolic pressure exceeding 15 mm Hg (see Figure 234 in the Echocardiography Syllabus).To obtain an estimate of LA pressure, one should inspect the transmitral E velocity and the tissue Doppler E’. These values are approximately 120 and 9 cm/sec. The quotient E/E’ is therefore 13, which is an intermediate value (between 10 and 15), suggestive of mild elevations in LA pressure. While LA and LV diastolic pressures do track together, there are instances where the mean LA (or pulmonary capillary wedge pressure) can be lower than the post-A wave LV end-diastolic pressure. This may be seen in instances where the LV has very poor compliance (e.g., coronary heart or hypertensive heart disease) and there is a large increment in pressure following atrial contraction. Such a patient might be expected to fare poorly with the onset of atrial fibrillation, as this “booster function” may serve to preserve ventricular fiber stretch despite only modest elevation in LA pressure. Therefore, of the choices given, option C comes closest to describing the clinical findings.

(nothing short of fascinating)