Association of Left Ventricular Filling Parameters Assessed by Pulsed Wave Doppler and Color M-Mode Doppler Echocardiography With Left Ventricular Pathology, Pulmonary Congestion, and Left Ventricular End-Diastolic Pressure Ehud Schwammenthal, MD, Bogdan A. Popescu, MD, Andreea C. Popescu, MD, Elio Di Segni, MD, Victor Guetta, MD, Shmuel Rath, MD, Michael Eldar, MD, and Micha S. Feinberg, MD Among 90 consecutive patients with various degrees of left ventricular (LV) dysfunction (normal patients, LV hypertrophy, LV ejection fraction <50%, and <30%), the mitral valve pulse-wave E/A ratio showed a char- acteristic U-shaped curve with increasing severity of LV dysfunction. In contrast, there was a significant progressive decrease in flow propagation velocity of the E-wave (Vp) and a significant increase in E/Vp values with increasing severity of LV dysfunction. The E/Vp ratio was the best predictor of pulmonary con- gestion, and in a subgroup of patients who under- went cardiac catheterization, it was the only signifi- cant predictor of LV end-diastolic pressure. 2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;94:488 – 491) L eft ventricular (LV) diastolic dysfunction has been recognized as a major cause of heart failure in patients with and without significant systolic dysfunc- tion. Its noninvasive assessment is an important goal, yet remains elusive, because opposing effects of im- paired relaxation and filling pressures on the transmi- tral flow pattern confound its interpretation. As a result, the significance of any given E/A ratio mea- sured by mitral valve pulse-wave Doppler cannot be determined unambiguously without additional infor- mation or maneuvers that vary preload. 1,2 The propa- gation velocity of the E wave, as assessed by color Doppler M-mode, has been demonstrated to be a mea- sure of ventricular relaxation, 3 which is essentially independent of preload. 4 We sought to determine which noninvasive assessment—pulse-wave Doppler or color M-Mode Doppler, or their combination—shows the closest association with the severity of LV pathology and clinical events of pulmonary congestion. ••• One hundred twenty consecutive subjects referred to our echocardiography laboratory were examined. Patients in atrial fibrillation, with first-degree atrio- ventricular block, a prosthetic mitral valve, mitral stenosis, significant aortic stenosis, previous coronary bypass grafting, or inadequate echocardiographic im- ages were excluded. The remaining 90 patients (71 men; mean age 56  17 years, range 18 to 94) represent the study group. LV pathology was graded as follows: normal (n = 25) in subjects without a history and symptoms of cardiovascular disease, with- out cardiac medications, and having a normal echo- cardiographic study; LV hypertrophy, in patients with a mean wall thickness 11 mm and an ejection frac- tion 50% (n = 24); LV ejection fraction 30% and 50% (n = 20); and LV ejection fraction 30% (n = 21). Pulmonary congestion events were retrospectively adjudicated by reviewing all pertinent data, as de- scribed by Gottdiener et al. 5 Thus, all patients with a a history of 1 episode of pulmonary congestion were identified. A complete echocardiographic study was carried out according to the guidelines of the American So- ciety of Echocardiography 6 with measurements per- formed blinded to clinical data. Three optimal beats were averaged for assessment of each Doppler vari- able. The mitral inflow velocity was recorded using pulse-wave Doppler with a 1- to 2-mm sample volume at the tips of the mitral leaflets. The color Doppler From the Heart Institute, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; ”Prof. Dr. C.C. Iliescu” Institute of Cardiovascular Diseases, Bucharest, Ro- mania; and Cardiology Department, Elias Hospital, Bucharest, Roma- nia. This study was supported by a grant from the Israel Science Foundation, Jerusalem, Israel. Dr. Schwammenthal’s address is: Heart Institute, Sheba Medical Center, Tel Hashomer 52621, Israel. E-mail: sehud@post.tau.ac.il. Manuscript received November 19, 2003; re- vised manuscript received and accepted April 20, 2004. FIGURE 1. The slope of color M-mode velocity propagation in the left ventricle. (A) Normal and (B) severe LV dysfunction. 488 ©2004 by Excerpta Medica, Inc. All rights reserved. 0002-9149/04/$–see front matter The American Journal of Cardiology Vol. 94 August 15, 2004 doi:10.1016/j.amjcard.2004.04.065