Echocardiographic Assessment of Left Ventricular Diastolic Function

Definitions and Physiological Basis

The European Society of Cardiology recommends that E represents the early diastolic transmitral flow velocity measured by conventional Doppler echocardiography, reflecting the pressure gradient between the left atrium and left ventricle during early diastole 1
The E wave is influenced by left ventricular relaxation, restoring forces, and left atrial pressure at mitral valve opening (lengthening load) 1, 2
e' is the early diastolic mitral annular velocity measured by tissue Doppler imaging (TDI), primarily reflecting left ventricular relaxation with minimal influence from loading conditions when relaxation is impaired 3, 4

The American Heart Association suggests that the E/e' ratio is used to estimate left ventricular filling pressures, with values for average E/e' ratio < 8 usually indicating normal LV filling pressures, and values > 14 having high specificity for increased LV filling pressures 4, 5
The European Society of Cardiology recommends that e' should be measured at both septal and lateral mitral annulus sites, with proper sample volume positioning being critical for accurate measurement 4

The American College of Cardiology recommends that when E/A ratio ≤ 0.8 with peak E velocity ≤ 50 cm/sec, mean left atrial pressure is normal/low (grade I diastolic dysfunction), and when E/A ratio ≥ 2, left atrial pressure is elevated (grade III diastolic dysfunction) 1
The European Society of Cardiology suggests that for intermediate values, additional parameters including E/e' are needed for accurate assessment of diastolic dysfunction 1

The European Society of Cardiology notes that E/e' has limited accuracy in normal subjects, patients with heavy annular calcification, mitral valve disease, pericardial disease, and coronary artery disease with regional dysfunction 1, 4, 5
Different cutoff values apply depending on the sampling site (septal vs. lateral) 4
The correlation between E/e' and invasively measured filling pressures is modest (pooled correlation coefficient r = 0.56) 6

An E/E' ratio ≤8 indicates normal left ventricular filling pressures and confirms adequate decongestion, while values >15 definitively indicate elevated filling pressures and persistent congestion 7, 8, 9
The European Society of Cardiology recommends measuring e' at both septal and lateral mitral annulus positions and calculating the average for optimal assessment of global diastolic function 10
Septal e' values <8 cm/s, lateral e' <10 cm/s, or average e' <9 cm/s indicate delayed LV relaxation 7, 8

E/E' <8 indicates normal LV filling pressures and confirms the patient is well-decongested 7, 8, 9
E/E' >15 indicates high LV filling pressures and persistent congestion requiring continued diuresis 7, 8, 9, 11
Values between 8-15 are indeterminate and require additional parameters to assess filling pressures, such as left atrial volume index >34 mL/m² 11, 9, tricuspid regurgitation peak velocity >2.8 m/s 9, or mitral inflow E/A ratio >2 7, 8

Heavy mitral annular calcification, mitral valve disease, pericardial disease, regional wall motion abnormalities, and atrial fibrillation may limit the accuracy of E/E' ratio 10, 11, 8
The correlation between E/e' and invasively measured filling pressures is modest (r = 0.56), highlighting the need to integrate E/E' with other clinical and echocardiographic parameters 11, 9

The European Society of Cardiology recommends calculating the E/e' ratio using the E velocity and e' velocity values, with a normal e' septal value of ≥7 cm/s and a normal e' lateral value of ≥10 cm/s 12, 13

The E/A ratio is extremely elevated at 17.77, suggesting a restrictive pattern (Grade III diastolic dysfunction), with an E/A ratio of ≥2 typically indicating elevated left atrial pressure and Grade III diastolic dysfunction 12
The MV Peak A value is abnormally low at 0.04 m/s, possibly indicating minimal atrial contribution 12

The European Society of Cardiology recommends requesting a complementary echocardiogram with tissue Doppler specific to the mitral annulus to obtain the e' septal and lateral velocities, which are essential for evaluating left ventricular filling pressures in this patient with a suggestive mitral flow pattern of advanced diastolic dysfunction 12, 13

The European Heart Journal (2015) states that the E/e′ ratio cannot be reliably calculated without directly measuring early diastolic mitral annular velocity (e′) using tissue‑Doppler imaging of the mitral annulus. 14

Deceleration time (DT) of early transmitral flow is normally 142–258 ms in individuals older than 60 years. 14
Age‑adjusted normal e′ velocities for patients > 60 years are ≥6.2 cm/s at the septal annulus and ≥5.9 cm/s at the lateral annulus. 14

An E/e′ < 8 is considered normal, whereas an E/e′ > 14 indicates elevated left‑ventricular filling pressures. 14
In hypertensive patients, an E/e′ ≥ 15 independently predicts adverse cardiovascular outcomes. 14

e′ should be obtained at both septal and lateral mitral annulus positions. 14
When regional left‑ventricular dysfunction is present, the average of septal and lateral e′ values provides the most accurate assessment. 14

The 2015 European Heart Journal guideline specifically recommends incorporating E/e′ measurement into the evaluation of cardiac target‑organ damage and left‑ventricular filling pressures. 14