In 1988, Appleton et al. (1) investigated the relation between transmitral Doppler flow dynamics and invasively determined measurements of pressure and flow in a variety of heart diseases. Based on their findings, three abnormal transmitral flow patterns by Doppler echocardiography have been proposed: 1) impaired relaxation, 2) pseudonormal and 3) restrictive patterns that reflect the pathophysiology of left ventricular (LV) diastolic dysfunction (2,3) (Fig. 1). The impaired relaxation pattern is characterized by a long isovolumic relaxation time, slow deceleration of early filling (E) and high atrial filling (A) velocities, with a decreased E/A ratio. In this type of filling pattern, intracardiac pressures are unaffected, but less effective suction from LV relaxation results in a delayed and diminished left atrial (LA) to LV early diastolic pressure gradient, leading to a decreased E velocity and a prolonged E deceleration time.
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