14.3 Diastolic Function, Filling Pressure, Grading, and Pitfalls
Key Takeaways
- Acquire mitral inflow, septal and lateral e′, TR velocity or PASP, LA volume and function, and supplemental pulmonary-vein or IVRT data with rhythm, heart rate, and blood pressure documented.
- The 2025 ASE general algorithm estimates mean LA pressure using concordance among relaxation, E/e′, and PASP/TR evidence, then uses supplemental variables when the primary findings disagree.
- Grade 1 denotes impaired relaxation with normal mean LA pressure, whereas grades 2 and 3 require elevated mean LA pressure and are separated by mitral E/A below versus at least 2.
- Do not apply the general sinus-rhythm algorithm to AF, severe primary MR, MS, moderate/severe MAC, mitral repair or replacement, noncardiac PH, constriction, LVAD, or transplant patients; use population-specific guidance.
Acquire the dataset before choosing the pathway
CCI task D3 is to evaluate diastolic function. Record rhythm, heart rate, and blood pressure because relaxation and every Doppler pattern are load and rate dependent. Place PW at the mitral leaflet tips for E and A velocities, E/A ratio, E deceleration time, and A duration. Use a 5–10 mm tissue Doppler sample at both septal and lateral mitral annulus, aligned with longitudinal motion, for e′. Measure maximum LA volume by biplane disks, excluding pulmonary veins and appendage; acquire LA reservoir strain (LARS) at adequate frame rate when available. Obtain a complete TR CW envelope from multiple windows and estimate PASP only when both TR velocity and RA pressure are defensible.
Supplemental acquisition may include right upper pulmonary-vein PW for systolic/diastolic flow and atrial reversal, IVRT, PR end-diastolic velocity, and mitral L-wave. Match beats in irregular rhythm and avoid postectopic cycles. Confirm that E and A are not fused by tachycardia or first-degree AV block. Save Valsalva inflow continuously through strain when requested; a technically inadequate maneuver should not be interpreted as negative.
Apply the 2025 general sinus-rhythm algorithm
The pathway first asks whether relaxation is reduced: septal e′ at or below 6 cm/s, lateral e′ at or below 7 cm/s, or average e′ at or below 6.5 cm/s supports impaired relaxation, with age-specific limits also available. Then assess average E/e′ at least 14 and PASP at least 35 mmHg when RA pressure is known; if RA pressure cannot be estimated, peak TR velocity at least 2.8 m/s supports elevated mean LA pressure after excluding pulmonary parenchymal or vascular disease.
| Primary pattern | Interpretation or next step |
|---|---|
| e′, E/e′, and PASP/TR all normal | Normal diastolic function and normal mean LA pressure in the eligible population |
| All three meet abnormal thresholds | Elevated mean LA pressure; grade using E/A |
| Reduced e′ only with E/A at or below 0.8 | Grade 1 dysfunction with normal mean LA pressure |
| Only E/e′ or PASP/TR abnormal, any two abnormal, or reduced e′ with E/A above 0.8 | Use reliable supplemental pressure markers |
| Supplemental markers support elevation | Elevated mean LA pressure; E/A below 2 gives grade 2, E/A at least 2 gives grade 3 |
Recommended supplemental markers are LARS at or below 18%, pulmonary-vein S/D at or below 0.67, or LAVi above 34 mL/m²; IVRT at or below 70 ms is an alternative. These values do not become independent diagnoses. LA enlargement also occurs with AF, anemia, athletic remodeling, high output, and mitral disease and may be absent when pressure rose recently. LARS depends on tracking, vendor, age, rhythm, and LV systolic function. PASP may reflect lung or pulmonary vascular disease rather than left-heart pressure.
Diastolic dysfunction and filling pressure are related but distinct. Grade 1 is impaired relaxation with normal mean LA pressure. When mean LA pressure is elevated, E/A below 2 indicates grade 2 with mild-to-moderate elevation, while E/A at least 2 indicates grade 3 with marked elevation. A patient can have elevated LV end-diastolic pressure before mean LA pressure rises; pulmonary-vein atrial reversal duration more than 30 ms longer than mitral A supports this stage. Report the pressure being estimated rather than using “filling pressure” ambiguously.
Divert special populations and explain uncertainty
Do not use the general algorithm in AF, severe primary MR, any MS, moderate/severe mitral annular calcification, mitral repair or replacement, transcatheter edge-to-edge repair, noncardiac PH, pericardial constriction, LVAD, or heart transplantation. These conditions directly change inflow, annular motion, atrial behavior, or pulmonary pressure. HCM and RCM also have population-specific combinations: in HCM, average E/e′, Ar–A duration, TR velocity, and LAVi are integrated; in advanced RCM, high E/A, short deceleration and IVRT, and low e′ create restrictive physiology. Do not substitute one general cutoff.
AF has no true A wave, variable cycle lengths, and altered LA function. Average several representative beats with similar preceding and pre-preceding intervals and use AF-specific evidence. LBBB, RV pacing, and CRT can reduce septal e′ through dyssynchrony, making lateral e′ and other measures more informative. Regional infarction, mitral rings, severe MAC, prostheses, significant MR, and annular tethering invalidate simple E/e′ assumptions. Constriction may preserve medial e′ despite high pressures.
Age slows relaxation and lowers E/A and e′; this can be physiologic when remodeling and pressure markers are normal. Conversely, a pseudonormal E/A near 1 can hide dysfunction when e′ is reduced and pressure markers are abnormal. Tachycardia fuses waves, preload changes alter E, and an incomplete or overgained TR signal misstates PASP. Never force a grade from missing or contradictory inputs—report indeterminate diastolic function or mean LA pressure and list why.
In symptomatic patients with grade 1 dysfunction or indeterminate/normal resting pressure but structural or functional clues, an authorized diastolic exercise study can uncover exertional elevation. Acquire E, e′, and TR at rest and during exercise or promptly after before E/A fusion. Average E/e′ at least 14 (or septal at least 15) together with peak TR velocity at least 3.2 m/s supports an abnormal exercise response.
The report states relaxation, mean LA pressure, grade when determinable, rhythm/rate/BP, core values, supplemental evidence used, special-population pathway, and serial change. This makes uncertainty explicit and prevents a single E/e′, LA volume, or E/A ratio from becoming the entire diagnosis.
An eligible patient in sinus rhythm has reduced septal and lateral e′, average E/e′ of 9, normal PASP, and mitral E/A of 0.7. Which current classification is most appropriate?
A patient with atrial fibrillation and a prosthetic mitral valve has a high transmitral E velocity and average E/e′ above 14. What is the best approach?