Noninvasive assessment of left ventricular end-diastolic pressure by the response of the transmitral A-wave velocity to a standardized valsalva maneuver

impaired relaxation is frequently masked by elevated filling pressures, res ulting in a pseudonormal flow pattern (E/A >1.0). Because the EIA wave rati o increases as filling pressures rise, it is generally assumed that patient s with an E/A ratio of <1.0 (impaired relaxation pattern) have relatively l ow filling pressures. Nevertheless, patients with an E/A ratio of <1.0 can have as profoundly elevated filling pressures as patients with a pseudonorm al or restrictive filling pattern. Because left ventricular (LV) pressure d uring end-diastole essentially determines atrial afterload, the response of the A-wave velocity to a reduction of atrial afterload by a standardized V alsalva maneuver should allow estimation of LV end-diastolic pressure (LVED P) regardless of the baseline Doppler flow pattern. This was tested in 20 c onsecutive patients who were studied by pulse-wave Doppler echocardiography during cardiac catheterization. There was a close correlation between LVED P and the change in A-wave velocity during the Valsalva maneuver (r = 0.85, SEE 6.7 mm Hg) regardless of the baseline E/A ratio. In patients with a LV EDP of <15 mm Hg the A wave decreased by 21 +/- 15 cm/s. In patients with a LVEDP of >25 mm Hg the A wave increased by 18 +/- 13 cm/s. The change in t he E/A ratio during Valsalva correlated fairly with LVEDP (r = -0.72, SEE 8 .8 mm Hg), the baseline E/A ratio correlated poorly, and scatter was substa ntial (r = 0.46, SEE 11.2 mm Hg). Just as elevated filling pressures can ma sk impaired relaxation, the impaired relaxation pattern can mask the presen ce of elevated filling pressures. This can be revealed by testing the respo nse of the A wave to the Valsalva maneuver, allowing estimation of LVEDP in dependent of the baseline E/A ratio. (C)2000 by Excerpta Medica, Inc.