title: Pseudonormalization of transmitral pulsed doppler flow: A/e' ratio during the valsalva maneuver--a new discriminative index.
abstract: The Valsalva maneuver (VM) has frequently been suggested as a useful method in evaluation of left ventricular (LV) grade II diastolic dysfunction (DDII) through inversion of a pseudonormalized ratio between diastolic transmitral early (E) and late atrial (A) waves assessed by pulsed Doppler. The purpose of our study was to determine the sensitivity and specificity of E/A inversion during VM in LV DDII patients and its correlation with mitral annulus motion evaluated by tissue Doppler imaging (TDI). Using the echocardiographic criteria of the European Society of Cardiology for the diagnosis of diastolic dysfunction, we studied a group of 44 patients, 27 male, aged 59 +/- 14 years, with DDII (DDII-group) and compared them with a control group (N group) composed of 33 healthy individuals, 17 male, aged 36 +/- 9 years. Using transmitral pulsed Doppler analysis, we quantified the peak diastolic velocities of transmitral flow (E and A waves in cm/sec), pulmonary venous systodiastolic flow (PVF: S<D and atrial reversal >35 cm/sec) and the first aliasing LV diastolic flow propagation velocity by color M-mode Doppler (PVF <45 cm/sec for LV DDII). Using TDI we measured the peak systolic (s'), and diastolic rapid filling (e') and atrial (a') velocities (Vm in cm/sec) at four points of the mitral annulus: adjacent to the interventricular septum (P4), and the lateral (P2), inferior (P3) and anterior (P4) LV walls. VM was performed by all patients, with repeated measurements of the above parameters (except for PVF) at the point of their maximum shift.
  
  
  RESULTS
  Four patients in the DDII-group were excluded due to degradation of the acoustic window during VM. The sensitivity and specificity of E/A inversion during VM in diagnosing LV DDII were respectively 88% and 57%. On ROC curve analysis, the most discriminative index for DDII diagnosis A/e' > 4.06 in P2 during VM (area under ROC curve [AUROC] = 0.883 [0, 78, 0, 94]). There was a significant increase in AUROC (0.74 vs. 0.88, p = 0.006) during VM. For A/e' > 4.06, the sensitivity and specificity for DDII diagnosis were respectively 62% and 78% pre-VM and 85% and 78% during VM.
  
  
  CONCLUSIONS
  Inversion of a pseudonormalized pulsed Doppler E/A ratio during VM has high sensitivity, but its low specificity makes it of little clinical use. An A/e' ratio > 4.1 during VM is a new, highly discriminative index that can be used in practice to diagnose LV grade II diastolic dysfunction in the presence of a pseudonormalized pulsed Doppler E/A ratio.
authors.affiliation: Centro Hospitalar de Lisboa Ocidental, Serviço de Cardiologia, Hospital de S. Francisco Xavier, Lisboa, Portugal.
authors.forename: Antonio Oliveira
authors.initials: AO
authors.lastname: Anão
authors.forename: José
authors.initials: J
authors.lastname: Monge
authors.forename: João
authors.initials: J
authors.lastname: Galvão
authors.forename: Luís
authors.initials: L
authors.lastname: Bronze
authors.forename: José
authors.initials: J
authors.lastname: Azevedo
authors.forename: Helena
authors.initials: H
authors.lastname: Custódio
authors.forename: Isabel
authors.initials: I
authors.lastname: Arroja
authors.forename: Ana
authors.initials: A
authors.lastname: Aleixo
mesh_terms: D000328:Adult; D003971:Diastole; D018619:Echocardiography, Doppler, Pulsed; D005260:Female; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000503:physiopathology; D006331:Heart Diseases / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve; D012680:Sensitivity and Specificity; D014636:Valsalva Maneuver