Table 7 Table of the non-routine measures of LV diastolic function

IVRT

IVRT can be measured using either PW or CW Doppler. From an apical 3 or 5-chamber view, the sample volume or cursor is moved from the mitral leaflet tips toward the left ventricular outflow tract until it captures both the completion of aortic ejection and the onset of mitral inflow. NB, the low-velocity reject/wall filter should be adjusted to ensure the end of aortic and onset of mitral flow can be clearly identified

IVRT can also be measured from a TDI trace, although this requires multiple (ideally four) annular measurements to average the significant regional variation between annular points measured. The IVRT is longer in the anteroseptal wall compared with the lateral wall and longer in ischaemic segments [131]. The interval begins at the cessation of the S-wave and ends with the start of the e′ wave

Mitral annular tissue-Doppler imaging—e′/a′ ratio

Peak modal velocity at the leading edge of the spectral waveform in early diastole (after the T-wave). Gain and reject settings should be optimised to display high amplitude annular velocities with reduced clearly defined modal waveform. Measurements should be averaged over 3 cardiac cycles, at end expiration

Pulmonary vein S and D wave deceleration times

The PVS and PVD deceleration slopes are measured from the peak velocity of the jet to the end of flow. Greater PW Doppler scale will enlarge the spectral waveform and increase measurement accuracy

Vp

Acquisition is performed in the A4C. A narrow CFD sector should extend across the mitral valve and at least 4 cm into the LV with the M-mode cursor carefully aligned with the direction of blood flow at a sweep speed of > 100 cm/s. The Nyquist limit is adjusted to around 40–50% of the peak E velocity to generate aliasing of the higher velocity flow at the centre of the blood flow column [148]. The flow propagation slope is measured

IVRT/T_E-e′

When measuring IVRT/T_E-e′, both waveforms are acquired as per described previously but at a faster sweep-speed of 100 mm/s and greater spectral Doppler scale to improve temporal resolution and increase measurement accuracy of these short time-periods. The time is measured between the peak R-wave on the ECG to the onset of both the E and e′ waves. Due to the non-simultaneous method, R-R intervals should be matched. Low gain and wall-filter settings should be optimised to provide waveforms with clear onset. The e′ should be measured at the four annular sites from the A4 and A2C views and an average time calculated. The ratio of IVRT to T_E-e′ indexes the measure to LV relaxation time and can be useful in borderline cases or significant mitral valve disease; a ratio < 2 suggest holds high sensitivity and specificity for raised LVFP [144, 145]

A-wave transit time

When both the transmitral E/A and Er/Ar waves are identifiable on the same Doppler trace, a simple measure of the time to onset or time to peak velocity can be made. If it is not possible to identify both signals on the same spectral Doppler display, individual time measures can be made using the ECG R wave as the starting reference point and the time difference established—similar R-R intervals is essential for the accuracy of this measure