Tissue Doppler image with colour kinesis in the inset. E/E’ of the medial mitral annulus shown as 19.1, indicating type II left ventricular diastolic dysfunction. In diastolic dysfunction, as the relaxation of the ventricle is impaired, the velocity of medial mitral annulus is reduced so that the E/E’ ratio is increased. E wave is measured prior to tissue Doppler imaging and stored (see image below) so that the software application displays the E/E’ as soon as the E’ is measured.
Though the E/E’ ratio is increased in this case, there is no E/A reversal which is the more commonly used indicator of left ventricular diastolic dysfunction (Type I diastolic dysfunction). When there E/A ratio is used, there could be several grades of type I left ventricular diastolic dysfunction. First the E/A ratio equalises, then there is reversal as the A wave becomes taller than the E wave. E wave is early diastolic and A wave occurs after atrial systole. In more severe diastolic dysfunction, as the left atrial pressure becomes very high, the E wave becomes much taller than the A wave, with a sharp decceleration slope. This pattern is known as a restrictive pattern.