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Echo-of-the-Day Information
The Echo-of-the-Day is a presentation of 1 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Echo of the Day Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
E and E` Ratio
Case#: 167
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes.
A patient presented with two loops: An LVI with the E velocity shown below and a Tissue Doppler of the lateral mitral valve annulus with the E` velocity shown below.
Case Discussion
The LVI E velocity represents the velocity of the flow of blood into the LV from the LA during the rapid filling phase of diastole. If the LAP is low the velocity will be lower. If the LAP is high, then the velocity of the blood will be higher. In severe MR, an E velocity > 120 cm/sec indicates severe MR.

The TDI E` velocity measures the velocity of the mitral valve annulus during ventricular relaxation and early passive filling. As the ventricle relaxes and fills, the mitral valve annulus moves away from the LV apex. During atrial systole, the mitral valve annulus is pulled away from the LV apex by atrial contraction resulting in the TDI A` velocity measurement. If a ventricle relaxes poorly, then the mitral valve annulus velocity is decreased. If the LAP is low, the speed of filling is slower but the velocity of the mitral valve annulus is near normal. If the LAP is higher, the speed of filling is increased but the mitral valve annular velocity is near normal. Therefore, the E` velocity indicates the speed of LV lengthing during rapid filling of the LV.

Isaaz et al (Am J Cardiol 1989;64:66-75) first reported DTI of the posterior wall, however, in the 1990s the E/E` ratio was used to compare the passive LV inflow velocities to the velocity of LV lengthening. If the LAP is high, the LVI E velocity is high and, in the case of normal relaxation, the LV lengthening will be near normal yielding a high ratio. If the LAP is low the LVI E velocity is low, however, LV lengthing is near normal yielding a low ratio. In diastolic dysfunction, the LVI E velocity can appear while the LAP is high, however, the LV lengthening is decreased yielding a high ratio. Therefore, the mitral valve annlus E` velocity corrects the LVI E wave velocity for LV lengthing. The E/E` ratio has been shown to be predictive of LAP or PCWP .

A low E/E` ratio is < 8 which indicates a LAP < 10 mmHg. A high E/E` ratio is > 15 and indicates a LAP > 15 mmHg. As with other echocardiographic measurements, other methods should be performed to confirm the LAP (Valsalva maneuver, pulmonary S/D ratio, pulmonary vein A wave velocity, mitral A wave duration/pulmonary A wave duration).

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