so I hope I didn't confuse you too much so far I know it's a very difficult issue and a very complicated topic but to give you a Hands-On approach I defined a few rules if you obey these rules you will probably get by in 90 or 95% of patients rule number one if Echo is normal and the patient is below 45 years of age and E is taller than a-wave as in this example then the patient simply has normal diastolic function and you do not need to do anything else rule number two if the a wve is taller than the ewave in other words the e to a ratio is less than one then the patient has impaired relaxation filling pressure in these patients is usually normal or only mildly elevated if you want to know if filling pressure is normal or elevated you can perform tissue Doppler Imaging if the E to e Prime ratio is more than 12 to 15 then the patient has an elevated filling pressure rule number three if the echo is abnormal in other words if the patient has hypertensive heart disease with left ventricular hypertrophy reduced left ventricular function or any other pathology and the patient is above 65 years of age and E is taller than a-wave in other words the e2a ratio is more than one then the patient must have pseudonormal filling he cannot have normal filling pattern and left ventricular filling pressure is probably elevated if you want to be 100% sure you can also perform other measurements for example you can look at the deceleration time or the E to e Prime ratio and remember you can also use the 2D image because patients who have elevated filling pressure usually also have an enlargement of the left atrium rule four if the E velocity is twice or at more than twice the size of the a velocity in other words the ratio is above two then the patient must have restrict to filling pattern and left atrial or left ventricular filling pressures are usually significantly elevated there is one exception to this rule in young very healthy adults you will have have supernormal diastolic function which means that during early diastole we have suction which causes a very high e-wave and thereby a pattern which looks very similar to a restrictive filling pattern however in reality you will never have a problem to distinguish the two patients with supernormal pattern are young healthy and often athletes this is such an example where we have an e-wave which is taller than the a-wave then we perform a Sala maneuver and all of a sudden you can see that the a-wave is taller than the e-wave we reversed the pseudonormal pattern to a relaxation pattern and thereby demasked and elevated filling pressure this diagram again shows you the different grades of diastolic dysfunction and also what happens if you perform valava so if you perform valava in a patient who has a pseudonormal pattern you can reverse this pattern to a relaxation pattern if you perform vavva in a patient who has a restrictive filling pattern you can reverse it to a pseudonormal pattern if it is reversible and you cannot reverse it if is an irreversible pattern here's demonstration of a patient which shows you how you can apply these rules let's look at diastolic function in this patient let's start with the mro flow signal okay so we freeze the image here and we can immediately see that the a wve is taller than the ewave so this shows that the patient has impaired relaxation and what we'll do now is we'll measure the maximum velocity which is somewhere in the range of 0.8 of the e-wave and then we'll also perform tissue Doppler of the micro anulus so let's put the post wave doter here in the region of the anulus okay and then we'll freeze the image and measure e Prime which is 0.5 and then we we calculate the E to e Prime ratio we get a value of 16 which shows that the patient has elevated left natural filling pressures so you see it's not that difficult after all but always keep in mind that we have to look at diastolic dysfunction in the context of the whole heart of all pathologies and of the clinical situation here's another example so I will now show you how to analyze a patient uh for diastolic function this is a patient who has an e to a ratio which is above one so the e-wave is taller than the a-wave so the question is does the patient have normal filling or does he have pseudonormal filling let's measure the size or the the maximum velocity of the a wve which is somewhere in the range of 0.8 okay and now let's perform a tissue Doppler across the micro valve anulus okay this is the Maxima e Prime velocity which is 0.7 or 0.6 0.7 somewhere in that region if we now calculate the E to e Prime ratio we get a value which is above 12 13 um which means the patient has diastolic dysfunction uh in other words elevated left AAL filling pressure so the e to a ratio which is could also be normal is certainly not a normal pth pattern but a pseudonormal pattern but there's also other ways of looking at this patient at his diastolic function just by purely looking at the 2D image you can recognize that the patient has severe left entrical hypertrophy he has hypertrophic cardiopathy and such patients just cannot have normal diastolic function so clearly all you would need to have is the 2D image and there's another way of looking at it let's take a look at the post-wave doer signal again okay so we see again this E and A are about the same size now let's let him press to the Vol Sala maneuver by and see with the vavo maneuver the a-wave increases even more and more here we go and all of a sudden we have uh relaxation pattern thereby demasking the pseudonormal pattern and showing that the patient does not have a normal but elevated left tal filling pressure I personally believe if things are made too complex then the people don't use them and if they don't use them they're useless so that's why I think that you should use simple things such as a simple approach also to diastolic function