Carlos El-Tallawi, MD, FACC, FASE

Pulmonary vein Doppler tracks LA–LV hemodynamics beat-to-beat: •S wave → LA relaxation + annular descent (systolic suction) •D wave → LV filling (mirrors mitral E) •Ar wave → atrial contraction (retrograde) Blunted S, dominant D, ↑Ar? → elevated LA pressure & reduced compliance. Simple waveform. High-yield physiology. 🫀

Intracardiac lipoma (dark delineating rim around the mass is a signal cancellation artifact at the interface of fat and water residing protons)

I’m just answering the general gradient vs AVA question. A valve that can potentially result in such load on the myocardium is a pretty sick one. Also, I would use the transvalvular flow rate on resting echo before using the AV calcium score — Very underutilized parameter.

@HeartToProve @echo_stepbystep Right but the myocardium does not consistently feel the PVcs either. A sick heart can also increase SV after a PVC but you wouldn’t use that for their CO. Just food for thought. Perhaps an AV calcium score is the answer here (new ESC guidelines).

Sometimes Dobutamine stress echo is not needed in low-flow low-gradient AS

@DMohananey @echo_stepbystep The question is: does the myocardium “feel” the pressure gradient, or the human made AVA?

@HeartToProve @echo_stepbystep Alright so this is interesting- I have had the same internal debate for some time. Do you also need a post PVC LV VTI? Because if the SV rises to the degree where the AVA is now >1; you would say that is moderate AS if you were doing a DSE.

Intra- and extra- cardiac shunt can coexist. Differentiate mainly via flow pattern not cycle timing. •PFO: transient/intermittent bolus which can be late if RAP>LAP occurs late. •Transpulmonary: continuous trail of bubbles; can occur early for example in liver cirrhosis patients with large stroke volumes.

Dr. @HeartToProve shares what dairy foods are beneficial for your heart in @EatingWell. spr.ly/6016B6HPEe

@SachinGoelMD @NadeenFaza I believe because the LA-LV gradient depends on *both* LAP and LV diastolic pressure. Mitral MG can be elevated in low LV diastolic pressure, even when LAP not too high. It also can be relatively reduced in high LV diastolic pressure despite a high LAP. ahajournals.org/doi/full/10.11…

@HeartToProve @NadeenFaza In MS why is Mean transmitral gradient not a factor, just curious

Summary of parameters used to assess LAP in valvular heart disease -- #ASEchoJC

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @iamritu @SIwa23288585 @SFNagueh The H2FPEF score effectively excludes HFpEF when the probability score is low (<30%); however, it needs to be supplemented with the new diastology guidelines to rule in a diagnosis of HFpEF. #ASEchoJC @SFNagueh

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @iamritu @SIwa23288585 RECOMMENDED READ ON THIS SUBJECT "Improving the Diagnosis of HFpEF: A Comparison of the H2FPEF Score and the 2025 ASE Diastolic Function Guideline Recommendations Using Invasive Hemodynamics as the Gold Standard" #ASEchoJC jacc.org/doi/abs/10.101… @SFNagueh

#ASEchoJC Q 10. How are echocardiographic findings integrated with clinical and laboratory data in the diagnosis of HFpEF? @SNagueh @dysanborn @BonitaEcho @PWesslyMD @HeartToProve

🔑 HFpEF is not an echocardiographic diagnosis alone. It requires: 🔹 HF symptoms 🔹 Preserved EF 🔹 Objective evidence of elevated filling pressures from echo, biomarkers, or hemodynamics ⚠️ Always exclude HFpEF mimics: CAD, infiltrative disease, HCM, constriction, significant VHD Diagnosis requires integration of clinical, imaging, and laboratory data. #ASEchoJC #EchoFirst @ASE360 #HFpEF

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @iamritu @SIwa23288585 Remember that HFpEF is a clinical diagnosis. It can be complex. Integrate all the tools at hand to make the correct diagnosis. #ASEchoJC

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @HeartToProve @ASE360 🫀 Diastology in Atrial Fibrillation — key challenge AF complicates LV filling pressure assessment due to: 🔹 Variable cycle length 🔹 Loss of atrial contraction 🔹 Tachycardia 🔹 Frequent LA enlargement #ASEchoJC #EchoFirst @ASE360

@PWesslyMD @NadeenFaza @SNagueh @dysanborn @BonitaEcho @ASE360 #ASEchoJC

🫀 HCM Case — Diastology Puzzle 51-year-old male with HCM (reverse septal curvature) Symptoms: DOE — can do 30 min circuit/weights but unable to run >10 min. How would you interpret these findings? 👇 🔹 E/e′ = 7.5 🔹 TR velocity = 2.7 m/s 🔹 PV S/D ≈ 1 🔹 Ar–A = 50 ms 🔹 PV Ar velocity = 60 cm/s What do these suggest about LV filling pressures? #ASEchoJC #EchoFirst @ASE360

#ASEchoJC Q 9. How should diastolic function and filling pressures be assessed in HCM and restrictive cardiomyopathy? @SNagueh @dysanborn @BonitaEcho @PWesslyMD & @HeartToProve @ASE360

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @ASE360 A practical trick in AF: Patients with less E wave beat-to-beat variability usually have elevated LAP (use high sweep speed). #ASEchoJC

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @ASE360 Markers associated with elevated filling pressures in AF patients #ASEchoJC

#ASEchoJC Q 8. How do we estimate LV filling pressures in special populations such as AF, heart transplant recipients, and pulmonary hypertension? @SNagueh @dysanborn @BonitaEcho @PWesslyMD & @HeartToProve @ASE360

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @ASE360 Pulmonary hypertension: which E/e′ matters? --> Lateral #ASEchoJC

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @ASE360 Heart transplant patients have baseline differences we need to recognize #ASEchoJC

@NadeenFaza @SNagueh @dysanborn @BonitaEcho @PWesslyMD @ASE360 In AF -- Diastology can get PAINFUL #ASEchoJC