From the Guidelines
Grade II pseudonormalization of the left ventricle is characterized by a normal-appearing mitral inflow pattern on echocardiography, despite underlying diastolic dysfunction, with an E/A ratio between 0.8 and 2, and is associated with elevated left ventricular filling pressures and increased risk of heart failure. This condition occurs due to increased left atrial pressure compensating for the stiff left ventricle, resulting in a seemingly normal early (E) to late (A) ventricular filling ratio on Doppler imaging, as described in the 2016 European Heart Journal study 1. However, other parameters like tissue Doppler and pulmonary vein flow reveal the underlying dysfunction.
Key characteristics of Grade II pseudonormalization include:
- E/A ratio between 0.8 and 2
- Deceleration time 160-240 ms
- Isovolumic relaxation time <90 ms
- Elevated E/e' ratio (>15)
- Decreased e' velocity
- Reversed systolic to diastolic pulmonary vein flow ratio These characteristics are supported by the 2016 study published in the European Heart Journal, which provides recommendations for the evaluation of left ventricular diastolic function by echocardiography 1. The study emphasizes the importance of using multiple parameters to accurately evaluate diastolic function, including mitral inflow, tissue Doppler, and pulmonary vein flow.
Management of Grade II pseudonormalization focuses on treating the underlying cause (e.g., hypertension, coronary artery disease) and optimizing volume status, as well as regular follow-up with echocardiography to monitor for further progression, as recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging 1. It is essential to recognize Grade II pseudonormalization as a stage of diastolic dysfunction that requires prompt attention to prevent further progression and reduce the risk of heart failure.
From the Research
Definition of Grade II Pseudonormalization of the Left Ventricle (LV)
- Grade II pseudonormalization of the Left Ventricle (LV) is characterized by a normal Doppler echocardiographic transmitral flow pattern due to an opposing increase in left atrial pressures 2.
- This stage is also known as pseudonormalization, where the mitral inflow pattern appears normal despite underlying diastolic dysfunction 2.
- Pseudonormalization can make it difficult to diagnose diastolic dysfunction, as the mitral inflow pattern may appear normal despite elevated left ventricular end-diastolic pressure 3, 4.
Characteristics of Grade II Pseudonormalization
- Reduced left ventricular filling in early diastole with normal left ventricular and left atrial pressures and normal compliance is not present in Grade II pseudonormalization 2.
- Instead, Grade II pseudonormalization is characterized by an increase in left atrial pressures, which normalizes the mitral inflow pattern 2.
- Patients with Grade II pseudonormalization may have symptoms of heart failure, such as exercise intolerance, fatigue, and chest pain 2.
- Echocardiographic parameters, such as the E/A ratio, deceleration time, and isovolumic relaxation time, may not be able to distinguish between patients with and without pseudonormalization 3, 4.
Diagnosis of Grade II Pseudonormalization
- Tissue Doppler imaging (TDI) and mitral annulus motion analysis can be used to detect pseudonormalization 3, 4.
- Parameters such as peak diastolic velocities of the septal mitral annulus (E(T), A(T), E(T)/A(T)) and the time interval from Q in the ECG to the onset of E(T) can be used to diagnose pseudonormalization 4.
- Propagation velocity (Vp) of early and atrial mitral inflow wave can also be used to diagnose pseudonormalization 5.