What is the left ventricular rapid filling wave?

Left Ventricular Rapid Filling Wave

The left ventricular rapid filling wave (RFW) is a hemodynamic phenomenon that occurs during early diastole, representing the pressure rise in the left ventricle as blood rapidly enters from the left atrium following mitral valve opening. 1

Definition and Physiological Significance

• The rapid filling wave appears on left ventricular pressure recordings as a distinct pressure rise that occurs after the left ventricular minimal pressure and before the pre-A pressure (pressure just before atrial contraction) 1
• It represents the early passive phase of ventricular filling, which accounts for approximately 70-80% of total ventricular filling in normal hearts 2
• This phase is primarily driven by the pressure gradient between the left atrium and left ventricle, which develops during ventricular relaxation 1

Hemodynamic Determinants

• The rapid filling wave is influenced by multiple factors:
  • Left ventricular relaxation (lusitropy) 1
  • Left ventricular compliance (stiffness) 1
  • Left atrial pressure 1
  • Mitral valve function 1

Assessment by Echocardiography

• The rapid filling phase corresponds to the E-wave on mitral inflow Doppler 1
• Key parameters that reflect this phase include:
  • Mitral E velocity - peak velocity of early diastolic flow 1
  • E-wave deceleration time (DT) - influenced by LV relaxation, diastolic pressures, and stiffness 1
  • Tissue Doppler e' velocity - reflects early diastolic myocardial relaxation 1

Clinical Significance

• Alterations in the rapid filling wave can indicate diastolic dysfunction 1
• In grade 1 diastolic dysfunction (impaired relaxation), the contribution of rapid filling decreases, with compensatory increases in slow filling and atrial contraction 3
• In more advanced diastolic dysfunction (pseudonormal or restrictive patterns), the rapid filling wave may appear enhanced due to increased left atrial pressure despite impaired relaxation 1
• The E/e' ratio helps distinguish between normal and elevated filling pressures by correcting for the effect of relaxation on the E wave 1

Pathological Considerations

• In patients with left ventricular hypertrophy, the rapid filling phase may be impaired due to delayed relaxation 4
• In coronary artery disease with systolic dysfunction, there is often increased dependence on slow filling rather than rapid filling 3
• Vortex ring formation during rapid filling is important for efficient ventricular filling, and abnormalities in this process may occur in conditions like dilated cardiomyopathy 5

Relationship to Other Diastolic Parameters

• The rapid filling wave should be interpreted in context with other diastolic parameters:
  • Left atrial size 1
  • Pulmonary vein flow patterns 6
  • Tricuspid regurgitation velocity (for estimating pulmonary pressures) 1
  • Presence of L wave (mid-diastolic flow) 1

Clinical Pitfalls in Assessment

• Heart rate and rhythm abnormalities can significantly affect the rapid filling wave assessment 1
• First-degree AV block or tachycardia may cause fusion of E and A waves, complicating interpretation 1
• Age-related changes in diastolic function must be considered when interpreting rapid filling parameters 1
• Pulmonary venous flow analysis should be included when evaluating filling pressures, as relying solely on mitral inflow parameters may miss patients with elevated end-diastolic pressures 6