Eur J Echocardiography (2002) 3, 229–232 doi:10.1053/euje.2002.0155, available online at http://www.idealibrary.com on TEACHING CORNER M. Pozzoli and G. S. de Ruiter Case 3: A Patient with Atypical Chest Pain A 73-year-old female patient with a history of hypertension complains of dyspnoea at exercise and atypical chest pain. She is in sinus rhythm. A systolic ejection murmur, 3/6 of intensity is heard at the base of the heart. Right and left heart catheterization and a simultaneous echocardiogram is performed. The echocardiogram shows a hypertrophied LV with normal systolic function (Fig. 1) and moderate-to-severe aortic stenosis (peak pressure gradient 69 mmHg). What is the LV filling pressure? Downloaded from by guest on October 28, 2014 Figure 1 1525-2167/02/030229+04 $35.00/0 230 Teaching Corner Answer Invasive See Fig. 3. Non-invasive Quantification PCWP=1·55+1·47(E/E) PCWP=1·55+1·47(7·3) PCWP=1·55+10·7=12 Eur J Echocardiography, Vol. 3, issue 3, September 2002 Downloaded from by guest on October 28, 2014 Comment This patient has a hypertrophic LV with normal systolic function. Doppler of mitral flow shows an ‘abnormal relaxation’ pattern, which is an unequivocal sign of low PCWP in patients with LV systolic dysfunction. In patients with normal LV systolic function and severe diastolic dysfunction, however, it is less reliable to predict low filling pressures. In fact, if relaxation is markedly abnormal, E wave can be relatively low (and its deceleration prolonged) even when the left atrial pressure is high. Similarly, the S wave of the pulmonary venous can be relatively high even when left atrial pressure is elevated if the LV produces vigorous downward displacement of the mitral annulus. In this kind of patient the most reliable parameters to use in order to estimate LV filling pressure are those that are independent from LV relaxation such as the diﬀerence in duration between the retrograde pulmonary venous flow (dZ) and the forward mitral flow (dA) at atrial contraction and the ratio E/E. In this patient dZ-dA is prologed (indicating an LVEDP >15 mmHg), while E/E is low (indicating low left atrial pressure; Fig. 2). Indeed, LVEDP turned out to be moderately elevated, while mean PCWP was normal at catheterization (Fig. 3). This example underlines the fact that, although LVEDP and PCWP are correlated, significant discrepancies may exist in patients with normal left atrial pressure during systole and early diastole and elevated pressure in late diastole after atrial contraction. Downloaded from by guest on October 28, 2014 Figure 2 232 Teaching Corner Downloaded from by guest on October 28, 2014 Figure 3 Eur J Echocardiography, Vol. 3, issue 3, September 2002