Figure 8

Figure 8

 Mid diastolic flow represents an atypical pattern of pseudonormal filling modified by bradycardia; two patterns (A) and (B) are seen. (A1) Transmitral flow at rest demonstrating E/A ratio > 1 with a distinct change in the slope of the E deceleration line. (A2) The E deceleration slope with Valsalva manoeuvre is similar to the slope of the mid diastolic flow deceleration in the resting Doppler; also note the short A wave duration which lengthens during Valsalva. (B1) A discrete period of diastolic forward flow after cessation of the E wave. (B2) The underlying impaired relaxation pattern is unmasked by preload reduction with the Valsalva manoeuvre. This pattern of mid diastolic flow is also discernable in fig 3A and 6.