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Pulmonary Vein (PV) Doppler Patterns

 

Pulmonary Vein (PV) Doppler Patterns – Normal and in Disease

Pulmonary vein Doppler is recorded using pulsed-wave Doppler (usually from apical 4-chamber view for right upper PV or by TEE). It reflects left atrial (LA) pressure and compliance, and is essential in diastology and mitral valve assessment.


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1. Normal Pulmonary Vein Doppler Pattern


Normal waveform has three components:


1️⃣ S wave (Systolic forward flow)


• Occurs during LV systole

• Blood flows from pulmonary veins → LA

• Normally S ≥ D in younger adults

• Reflects LA relaxation and descent of mitral annulus


2️⃣ D wave (Diastolic forward flow)


• Occurs during early LV diastole

• Corresponds to mitral E wave

• Reflects LA pressure and LV relaxation


3️⃣ Ar wave (Atrial reversal)


• Occurs during atrial contraction

• Small retrograde flow into pulmonary veins

• Normally:


Ar velocity < 35 cm/s


Ar duration < mitral A duration



πŸ‘‰ Normal Pattern: S wave dominant or equal to D

Small Ar reversal


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2. PV Doppler in Diastolic Dysfunction


Grade I (Impaired Relaxation)


• S wave > D wave (more systolic dominance)

• Normal or mildly increased Ar


Mechanism: Delayed LV relaxation, low early filling.



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Grade II (Pseudonormal)


• S wave < D wave

• Increased Ar velocity

• Ar duration > mitral A duration


Mechanism: Elevated LA pressure.


πŸ‘‰ Clue: PV Doppler helps unmask pseudonormal mitral inflow.



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Grade III/IV (Restrictive Filling)


• Markedly dominant D wave

• Blunted S wave

• Prominent Ar reversal


Mechanism: Severely elevated LA pressure and reduced compliance.


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3. Pulmonary Vein Doppler in Mitral Regurgitation (MR)


Mild MR


• Reduced S wave amplitude


Moderate MR


• Blunted S wave (S < D)


Severe MR


• Systolic flow reversal (retrograde flow in systole)

• Highly specific for severe MR


Mechanism: Regurgitant jet increases LA pressure in systole → reverses PV flow.


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4. Pulmonary Vein Doppler in Atrial Fibrillation


• No Ar wave (no organized atrial contraction)

• Variable S and D waves

• May show reduced systolic dominance


Important in estimating filling pressures.


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5. Constrictive Pericarditis


• Prominent respiratory variation in PV flow

• Marked decrease in D wave during inspiration


Helps differentiate from restrictive cardiomyopathy.


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6. Left Atrial Hypertension


Seen in: • Advanced diastolic dysfunction

• Severe MR

• LV systolic dysfunction


Pattern: • D wave dominance

• Increased Ar velocity

• Prolonged Ar duration


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Quick Summary Table


Normal

S ≥ D, small Ar


Impaired relaxation

S > D


Pseudonormal

S < D, ↑ Ar


Restrictive

D >>> S, prominent Ar


Severe MR

Systolic flow reversal


AF

No Ar wave


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