Author + information
- Frank A. Flachskampf, MD, PhD∗ (, )
- Tor Biering-Sørensen, MD, PhD,
- Scott D. Solomon, MD,
- Olov Duvernoy, MD, PhD,
- Tomas Bjerner, MD, PhD and
- Otto A. Smiseth, MD, PhD
- ↵∗Uppsala Universitet, Institutionen för Medicinska Vetenskaper, Akademiska Sjukhuset, Ingång 40, Plan 5, Uppsala 751 85, Sweden
We thank Drs. Chung and Afonso for their interest and careful scrutiny of our article (1). We fully agree that heart rate and the fusion of the transmitral diastolic E-wave and A-wave occurring at higher heart rates are an important concern in assessing left ventricular diastolic function and find the example in Figure 1A of their letter, in particular regarding the shortened apparent deceleration time of the fused E-A signal. The authors raise the possibility that E-A fusion is present in our example of restrictive transmitral filling (Figure 4 ). This example is from a 40-year-old patient with uncontrolled hypertension, severe heart failure with pulmonary congestion, and a left ventricular ejection fraction of 30%. In general, at a heart rate of 100 beats/min, there may be E-A fusion. In our case, however, this would imply that the fused A-wave would occur before the end of the P-wave (Figure 1A, dashed blue line in the magnified beat from our original recording), which seems unlikely. We agree that the bright small wave well after the QRS duration is probably not the A-wave, but a small A-wave is visible immediately after the P-wave in the magnified beat (red arrow). We present an additional recording (Figure 1B) from this patient 3 days earlier than the that reproduced in our article, at a heart rate of 92 beats/min, again with a restrictive transmitral pattern, where the A-wave in beats 2 and 5 is well recognizable and the E-wave deceleration time is 95 ms, similar to the deceleration time of 102 ms in Figure 4 in our paper (1). In the other beats in Figure 1A, the A-wave is less well defined, but definitely not merged with the peak of the E-wave. We did not choose this recording as an example because of the variability in the A-wave signal. Note that E-wave peak velocities in the 2 recordings, at 100 beats/min and 92 beats/min, are both nearly equal at ∼100 cm/s, different from the example of E-A fusion in their letter, where the fused signal has a substantially higher peak velocity than the nonfused E-wave. However, we agree that E-A fusion must be considered in the recording in Figure 4 of our article and regret the ambiguity in the recording. We commend the authors of the letter for their clever and instructive “detective work” in pointing this out.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation