Purpose: The difference in duration between pulmonary venous (PV) atrial systolic reversal wave (PVA) and atrial systolic wave (A) of transmitral flow (ΔA_dur) reflects the late-diastolic left ventricular (LV) operating stiffness and has a limitation on reproducibility. Using the Dual Gate Doppler technique, simultaneous recording of PV and transmitral flows can be obtained, which may contribute to improving the accuracy and reproducibility of ΔA_dur measurements.

Methods and Results: We examined 80 patients who underwent echocardiography using Dual Gate Doppler recording. Using the conventional Doppler recording, we measured the difference in duration between the PVA and transmitral A-wave (S-ΔA_dur). Additionally, the ratio of the time–velocity integral (TVI) of the PVA to that of the whole PV flow (F_PVA) and the ratio of the TVI in transmitral A-wave of the whole transmitral flow (F_A) were calculated, and F_PVA/F_A was obtained as an index of LV operating stiffness. From the Dual Gate Doppler recording of PV and transmitral flows, we measured ΔA_dur (D-ΔA_dur) and time from the end of transmitral A-wave to the end of PVA (D-ΔA_end).

Results: Each of S-ΔA_dur, D-ΔA_dur, and D-ΔA_end significantly correlated with F_PVA/F_A (r＝0.50, 0.51, and 0.71, respectively), and the correlation between F_PVA/F_A and D-ΔA_end was significantly greater than that between F_PVA/F_A and S-ΔA_dur and between F_PVA/F_A and D-ΔA_dur (p＜0.001 for both). The intraclass correlation coefficients for the inter- and intra-observer comparisons were excellent for D-ΔA_end, adequate for D-ΔA_dur, and fair for S-ΔA_dur.

Conclusion: Dual Gate Doppler-derived D-ΔA_end has higher reproducibility and usefulness for assessing late-diastolic LV operating stiffness than the conventional Doppler-derived S-ΔA_dur.

A woman in her 50s was admitted to our hospital due to sudden dysarthria and left paresis. She had a history of pulmonary embolism and cerebral embolism; thus, she was receiving anticoagulant therapy. Emergent endovascular thrombectomy was performed to treat the acute cerebral embolism in the right middle cerebral artery. Transthoracic echocardiography (TTE) revealed right ventricular enlargement and leftward ventricular septal shift with an increase in tricuspid systolic pressure gradient. A contrast-enhanced computed tomography revealed a pulmonary embolisms and deep vein thrombosis. Pulmonary blood flow scintigraphy, pulmonary angiography, and right heart catheterization suggested recurrence of pulmonary embolism following chronic thromboembolic pulmonary hypertension (CTEPH). Since cerebral embolism occurred due to the right-sided pressure overload due to pulmonary hypertension; pathologically, paradoxical cerebral embolism was strongly suspected in this patient. In the microbubble tests by TTE and transcranial color Doppler imaging (TCCFI), a massive right-to-left shunt at the atrial level in the TTE and a large number of micro-embolic signals in TCCFI were confirmed without performing the Valsalva maneuver. Transesophageal echocardiography confirmed a patent foramen ovale and right-to-left shunt flow at rest, and the microbubble test was positive at grade 3 in the left atrium. Thus, we treated a case of venous thrombosis that developed paradoxical cerebral embolism through the foramen ovale in a patient with CTEPH. Here we report the diagnostic approach and the importance of ultrasonography for such a pathologically complicated condition.