×

Search Radiopaedia.org
Articles
Log In
Cases
Sign Up
Courses
Quiz
Blog
Donate
About
×

Search Radiopaedia.org
Menu

Search
Radiopaedia is free thanks to our Supporters & AdvertisersBecome a Gold Supporter, and see no ads

Articles
Cases
Courses
Log In

Log in
Sign up

{"url":"/signup-modal-props.json?lang=us\u0026email="}

Sign up

Enter your email and create a password for your account

Email*
Password*
Show password
Must contain:

at least 8 characters
1 uppercase letter, 1 lowercase letter, 1 number

Next Step

Step 1 of 4

ArticlesCasesCoursesQuiz
AboutBlogGo ad-free
Privacy - Terms
Search Radiopaedia.org Search
Normal pulmonary venous Doppler
Dr David Carroll ◉ et al.

Normal pulmonary venous blood flow in the pulmonary veins may be investigated during
echocardiography with spectral Doppler analysis. Perturbations in the normal pulmonary venous
waveform may indicate the presence of diastolic dysfunction and elevated filling pressures in the left
atrium and ventricle. 

Radiographic features

Pulsed wave Doppler (PWD) of the right superior pulmonary vein, which one may insonate from an
apical four-chamber view (A4C), will typically yield a waveform with three positive deflections
(S1,S2,D) and one negative deflection (AR) 1. 

Superior angulation of the transducer from an adequate A4C is often necessary to obtain adequate
visualization of the right upper pulmonary vein. Color flow Doppler insonation of the posteromedial left
atrium should precede use of PWD to ensure optimal alignment with the pulmonary venous flow.
Reduction of the set Nyquist limit is often necessary as the flow velocities of interest are typically
modest.

Pulsed wave Doppler

systolic deflections
positive, referred to as S1 and S2, often indistinguishable and simply referred to as the S
wave
the first (S1) component denotes atrial diastole, with suction of blood into the left atrium
abolished with atrial fibrillation
the second (S2) component occurs when the mitral annulus is apically displaced with
ventricular systole, decreasing left atrial pressure and creating a gradient for forward flow
blunted by mitral regurgitation
diastolic deflections
normally a prominently positive, albeit more diminutive, deflection following the sequential
systolic components
referred to as the D wave
atrial reversal
the downstroke of the D wave will often dip below the baseline, indicating flow away
from the transducer
referred to as the AR wave, corresponding to atrial contraction and "reversal" of flow
positively correlated with inotropic function of the left atrium

Differential diagnosis

While various pathological entities may disturb flow through the pulmonary veins, a series of
predictable changes in the aforementioned waveforms occurs during the progression of diastolic
dysfunction. A progressive increase in left atrial pressure will blunt the systolic flow velocities in the
pulmonary veins, with the majority of forward flow increasingly occurring during diastole. The
elevation in left ventricular end diastolic pressure, secondary to lusitropic incompetence, will
exaggerate the flow reversal that occurs with atrial contraction, prolonging the AR wave 4.

diastolic dysfunction on pulmonary venous Doppler

the S/D ratio
normal filling patterns are predominantly systolic, with an S/D ratio > 1
a pathologic increase in mean left atrial pressure will reverse this pattern, resulting in
an S/D ratio < 1 and a diastolic filling predominance
progressive increase in amplitude of D wave and a decrease in S wave with
increasing filling pressures
atrial reversal velocity and duration
normally the peak of the AR wave is < 35 cm/s
a peak velocity exceeding this upper limit implies elevated filling pressures
the AR wave duration is typically examined in concert with the mitral inflow velocities
 the transmitral A wave and the pulmonary venous AR wave should be roughly
similar in length
the duration of the latter should only exceed the former by < 20 m/s, with
greater discrepancies occurring with elevated filling pressures 3
a sensitive indicator of pseudonormalization of the filling pattern (stage III
diastolic dysfunction)
atrial fibrillation on pulmonary venous Doppler
abolition of organized atrial contraction decreases the peak of the S1 wave and decreases
the peak velocity of the AR wave
elevated lusitropy on pulmonary venous Doppler
the enhanced relaxation found in young patients may also reverse the S/D ratio and mimic
advanced diastolic dysfunction
vigorous left ventricular suction results in elevated peak D wave velocities, with a restrictive
transmitral filling pattern
if doubt exists regarding the consequence of these findings, tissue Doppler of the mitral
annulus is required
heart failure with a preserved ejection fraction
vigorous longitudinal excursion of the mitral annulus during systole may obfuscate
increased filling pressures by preserving the (S>D) pulmonary venous systolic filling
dominance
the velocity of the S2 wave is proportionate to the pressure gradient created by this
contraction
however, increased LVEDP imposes an afterload on the left atrium, shortening the duration
of the transmitral A wave while simultaneously prolonging the duration of the pulmonary
AR wave
increasing disparity between the AR duration and the A wave duration correlates with
elevations in filling pressures

References
Related Radiopaedia articles

Ultrasound - general index

ultrasound (introduction)
ultrasound physics
basic physics
absorption
acoustic impedance
attenuation
decibel
propagation speed
reflection
refraction
scattering
transducers
ultrasound frequencies
piezoelectric effect
linear array
convex array
phased array
beam focusing
beam steering
gain
time gain compensation
power output
focal zone
dynamic range
frame rate
line density
frame averaging (frame persistence)
 ultrasound image resolution
axial resolution
lateral resolution
elevational (azimuthal) resolution
temporal resolution
imaging modes and display
pulse-echo imaging
grey-scale imaging
time-gain compensation
harmonic imaging
real-time imaging
Doppler imaging
Doppler effect
color Doppler
power Doppler
B flow
color box
Doppler angle
pulse repetition frequency and scale
wall filter
color write priority
packet size (dwell time)
resistive index
pulsatility index
panoramic imaging
compound imaging
harmonic imaging
elastography
transient elastography
shear wave elastography
strain elastography
Young's modulus
scanning modes
2D ultrasound
3D ultrasound
4D ultrasound
M-mode
ultrasound artifacts
acoustic shadowing
acoustic enhancement
beam width artifact
reverberation artifact
comet tail artifact
color comet tail artifact
ring down artifact
mirror image artifact
side lobe artifact
speed displacement artifact
refraction artifact
multipath artifact
anisotropy
electrical interference artifact
Doppler artifacts
aliasing
tissue vibration
spectral broadening
blooming
motion (flash) artifact
twinkle artifact
acoustic streaming
biological effects of ultrasound
 mechanical index
thermal index
history of ultrasound
obstetric ultrasound
other
polyhydramnios
oligohydramnios
anhydramnios
gestational trophoblastic disease
retained products of conception
placenta
low lying placenta
placental abruption
placenta previa
vasa previa
abruption
placenta percreta
placenta increta
placenta accreta
circumvallate placenta
succenturiate placenta
velamentous cord insertion
marginal cord insertion
uteroplacental blood flow assessment
placental tumors
second trimester
fetal biometry
basic biometry
biparietal diameter (BPD)
head circumference (HC)
abdominal circumference (AC)
femur length (FL)
fetal morphology assessment
fetal echocardiography views
soft markers
nuchal fold thickness
ventriculomegaly
absent nasal bone
hypoplastic nasal bone
echogenic intracardiac focus
choroid plexus cysts
echogenic bowel
aberrant right subclavian artery
amnioreduction
echogenic fetal bowel
umbilical artery Doppler assessment
absent umbilical arterial end diastolic flow
reversal of umbilical arterial end diastolic flow
chorionic villus sampling (CVS) and amniocentesis
nuchal translucency
failed early pregnancy
subchorionic hematoma
multiple gestations
monochorionic monoamniotic twin pregnancy
monochorionic diamniotic twin pregnancy
dichorionic diamniotic twin pregnancy
twin peak sign
ectopic pregnancy
tubal ectopic
interstitial or cornual ectopic
cervical ectopic
 ovarian ectopic
abdominal ectopic
heterotopic pregnancy
Cesarean scar ectopic
first trimester and early pregnancy
gestational sac
double decidual sac sign
intradecidual sac sign
mean sac diameter
empty gestational sac
pseudogestational sac
yolk sac
embryo/fetus
crown-rump length (CRL)
fetal heart rate
fetal tachycardia
fetal bradycardia
fetal bradyarrhythmia(s)
physiologic gut herniation
embryonic rhombencephalon
amnion
chorion
Beta-hCG levels
gynecologic ultrasound
acute pelvic pain
chronic pelvic pain
uterus
endometrium
endometrial thickness
abnormal endometrial thickness differential
endometrial hyperplasia
endometrial carcinoma
endometrial polyp
endometrial fluid
endometritis
intrauterine device
tubal occlusion device
IUD perforation
myometrium
fibroids
adenomyosis
lipoleiomyoma
leiomyosarcoma
c-section scar
Mullerian duct anomalies
Mullerian agenesis or hypoplasia
unicornuate uterus
uterus didelphys
bicornuate uterus
septate uterus
arcuate uterus
DES-related uterine abnormalities
ovaries
ovarian torsion
pelvic inflammatory disease
tubo-ovarian abscess complex
ovarian cysts and masses
ovarian cyst
corpus luteum
hemorrhagic ovarian cyst
ruptured ovarian cyst
 endometrioma
serous cystadenoma and cystadenocarcinoma
mucinous cystadenoma and cystadenocarcinoma
dermoid
fibroma
thecoma
fibrothecoma
granulosa cell tumor
metastasis
paraovarian cyst
polycystic ovaries
ovarian hyperstimulation syndrome
post-hysterectomy ovary
cervix
cervical stenosis
cervical polyp
cervical cancer
cervical fibroid
fallopian tube
hydrosalpinx
pyosalpinx
hematosalpinx
torsion
other
pelvic congestion syndrome
peritoneal inclusion cyst
vascular ultrasound
carotids
internal carotid artery
cartoid stenosis
extremities
ankle brachial index
mesenteric vessels
chronic mesenteric ischemia
other
fibrin sheath
tardus parvus
breast ultrasound
benign and malignant characteristics of breast lesions at ultrasound
hyperechoic breast lesions on ultrasound
differential diagnosis of dilated ducts on breast imaging
musculoskeletal ultrasound
technique/artifacts
anisotropy
ultrasound of arthropathies
musculoskeletal manifestations of rheumatoid arthritis
skin/soft tissue ultrasound
lipoma
parasitic infection
scrotal filariasis
filarial dance sign
other
sonographic features of malignant lymph nodes
sonography of peripheral nerves
pediatric musculoskeletal ultrasound
ultrasound classification of developmental dysplasia of the hip
alpha angle
beta angle
ankle/foot ultrasound
Morton neuroma
knee ultrasound
 Baker cyst (popliteal cyst)
infrapatellar bursitis
hip ultrasound
Morel-Lavallee lesion
hand ultrasound
gamekeeper thumb
glomus tumor
wrist ultrasound
anterior interosseous nerve syndrome
carpal tunnel syndrome
ganglion cyst
elbow ultrasound
medial epicondylitis
ulnar nerve dislocation
snapping triceps syndrome
lateral epicondylitis
shoulder ultrasound
sonographic evaluation of rotator cuff tears
liver ultrasound
liver
focal
hyperechoic liver lesions
hypoechoic halo sign / target lesions
simple hepatic cyst
hepatic hemangioma
focal nodular hyperplasia
hepatic adenoma
hepatic metastases
hepatic abscess
diffuse
acute hepatitis
cirrhosis
hyperechoic liver
diffuse hepatic steatosis
coarsened hepatic echotexture
generalized decrease in hepatic echogenicity
"starry sky appearance" of the liver
hepatic vasculature
normal hepatic vein Doppler
portal hypertension
portal vein thrombosis
developed collaterals / portosystemic shunts
other
hepatic trauma on ultrasound
liver transplant
hepatic arterial resistive index
biliary
choledocholithiasis
dilated intrahepatic bile ducts
bile duct wall thickening
cholangiocarcinoma
Mirizzi syndrome
gallbladder ultrasound
diffuse gallbladder wall thickening (differential)
focal gallbladder wall thickening (differential)
gallstones
twinkling artifact
wall-echo-shadow sign
gallbladder sludge
hepatisation of the gallbladder
acute cholecystitis
 acalculous cholecystitis
gangrenous cholecystitis
perforated gallbladder
emphysematous cholecystitis
hemorrhagic cholecystitis
chronic cholecystitis
gallbladder polyp
benign vs malignant gallbladder polyps
cholesterol polyps
adenoma
inflammatory polyps
gallbladder cholecystoses
adenomyomatosis
gallbladder wall cholesterolosis
strawberry gallbladder
porcelain gallbladder
gallbladder carcinoma
gallbladder metastases
gallbladder lymphoma
gallbladder volvulus / torsion
variants
phrygian cap
agenesis
duplication
variants and anomalies
phrygian cap
agenesis
duplication
pancreatic ultrasound
pancreatitis
acute 
chronic
pseudocyst
pancreatic necrosis
pancreatic abscess
pancreatic carcinoma
pancreatic endocrine tumors / islet cell tumors
cystic pancreatic neoplasms
intraductal papillary mucinous neoplasm (IPMN)
pancreatic metastases
pancreatic lymphoma
pancreatic trauma
pancreas transplant
gastrointestinal ultrasound
appendicitis
hyperechoic bowel
inguinal hernia
renal ultrasound
hydronephrosis
renal stone
focal lesion
renal cyst
autosomal dominant polycystic kidney disease
renal cell carcinoma
urothelial cell carcinoma / transitional cell carcinoma
angiomyolipoma
diffuse
pyelonephritis
renal abscess
renal vascular
renal artery stenosis
 renal transplant ultrasound
renal artery stenosis
renal vein thrombosis
pseudoaneurysm
arteriovenous fistula
other
renal trauma
bladder ultrasound
bladder wall thickening
urothelial carcinoma of the bladder
bladder outlet obstruction
neurogenic bladder
infectious cystitis
cystitis following radiation or chemotherapy
bladder diverticulum
bladder calculi
ureterocele
pseudoureterocele
schistosomiasis
testicular and scrotal ultrasound
other
polyorchidism
cryptorchidism
tubular ectasia of the rete testis
cystadenoma of the rete testis
testicular sarcoidosis
testicular tuberculosis
spermatic cord lipoma
scrotal leiomyosarcoma
fibrous pseudotumor of the scrotum
testicular adrenal rest tumors (TARTs)
splenogonadal fusion
inguinal hernia
epididymis
epididymo-orchitis
epididymal abscess
epididymal head cyst
torsion of the epididymal appendix
adenomatoid tumor
paratesticular lesions
hydrocele
spermatocele
haematocele
scrotoliths
cyst of the tunica albuginea
varicocele
bilateral testicular lesion
testicular microlithiasis
testicular lymphoma
metastases to the testicle
unilateral testicular lesion
testicular torsion
orchitis
testicular rupture
germ cell tumor of the testis
testicular seminoma
non seminomatous germ cell tumors
mixed germ cell tumor
yolk sac tumor (endodermal sinus tumor)
embryonal cell carcinoma
choriocarcinoma
 testicular teratoma
testicular epidermoid (teratoma with ectodermal elements only)
burned out testis tumor
sex cord / stromal tumors of the testis
Leydig cell tumor
prostate ultrasound
transrectal ultrasound (TRUS)
prostate carcinoma
prostatitis
other lower genitourinary ultrasound
urachal cyst
urethra
penis
Peyronie's disease
priapism
neck and thyroid ultrasound
thyroid
multinodular goiter
colloid cyst
thyroglossal duct cyst
parathyroid
echocardiography
echocardiographic modalities
transthoracic echocardiography (TTE)
transesophageal echocardiography (TEE)
three dimensional (3D) echocardiography
epicardial echocardiography
contrast enhanced echocardiography
fetal echocardiography
speckle tracking echocardiography
physics and imaging modes
grey-scale (B-mode)
motion mode (M-mode)
color flow Doppler (CFD)
spectral Doppler
pulsed wave Doppler (PWD)
continuous wave Doppler (CWD)
tissue Doppler imaging (TDI)
left ventricular systolic and diastolic function
structure and morphology
systolic function
ejection fraction (EF)
global longitudinal strain (GLS)
wall motion score index (WMSI)
cardiac output
depressed LV systolic function
diastolic function
mitral inflow pulsed wave Doppler
pulmonary venous Doppler
mitral annular tissue Doppler imaging
diastolic dysfunction
right ventricular assessment
structure and morphology
right ventricular (RV) dysfunction
right and left atria
right atrial enlargement
left atrial enlargement
valvular structure and function
mitral valve
mitral regurgitation
mitral stenosis
 aortic valve
aortic stenosis
aortic regurgitation
pulmonic valve
pulmonic regurgitation
pulmonic stenosis
tricuspid valve
tricuspid regurgitation
tricuspid stenosis
hemodynamics
cardiac tamponade
ventricular interdependence
dynamic left ventricular outflow tract obstruction
differentiation of shock states
focus assessed transthoracic echocardiography
pericardium
pericardial effusion
constrictive pericarditis
cardiomyopathies
restrictive cardiomyopathy
hypertrophic cardiomyopathy
left ventricular non-compaction
arrhythmogenic right ventricular cardiomyopathy
dilated cardiomyopathy
congenital heart disease
echocardiographic approach
deductive echocardiography
great vessels
thoracic aorta
thoracic aortic aneurysm
thoracic aortic dissection
main pulmonary artery
pulmonary embolism
inferior vena cava
collapsability index
distensibility index
superior vena cava
pediatric ultrasound
intussusception
appendicitis
vesicoureteric reflux grading
transcranial ultrasound
ultrasound interventions
ultrasound-guided biopsy
fine needle aspiration (FNA)
cell block cytology
gene expression classifier
core biopsy
ultrasound-guided renal biopsy
ultrasound-guided breast biopsy
ultrasound-guided liver biopsy
ultrasound-guided biopsy of a peripheral soft tissue mass
ultrasound-guided percutaneous drainage
thoracentesis
ultrasound-guided musculoskeletal interventions
joint injection
nerve blocks
interscalene brachial plexus block
ultrasound-guided intravenous cannulation
contrast-enhanced ultrasound
liver
 hepatic metastasis
cystadenoma/cystadenocarcinoma
cholangiocarcinoma
hepatocellular carcinoma
hepatic adenoma
focal nodular hyperplasia
hepatic hemangioma
kidney
renal cell carcinoma
complex renal cysts
angiomyolipoma
ischemia/infarction

Promoted articles (advertising)

Predictive Technology Group, Atrin Pharmaceuticals Gene Profiling Uncovers Actionable Mutations in More
Launch Oncology MDx Collaboration Than Half of Non-Small Cell Lung Cancers
Precision Oncology News, 2020 Precision Oncology News, 2017

Powered by

Edit article Share article

View revision history

Report problem with Article

URL of Article https://radiopaedia.org/articles/normal-pulmonary-v

Article information
rID: 66714
System: Cardiac
Section: Approach
Tags: cardiology, emergencymedicine, pocus
Synonyms or Alternate Spellings:

Support Radiopaedia and see fewer ads

Cases and figures

Case 1: apical 4 chamber viewCase 1: apical 4 chamber view

Drag here to reorder.

Case 2: right upper pulmonary veinCase 2: right upper pulmonary vein

Drag here to reorder.

Case 3: pulmonary venous doppler waveform illustrationCase 3: pulmonary venous doppler waveform
illustration
Drag here to reorder.
:

Encyclopaedia
By Section:

Anatomy
Approach
Artificial Intelligence
Classifications
Gamuts
Imaging Technology
Interventional Radiology
Mnemonics
Pathology
Radiography
Signs
Staging
Syndromes

By System:

Breast
Cardiac
Central Nervous System
Chest
Forensic
Gastrointestinal
Gynaecology
Haematology
Head & Neck
Hepatobiliary

Interventional
Musculoskeletal
Obstetrics
Oncology
Paediatrics
Spine
Trauma
Urogenital
Vascular
Not Applicable

Patient Cases
Breast
Cardiac
Central Nervous System
Chest
Forensic
Gastrointestinal
Gynaecology
Haematology
Head & Neck
Hepatobiliary

Interventional
Musculoskeletal
Obstetrics
Oncology
Paediatrics
Spine
Trauma
Urogenital
Vascular
 Not Applicable

Radiopaedia.org
About
Blog
Feature Sponsor
Donate

Editors
Expert advisers
Help

Facebook

Twitter

Newsletter

Contact Us
Terms of Use
Privacy Policy
Licensing
Sponsorship
Developers

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.

© 2005–2020 Radiopaedia.org
Accept
This site is for use by medical professionals. To continue you must accept our use of cookies and the
site's Terms of Use.