We have previously shown that the systolic and diastolic pulmonary venous flow (PVF) distribution is predictive of left atrial pressure. This study was designed to define the confounding influences of left atrial expansion, descent of the mitral anulus, and left ventricular contractile function on that relationship; to define normal PVF patterns; and to document the interaction of PVF with mitral inflow. Therefore we studied 27 consecutive intraoperative patients with coronary artery disease (22 men and 5 women, ages 35 to 78 years) using transesophageal echocardiography. A group of 12 normal subjects served as a control. Doppler and two-dimensional echocardiographic parameters were obtained simultaneously with monitoring pulmonary capillary wedge pressure (PCWP). We found that neither left atrial expansion nor the descent of the mitral anulus influenced the relationship between PVF and PCWP, but that left ventricular fractional shortening confounded this relationship. In normal subjects PVF was dominant in systole, whereas PVF in patients with elevated PCWP was dominant in diastole (systolic fraction of 68 +/- 6% [SD] in normals versus 42 +/- 15% in patients with PCWP greater than or equal to 15 mm Hg). PVF velocities interacted with transmitral flow velocities. Peak early diastolic mitral inflow velocities increased linearly with peak early diastolic PVF velocities (r = 0.62). We conclude that systolic and diastolic PVF distribution is mainly determined by the level of PCWP and to a lesser extent by left ventricular contraction, but not by left atrial expansion or by mitral anulus descent. Transesophageal pulsed Doppler echocardiography of PVF provides useful clinical information about the level of PCWP in intraoperative patients with coronary artery disease.