Left Ventricle

Left Ventricular Systolic Function

Reference limits and values and partition values of left ventricular function[1]
Women

Men

Reference Mildly
range
abnormal

Moderately
abnormal

Severely
abnormal

Reference Mildly
range
abnormal

Moderately
abnormal

Severely
abnormal

Endocardial
fractional
shortening, %

2745

2226

1721

16

2543

2024

1519

14

Midwall
fractional
shortening, %

1523

1314

1112

10

1422

1213

1011

10

55

4554

3044

<30

55

4554

3044

<30

Linear method

2D Method
Ejection
fraction, %

2D, Two-dimensional.
Green values: Recommended and best validated.

Left Ventricular Diastolic Function

Normal values for Doppler-derived diastolic measurements[2]

Age group (y)
Measurement

16-20

21-40

41-60

>60

IVRT (ms)

50 9 (32-68)

67 8 (51-83)

74 7 (60-88)

87 7 (73-101)

E/A ratio

1.88 0.45 (0.98-2.78)

1.53 0.40 (0.73-2.33)

1.28 0.25 (0.78-1.78)

0.96 0.18 (0.6-1.32)

DT (ms)

142 19 (104-180)

166 14 (138-194)

181 19 (143-219)

200 29 (142-258)

A duration (ms)

113 17 (79-147)

127 13 (101-153)

133 13 (107-159)

138 19 (100-176)

PV S/D ratio

0.82 0.18 (0.46-1.18)

0.98 0.32 (0.34-1.62)

1.21 0.2 (0.81-1.61)

1.39 0.47 (0.45-2.33)

PV Ar (cm/s)

16 10 (1-36)

21 8 (5-37)

23 3 (17-29)

25 9 (11-39)

PV Ar duration (ms)

66 39 (1-144)

96 33 (30-162)

112 15 (82-142)

113 30 (53-173)

Septal e (cm/s)

14.9 2.4 (10.1-19.7)

15.5 2.7 (10.1-20.9)

12.2 2.3 (7.6-16.8)

10.4 2.1 (6.2-14.6)

Septal e/a ratio

2.4

1.6 0.5 (0.6-2.6)

1.1 0.3 (0.5-1.7)

0.85 0.2 (0.45-1.25)

Lateral e (cm/s)

20.6 3.8 (13-28.2)

19.8 2.9 (14-25.6)

16.1 2.3 (11.5-20.7)

12.9 3.5 (5.9-19.9)

1.9 0.6 (0.7-3.1)

1.5 0.5 (0.5-2.5)

0.9 0.4 (0.1-1.7)

Lateral e/a ratio

3.1

Data are expressed as mean SD (95% confidence interval). Note that for e velocity in subjects aged 16 to 20 years, values overlap with those for subjects aged 21 to 40 years.
This is because e increases progressively with age in children and adolescents. Therefore, the e velocity is higher in a normal 20-year-old than in a normal 16-year-old, which
results in a somewhat lower average e value when subjects aged 16 to 20 years are considered.

Standard deviations are not included because these data were computed, not directly provided in the original articles from which they were derived.

Left Ventricular Mass and Geometry

Reference limits and partition values of left ventricular mass and geometry[1]
Women

Men

Reference
range

Mildly
abnormal

Moderately
abnormal

Severely
abnormal

Reference
range

Mildly
abnormal

Moderately
abnormal

Severely
abnormal

LV mass, g

67162

163186

187210

211

88224

225258

259292

293

LV mass/BSA, g/m2

4395

96108

109121

122

49115

116131

132148

149

LV mass/height, g/m

4199

100115

116128

129

52126

127144

145162

163

LV mass/height2, g/m2

1844

4551

5258

59

2048

4955

5663

64

Relative wall thickness, cm

0.220.42

0.430.47

0.480.52

0.53

0.240.42

0.430.46

0.470.51

0.52

Linear Method

Septal thickness, cm

0.60.9

1.01.2

1.31.5

1.6

0.61.0

1.11.3

1.41.6

1.7

Posterior wall thickness, cm

0.60.9

1.01.2

1.31.5

1.6

0.61.0

1.11.3

1.41.6

1.7

66150

151171

172182

>193

96200

201227

228254

>255

4488

89100

101112

113

50102

103116

117130

131

2D Method
LV mass, g
LV mass/BSA, g/m

BSA, Body surface area; LV, left ventricular; 2D, 2-dimensional.

Green values: Recommended and best validated.

Left Ventricular Size

Reference limits and partition values of left ventricular size[1]

Women

Men

Reference
range

Mildly
Moderately
abnormal abnormal

Severely Reference
abnormal range

Mildly
Moderately
abnormal abnormal

Severely
abnormal

LV diastolic diameter

3.95.3

5.45.7

5.86.1

6.2

4.25.9

6.06.3

6.46.8

6.9

LV diastolic diameter/BSA, cm/m2

2.43.2

3.33.4

3.53.7

3.8

2.23.1

3.23.4

3.53.6

3.7

LV diastolic diameter/height, cm/m

2.53.2

3.33.4

3.53.6

3.7

2.43.3

3.43.5

3.63.7

3.8

56104

105117

118130

131

67155

156178

179201

201

3575

7686

8796

97

3575

7686

8796

97

1949

5059

6069

70

2258

5970

7182

83

LV dimension

LV volume
LV diastolic volume, mL
LV diastolic volume/BSA, mL/m
LV systolic volume, mL

LV systolic volume/BSA, mL/m2

1230

3136

3742

43

1230

3136

3742

43

BSA, body surface area; LV, left ventricular.

Green values: Recommended and best validated.

Right Ventricle
Right Ventricular and Pulmonary Artery Size
Reference limits and partition values of right ventricular and pulmonary artery size[1]
Reference range

Mildly abnormal

Moderately
abnormal

Severely abnormal

Basal RV diameter (RVD 1), cm

2.02.8

2.93.3

3.43.8

3.9

Mid-RV diameter (RVD 2), cm

2.73.3

3.43.7

3.84.1

4.2

Base-to-apex length (RVD 3), cm

7.17.9

8.08.5

8.69.1

9.2

Above aortic valve (RVOT 1), cm

2.52.9

3.03.2

3.33.5

3.6

Above pulmonic valve (RVOT 2), cm

1.72.3

2.42.7

2.83.1

3.2

1.52.1

2.22.5

2.62.9

3.0

RV dimensions

RVOT diameters

PA diameter
Below pulmonic valve (PA 1), cm

RV, Right ventricular; RVOT, right ventricular outflow tract; PA, pulmonary artery.
Data from Foale et al.[3]
Right Ventricular Size and Function
Reference limits and partition values of right ventricular size and function as measured in the apical 4-chamber view[1]
RV diastolic area, cm2

Reference range

Mildly abnormal

Moderately abnormal

Severely abnormal

1128

2932

3337

38

RV systolic area, cm2

7.516

1719

2022

23

RV fractional area change, %

3260

2531

1824

17

TAPSE, (cm)

1.5-2.0[1]

1.3-1.5[4]

1.0-1.2[4]

<1.0[4]

RV, Right ventricular.

Data from Weyman.[5]

Atria
Left Atrial Dimensions / Volumes

Reference limits and partition values for left atrial dimensions/volumes[1]

Women

Men

Reference Mildly
Moderately Severely Reference Mildly
Moderately Severely
range
abnormal abnormal
abnormal range
abnormal abnormal
abnormal
Atrial dimensions
LA diameter, cm

2.73.8

3.94.2

4.34.6

4.7

3.04.0

4.14.6

4.75.2

5.2

1.52.3

2.42.6

2.72.9

3.0

1.52.3

2.42.6

2.72.9

3.0

RA minor-axis dimension, cm

2.94.5

4.64.9

5.05.4

5.5

2.94.5

4.64.9

5.05.4

5.5

RA minor-axis dimension/BSA, cm/m2

1.72.5

2.62.8

2.93.1

3.2

1.72.5

2.62.8

2.93.1

3.2

20

2030

3040

>40

20

2030

3040

>40

2252

5362

6372

73

1858

5968

6978

79

22 6

2933

3439

40

22 6

2933

3439

40

LA diameter/BSA, cm/m

Atrial area
LA area, cm2
Atrial volumes
LA volume, mL
LA volume/BSA, mL/m

BSA, Body surface area; LA, left atrial; RA, right atrial.
Green values: Recommended and best validated.

Left Atrial Pressure

Estimation
pressure in

atrial
normal LVEF. After
Estimation of left
reduced LVEF. After [2]

of left

[2]
atrial pressure in

Aortic Valve
Aortic valve stenosis - severity
Recommendations for classification of AS severity[6]
Aortic sclerosis

Mild

Moderate

Severe

Aortic jet velocity (m/s)

2.5 m/s

2.6-2.9

3.0-4.0

>4.0

Mean gradient (mmHg)

<20 (<30a)

20-40b (30-50a)

>40b (>50a)

AVA (cm2)

>1.5

1.0-1.5

<1

Indexed AVA (cm /m )

>0.85

0.60-0.85

<0.6

Velocity ratio

>0.50

0.25-0.50

<0.25

ESC Guidelines.[7] AHA/ACC Guidelines.[8]

Aortic regurgitation - severity

Application of specific and supportive signs, and quantitative parameters in the grading of aortic regurgitation severity[9]

Mild

Moderate

Severe

Central Jet, width < 25% of LVOT

Vena contracta < 0.3 cm
No or brief early diastolic flow reversal in
descending aorta

Signs of AR>mild present but no criteria for

severe AR

Central Jet, width 65% of LVOT

Vena contracta > 0.6cm

Pressure half-time > 500 ms

Normal LV size

Intermediate values

Pressure half-time < 200 ms

Holodiastolic aortic flow reversal in
descending aorta
Moderate or greater LV enlargement

R Vol, ml/beat

< 30

30-44

45-59

60

RF %

< 30

30-39

40-49

50

< 0.10

0.10-0.19

0.20-0.29

0.30

Specific signs for AR

severity

Supportive signs
Quantitative parameters

EROA, cm

AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, left ventricular outflow tract; R Vol, regurgitant volume; RF, regurgitant fraction.

LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis 2.8 cm/m 2, LV end-diastolic volume 82 ml/m2 (2). At a Nyquist limit of 5060 cm/s.

In the absence of other etiologies of LV dilatation.

Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe regurgitation as shown.

Mitral Valve
Mitral regurgitation - severity
Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity[9]
Mild

Moderate

Specific signs of
severity

Small central jet <4 cm2 or

<20% of LA area
Vena contracta width <0.3
cm
No or minimal flow
convergence

Signs of MR>mild present, but no Vena contracta width 0.7cm with large central MR jet (area < 40%
criteria for severe MR
of LA) or with a wall-impinging jet of any size, swirling in LA
Large flow convergence
Systolic reversal in pulmonary veins
Prominent flail MV leaflet or ruptured papillary muscle
Intermediate signs/findings

Supportive signs

Systolic dominant flow in

pulmonary veins
A-wave dominant mitral
inflow
Soft density, parabolic CW
Doppler MR signal
Normal LV size

Quantitative parameters

Severe

Dense, triangular CW Doppler MR jet

E-wave dominant mitral inflow (E >1.2 m/s) Enlarged LV and LA
size, (particularly when normal LV function is present).

R Vol (ml/beat)

< 30

30-44

45-59

60

RF (%)

< 30

30-39

40-49

50

EROA (cm2)

< 0.20

0.20-0.29

0.30-0.39

0.40

CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MV, mitral valve; MR, mitral regurgitation; R Vol, regurgitant
volume; RF, regurgitant fraction.

LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis 2.8 cm/m2, LV end-diastolic volume 82 ml/m2, maximal LA anteroposterior diameter 2.8 cm/m2, maximal LA volume 36 ml/m2 (2;33;35).

In the absence of other etiologies of LV and LA dilatation and acute MR.

At a Nyquist limit of 50-60 cm/s.

Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.

Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and 0.9 cm for central jets, respectively, with a baseline shift at a
Nyquist of 40 cm/s; Cut-offs for eccentric jets are higher, and should be angle corrected (see text).

Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.
Mitral stenosis - severity
Recommendations for classification of mitral stenosis severity[6]
Mild

Moderate

Severe

>1.5

1.0-1.5

<1.0

Mean gradient (mmHg)a

<5

5-10

>10

Pulmonary artery pressure (mmHg)

<30

30-50

>50

Specific findings
Valve area (cm2)
Supportive findings

At heart rates between 60 and 80 bpm and in sinus rhythm.

Mitral valve stenosis - Wilkins score
Assessment of mitral valve anatomy according to the Wilkins score[10]
Grade

Mobility

Thickening

Calcification

Subvalvular Thickening

Highly mobile valve with only leaflet

tips restricted

Leaflets near normal in thickness (4-5

mm)

A single area of increased echo

brightness

Minimal thickening just below the mitral leaflets

Leaflet mid and base portions have

normal mobility

Midleaflets normal, considerable

thickening of margins (5-8 mm)

Scattered areas of brightness

confined to leaflet margins

Thickening of chordal structures extending to one-third

of the chordal length

Valve continues to move forward in

diastole, mainly from the base

Thickening extending through the

entire leaflet (5-8mm)

Brightness extending into the midportions of the leaflets

Thickening extended to distal third of the chords

No or minimal forward movement of

the leaflets in diastole

Considerable thickening of all leaflet

tissue (>8-10mm)

Extensive brightness throughout

much of the leaflet tissue

Extensive thickening and shortening of all chordal

structures extending down to the papillary muscles

The total score is the sum of the four items and ranges between 4 and 16.

Mitral stenosis - routine measurements

Recommendations for data recording and measurement in routine use for mitral stenosis quantitation[6]
Data element

Planimetry

Mitral flow

Systolic pulmonary artery

pressure

Recording

Measurement

- 2D parasternal short-axis view

- contour of the inner mitral orifice

- determine the smallest orifice by scanning from apex to

base

- include commissures when opened

- positioning of measurement plan can be oriented by 3D

echo

- in mid-diastole (use cine-loop)

- lowest gain setting to visualize the whole mitral orifice

- average measurements if atrial fibrillation

- continuous-wave Doppler

- mean gradient from the traced contour of the diastolic mitral flow

- apical windows often suitable (optimize intercept angle)

- pressure half-time from the descending sLope of the E-wave (mid-diastole slope if not
linear)

- adjust gain setting to obtain well-defined flow contour

- average measurements if atrial fibrillation

- continuous-wave Doppler

- maximum velocity of tricuspid regurgitant flow

- multiple acoustic windows to optimize intercept angle

- estimation of right atrial pressure according to inferior vena cava diameter

Valve anatomy
- parasternal short-axis view
- valve thickness (maximum and heterogeneity)
- commissural fusion
- extension and location of localized bright zones (fibrous nodutes or calcification)
- parasternal long-axis view
- valve thickness
- extension of calcification
- valve pliability
- subvalvular apparatus (chordal thickening, fusion, or shortening)
- apical two-chamber view
- subvalvular apparatus (chordal thickening, fusion, or shortening)

Detail each component and summarize in a score

Tricuspid Valve
Tricuspid regurgitation - severity
Echocardiographic and Doppler parameters used in grading tricuspid regurgitation severity[9]
Parameter

Mild

Tricuspid valve

Usually normal

Moderate

Severe

Normal or abnormal

Abnormal/Flail leaflet/Poor coaptation

Normal or dilated

Usually dilated

RV/RA/IVC size

Normal

Jet area-central jets (cm2)

<5

5-10

> 10

Not defined

Not defined, but < 0.7

> 0.7

0.5

0.6-0.9

> 0.9

Jet density and contourCW

Soft and parabolic

Dense, variable contour

Dense, triangular with early peaking

Hepatic vein flow

Systolic dominance

Systolic blunting

Systolic reversal

VC width (cm)

PISA radius (cm)

CW, Continuous wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena contracta width.

Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical 4-chamber view: RV medio-lateral end-diastolic dimension 4.3 cm, RV enddiastolic area 35.5 cm2, maximal RA medio-lateral and supero-inferior dimensions 4.6 cm and 4.9 cm respectively, maximal RA volume 33 ml/m 2(35;89).

Exception: acute TR.

At a Nyquist limit of 50-60 cm/s. Not valid in eccentric jets. Jet area is not recommended as the sole parameter of TR severity due to its dependence on hemodynamic and
technical factors.

At a Nyquist limit of 50-60 cm/s. Baseline shift with Nyquist limit of 28 cm/s. Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated RA pressure).

Tricuspid stenosis - severity

Findings indicative of haemodynamically significant tricuspid stenosis[6]
Specific findings

Mean pressure gradient

5 mmHg

Inflow time-velocity integral

>60 cm

T1/2
Valve area by continuity equation

190 ms
a

1 cm2

Supportive findings
Enlarged right atrium moderate
DHated inferior vena cava
a

Stroke volume derived from left or right ventricular outflow. In the presence of more than mild TR, the derived valve area will be underestimated. Nevertheless, a value 1 cm 2 implies a significant haemodynamic
burden imposed by the combined lesion.

Pulmonary Valve
Pulmonary regurgitaion - severity
Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity[9]
Parameter

Mild

Moderate

Severe

Pulmonic valve

Normal

Normal or abnormal

Abnormal

RV size

Normal

Normal or dilated

Dilated

Jet size by color Doppler

Thin (usually < 10 mm in length) with a

narrow origin

Intermediate

Usually large, with a wide origin; May be brief in

duration

Jet density and deceleration rate CW

Soft; Slow deceleration

Dense; variable deceleration

Dense; steep deceleration, early termination of

diastolic flow

Pulmonic systolic flow compared to systemic

flow PW

Slightly increased

Intermediate

Greatly increased

CW, Continuous wave Doppler; PR, pulmonic regurgitation; PW, pulsed wave Doppler; RA, right atrium; RF, regurgitant fraction; RV, right ventricle.

Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-chamber view; RV medio-lateral end-diastolic dimension 4.3 cm, RV enddiastolic area 35.5 cm2(89).

Exception: acute PR

At a Nyquist limit of 50-60 cm/s.

Cut-off values for regurgitant volume and fraction are not well validated.
Steep deceleration is not specific for severe PR.

Pulmonary stenosis - severity

Grading of pulmonary stenosis[6]
Mild

Moderate

Severe

Peak velocity (m/s)

<3

3-4

>4

Peak gradient (mmHg)

<36

36-64

>64