European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271 POSITION PAPER

doi:10.1093/ehjci/jev014

Recommendations for Cardiac Chamber

Quantification by Echocardiography in Adults:
An Update from the American Society of

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Echocardiography and the European Association
of Cardiovascular Imaging
Roberto M. Lang, MD, FASE, FESC, Luigi P. Badano, MD, PhD, FESC,
Victor Mor-Avi, PhD, FASE, Jonathan Afilalo, MD, MSc, Anderson Armstrong, MD, MSc,
Laura Ernande, MD, PhD, Frank A. Flachskampf, MD, FESC, Elyse Foster, MD, FASE,
Steven A. Goldstein, MD, Tatiana Kuznetsova, MD, PhD, Patrizio Lancellotti, MD, PhD,
FESC, Denisa Muraru, MD, PhD, Michael H. Picard, MD, FASE, Ernst R. Rietzschel, MD,
PhD, Lawrence Rudski, MD, FASE, Kirk T. Spencer, MD, FASE, Wendy Tsang, MD,
and Jens-Uwe Voigt, MD, PhD, FESC
Chicago, Illinois; Padua, Italy; Montreal, Quebec and Toronto, Ontario, Canada; Baltimore, Maryland; Créteil, France; Uppsala, Sweden; San Francisco, California; Washington, District of Columbia;
Leuven, Liège, and Ghent, Belgium; Boston, Massachusetts

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments
have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the
goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial de-
formation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this
document attempts to eliminate several minor discrepancies that existed between previously published guidelines.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Adult echocardiography † Transthoracic echocardiography † Ventricular function † Normal values

From the University of Chicago Medical Center, Chicago, Illinois (R.M.L., V.M.-A., K.T.S.); the University of Padua, Padua, Italy (L.P.B., D.M.); Jewish General Hospital, McGill University,
Montreal, Quebec, Canada (J.A., L.R.); Johns Hopkins University, Baltimore, Maryland (A.A.); INSERM U955 and Hôpital Henri Mondor, Créteil, France (L.E.); Uppsala University, Uppsala,
Sweden (F.A.F.); the University of California, San Francisco, San Francisco, California (E.F.); Medstar Washington Hospital Center, Washington, District of Columbia (S.A.G.); University
Hospital Leuven, Leuven, Belgium (T.K., J.-U.V.); the University of Liège Hospital, Liège, Belgium (P.L.); Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
(M.H.P.); Ghent University Hospital, Ghent, Belgium (E.R.R.); and the University of Toronto, Toronto, Ontario, Canada (W.T.).
The following authors reported no actual or potential conflicts of interest in relation to this document: Jonathan Afilalo, MD, MSc, Anderson Armstrong, MD, MSc, Laura Ernande, MD,
PhD, Frank A. Flachskampf, MD, FESC, Steven A. Goldstein, MD, Tatiana Kuznetsova, MD, PhD, Patrizio Lancellotti, MD, PhD, FESC, Victor Mor-Avi, PhD, FASE, Michael H. Picard, MD,
FASE, Ernst R. Rietzschel, MD, PhD, Kirk T. Spencer, MD, FASE, Wendy Tsang, MD, and Jens-Uwe Voigt, MD, PhD, FESC. The following authors reported relationships with one or more
commercial interests: Luigi P. Badano, MD, PhD, FESC, received grants from GE Healthcare, Siemens, and Esaote and serves on the speakers’ bureau for GE Healthcare. Elyse Foster, MD,
FASE, received grant support from Abbott Vascular Structural Heart. Roberto M. Lang, MD, FASE, FESC, received grants from and serves on the speakers’ bureau and advisory board for
Philips Medical Systems. Denisa Muraru, MD, received research equipment from and served as a consultant for GE Healthcare. Lawrence Rudski, MD, FASE, holds stock in GE.
Drs Lang and Badano co-chaired the Writing Group.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [Link]@[Link].
234 R.M. Lang et al.

Table of Contents
I. The Left Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 V. The Inferior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . . . 265
1. Measurement of LV Size . . . . . . . . . . . . . . . . . . . . . . . 235 Notice and Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
1.1. Linear Measurements . . . . . . . . . . . . . . . . . . . . . 235 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
1.2. Volumetric Measurements . . . . . . . . . . . . . . . . . . 235 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
1.3. Normal Reference Values for 2DE . . . . . . . . . . . . . 238 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
1.4. Normal Reference Values for 3DE . . . . . . . . . . . . . 238 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Recommendation . . . . . . . . . . . . . . . . . . . . . . . 238 Echocardiographic Measurements . . . . . . . . . . . . . . . . . . . . . 271
2. LV Global Systolic Function . . . . . . . . . . . . . . . . . . . . 238 Statistical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
2.1. Fractional Shortening . . . . . . . . . . . . . . . . . . . . . . 238

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2.2. EF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
2.3. Global Longitudinal Strain (GLS) . . . . . . . . . . . . . . 239
2.4. Normal Reference Values . . . . . . . . . . . . . . . . . . . 239 The quantification of cardiac chamber size and function is the corner-
Recommendations . . . . . . . . . . . . . . . . . . . . . . 242 stone of cardiac imaging, with echocardiography being the most com-
3. LV Regional Function . . . . . . . . . . . . . . . . . . . . . . . . . 242 monly used noninvasive modality because of its unique ability to
3.1. Segmentation of the Left Ventricle . . . . . . . . . . . . . 242 provide real-time images of the beating heart, combined with its avail-
3.2. Visual Assessment . . . . . . . . . . . . . . . . . . . . . . . 243 ability and portability. Standardization of the methodology used to
3.3. Regional Wall Motion during Infarction and Ischemia . 243 quantify cardiac chambers is maintained by creating and disseminating
3.4. Regional Abnormalities in the Absence of Coronary official recommendations, which when followed by practitioners
Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 provides uniformity and facilitates communication. Recommenda-
3.5. Quantification of Regional Wall Motion Using tions for echocardiographic chamber quantification were last pub-
Doppler and STE . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 lished in 2005 by the American Society of Echocardiography (ASE)
Recommendations . . . . . . . . . . . . . . . . . . . . . . 245 and the European Association of Echocardiography (renamed the
4. LV Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 European Association of Cardiovascular Imaging [EACVI]).1,2
Recommendations . . . . . . . . . . . . . . . . . . . . . . 248 Since then, echocardiographic technology has continued evolving,
II. The Right Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 with two major developments being real-time three-dimensional
5. General Recommendations for RV Quantification . . . . . . 249 (3D) echocardiography (3DE) and myocardial deformation imaging.
6. Essential Imaging Windows and Views . . . . . . . . . . . . . . 249 The goal of this document is to provide an update to the previously
7. RV Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . 249 published guidelines, as well as recommendations and reference
7.1. Linear Measurements . . . . . . . . . . . . . . . . . . . . . 249 values, while eliminating the minor discrepancies that existed
7.2. Volumetric Measurements . . . . . . . . . . . . . . . . . . 251 between previous guidelines. The normal values in this update
Recommendations . . . . . . . . . . . . . . . . . . . . . . 251 include 3DE and myocardial deformation, when possible. Important-
8. RV Systolic Function . . . . . . . . . . . . . . . . . . . . . . . . . 253 ly, compared with the previous guidelines, this update is based on
8.1. RIMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 considerably larger numbers of normal subjects, compiled from mul-
8.2. TAPSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 tiple databases, to improve the reliability of the reference values.
8.3. RV 2D FAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Although most issues covered in this document reflect a broad
8.4. DTI-Derived Tricuspid Lateral Annular Systolic consensus among the members of the writing group, one important
Velocity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 issue the group debated was partition values for severity of abnormal-
8.5. RV Strain and Strain Rate . . . . . . . . . . . . . . . . . . . 255 ities. Most often, in addition to describing a parameter as normal or
Recommendations . . . . . . . . . . . . . . . . . . . . . . 256 abnormal (reference values), clinical echocardiographers qualify
8.6. RV 3D EF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 the degree of abnormality with terms such as mildly, moderately,
Recommendation . . . . . . . . . . . . . . . . . . . . . . . 256 and severely abnormal, which reflect the degree to which measure-
III. The Left and Right Atria . . . . . . . . . . . . . . . . . . . . . . . . . 256 ments deviate from normal. In addition to providing normative
9. LA Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . 257 data, it would be beneficial to standardize cutoffs for severity of ab-
9.1. General Considerations for LA Size . . . . . . . . . . . . 257 normality for all parameters across echocardiography laboratories,
9.2. Linear Dimensions and Area Measurements . . . . . . . 257 such that the term moderately abnormal, for example, would have
9.3. Volume Measurements . . . . . . . . . . . . . . . . . . . . 257 the same meaning universally. However, different approaches may
9.4. Normal Values of LA Measurements . . . . . . . . . . . . 257 be used for determining cutoff values for the different degrees of
Recommendations . . . . . . . . . . . . . . . . . . . . . . 260 abnormality, all of which have significant limitations.
10. Right Atrial measurements . . . . . . . . . . . . . . . . . . . . 260 The first approach would be to empirically define cutoffs for mild,
Recommendations . . . . . . . . . . . . . . . . . . . . . . 260 moderate, and severe abnormalities on the basis of SDs above or
IV. The Aortic Annulus and Aortic Root . . . . . . . . . . . . . . . . . 260 below the reference limit derived from a group of healthy people.
11. The Aortic Annulus . . . . . . . . . . . . . . . . . . . . . . . . . 260 The advantage of this method is that these data readily exist for
12. The Aortic Root . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 most echocardiographic parameters. However, this approach is
13. Identification of Aortic Root Dilatation . . . . . . . . . . . . 264 fundamentally flawed. First, not all echocardiographic parameters
Recommendations . . . . . . . . . . . . . . . . . . . . . . 265 are normally distributed (or Gaussian), even in a normal population.
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 235

Second, even if a particular parameter is normally distributed in the same range of normal values for LV and right ventricular (RV)
normal subjects, most echocardiographic parameters, when mea- chamber dimensions and volumes apply for both TEE and TTE. For
sured in the general population, have a significant asymmetric distri- details on specific views for optimal measurements, please refer to
bution in one direction (abnormally large for size or abnormally low the recently published TEE guidelines.3
for function parameters). An alternative method would be to define All measurements described in this document should be per-
abnormalities on the basis of percentile values (e.g., 95th, 99th) of formed on more than one cardiac cycle to account for interbeat vari-
measurements derived from a population that includes both ability. The committee suggests the average of three beats for patients
healthy people and those with disease. Although these data would in normal sinus rhythm and a minimum of five beats in patients with
still not be normally distributed, they would account for the asym- atrial fibrillation. Because the committee acknowledges that the im-
metric distribution and the range of abnormality present within the plementation of this recommendation is time consuming, the use
general population. The major limitation of this approach is that of representative beats is acceptable in the clinical setting.

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such population data sets simply do not exist for most echocardio-
graphic variables.
Ideally, an approach that predicts outcomes or prognosis would be I. The Left Ventricle
preferred. That is, defining a variable as moderately deviated from
normal would imply that there is a moderate risk for a particular 1. Measurement of LV Size
adverse outcome for a patient. Although sufficient data linking risk The most commonly used parameters to describe LV cavity size
and cardiac chamber sizes exist for several parameters (e.g., left ven- include linear internal dimensions and volumes. Measurements are
tricular [LV] size and ejection fraction [EF], left atrial [LA] volume), commonly reported for end-diastole and end-systole, which are
outcomes data are lacking for many other parameters. Unfortunately, then used to derive parameters of global LV function. To allow com-
this approach also has limitations. The first obstacle is how to parison among individuals with different body sizes, chamber mea-
best define risk. The cutoffs suggested for the same parameter surements should be reported indexed to BSA.
vary broadly for different risks in different patient populations and
disease states. 1.1 Linear Measurements
Last, cutoff values may be determined by experience-based con- It is recommended that linear internal measurements of the left ven-
sensus of expert opinions. An extensive debate arose among the tricle and its walls be performed in the parasternal long-axis view.
members of the writing group, some of whom felt that providing Values should be carefully obtained perpendicular to the LV long
partition values on the basis of this scientifically less-than-rigorous axis and measured at or immediately below the level of the mitral
approach would be a disservice to the echocardiography community valve leaflet tips. In this regard, the electronic calipers should be
and that a disease-specific approach might be required to achieve positioned on the interface between the myocardial wall and cavity
meaningful clinical categorization of the severity of abnormality. and the interface between the wall and the pericardium. Internal
Others felt that such cutoffs would provide a uniform reference for dimensions can be obtained with a two-dimensional (2D) echocardi-
echocardiographic reporting, which would be easier to interpret ography (2DE)-guided M-mode approach, although linear measure-
by referring clinicians. The compromise was to provide experience- ments obtained from 2D echocardiographic images are preferred
based partition values only for LV EF and LA volume, while suggested to avoid oblique sections of the ventricle (Table 1).
partition values for additional parameters of LV size and mass are
listed in the Appendix. All partition values should interpreted with 1.2 Volumetric Measurements
caution in this perspective. LV volumes are measured using 2DE or 3DE. Volume calculations
For parameters other than LV size, function, and mass as well derived from linear measurements may be inaccurate, because they
as LA volume, only the mean value and the SD of gender-, age-, rely on the assumption of a fixed geometric LV shape such as a
and body surface area (BSA)-normalized cutoffs or upper and prolate ellipsoid, which does not apply in a variety of cardiac
lower limits are reported in the appropriate sections of this docu- pathologies. Accordingly, the Teichholz and Quinones methods for
ment. For these parameters, measurements exceeding + 1.96 SDs calculating LV volumes from LV linear dimensions are no longer
(i.e., the 95% confidence interval) should be classified as abnormal. recommended for clinical use.
Any description of the degree of deviation from normality in the Volumetric measurements are usually based on tracings of the
echocardiographic report should remain at the discretion of the indi- interface between the compacted myocardium and the LV cavity.
vidual laboratory, and the writing group does not recommend specif- At the mitral valve level, the contour is closed by connecting the
ic partition values. two opposite sections of the mitral ring with a straight line. LV
Quantification using transesophageal echocardiography (TEE) has length is defined as the distance between the bisector of this line
advantages and disadvantages compared with transthoracic echocar- and the apical point of the LV contour, which is most distant to it.
diography (TTE). Although visualization of many cardiac structures is The use of the longer LV length between the apical two- and four-
improved with TEE, some differences in measurements have been chamber views is recommended.
found between TEE and TTE, particularly for chamber dimensions LV volumes should be measured from the apical four- and two-
and thickness. These differences are primarily attributable to the in- chamber views. Two-dimensional echocardiographic image acquisi-
ability to obtain from the transesophageal approach the standardized tion should aim to maximize LV areas, while avoiding foreshortening
imaging planes and views used when quantifying chamber dimensions of the left ventricle, which results in volume underestimation. Acquir-
transthoracically. It is the recommendation of this writing group that ing LV views at a reduced depth to focus on the LV cavity will reduce
236 R.M. Lang et al.

Table 1 Recommendations for the echocardiographic assessment of LV size and function

Parameter and method Technique Advantages Limitations

...............................................................................................................................................................................
Internal linear dimensions M-mode tracing † Reproducible † Beam orientation
Linear internal measurements of the † High temporal resolution frequently off axis
LV should be acquired in the † Wealth of published data † Single dimension, i.e.,
parasternal long-axis view carefully representative only in
obtained perpendicular to the LV long normally shaped
axis, and measured at the level of the ventricles
mitral valve leaflet tips. Electronic
calipers should be positioned on the
interface between myocardial wall and

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cavity and the interface between wall
and pericardium (orange arrows).

2D-guided linear measurements † Facilitates orientation † Lower frame rates than

perpendicular to the M-mode
ventricular long axis † Single dimension, i.e.,
representative only in
normally shaped
ventricles

Volumes Biplane disk summation † Corrects for shape † Apex frequently

Volume measurements are usually distortions foreshortened
based on tracings of the blood-tissue † Less geometrical † Endocardial dropout
interface in the apical four- and assumptions compared † Blind to shape
two-chamber views. At the mitral with linear dimensions distortions not
valve level, the contour is closed by visualized in the apical
connecting the two opposite sections two- and four-chamber
of the mitral ring with a straight line. LV planes
length is defined as the distance
between the middle of this line and the
most distant point of the LV contour.

Area-length † Partial correction for † Apex frequently

shape distortion foreshortened
† Heavily based on
geometrical
assumptions
† Limited published data
on normal population

Continued
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 237

Table 1 Continued

Parameter and method Technique Advantages Limitations

...............................................................................................................................................................................
Endocardial border enhancement † Helpful in patients with † Same limitations as the
suboptimal acoustic above non-contrast 2D
window techniques
† Provides volumes that † Acoustic shadowing in
are closer to those LV basal segments with
measured with cardiac excess contrast
magnetic resonance

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3D data sets † No geometrical † Lower temporal
assumption resolution
† Unaffected by † Less published data on
foreshortening normal values
† More accurate and † Image quality
reproducible compared dependent
to other imaging
modalities

Global longitudinal strain † Angle independent † Vendor dependent

Peak value of 2D longitudinal speckle † Established prognostic
tracking derived strain (%). value

2D, two-dimensional; 3D, three-dimensional; A2C, apical 2-chamber view; A4C, apical 4-chamber view; EDV, end-diastolic volume; ESV, end-systolic volume; LV, left ventricular.

the likelihood of foreshortening and minimize errors in endocardial should be taken to avoid acoustic shadowing, which may occur in
border tracings (Table 1). Because the issue of foreshortening is LV basal segments in the presence of high concentrations of contrast.
less relevant in 3D data sets, 3D image acquisition should focus Normal reference values for LV volumes with contrast enhancement
primarily on including the entire left ventricle within the pyramidal are not well established.
data set. To ensure reasonably accurate identification of end-systole, The most commonly used method for 2D echocardiographic
the temporal resolution of 3D imaging should be maximized without volume calculations is the biplane method of disks summation (modi-
compromising spatial resolution. fied Simpson’s rule), which is the recommended 2D echocardio-
Contrast agents should be used when needed to improve endo- graphic method by consensus of this committee (Table 1). An
cardial delineation when two or more contiguous LV endocardial alternative method to calculate LV volumes when apical endocardial
segments are poorly visualized in apical views, as per published guide- definition precludes accurate tracing is the area-length method, in
lines.4 Contrast-enhanced images may provide larger volumes than which the LV is assumed to be bullet shaped. The mid-LV cross-
unenhanced images that are closer to those obtained with cardiac sectional area is computed by planimetry in the parasternal short-axis
magnetic resonance (CMR) in head-to-head comparison.5 Care view and the length of the ventricle taken from the midpoint of the
238 R.M. Lang et al.

annular plane to the apex in the apical four-chamber view (Table 1). accuracy of 3DE is comparable with that of CMR, although
The shortcoming of this method is that the bullet-shape assumption volumes tend to be lower on echocardiography.6
does not always hold true. One of the advantages of 3D echocardio- The effects of ethnicity on 3D echocardiographic LV volumes were
graphic volume measurements is that they do not rely on geometric investigated in one study, which reported that LV volumes were
assumptions. In patients with good image quality, 3D echocardio- smaller among Asian Indians than white Europeans, but EF did not
graphic measurements are accurate and reproducible and should differ among ethnic groups.14 In most 3D echocardiographic
therefore be used when available and feasible.6 The advantages and studies, the relationship between age and 3D echocardiographic LV
disadvantages of the various methods are summarized in Table 1. volumes was examined, and weak to moderate negative correlations
were seen between age and LV volumes, while EF did not change sig-
nificantly with age.10,15,16 This finding is similar to those described in
1.3 Normal Reference Values for 2DE
the CMR literature.17,18 On the basis of weighted averages of three
Data were extracted from seven databases, including Asklepios (year

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studies,16,19,20 3D echocardiographic LV volumes were larger than
0 and year 10),7 Flemengho,8 CARDIA5 and CARDIA25,9 Padua 3D
2D echocardiographic values, and corresponding upper limits of
Echo Normal,10 and the Normal Reference Ranges for Echocardiog-
the normal range were EDVs of 79 mL/m2 for men and 71 mL/m2
raphy study,11,12 to obtain reference values in normal subjects for the
for women and ESVs of 32 mL/m2 for men and 28 mL/m2 for
left ventricle and the left atrium (see section 10). All data were
women. Ultimately, a large study in a diverse population will be
obtained without the use of contrast agents. Data sets for all patients
needed to establish normal reference ranges for 3DE for different
included age, gender, ethnicity, height, and weight. To ensure a
ethnic groups.
normal population, subjects in these studies were excluded if
any of the following criteria were met: systolic blood pressure
Recommendation
.140 mm Hg, diastolic blood pressure .80 mm Hg, history of drug-
LV size should be routinely assessed on 2DE by calculating volumes
treated hypertension, diagnosis of diabetes, impaired fasting glucose
using the biplane method of disks summation technique. In laborator-
.100 mg/dL, body mass index .30 kg/m2, creatinine .1.3 mg/dL,
ies with experience in 3DE, 3D measurement and reporting of LV
estimated glomerular filtration rate ,60 mL/min/1.73 m2, total chol-
volumes is recommended when feasible depending on image
esterol .240 mg/dL, low-density lipoprotein cholesterol .130 mg/
quality. When reporting LV linear dimensions, the recommended
dL, and total triglycerides .150 mg/dL. Details of the statistical ana-
method is 2D-guided measurements. LV size and volume measure-
lysis are described in the Appendix. Because of varied study aims, not
ments should be reported indexed to BSA. For general reference,
all echocardiographic measurements were available for each data-
2D echocardiographic LV EDVs of 74 mL/m2 for men and 61 mL/
base. Supplemental Table 1 summarizes the sources of the data for
m2 for women and LV ESVs of 31 mL/m2 for men and 24 mL/m2
each measurement group and their baseline characteristics.
for women should be used as the upper limits of the corresponding
Table 2 shows the normal values for 2D echocardiographic para-
normal range.
meters of LV size and function according to gender, while Supple-
mental Table 2 provides expanded data for the same parameters,
2. LV Global Systolic Function
obtained from different echocardiographic views, and also includes
Global LV function is usually assessed by measuring the difference
the corresponding number of subjects used to obtain these data. Sup-
between the end-diastolic and end-systolic value of a one-
plemental Table 3 lists normal ranges and consensus-based partition
dimensional, 2D, or 3D parameter divided by its end-diastolic
cutoffs for LV dimensions, volumes, EF, and mass. On multivariate
value. For this, end-diastole is preferably defined as the first frame
analysis, age, gender, and BSA were found to have a significant
after mitral valve closure or the frame in the cardiac cycle in which
independent influence on LV end-diastolic volume (EDV) and LV
the respective LV dimension or volume measurement is the largest.
end-systolic volume (ESV). The results across genders and age
End-systole is best defined as the frame after aortic valve closure
deciles subdivided into absolute and BSA-normalized values are
or the frame in which the cardiac dimension or volume is smallest.
shown in Supplemental Table 4 (see Appendix).
In patients with regular heart rhythm, measurements of the timing
Because ethnicity is an important factor, results of analysis by race
of valve openings and closures derived from M-mode echocardiog-
and gender are presented in Supplemental Table 5. From the regres-
raphy, pulsed-wave (PW) or continuous-wave Doppler may be
sion analysis, nomograms are provided for plotting observed LV
used for accurate definitions of ventricular time intervals.
dimensions versus BSA or BSA-indexed LV volumes versus age
(Figures 1 and 2). Nomograms for absolute LV measurements
2.1 Fractional Shortening
against age (Supplemental Figures 1 and 2) and BSA (Supplemental
Fractional shortening can be derived from 2D-guided M-mode
Figures 3 and 4) are also provided (see Appendix).
imaging or preferably from linear measurements obtained from 2D
images. Deriving global LV function parameters from linear measure-
1.4 Normal Reference Values for 3DE ments is problematic when there are regional wall motion abnormal-
Several studies have published 3D echocardiographic reference ities due to coronary disease or conduction abnormalities. In patients
values for healthy normotensive subjects, which are summarized in with uncomplicated hypertension, obesity or valvular diseases, such
Table 3.13 The reported variations in the normal ranges from study regional differences are rare in the absence of clinically recognized
to study are likely due to differences in populations, echocardio- myocardial infarction, and accordingly, this parameter may provide
graphic equipment, and analysis software, as well as variability in useful information in clinical studies.21 In patients with normal size
measurement techniques. In patients with good image quality, the of the LV base but enlarged midventricular and distal portions, LV
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 239

Table 2 Normal values for 2D echocardiographic parameters of LV size and function according to gender

Male Female
.................................................. ..................................................
Parameter Mean + SD 2-SD range Mean + SD 2-SD range
...............................................................................................................................................................................
LV internal dimension
Diastolic dimension (mm) 50.2 + 4.1 42.0– 58.4 45.0 + 3.6 37.8– 52.2
Systolic dimension (mm) 32.4 + 3.7 25.0– 39.8 28.2 + 3.3 21.6– 34.8
LV volumes (biplane)
LV EDV (mL) 106 + 22 62– 150 76 + 15 46– 106
LV ESV (mL) 41 + 10 21– 61 28 + 7 14– 42

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LV volumes normalized by BSA
LV EDV (mL/m2) 54 + 10 34– 74 45 + 8 29– 61
LV ESV (mL/m2) 21 + 5 11– 31 16 + 4 8– 24
LV EF (biplane) 62 + 5 52– 72 64 + 5 54– 74

BSA, body surface area; EDV, end-diastolic volume; EF, ejection fraction; ESV, end-stystolic volume; LV, left ventricular; SD, standard deviation.

volume would be a better marker of LV size than linear dimension After optimizing image quality, maximizing frame rate, and minim-
measured at the LV base. izing foreshortening, which are all critical to reduce measurement
variability, GLS measurements should be made in the three standard
2.2 EF apical views and averaged.25 Measurements should begin with the
EF is calculated from EDV and ESV estimates, using the following apical long-axis view to visualize aortic valve closure, using opening
formula: and closing clicks of the aortic valve or aortic valve opening and
closing on M-mode imaging. When regional tracking is suboptimal
EF = (EDV − ESV)/EDV.
in more than two myocardial segments in a single view, the calculation
of GLS should be avoided. In such cases, alternative indices may be
LV volume estimates may be derived from 2DE or 3DE, as
used to gain insight into longitudinal LV function, such as mitral
described above (section 1.2). The biplane method of disks (modified
annular plane systolic excursion or pulsed Doppler tissue imaging
Simpson’s rule) is the currently recommended 2D method to assess
(DTI)-derived mitral annular peak systolic velocity (s′ ).
LV EF by consensus of this committee. Table 4 lists 2DE-derived
There are concurrent definitions as a basis for GLS calculation
biplane LV EF, including normal ranges and consensus-based severity
using endocardial, midwall, or average deformation.24 This commit-
partition cutoffs according to gender. In patients with good image
tee refrains from recommendations in this regard and refers to the
quality, 3DE-based EF measurements are accurate and reproducible
ongoing joint standardization initiative of the ASE, EACVI, and the
and should be used when available and feasible.6,10,15,16,19,20
ultrasound imaging industry.24,26 Because of intervendor and inter-
2.3 Global Longitudinal Strain (GLS) software variability and age and load dependency, serial assessment
Lagrangian strain is defined as the change in length of an object within of GLS in individual patients should be performed using the same
a certain direction relative to its baseline length: vendor’s equipment and the same software.
The preponderance of currently available data is for midwall GLS.
Strain(%) = (Lt − L0 )/L0 , Although the evidence base for its use in routine clinical echocardiog-
raphy is far smaller than that for EF, measures of midwall GLS have
where Lt is the length at time t, and L0 is the initial length at time 0. been shown in several studies to be robust and reproducible27 and
The most commonly used strain-based measure of LV global systolic to offer incremental predictive value in unselected patients undergo-
function is GLS. It is usually assessed by speckle-tracking echocardi- ing echocardiography for the assessment of resting function,28,29 as
ography (STE)22 – 24 (Table 1). On 2DE, peak GLS describes the well as in predicting postoperative LV function in patients with
relative length change of the LV myocardium between end-diastole valve disease.30,31
and end-systole:

GLS(%) = (MLs − MLd)/MLd, 2.4 Normal Reference Values

Normal reference values for LV EF derived from 2DE have been
where ML is myocardial length at end-systole (MLs) and end-diastole updated using the population-based studies described in section
(MLd). Because MLs is smaller than MLd, peak GLS is a negative 1.3 above. Details can be found in Tables 2 and 4 and Supplemental
number. This negative nature of GLS can lead to confusion when de- Tables 2–5 (see Appendix). EF is not significantly related to gender,
scribing increases or decreases in strain. We recommend that all age, or body size, as measured by BSA. Normal EF was 63 + 5%
references to strain changes specifically mention an increase or de- using the biplane method of disks. Therefore, in individuals aged
crease in the absolute value of strain, to avoid confusion. .20 years, EF in the range of 53% to 73% should be classified
240 R.M. Lang et al.

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Figure 1 For men (left) and women (right), the 95% confidence intervals for the following measurements are presented: LV end-diastolic dimen-
sion measured from a parasternal long-axis window on the basis of BSA (top), BSA-indexed LV EDV measured from an apical four-chamber view on
the basis of age (middle), and BSA-indexed biplane LV EDV on the basis of age (bottom). For example, a normal BSA-indexed LV EDV measured from
the four-chamber view in a 40-year-old woman would fall between approximately 30 and 78 mL/m2.
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 241

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Figure 2 For men (left) and women (right), the 95% confidence intervals for the following measurements are presented: LV end-systolic dimen-
sions measured from a parasternal long-axis window on the basis of BSA (top), BSA-indexed LV ESVs measured from an apical four-chamber view on
the basis of age (middle), and BSA-indexed biplane LV ESVs based on age (bottom).
242 R.M. Lang et al.

Table 3 Normal values for LV parameters obtained with 3DE

Aune et al. (2010) Fukuda et al. (2012) Chahal et al. (2012) Muraru et al. (2013)
...............................................................................................................................................................................
Number of subjects 166 410 978 226
Ethnic makeup of population Scandinavian Japanese 51% European white, 49% Asian Indian White European
EDVi (mL/m2)
Men, mean (LLN, ULN) 66 (46, 86) 50 (26, 74) White: 49 (31, 67); Indian: 41 (23, 59) 63 (41, 85)
Women, mean (LLN, ULN) 58 (42, 74) 46 (28, 64) White: 42 (26, 58); Indian: 39 (23, 55) 56 (40, 78)
ESVi (mL/m2)
Men, mean (LLN, ULN) 29 (17, 41) 19 (9, 29) White: 19 (9, 29); Indian: 16 (6, 26) 24 (14, 34)

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Women, mean (LLN, ULN) 23 (13, 33) 17 (9, 25) White: 16 (8, 24); Indian: 15 (7, 23) 20 (12, 28)
EF (%)
Men, mean (LLN, ULN) 57 (49, 65) 61 (53, 69) White: 61 (49, 73); Indian: 62 (52, 72) 62 (54, 70)
Women, mean (LLN, ULN) 61 (49, 73) 63 (55, 71) White: 62 (52, 72); Indian: 62 (52, 72) 65 (57, 73)

EDVi, LV EDV index; ESVi, LV ESV index; LLN, lower limit of normal; NR, not reported; RT3DTTE, real-time 3D TTE; SVi, LV stroke volume index; ULN, upper limit of normal.
Modified with permission from Bhave et al.13 LLN and ULN are defined as mean + 2 SDs.

Table 4 Normal ranges and severity partition cutoff values for 2DE-derived LV EF and LA volume

Male Female
................................................................ ................................................................
Normal Mildly Moderately Severely Normal Mildly Moderately Severely
range abnormal abnormal abnormal range abnormal abnormal abnormal
...............................................................................................................................................................................
LV EF (%) 52– 72 41–51 30–40 ,30 54– 74 41–53 30– 40 ,30
Maximum LA volume/BSA (mL/m2) 16– 34 35–41 42–48 .48 16– 34 35–41 42– 48 .48

as normal. Three-dimensional echocardiographic normal values have guidance, a peak GLS in the range of 220% can be expected in a
been recently reported in different ethnic populations (Table 3). healthy person, and the lower the absolute value of strain is below
Normal values for GLS depend on the definition of the measure- this value, the more likely it is to be abnormal.
ment position in the myocardium, the vendor, and the version of
the analysis software, resulting in considerable heterogeneity in the
published literature.27,32,33 It is the consensus of this writing commit- 3. LV Regional Function
tee that differences among vendors and software packages are still 3.1 Segmentation of the Left Ventricle
too large to recommend universal normal values and lower limits For the assessment of regional LV function, the ventricle is divided
of normal. To provide some guidance, a peak GLS in the range of into segments. Segmentation schemes should reflect coronary perfu-
220% can be expected in a healthy person. A selection of recently sion territories, result in segments with comparable myocardial mass,
published data is provided in the Appendix together with the lower and allow standardized communication within echocardiography and
normal limits (Supplemental Table 6). There is evidence that with other imaging modalities (Figure 3). Accordingly, a 17-segment
women have slightly higher absolute values of GLS than men and model is commonly used. Beginning at the anterior junction of the
that strain values decrease with age.32,34 GLS is a valuable and sensi- interventricular septum and the RV free wall and continuing counter-
tive tool for follow-up examinations, provided the same equipment, clockwise, basal and midventricular segments should be labeled as
tracing methodology, and software are used. anteroseptal, inferoseptal, inferior, inferolateral, anterolateral, and
anterior. In this 17-segment model, the apex is divided into five seg-
Recommendations ments, including septal, inferior, lateral, and anterior segments, as well
LV systolic function should be routinely assessed using 2DE or 3DE as the “apical cap,” which is defined as the myocardium beyond the
by calculating EF from EDV and ESV. LV EFs of ,52% for men and end of the LV cavity (Figures 3 and 4).35 The 17-segment model may
,54% for women are suggestive of abnormal LV systolic function. be used for myocardial perfusion studies or when comparing
Two-dimensional STE-derived GLS appears to be reproducible and between different imaging modalities, specifically single photon-
feasible for clinical use and offers incremental prognostic data over emission computed tomography, positron emission tomography,
LV EF in a variety of cardiac conditions, although measurements and CMR. Figure 5 shows a schematic representation of the perfusion
vary among vendors and software versions. To provide some territories of the three major coronary arteries. When using this
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 243

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Figure 3 Schematic diagram of the different LV segmentation models: 16-segment model (left),36 17-segment model (center),35 and 18-segment
model (right). In all diagrams, the outer ring represents the basal segments, the middle ring represents the segments at midpapillary muscle level, and
the inner ring represents the distal level. The anterior insertion of the right ventricular wall into the left ventricle defines the border between the
anteroseptal and anterior segments. Starting from this point, the myocardium is subdivided into six equal segments of 608. The apical myocardium in
the 16- and 17-segment models is divided instead into four equal segments of 908. In the 17-segment model an additional segment (apical cap) is added
in the center of the bull’s-eye. (modified from Voigt et al.24).

17-segment model to assess wall motion or regional strain, the 17th average of the scores of all segments visualized. The following
segment (the apical cap) should not be included. scoring system is recommended: (1) normal or hyperkinetic, (2)
Alternative segmentation models treat the apex differently: the hypokinetic (reduced thickening), (3) akinetic (absent or negligible
16-segment model36 divides the entire apex into the same four seg- thickening, e.g., scar), and (4) dyskinetic (systolic thinning or stretch-
ments (septal, inferior, lateral, and anterior; Figure 3, left). Also, some ing, e.g., aneurysm).
segmentation schemes divide the apex into six segments, similar to An aneurysm is a morphologic entity that demonstrates focal dila-
the basal and midventricular levels, resulting in an 18-segment tation and thinning (remodeling) with either akinetic or dyskinetic
model (Figure 3, right) that is simple but results in a slight over- systolic deformation.38 In contrast to the recommendation of previ-
representation of the distal myocardium when scoring. ous guidelines,1,2 this committee refrains from assigning a separate
All segments can be visualized by 2DE. On average, the wall motion score for aneurysm.
two-chamber view and the apical long-axis view intersect with the
four-chamber view at angles of approximately 538 and 1298, respect- 3.3 Regional Wall Motion during Infarction and Ischemia
ively,37 allowing the assessment of the central region of all segments Depending on the regional coronary flow reserve, stress echocardi-
from an apical window, independent of the model used. Although ography may reveal significant coronary artery stenoses by means of
certain variability exists in the coronary artery blood supply to myo- inducing a wall motion abnormality. Myocardial scar may also result in
cardial segments, segments are usually attributed to the three major regional dysfunction of variable severity. Echocardiography can over-
coronary arteries (Figure 5).35 or underestimate the amount of ischemic or infarcted myocardium,
depending on the function of adjacent regions, regional loading con-
3.2 Visual Assessment ditions, and stunning.39 In stress echocardiography, visual recognition
In echocardiography, regional myocardial function is assessed on the of regional dysfunction can be improved with a synchronized
basis of the observed wall thickening and endocardial motion of side-by-side comparison of baseline and stress images using digital
the myocardial segment. Because myocardial motion may be technology.40
caused by adjacent segment tethering or overall LV displacement,
regional deformation (thickening, shortening) should be the focus 3.4 Regional Abnormalities in the Absence of Coronary
of the analysis. However, it must be recognized that deformation Artery Disease
can also be passive and therefore may not always accurately reflect Regional wall motion abnormalities may also occur in the absence of
myocardial contraction. coronary artery disease, in a variety of conditions, such as myocardi-
It is recommended that each segment be analyzed individually in tis, sarcoidosis, and stress-induced (takotsubo) cardiomyopathy. Ab-
multiple views. A semiquantitative wall motion score can be assigned normal motion patterns of the interventricular septum may be found
to each segment to calculate the LV wall motion score index as the postoperatively or in the presence of a left bundle branch block or RV
244 R.M. Lang et al.

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Figure 4 Orientation of apical four-chamber (A4C), apical two-chamber (A2C), and apical long-axis (ALX) views in relation to the bull’s-eye
display of the LV segments (center). Top panels show actual images, and bottom panels schematically depict the LV wall segments in each view.

epicardial pacing, as well as RV dysfunction caused by RV pressure or deformation rate. Because velocity and motion are measured relative
volume overload. Furthermore, some conduction delays can cause to the transducer, measurements may be influenced by tethering or
regional wall motion abnormalities in the absence of primary myocar- overall heart motion. Accordingly, the use of deformation para-
dial dysfunction. This regional dysfunction is due to the abnormal se- meters, such as strain and strain rate, is preferable.
quence of myocardial activation, which causes heterogeneous The most commonly used deformation parameter is longitudinal
loading conditions and remodeling.41 Ideally, the temporal sequence strain during LV systole. Similar to global strain, with current tech-
of activation and motion should be described. Characteristic motion nology, regional deformation measurements may vary in amplitude,
patterns, which result from abnormal activation sequences, such as depending on the myocardial region being investigated, the measure-
septal bounce (“beaking,” “flash”) or lateral apical motion during ment methodology, the vendor, and sample volume definition.
systole (“apical rocking”) should be reported.42 – 45 Therefore, no specific normal ranges are provided in this document.
These values await the upcoming consensus document of the joint
3.5 Quantification of Regional Wall Motion Using task force of the ASE, EACVI, and the industry for the standardization
Doppler and STE of quantitative function imaging.23,25
Echocardiographic quantification of regional myocardial function is Independent of strain magnitude, characteristic changes in tem-
currently based on DTI or speckle-tracking echocardiographic tech- poral pattern of myocardial deformation can be assessed as well. Lon-
niques.46 – 48 Both techniques provide comparable data quality, gitudinal shortening or radial thickening of the myocardium after
although DTI is known to be angle dependent and prone to under- aortic valve closure (postsystolic shortening or thickening, some-
estimating motion that is not parallel to the ultrasound beam. Com- times referred to as tardokinesis) of .20% of the total deformation
monly used parameters include velocity, motion, deformation, and during the cardiac cycle is a consistent sign of regional functional
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 245

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Figure 5 Typical distributions of the right coronary artery (RCA), the left anterior descending coronary artery (LAD), and the circumflex
coronary artery (CX). The arterial distribution varies among patients. Some segments have variable coronary perfusion.

inhomogeneity (e.g., ischemia, scar).44 The development of postsys- of LV myocardium, while 3DE can measure it directly. All methods
tolic shortening during a stress test has been proposed as an indicator then convert the volume to mass by multiplying the volume of myo-
of regional ischemia.49 The value of regional deformation parameters cardium by the myocardial density (approximately 1.05 g/mL).
and temporal patterns of strain derived by speckle-tracking from When the entire ventricle is measured from 2D echocardiograph-
either 2D or 3D echocardiographic data sets is the subject of ic images, either the area-length or truncated ellipsoid technique is
ongoing research and remains to be determined.50,51 used.1 Each method for LV mass measurement has advantages, disad-
vantages, and value in specific situations (Table 5).
Recommendations To measure LV mass in an individual patient over time, especially
Different LV segmentation models are used in clinical practice. those with cardiac disease, the 2D echocardiographic methods
The 17-segment model is recommended to assess myocardial per- have advantages compared with the linear dimension technique.1
fusion with echocardiography and other imaging techniques. The There are, however, fewer studies of the prognostic value of LV
16-segment model is recommended for routine studies assessing mass calculated by these methods compared with the linear dimen-
wall motion, because endocardial excursion and thickening of the sion method described below. Unlike the linear dimension or
tip of the apex are imperceptible. To assess wall motion, each M-mode method, the 2D echocardiographic methods can accom-
segment should be evaluated in multiple views and a four-grade modate for the shape of the ventricle and account for changes in
scoring should be applied: (1) normal or hyperkinetic, (2) hypokinetic LV size that might occur along the long axis of the chamber. This is
(reduced thickening), (3) akinetic (absent or negligible thickening), an important consideration, because changes in LV geometry are
and (4) dyskinetic (systolic thinning or stretching). Despite promising common in various cardiac diseases.
data, quantitative assessment of the magnitude of regional LV de- However, when there is a need to screen or study large popula-
formation cannot be recommended at this stage because of lack of tions, the M-mode method has advantages, because it is simple,
reference values, suboptimal reproducibility, and considerable inter- quick, and subject to less measurement variability. There is a large
vendor measurement variability. body of evidence to support the accuracy of this method. Most
studies that relate LV mass to prognosis are based on this
4. LV Mass method.56 However, several caveats need to be mentioned. First, it
LV mass is an important risk factor for, and a strong predictor of, car- is critical that the wall thickness and LV dimensions measured be
diovascular events.52 – 55 There are several methods that effectively truly perpendicular to the long axis of the left ventricle. Therefore,
calculate LV mass from M-mode echocardiography, 2DE, and 3DE 2D-guided M-mode imaging or measurements from 2D echocardio-
(Table 5). All measurements should be performed at the end of dia- graphic images are preferred over blind M-mode imaging. Second, the
stole (the frame before mitral valve closure or the frame in the formula includes a correction for the 20% overestimation that was
cardiac cycle in which the ventricular dimension or volume is found during the original validation studies of the M-mode technique.
largest). Those that use M-mode (either blinded or 2D-guided) and Because direct 2D measures of wall thickness may yield smaller
2D echocardiographic linear measurements of LV diastolic diameter values than the M-mode technique, LV mass calculated using this
and wall thickness rely on geometric formulas to calculate the volume formula may not be directly interchangeable (Table 5). This may be
 246
Table 5 Recommendations for the echocardiographic assessment of LV mass

Parameter and method Echocardiographic imaging Advantages Limitations

.............................................................................................................................................................................................................................................
† Fast and widely used † Based on the assumption that the left ventricle is a

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Linear method M-mode tracing
Cube formula † Wealth of published data prolate ellipsoid with a 2:1 long/short axis ratio
† Demonstrated prognostic value and symmetric distribution of hypertrophy
LV mass = 0.8 · 1.04 · [(IVS + LVID + PWT)3
† Fairly accurate in normally shaped † Beam orientation frequently off axis
− LVID3 ] + 0.6 g ventricles (i.e., systemic hypertension, † Since linear measurements are cubed, even small
aortic stenosis) measurement errors in dimensions or thickness
Where IVS is interventricular septum; LVID is LV
† Simple for screening large populations have an impact on accuracy
internal diameter, and PWT is inferolateral wall
† Overestimates LV mass
thickness.
† Inaccurate in the presence of asymmetric
Linear internal measurements of the LV should be
hypertrophy, dilated ventricles and other
acquired from the parasternal approach and carefully
diseases with regional variations in wall thickness
obtained perpendicular to the LV long axis, and
measured at the level of the mitral valve leaflet tips.
M-mode measurements should be obtained from a
targeted SAX or a parasternal LAX view. All
measurements should be performed at end-diastole.
2D † Facilitates orientation perpendicular to † Based on the same geometrical assumptions
the LV long axis as M-mode
† Same limitations as M-mode in patients with
abnormal LV geometry
† Impact of harmonic imaging on the mass
calculations and normal values remains to be
defined
† Normal values are less well established than for
M-mode measurements

2D based formulas † Partial correction for shape distortions † Good image quality and properly oriented
Truncated ellipsoid: † Less dependent on geometrical parasternal short-axis views (no oblique planes)
assumptions than the linear are required

measurements † Good epicardial definition is required
LV mass = 1.05p (b + t)2 † Cumbersome methodology
† Higher measurement variability
 
2 d3 † Few published normative data
(a + t) + d − † Limited prognostic data
3 3(a + t)2
 
2 d3
−b2 a + d − 2
3 3a

R.M. Lang et al.

 Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults
Area-length:

LV mass = 1.05
 
5

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A1 (a + d + t)
6
 
5
− A2 (a + d)
6
Mean wall thickness is calculated from epicardial (A1) and
endocardial (A2) cross-sectional areas in short-axis view at
the papillary muscle level (top panel, green line) with the
papillary muscles considered part of the LV cavity. The
short axis radius is calculated as:

A2
b
p
Then, mean wall thickness t is calculated as:


A1
t= −b
p

and the cross sectional area of the myocardium (Am) in

short-axis view is:

Am = A1 − A2
LV mass is calculated from these measurements plus the
LV length measured from the level of the short axis plane
to the base (d) and to the apex (a).
Key: a - distance from the minor axis to the endocardium at
the LV apex; b ¼ LV minor radius; d - distance from the
minor axis to the mitral valve plane; t - mean wall thickness.
LV mass ¼ (LV epicardial volume 2 LV endocardial
volume). 1.05 ¼ LV myocardial volume. 1.05
LV mass ¼ (LV epicardial volume 2 LV endocardial
volume). 1.05 ¼ LV myocardial volume. 1.05
3D based formula 3D data set † Direct measurement without † Normal values less well established
geometrical assumptions about cavity † Dependent on image quality
shape and hypertrophy distribution † Patient’s cooperation required
† More accurate than the linear or the
2D measurements
† Higher inter-measurement and test/
re-test reproducibility
† Better discriminates small changes
within a patient

247
248 R.M. Lang et al.

a less important consideration if the method is being used to identify

cutoff values for prognosis. It is also important to note that the Table 6 Normal ranges for LV mass indices
formula raises the linear dimensions to the power of 3, and thus Women Men
even small errors in dimensions can have significant effects on the cal- ................................................................................
culated LV mass. Linear method
Most studies that have compared 2D-guided M-mode measure- LV mass (g) 67–162 88– 224
ments of LV mass with the 2D echocardiographic area-length or trun- LV mass/BSA (g/m 2) 43 –95 49– 115
cated ellipsoid methods in normally shaped ventricles have shown Relative wall thickness (cm) 0.22–0.42 0.24– 0.42
subtle differences but no clear advantage of one technique over Septal thickness (cm) 0.6–0.9 0.6– 1.0
the other.57 However, comparison studies have not been performed Posterior wall thickness (cm) 0.6–0.9 0.6– 1.0
in the current era, when tremendous gains in 2D echocardiographic 2D method

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image quality have been made. In fact, large population studies con- LV mass (g) 66–150 96– 200
firming or reestablishing normal values for LV mass with harmonic LV mass/BSA (g/m 2) 44 –88 50– 102
imaging are limited.58,59
Because 3DE is the only echocardiographic method that directly Bold italic values: recommended and best validated.

measures myocardial volume, it is an appropriate approach. Numer-

ous validation studies have been performed.60 However, to date,
there have been few studies assessing its practical use, feasibility, vari-
ability, or prognostic value in large-scale clinical environments.61 Ac-
cordingly, it is the consensus of this committee that the 3D
echocardiographic LV mass data available in normal subjects are
not sufficient to recommend normal reference values. It must also
be noted that continuous improvements in the spatial and temporal
resolution of 3D echocardiographic imaging will also influence
normal values and measurement variability.
In patients with upper septal hypertrophy, the linear dimension
methods, which use basal ventricular measurements, result in over-
estimation of the true mass, because the thickest region of the inter-
ventricular septum is incorporated in the measurement. In contrast,
the area-length method, which uses mid-ventricular measurements,
underestimates LV mass, because the thickest part of the interventri-
cular septum is not included in the measurement. In the setting of dis-
crete upper septal or asymmetric hypertrophy, if these methods are
used to serially assess LV mass in a patient, it is critical to use the same
methodology over time and to measure the walls at the same level of
the ventricle. The 3D method has the advantage of accommodating Figure 6 Comparison of RWT. Patients with normal LV mass can
regional differences in wall thickness and therefore can provide the have either concentric remodeling (normal LV mass with increased
most accurate measurements of LV mass in this setting. RWT ≥ 0.42) or normal geometry (RWT ≤ 0.42) and normal LV
The values for LV mass vary according to gender, age, body mass. Patients with increased LV mass can have either concentric
(RWT ≥ 0.42) or eccentric (RWT ≤ 0.42) hypertrophy. These
size, obesity, and region of the world. Therefore, uniform reference
LV mass measurements are based on linear measurements.
values are difficult to define. LV mass is higher in men independent
of body size and increases with body size. Since the publica-
tion of the 2005 recommendations, several studies, mostly using
linear measurements, have reported normal values of LV mass
predict events in obese patients.65,70 However most large population
in normal populations.59,62 – 66 The larger studies reported values
studies reporting LV mass have indexed to BSA.
close to those recommended in the previous guidelines.62,65,66
Finally, calculation of relative wall thickness (RWT) with the
Therefore, the same reference values and abnormality partition
formula (2 × posterior wall thickness)/(LV internal diameter at end-
cutoffs as reported in the previous guidelines continue to be recom-
diastole) permits categorization of an increase in LV mass as either
mended (Table 6). However, characterization of the population being
concentric (RWT .0.42) or eccentric (RWT ≤ 0.42) hypertrophy
studied, and differences in mass between different ethnic populations
and allows the identification of concentric remodeling (normal LV
should be taken into account when determining normal
mass with increased RWT) (Figure 6).
values.10,16,67 – 69
The indexing of LV mass allows comparisons in subjects with differ-
ent body sizes. However, whether to use height, weight, or BSA as the Recommendations
indexing term remains controversial. Studies suggest that indexing to In the normally shaped left ventricle, both M-mode and 2D echocar-
height raised to allometric powers such as 1.7, 2.13, and 2.7 has diographic formulas to calculate LV mass can be used. Normal values
advantages over indexing to BSA, especially when attempting to for these techniques remain unchanged from the previous guidelines
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 249

and should be reported indexed to BSA. Reference upper limits of uses the same methodology as in the previous RV guidelines,
normal LV mass by linear measurements are 95 g/m2 in women whereby a meta-analysis was performed for each parameter.
and 115 g/m2 in men. Reference upper limits of normal LV mass by Not all of the recommended values are identical to those published
2D measurements are 88 g/m2 in women and 102 g/m2 in men in the previous guidelines.71 On the basis of the inclusion of new data
with 2D methods. Because 3DE is the only echocardiographic tech- published in recent reports, minor changes were made in the cutoff
nique that measures myocardial volume directly, without geometric values for RV dimension, S′ , TAPSE, and RIMP. New publications
assumptions regarding LV shape and distribution of wall thickening, since the last guidelines have resulted in changes in the reference
this technique is promising and may be used in abnormally shaped values for 3DE-derived RV EF and volumes (Tables 8 and 10). It is im-
ventricles or in patients with asymmetric or localized hypertrophy. portant for the reader to recognize that most of the values proposed
Limited upper normal limits of 3D echocardiographic LV mass data are not indexed to gender, BSA, or height, despite data suggesting the
are currently available in the literature but are insufficient to substan- advantages of indexing.72 – 75 As a result, it is possible that patients at

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tiate recommendations for reference values. either extreme of height or BSA may be misclassified as having
values outside the reference ranges, and it is recommended that the
interpreting physician consider these parameters when generating
II. The Right Ventricle the report. This potential misclassification also applies to other
groups, such as patients with congenital heart disease and endurance
The right ventricle has a unique crescent shape, which adds complex-
athletes, for whom specific reference values are nonexistent.76
ity to the quantification of its size and function. This chamber plays an
important role in the morbidity and mortality of patients presenting
6. Essential Imaging Windows and Views
with signs and symptoms of cardiopulmonary disease. Until recently,
little uniformity in echocardiographic imaging of the right heart Apical four-chamber, RV-focused apical four-chamber and modified
existed because of a lack of familiarity with various techniques, and apical four-chamber (Figure 7A), left parasternal long- and short-axis,
left parasternal RV inflow, and subcostal views provide the images
the enormous attention directed toward left heart quantification.
The ASE has recently published a guidelines document, endorsed required for a comprehensive assessment of RV size, systolic and dia-
by the EACVI and the Canadian Society of Echocardiography, stand- stolic function, and RV systolic pressures.71 In most cases, in the
RV-focused view, visualization of the entire RV free wall is better
ardizing the approach for the evaluation of right heart dimensions and
function during echocardiographic assessment of the right heart in than in a standard four-chamber view, which is centered on the left
adults.71 Compared with that document, this section provides ventricle. It is therefore recommended that to measure the right ven-
tricle, a dedicated view focused on the right ventricle be used.
updated reference values for RV dimensions and most parameters
of systolic and diastolic function, which should replace the previously Figure 7A and Table 7 show the different RV views and recommenda-
published guideline. tions for measurements.

7. RV Measurements
5. General Recommendations for RV 7.1 Linear Measurements
Quantification Quantitation of RV dimensions is critical and reduces interreader
In all clinical studies, a comprehensive examination of the right ven- variability compared with visual assessment alone.77 Measurements
tricle should be performed, taking into account the study indication by 2DE are challenging because of the complex geometry of the
and available clinical information. The operator should examine the right ventricle and the lack of specific right-sided anatomic landmarks
right ventricle using multiple acoustic windows, and the report to be used as reference points. The conventional apical four-chamber
should present an assessment based on both qualitative and quanti- view (i.e., focused on the left ventricle) results in considerable vari-
tative parameters. Parameters that can be measured include RV ability in how the right heart is sectioned, and consequently, RV
and right atrial (RA) size, a measure of RV systolic function, as linear dimensions and areas may vary widely in the same patient
assessed by at least one or a combination of the following: fractional with relatively minor rotations in transducer position (Figure 7B).
area change (FAC), DTI-derived tricuspid lateral annular systolic vel- RV dimensions are best estimated from a RV-focused apical four-
ocity wave (S′ ), tricuspid annular plane systolic excursion (TAPSE), chamber view obtained with either lateral or medial transducer
and RV index of myocardial performance (RIMP). RV systolic pres- orientation (Figure 7A and Table 7). Care should be taken to obtain
sure, typically calculated using the tricuspid regurgitation jet and an the image with the LV apex at the center of the scanning sector,
estimation of RA pressure based on inferior vena cava (IVC) size while displaying the largest basal RV diameter and thus avoiding fore-
and collapsibility, should be reported when a complete TR shortening. Of note, the accuracy of RV measurements may be
Doppler velocity envelope is present.71 When feasible, additional limited when the RV free wall is not well defined because of the di-
parameters such as RV volumes and EF using 3DE should comple- mension of the ventricle itself or its position behind the sternum.
ment the basic 2D echocardiographic measurements listed above. Recent data have suggested that indexing RV “size” to BSA may be
The recommended methods, as well as the advantages and limita- relevant in some circumstances, but the measurements used in
tions of each parameter, are summarized in Tables 7 and 9, those studies lacked the reference points of the RV-focused view
whereas the new reference values are displayed in Tables 8 and 10. and frequently used RV areas, rather than linear dimensions.73,74 Ref-
These reference values are based on published mean and SD data erence values for RV dimensions are listed in Table 8. In general, a
obtained from normal adult individuals without any histories of diameter ,41 mm at the base and .35 mm at the midlevel in the
heart or pulmonary disease (Supplemental Table 7). This document RV-focused view indicates RV dilatation.
250 R.M. Lang et al.

Table 7 Recommendations for the echocardiographic assessment of RV size

Echocardiographic imaging Recommended methods Advantages Limitations

...............................................................................................................................................................................
RV linear dimensions (inflow) * † Basal RV linear dimension † Easily obtainable † RV size may be underestimated due
(RVD1) ¼ maximal transversal † Simple to the crescent RV shape
dimension in the basal one third of RV † Fast † RV linear dimensions are dependent
inflow at end-diastole in the RV-focused † Wealth of published on probe rotation and different RV
view data views; in order to permit inter-study
† Mid-cavity RV linear dimension comparison, the echocardiography
(RVD2) ¼ transversal RV diameter in report should state the window
the middle third of RV inflow, from which the measurement was
approximately halfway between the performed.

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maximal basal diameter and the apex, at
the level of papillary muscles at
end-diastole.

RV linear dimensions (outflow) * † Proximal RV outflow diameter (RVOT † Easily obtainable † RVOT prox is dependent on imaging
prox) ¼ linear dimension measured † Simple plane position and less reproducible
from the anterior RV wall to the † Fast than RVOT distal
interventricular septal-aortic junction † Risk of underestimation or
(in parasternal long-axis view) or to the overestimation if the RV view is
aortic valve (in parasternal short-axis) obliquely oriented with respect to
at end-diastole RV outflow tract
† Distal RV outflow diameter (RVOT † RV outflow dimensions can be
distal) ¼ linear transversal dimension inaccurate in case of chest and spine
measured just proximal to the deformities
pulmonary valve at end-diastole † Endocardial definition of the RV
anterior wall is often suboptimal
† Limited normative data is available
† Regional measure; may not reflect
global RV size (underestimation or
overestimation)

RV areas (inflow) † Manual tracing of RV endocardial † Relatively easy to † Challenging in case of suboptimal
border from the lateral tricuspid measure image quality of RV free wall
annulus along the free wall to the apex † Challenging in the presence of
and back to medial tricuspid annulus, trabeculation
along the interventricular septum at † RV size underestimation if RV cavity
end-diastole and at end-systole is foreshortened
† Trabeculations, papillary muscles and † Due to the LV twisting motion and
moderator band are included in the the crescent RV shape, the
cavity area end-diastolic RV image may not be in
the same tomographic plane as the
end-systolic one
† May not accurately reflect global RV
size (underestimation or
overestimation)
3DE RV volumes † Dedicated multibeat 3D acquisition, † Unique measures of † Dependent on image quality, regular
with minimal depth and sector angle RV global size that rhythm, patient cooperation
(for a temporal resolution .20– 25 includes inflow, † Needs specific 3D
volumes/sec) that encompasses entire outflow and apical echocardiographic equipment and
RV cavity regions training
† Automatically identified timing of † Independent of † Reference values established in few
end-diastole and end-systole should be geometric publications
verified assumptions
† Myocardial trabeculae and moderator † Validated against
band should be included in the cavity cardiac magnetic
resonance

Continued
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 251

Table 7 Continued

Echocardiographic imaging Recommended methods Advantages Limitations

...............................................................................................................................................................................
RV wall thickness † Linear measurement of RV free wall † Easy to perform † Single-site measurement
thickness (either by M-mode or 2DE) † Harmonic imaging and oblique
performed at end-diastole, below the M-mode sampling may overestimate
tricuspid annulus at a distance RV wall thickness
approximating the length of anterior † Challenging in case of thickening of
tricuspid leaflet, when it is fully open visceral pericardium
and parallel to the RV free wall. † There is no criterion for defining an
† Trabeculae, papillary muscles and abnormally thin RV wall
epicardial fat should be excluded

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† Zoomed imaging with focus on the RV
mid-wall and respiratory maneuvers may
improve endocardial border definition

*
All linear dimensions should be obtained using inner-edge-to-inner-edge method.

imperfect image quality or severely enlarged right ventricles, a rea-

Table 8 Normal values for RV chamber size sonably accurate estimate of RV EDV and ESV can be obtained, and
Parameter Mean + SD Normal range RV EF can be calculated.
................................................................................ Practical recommendations regarding RV 3D imaging and analysis
RV basal diameter (mm) 33 + 4 25– 41 have been recently published by the European Association of Echo-
RV mid diameter (mm) 27 + 4 19– 35 cardiography and the ASE.61 During analysis of RV volume, it is crit-
RV longitudinal diameter (mm) 71 + 6 59– 83 ically important to manually define end-diastolic and end-systolic
RVOT PLAX diameter (mm) 25 + 2.5 20– 30 frames using maximal and minimal RV volumes, respectively, rather
RVOT proximal diameter (mm) 28 + 3.5 21– 35 than LV chamber changes (Table 7). Myocardial trabeculae and the
RVOT distal diameter (mm) 22 + 2.5 17– 27 moderator band should be included in the cavity, and RV contours
RV wall thickness (mm) 3+1 1– 5 on dynamic images should closely follow endocardial displacement
RVOT EDA (cm2) and excursion of the tricuspid annulus throughout the cardiac cycle.
Men 17 + 3.5 10– 24 Even though 3DE tends to underestimate RV volumes compared
Women 14 + 3 8– 20 CMR,78 3DE has identified relationships between RV volumes and
RV EDA indexed to BSA (cm2/m2) EF to age and gender, which are very similar to those described
Men 8.8 + 1.9 5– 12.6 by CMR.72 Overall, women have smaller 3D echocardiographic
Women 8.0 + 1.75 4.5– 11.5 RV volumes, despite indexing to BSA, and higher EFs.75 Also, older
RV ESA (cm2) age is associated with smaller volumes (expected decrements of
Men 9+3 3– 15 5 mL/decade for EDV and 3 mL/decade for ESV) and higher EF
Women 7+2 3– 11 (an expected increment of 1% per decade).75 Reference values of
RV ESA indexed to BSA (cm2/m2) 3DE-derived RV volumes (indexed to BSA) and EF obtained from
Men 4.7 + 1.35 2.0– 7.4 the meta-analyses of all studies are summarized in Tables 8 and 10.
Women 4.0 + 1.2 1.6– 6.4 Details of the above-described study factoring in age, gender, and
RV EDV indexed to BSA (mL/m2) BSA are listed in Supplemental Table 8.75 Although RV volumes by
Men 61 + 13 35– 87 CMR appear to be significantly influenced by race,72 no 3D echocar-
Women 53 + 10.5 32– 74 diographic data are yet available.
RV ESV indexed to BSA (mL/m2)
Men 27 + 8.5 10– 44
Women 22 + 7 8– 36 Recommendations
RV size should be routinely assessed by conventional 2DE using mul-
EDA, end-diastolic area; ESA, end-systolic area; PLAX, parasternal long-axis view; tiple acoustic windows, and the report should include both qualita-
RVOT, RV outflow tract. tive and quantitative parameters. In laboratories with experience in
3DE, when knowledge of RV volumes may be clinically important,
3D measurement of RV volumes is recommended. Although
7.2 Volumetric Measurements normal 3D echocardiographic values of RV volumes need to be
Three-dimensional echocardiography allows measurements of established in larger groups of subjects, current published data
RV volumes (Figure 8), thereby overcoming the limitations of conven- suggest RV EDVs of 87 mL/m2 in men and 74 mL/m2 in women,
tional 2DE RV views with respect to orientation and reference points. and RV ESVs of 44 mL/m2 for men and 36 mL/m2 for women as the
Although technically challenging, particularly in patients with upper limits of the corresponding normal ranges.
252 R.M. Lang et al.

Table 9 Recommendations for the echocardiographic assessment of RV function

Echocardiographic imaging Recommended methods Advantages Limitations

...............................................................................................................................................................................
RV global function RIMP (Tei index) by pulsed † Prognostic value † Requires matching for R-R
Pulsed Doppler RIMP Doppler: † Less affected by intervals when
RIMP ¼ (TCO 2 ET)/ET heart rate measurements are
performed on separate
recordings
† Unreliable when RA
pressure is elevated

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Tissue Doppler RIMP RIMP by tissue Doppler: † Less affected by † Unreliable when RA
RIMP ¼ (IVRT + IVCT)/ heart rate pressure is elevated
ET ¼ (TCO 2 ET)/ET † Single-beat
recording with no
need for R-R
interval matching

RV global systolic function RV FAC in RV-focused apical † Established † Neglects the contribution
FAC four-chamber view: prognostic value of RV outflow tract to
RV FAC (%) ¼ 100 × (EDA † Reflects both overall systolic function
2 ESA)/EDA longitudinal and † Only fair inter-observer
radial components reproducibility
of RV contraction
† Correlates with RV
EF by CMR

EF Fractional RV volume change † Includes RV † Dependent on adequate

by 3D TTE: outflow tract image quality
RV EF (%) ¼ 100 × (EDV 2 contribution to † Load dependency
ESV)/EDV overall function † Requires offline analysis
† Correlates with RV and experience
EF by CMR † Prognostic value not
established

Continued
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 253

Table 9 Continued

Echocardiographic imaging Recommended methods Advantages Limitations

...............................................................................................................................................................................
RV longitudinal systolic function † Tricuspid annular † Established † Angle dependency
TAPSE longitudinal excursion by prognostic value † Partially representative of
M-mode (mm), measured † Validated against RV global function*
between end-diastole and radionuclide EF
peak systole
† Proper alignment of
M-mode cursor with the
direction of RV
longitudinal excursion

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should be achieved from
the apical approach.

Pulsed tissue Doppler S wave † Peak systolic velocity of † Easy to perform † Angle dependent
tricuspid annulus by † Reproducible † Not fully representative of
pulsed-wave DTI (cm/sec), † Validated against RV global function,
obtained from the apical radionuclide EF particularly after
approach, in the view that † Established thoracotomy, pulmonary
achieves parallel alignment prognostic value thromboendarterectomy
of Doppler beam with RV or heart transplantation
free wall longitudinal
excursion

Color tissue Doppler S wave † Peak systolic velocity of † Sampling is † Angle dependent
tricuspid annulus by color performed after † Not fully representative of
DTI (cm/sec) image acquisition RV global function,
† Allows multisite particularly after
sampling on the thoracotomy, pulmonary
same beat thrombendarterectomy or
heart transplantation
† Lower absolute values and
reference ranges than
pulsed DTI S′ wave
† Requires offline analysis
GLS † Peak value of 2D † Angle independent † Vendor dependent
longitudinal speckle † Established
tracking derived strain, prognostic value
averaged over the three
segments of the RV free
wall in RV-focused apical
four-chamber view (%)

EDA, End-diastolic area; ESA, end-systolic area; ET, ejection time; GLS, gold longitudinal strain; IVCT, isovolumic contraction time; TCO, tricuspid valve closure–to –opening time.

8. RV Systolic Function and a growing body of data are currently available to provide
RV systolic function has been evaluated using multiple parameters normal reference values (Table 10 and Supplemental Table 8).
(Table 9), including RIMP, TAPSE, 2D FAC, 3DE EF, S′ , and longitudinal
strain and strain rate by DTI and 2D STE.25 Multiple studies have 8.1 RIMP
demonstrated the clinical utility and value of RIMP, TAPSE, 2D RIMP is an index of global RV performance. The isovolumic contrac-
FAC, and S′ of the tricuspid annulus, as well as longitudinal speckle- tion time, the isovolumic relaxation time, and ejection time intervals
tracking echocardiographic strain. RV EF by 3DE seems to be more should be measured from the same heartbeat using either PW spec-
reliable and have better reproducibility when properly performed, tral Doppler or DTI velocity of the lateral tricuspid annulus (Table 9).
254 R.M. Lang et al.

Table 10 Normal values for parameters of RV function

Parameter Mean + SD Abnormality threshold

...............................................................................................................................................................................
TAPSE (mm) 24 + 3.5 ,17
Pulsed Doppler S wave (cm/sec) 14.1 + 2.3 ,9.5
Color Doppler S wave (cm/sec) 9.7 + 1.85 ,6.0
RV fractional area change (%) 49 + 7 ,35
RV free wall 2D strain* (%) 229 + 4.5 . 220 (,20 in magnitude with the negative sign)
RV 3D EF (%) 58 + 6.5 ,45
Pulsed Doppler MPI 0.26 + 0.085 .0.43

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Tissue Doppler MPI 0.38 + 0.08 .0.54
E wave deceleration time (msec) 180 + 31 ,119 or .242
E/A 1.4 + 0.3 ,0.8 or .2.0
e′ /a′ 1.18 + 0.33 ,0.52
e′ 14.0 + 3.1 ,7.8
E/e′ 4.0 + 1.0 .6.0

MPI, Myocardial performance index.

*
Limited data; values may vary depending on vendor and software version.

Figure 7 (A) Three apical images demonstrating different views of the right ventricle (RV). The middle image shows the right ventricular-focused
view. (B) The rationale for maximizing the right ventricular basal dimension in the right ventricular-focused view. Below the cartoon, by manipulating
offline the same 3D right ventricular data set, it is apparent that minor variations in the four-chamber plane position (dashed line) with respect to the
right ventricular crescent shape may result in variability of right ventricular size when performed by linear measurements.

When using PW spectral Doppler to calculate RIMP, it important to 8.2 TAPSE

ensure that the nonconsecutive beats have similar RR intervals. This TAPSE is easily obtainable and represents a measure of RV longitudin-
limitation does not apply to the DTI-based RIMP measurements. al function. It is measured by M-mode echocardiography with the
RIMP can be falsely low in conditions associated with elevated RA cursor optimally aligned along the direction of the tricuspid lateral
pressures, which will shorten the IVRT. RIMP .0.43 by PW annulus in the apical four-chamber view (Table 9). Although this
Doppler and .0.54 by DTI indicate RV dysfunction. index predominantly reflects RV longitudinal function, it has shown
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 255

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Figure 8 Three-dimensional analysis of the right ventricle (RV). (A) A 3D data set is acquired from a right ventricular-focused apical four-chamber view
by stitching together the subvolumes generated from several (four to six) consecutive beats. (B) The right ventricular endocardial surface is semiauto-
matically identified after manual initialization in the right ventricular short-axis, four-chamber, and coronal views in both end-systole and end-diastole.
(C) The generated 3D surface model of the RV enables the quantitation of right ventricular ESV and ESV, stroke volume, and EF.

good correlations with parameters estimating RV global systolic func- to apex, while longitudinal strain rate is the rate of this shortening.
tion, such as radionuclide-derived RV EF, 2D echocardiographic RV RV longitudinal strain is less confounded by overall heart
FAC, and 2D echocardiographic EF. As a one-dimensional measure- motion79,81 but depends on RV loading conditions as well as RV
ment relative to the transducer position, TAPSE may over- or under- size and shape. RV longitudinal strain should be measured in the
estimate RV function because of cardiac translation.79 Although there RV-focused four-chamber view. Compared with STE-derived
may be minor variations in TAPSE values according to gender and strain, the angle dependency of DTI strain is a disadvantage. RV
BSA, generally, TAPSE ,17 mm is highly suggestive of RV systolic speckle-tracking echocardiographic strain is influenced by image
dysfunction. quality, reverberation and other artifacts, as well as attenuation.
Placing the basal reference points too low (i.e., on the atrial side of
8.3 RV 2D FAC the tricuspid annulus) might result in artifactually low basal strain
FAC provides an estimate of global RV systolic function. It is import- values. The width of the region of interest should be limited to the
ant to ensure that the entire right ventricle be contained in the myocardium, excluding the pericardium, which may be difficult
imaging sector, including the apex and the free wall, during both given the usually thin RV free wall (Table 9).
systole and diastole. While tracing the RV area, care must be taken In the context of the right ventricle, GLS is a parameter borrowed
to include the trabeculae in the RV cavity (Table 9). RV FAC ,35% from LV measurements, and software currently used to measure RV
indicates RV systolic dysfunction. GLS from most manufacturers has been designed for LV measure-
ments and later adapted for the right ventricle. The term RV GLS
8.4 DTI-Derived Tricuspid Lateral Annular Systolic
Velocity usually refers to either the average of the RV free wall and the
DTI-derived S′ -wave velocity is easy to measure, reliable, and repro- septal segments or the RV free wall segments alone (Figure 9). Peak
ducible, and it has been shown to correlate well with other measures global longitudinal RV strain excluding the interventricular septum
of global RV systolic function. Specific age-related cutoff values have has been recently reported to have prognostic value in various
been reported in a large sample of healthy subjects.80 It is important disease states, such as heart failure,82,83 acute myocardial infarction,84
to keep the basal segment and the annulus aligned with the Doppler pulmonary hypertension,85,86 and amyloidosis,87 and to predict RV
cursor to avoid velocity underestimation (Table 9). Similar to TAPSE, failure after LV assist device implantation.88
S′ is measured relative to the transducer and may therefore be influ- The largest body of evidence comes from the single-center studies
enced by overall heart motion. An S′ velocity ,9.5 cm/sec measured cited above, which involved predominantly imaging equipment and
on the free-wall side indicates RV systolic dysfunction. software from two vendors, where pooled data were derived from
limited number of subjects. Current reference values for global RV
8.5 RV Strain and Strain Rate free wall speckle-tracking echocardiographic strain are reported in
Strain and strain rate are useful parameters for estimating RV global Table 10. Pooled data (though heavily weighted by a single vendor)
and regional systolic function. Longitudinal strain is calculated as suggest that global longitudinal RV free wall strain . 220% (i.e.,
the percentage of systolic shortening of the RV free wall from base ,20% in absolute value) is likely abnormal.
256 R.M. Lang et al.

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Figure 9 Measurement of RV systolic strain by 2D STE. The upper panel demonstrates RV “global” free wall strain whereby the three segments of
the free wall are averaged, and the lower panel demonstrates “global” longitudinal strain of the six segments of the apical four-chamber view: three
free wall and three septal segments. Note that RV longitudinal strain is significantly higher (as an absolute value) than the strain averaged from both
septal and free wall segments. Until a universal standard is established, the interpretation of RV longitudinal strain values should take into account the
methodology and vendor- and method-specific reference values.

Recommendations on RV volume, the RV EF is slightly higher in women than in men,

Two-dimensional STE-derived strain, particularly of the RV free wall, because of smaller volumes, and it is recommended to refer to
appears to be reproducible and feasible for clinical use. Because of the gender-specific values (Supplemental Table 8).
need for additional normative data from large studies involving multi-
vendor equipment, no definite reference ranges are currently recom- Recommendation
mended for either global or regional RV strain or strain rate. In laboratories with appropriate 3D platforms and experience,
3DE-derived RV EF should be considered as a method of quantifying
RV systolic function, with the limitations mentioned above. Roughly,
8.6 RV 3D EF
an RV EF of ,45% usually reflects abnormal RV systolic function,
Three-dimensional echocardiographic RV EF is a global measure of
though laboratories may choose to refer to age- and gender-specific
RV systolic performance. Although RV EF does not directly reflect
values.
RV contractile function per se, it provides an integrated view of the
interaction between RV contractility and load. RV EF can be of par-
ticular clinical value in patients after cardiac surgery (in the absence
of marked septal shift), when conventional indices of longitudinal
III. The Left and Right Atria
RV function (i.e., TAPSE, S′ wave) are generally reduced and no The left atrium fulfills three major physiologic roles that influence LV
longer representative of overall RV performance.81,89,90 Three- filling and performance. The left atrium acts as a (1) contractile pump
dimensional echocardiography has been extensively validated that delivers 15% to 30% of the entire LV filling, (2) reservoir that col-
against CMR,78,91 and the volumetric semiautomated border lects pulmonary venous return during ventricular systole, and (3)
detection approach is the recommended method for the assessment conduit for the passage of stored blood from the left atrium to the
of RV EF. left ventricle during early ventricular diastole.92,93 An enlarged left
The limitations of 3D assessment of RV EF are load dependency, atrium is associated with adverse cardiovascular outcomes.94 – 99 In
interventricular changes affecting septal motion, poor acoustic the absence of mitral valve disease, an increase in LA size most com-
windows, and irregular rhythms. As described above in the section monly reflects increased wall tension as a result of increased LA
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 257

pressure,100 – 103 as well as impairment in LA function secondary to an 9.3 Volume Measurements

atrial myopathy.104,105 A clear relationship exists between an When assessing the LA size and remodeling, the measurement of LA
enlarged left atrium and the incidence of atrial fibrillation and volume is recommended. Evaluation of volume takes into account
stroke,92,106 – 115 risk for overall mortality after myocardial infarc- alterations in LA chamber size in all directions. LA volume has been
tion,104,105,116,117 risk for death and hospitalization in patients with shown to be a powerful prognostic variable in a variety of cardiac
dilated cardiomyopathy,118 – 122 and major cardiac events or death disease states.99,106,112,113,115 – 117,122,131 – 136 Compared with AP
in patients with diabetes mellitus.123 LA enlargement is a marker of diameter, LA volume has a stronger association with outcomes in
both the severity and chronicity of diastolic dysfunction and magni- cardiac patients.113,137 Two-dimensional echocardiographic LA
tude of LA pressure elevation.98,100 – 103 volumes are typically smaller than those reported from computed
tomography or CMR.138 – 142 Measurements of LA volumes are im-
portant, because they reflect the burden and chronicity of elevated

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9. LA Measurements LV filling pressures and are a strong predictor of outcomes.
Different methods exist for measuring LA volumes. Although the
9.1 General Considerations for LA Size
three linear measurements have been used to calculate LA volume
TTE is the recommended approach for assessing LA size. Recom-
using an ellipsoid model,131,137,143 the relative inaccuracy of these
mendations for LA quantification are summarized in Table 11. With
linear measurements limits this method. LA volume should be mea-
TEE, the entire left atrium frequently cannot be fit in the image
sured using the disk summation algorithm, similar to that used to
sector. Accordingly, TEE should not be used to assess LA size. LA
measure LV volume (Table 11).144,145
size should be measured at the end of LV systole, when the LA
The LA endocardial borders should be traced in both the apical
chamber is at its greatest dimension. While acquiring images to
four- and two-chamber views. A single-plane approach can also be
measure LA size and volumes, care should be taken to avoid fore-
used, but this method is based on the geometric assumption that
shortening of the left atrium. Because the longitudinal axes of the
the left atrium is circular in the short-axis cut plane, which may not
left ventricle and left atrium frequently lie in different planes, dedi-
be always accurate.146 Although not recommended for routine use,
cated acquisitions of the left atrium from the apical approach
this approach could be used in cases when planimetry in both
should be obtained for optimal LA volume measurements. The
views is difficult. Single-plane apical four-chamber indexed LA
base of the left atrium should be at its largest size, indicating that
volumes are typically 1 to 2 mL/m2 smaller than apical two-chamber
the imaging plane passes through the maximal short-axis area. LA
volumes.12,146
length should also be maximized to ensure alignment along the
Alternatively, a biplane calculation could also be performed using
true long axis of the left atrium. When using the biplane disk summa-
the LA areas and lengths measured from both the apical four- and
tion method to calculate LA volumes, the lengths of the long axes
two-chamber views (Table 11). Although the area-length method
measured in the two- and four-chamber views should be similar.
still assumes an ellipsoidal LA shape, it has the advantage of reducing
When tracing the borders of the left atrium, the confluences of the
linear dimensions to only two measurements of atrial length, of which
pulmonary veins and the LA appendage should be excluded. The
the shorter one is selected.98,147
atrioventricular interface should be represented by the mitral
annulus plane, not by the tip of the mitral leaflets.
9.4 Normal Values of LA Measurements
Since the publication of the 2005 chamber quantification guidelines,
9.2 Linear Dimensions and Area Measurements two articles have reported normal values for LA linear measure-
The most widely used linear dimension is the LA anter- ments.12,143 These values were in keeping with prior recommenda-
oposterior (AP) measurement in the parasternal long-axis tions, and accordingly, no modifications have been made to the
view using M-mode echocardiography or, preferably, normal values of LA AP diameters (Supplemental Table 9). Although
2DE.92,107,109,110,114,118,120,121,124,125 Although this measurement not recommended for routine clinical use, normal values for apical
has been used extensively in clinical practice and research, it has four- and two-chamber linear measurements and nonindexed LA
become clear that frequently it may not represent an accurate area and volume measurements have been reported.12
picture of LA size.126,127 Traditionally, the AP dimension was LA size is dependent on gender. However the gender differences in
widely used because it was known to be the most reproducible meas- LA size are generally accounted for when adjusting for body size.12
urement. However, assessment of LA size using only the AP diameter Several indexing methods have been proposed,137,148 but indexing
assumes that when the left atrium enlarges, all its dimensions change to BSA has yielded the most available data and is recommended by
similarly, which is often not the case during LA remodeling.128 – 130 the writing group. Indexing by BSA accounts for the gender differ-
Therefore, AP linear dimension should not be used as the sole ences in LA size, such that only the indexed value should be
measure of LA size. LA area can be planimetered in the apical four- reported.93,137,149,150
and two-chamber views and normal values for these parameters In the prior chamber quantification guideline document, the
have been reported.12 Optimal contours should be obtained orthog- reported BSA-indexed LA volume normal values were based on
onally around the long axis of the left atrium from good quality images two studies performed in a small number of subjects.98,144 Since
while avoiding foreshortening.1 The ease with which LA volumes can the publication of that document, eight additional studies (1,234
be obtained in clinical practice in conjunction with the existing robust patients) describing normal values of LA volumes using the area-
literature on normal values and the prognostic value of LA volumes length ellipsoid or the disk summation techniques have been
renders reporting of LA area unnecessary. reported.11,12,145,147,151 – 155 This has resulted in a change in the
 258
Table 11 Recommendations for the echocardiographic assessment of LA size

Parameter and method Echocardiographic imaging Advantages Limitations

.............................................................................................................................................................................................................................................
† Reproducible † Single dimension not

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Internal linear dimensions M-mode tracing
The anteroposterior diameter of the left atrium can be measured in † High temporal resolution representative of actual LA size
the parasternal long-axis view perpendicular to the aortic root long † Wealth of published data (particularly in dilated atria)
axis, and measured at the level of the aortic sinuses by using the
leading-edge to leading-edge convention.

2D-guided linear measurements † Facilitates orientation † Lower frame rates than in

perpendicular to LA M-mode
posterior wall † Single dimension only

Area 2D images † More representative of actual † Need for a dedicated view to

Measured in four-chamber apical view, at end-systole, on the frame LA size than anteroposterior avoid LA foreshortening
just prior to mitral valve opening by tracing the LA inner border, diameter only † Assumes a symmetric shape of
excluding the area under the mitral valve annulus and the inlet of the the atrium
pulmonary veins.

R.M. Lang et al.

 Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults
Volume 2DE † Enables accurate assessment † Geometric assumptions about
2D volumetric measurements are based on tracings of the Area-length technique of the asymmetric LA shape
blood-tissue interface on apical four- and two-chamber views. remodeling of the left atrium † Few accumulated data on
At the mitral valve level, the contour is closed by connecting the † More robust predictor of normal population

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two opposite sections of the mitral annulus with a straight line. cardiovascular events than † Single plane volume calculations
Endocardial tracing should exclude atrial appendage and pulmonary linear or area measurements are inaccurate since they are
veins. LA length L is defined as the shortest of the two long axes based on the assumption that
measured in the apical two- and four-chamber views (to provide A1 ¼ A2
reliable calculations the two lengths should not differ more than
5 mm). Volumes can be computed by using the area-length
approximation:
 
8 (A1 · A2 )
3p L

where A1 and A2 are the corresponding LA areas.

Alternatively LA volume can be calculated using the disk summation
technique by adding the volume of a stack of cylinders of height h and
area calculated by orthogonal minor and major transverse axes (D1
and D2) assuming an oval shape:

p/4(h) (D1)(D2)

3D data sets are usually obtained from the apical approach using a
multibeat full-volume acquisition
Biplane method of disks

3D data sets † No geometrical assumption † Dependent on adequate image

about LA shape quality
† More accurate when † Lower temporal resolution
compared to 2D † Limited data on normal values
measurements † Patient’s cooperation required

259
260 R.M. Lang et al.

recommended upper normal indexed LA volume to 34 mL/m2 (pre- echocardiographic techniques compared with 3DE.164,165,168 RA
viously 28 mL/m2). In addition, LA volume data became available in volumes in adult subjects appear to be smaller than LA
1,331 patients from the five databases described earlier in this docu- volumes.12,150,153,165 This is because the RA volumes were obtained
ment, wherein the mean calculated LA volume was 25 mL/m2. This using a single-plane method of disks, in contrast to the LA volumes,
upper normal revised value of 34 mL/m2 also seems to fit in well which were established using the biplane technique.
with a risk-based approach for determination of cutoffs between a
normal and an enlarged left atrium.106,123,134,136 This cutoff value is Recommendations
also consistent with the ASE and European Association of Echocar- The recommended parameter to assess RA size is RA volume, calcu-
diography guideline document on evaluation of diastolic function.156 lated using single-plane area-length or disk summation techniques in a
The 2DE-derived biplane LA volumes are listed in Table 4, including dedicated apical four-chamber view. The normal ranges for 2D echo-
normal ranges and severity partition cutoffs. Of note, LA volume cardiographic RA volume are 25 + 7 mL/m2 in men and 21 + 6 mL/

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can be increased in elite athletes, which needs to be taken into m2 in women.
account to avoid misinterpretation as abnormal.146
Three-dimensional echocardiography holds promise for assessing
LA volume and correlates with cardiac computed tomography157,158 IV. The Aortic Annulus and Aortic
and magnetic resonance imaging.159,160 Compared with 2D assess- Root
ment of LA volume, 3DE is more accurate compared with
CMR159,160 and has superior prognostic ability.161,162 Three- Detailed knowledge and quantification of the aortic root and aortic
dimensional echocardiographic LA volumes are typically larger valve morphology has become even more crucial with the increasing
than 2D echocardiographic volumes in most studies.160,163 Despite use of transcatheter aortic valve implantation (TAVI) and transcath-
these advantages, the lack of a standardized methodology and eter aortic valve replacement (TAVR) procedures. This knowledge
limited normative data164 prevent this committee from recommend- is critically important for preprocedural planning, intraprocedural
ing the use of 3D echocardiographic normal values at this time. guidance, and postprocedural assessment.
The aortic root extends from the basal attachments of the aortic
Recommendations valve leaflets within the LV outflow tract to their distal attachment
Because it is theoretically more accurate than the area-length at the tubular portion of the aorta (the sinotubular junction).169
method, the biplane disk summation technique, which incorporates The aortic root is a geometrically complex structure that includes
fewer geometric assumptions, should be the preferred method to (1) the aortic valve annulus, (2) the interleaflet triangles, (3) the semi-
measure LA volume in clinical practice. The upper normal limit for lunar aortic leaflets and their attachments, (4) the aortic sinuses of
2D echocardiographic LA volume is 34 mL/m2 for both genders. Valsalva, and (5) the sinotubular junction.170 – 172 Aortic measure-
ments should be made at the following sites: (1) the aortic valve
10. Right Atrial measurements annulus, (2) the maximal diameter of the sinuses of Valsalva, (3) the
Less research and fewer clinical outcomes data are available on the sinotubular junction (usually a demarcated transition between the
quantification of RA size. Although the right atrium can be assessed sinuses of Valsalva and the tubular portion of the ascending aorta),
from different views, quantification of RA size is most commonly per- and (4) the maximal diameter of the proximal ascending aorta, includ-
formed from the apical four-chamber view (Table 12). The minor-axis ing a notation of the distance between the measurement site and the
dimension should be taken from a plane perpendicular to the long sinotubular junction (Figure 10A).
axis of the right atrium, extending from the lateral border of the
right atrium to the interatrial septum. In contrast to the left atrium, 11. The Aortic Annulus
RA size appears to be gender dependent, but prior ASE guidelines The “aortic annulus” is not a true or distinct anatomic structure but is
did not have sufficient data to provide normative data by a virtual ring that may be defined by joining the basal attachments, or
gender.1,71 Recent data obtained from three cohorts of .2,400 nadirs, of the three aortic leaflets. The distal (uppermost) attach-
patients now provide normal values of RA dimensions for men and ments of the leaflets, in the shape of a crown, form a true anatomic
women.12,73,165 ring169,173 (Figure 10B). Approximately two-thirds of the circumfer-
As with the left atrium, RA volumes are likely to be more robust ence of the lower part of the aortic root is attached to the muscular
and accurate for determination of RA size compared with linear interventricular septum, while the remaining one-third is in fibrous
dimensions. At the time of the prior guideline document, limited continuity with the anterior mitral valve leaflet.174 Measurement of
data were available for the determination of normative RA the aortic valve annulus before TAVI or TAVR is a challenge, and
volumes. Because there are no standard orthogonal RA views to the ideal modality for its measurement has yet to be established.
use for an apical biplane calculation, a single-view area-length and/ During the initial TAVI and TAVR experience, aortic annular mea-
or disk summation techniques has been proposed for RA volume de- surements were routinely performed using 2DE.174,175 Although
termination.150,153,165 – 167 Of note, normal RA volumes for men are the standard approach during the early years of TAVI and TAVR
slightly larger than those for women, with indexing to BSA failing to was echocardiography using a one-dimensional measurement, this
equalize values between genders for reasons that are not fully under- method has clear limitations for TAVI and TAVR valve sizing. At
stood.150,165 Recommendations for RA volume normative data are present, the two most commonly used imaging techniques used for
made from the two largest most contemporary data sets12,165 measuring the aortic annulus before TAVI or TAVR are echocardiog-
(Table 13). RA volumes are underestimated with 2D raphy and multidetector computed tomography (MDCT).
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 261

Table 12 Recommendations for the echocardiographic assessment of RA size

Parameter and method Echocardiographic imaging Advantages Limitations

...............................................................................................................................................................................
Linear dimensions 2D-guided linear measurements † Easy to obtain † Single dimension only
The minor axis of the right atrium † Established normal † Assumes that RA
should be measured in the apical values enlargement is
four-chamber view as the distance symmetrical
between the lateral RA wall and † View dependent
interatrial septum, at the midatrial level
defined by half of RA long axis

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Area 2D view † More † Need of a dedicated view
Measured in the apical four-chamber representative of to avoid RA foreshortening
view at end-systole, on the frame just actual RA size than † Assumes a symmetrical
prior to tricuspid valve opening, by linear dimensions shape of the cavity
tracing the RA blood-tissue interface, † Established normal † View dependent
excluding the area under the tricuspid values
valve annulus.

Volume 2D view † More † Assumes a symmetrical

2D volumetric measurements are representative of shape of the cavity
usually based on tracings of the actual RA size than † Single plane volume
blood-tissue interface on the apical linear dimensions calculation may be
four-chamber view. At the tricuspid inaccurate since it assumes
valve level, the contour is closed by that RA enlargement is
connecting the two opposite sections symmetrical
of the tricuspid ring with a straight line. † Normal values not well
Volumes can be computed by using established
either the single plane area-length:
 
8 (A1 )2
3p L
or the disks summation technique.
3D data sets are usually obtained from
the apical approach using a full-volume
acquisition
3D data sets † No geometrical † Dependent on image
assumption quality
† Established normal † Lower temporal resolution
values † Patient’s cooperation
required

With echocardiography, measurements of the aortic annulus between the hinge point of the right coronary cusp and the edge of
should be made in the zoom mode using standard electronic calipers the sinus at the side of the commissures between the left coronary
in midsystole, when the annulus is slightly larger and rounder than in cusp and the noncoronary cusp) from inner edge to inner edge. All
diastole, between the hinge points of the aortic valve leaflets (usually other aortic measurements should be made at end-diastole, in a
262 R.M. Lang et al.

The anteroposterior diameter is commonly measured by both 2D

Table 13 Normal RA size obtained from 2D TTE (from the parasternal long-axis view) and 3D TEE (from the lon-
echocardiographic studies gitudinal view of the proximal aortic root, usually 1108 –1308) and
Women Men approximates the minor dimension of the annulus measured by
................................................................................ MDCT.3,176,180 However, because the annulus is often elliptical,
RA minor axis dimension (cm/m2) 1.9 + 0.3 1.9 + 0.3 with variable diameters, it is preferable to measure the annulus in a
RA major axis dimension (cm/m2) 2.5 + 0.3 2.4 + 0.3 cross-sectional view, using 3D imaging, as recommended by the
2D echocardiographic RA volume (mL/m2) 21 + 6 25 + 7 European Association of Echocardiography and ASE guidelines;181
the American College of Cardiology Foundation, American Associ-
Data are expressed as mean + SD. ation for Thoracic Surgery, Society for Cardiac Angiography and
Interventions, and Society of Thoracic Surgeons consensus docu-

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ment on TAVR;182 the Society of Cardiovascular Computed Tomog-
raphy expert consensus document on MDCT;183 and others.184 – 187
Using 3D TEE, both the smaller (anteroposterior, sagittal) and larger
(medial-lateral, coronal) diameters, as well as the perimeter and
annular area, should be measured in a cross-sectional view in midsys-
tole (Figure 11). It should be noted that the difference between major
and minor diameters may be up to 6 mm.173,188 – 193 For a detailed,
step-by-step approach to making these measurements using 3D
TEE, which is beyond the scope of this document, the reader is re-
ferred to four recent publications.184 – 187 By using these techniques,
close agreement with MDCT can be achieved.184,185
It should be noted that proponents of each of the two modalities
(3D TEE and MDCT) tout advantages. In fact, each of these methods
has certain strengths and limitations. Limitations of MDCT include
the need for contrast media, radiation exposure, inability to obtain
real-time measurements during the procedure, and the need to
control the heart rate for suitable gating. Three-dimensional TEE
also has limitations. First, the software required to use the method-
ology described by Kasel et al.184 and Pershad et al.185 is not currently
available on all echocardiographic platforms. Second, visualization of
the anterior portion of the annulus can be obscured by echo
“dropout” due to annular calcification. In addition, calcification at
Figure 10 (A) Sites for measurements of the aortic root and
the level of the annulus may hinder the ability to determine boundary
ascending aorta. This diagram illustrates the four sites at which mea-
surements are recommended (light blue arrows): (1) the aortic valve definition and may make its shape irregular. Third, the plane formed
annulus (hinge point of aortic leaflets), (2) the sinuses of Valsalva by the nadirs of the three cusps is often not orthogonal to the LV
(maximal diameter, usually the midpoint), (3) the sinotubular junc- outflow tract or aortic root; frequently the insertion of the right cor-
tion, and (4) the proximal ascending aorta (the distance between onary cusp is inferior to that of the left and noncoronary cusps.183
the measurement site and the annular plane [ purple arrowheads] Fourth, both the spatial and temporal resolution of 3D echocardiog-
should always be reported). The aortic annulus should be measured raphy is currently limited. Last, this technique is operator dependent
at peak systole, in contrast to the other dimensions, which are mea- and may be difficult at times, even in experienced hands.173,174
sured at end-diastole. The dashed lines, depicting the longitudinal Because of these potential limitations, it is desirable to use a multi-
axis of the left ventricle (LV) and that of the aortic root and proximal modality approach for aortic annular measurement.
ascending aorta, are different. Note that the angle between these
two axes varies from individual to individual and with age and path- 12. The Aortic Root
ology. (B) Normal anatomy of the aortic annulus. The aortic annulus
accounts for the tightest part of the aortic root and is defined as a With 2D TTE, the diameter of the aortic root (at the maximal diam-
virtual ring (shaded) with three anatomic anchor points at the eter of the sinuses of Valsalva) should be obtained from the paraster-
nadir of each of the attachments of the three aortic leaflets. Repro- nal long-axis view, which depicts the aortic root and the proximal
duced with permission from Kasel et al.184 Ao, Aorta; LA, left atrium. ascending aorta. This plane is slightly different from that of the long
axis of the left ventricle (Figure 10A). Acquisition of this LV long-axis
view may be performed from different intercostal spaces and at
strictly perpendicular plane to that of the long axis of the aorta. Aortic various distances from the left sternal border. Use of simultaneous
annular measurements may be difficult in patients with acoustic biplane orthogonal images provided by matrix transducers may be
blooming caused by a calcified aortic annulus.176 – 179 As a general helpful. The tubular ascending aorta is often not adequately visualized
rule, calcium protuberances should be considered as part of the from a standard parasternal window. In these instances, moving the
lumen, not of the aortic wall, and therefore excluded from the diam- transducer closer to the sternum may allow visualization of a
eter measurement. longer portion of the ascending aorta. In addition, the ascending
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 263

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Figure 11 The smaller (antero-posterior, sagittal) aortic root diameter is measured using CT (A) or 3D TEE (C, zoomed cross sectional view)
between the inner edges of the left (L) and non-coronary (NC) commissure to the opposite right (R) coronary sinus (A and C, yellow double
arrows). The larger diameter (medial-lateral) is measured from the middle of the right sinus to the most distal point of the NC sinus (A and C,
purple double arrows). Panel B shows zoomed cross-sectional CT views of aortic root at the sinus of Valsalva level using a double oblique image
for orientation. Panel D shows a long-axis view of the aorta in obtained by multiplanar reconstruction. The red lines in (B) and (D) represent the
planes from which the diameter of the aortic root should be measured at the level of the sinuses of Valsalva.

aorta may sometimes be well visualized from right parasternal long-standing reference values for the aorta were obtained using
windows in the second or third intercostal space, especially when the L-L convention.195,196 Second, the L-L convention provides stat-
the aorta is dilated. istically larger diameters than the I-I convention (by 2 –4 mm), and
Measurements should be made in the view that depicts the switching to the I-I convention raised a concern that patients at po-
maximum aortic diameter perpendicular to the long axis of the tential risk for developing life-threatening complications such as
aorta. In patients with tricuspid aortic valves, the closure line of aortic dissection and/or rupture would fall below a threshold for
the leaflets (typically the right coronary cusp and the noncoronary intervention recommendation by current guidelines. Accordingly,
cusp) is in the center of the aortic root lumen, and the closed leaflets the aortic annulus should be measured using the I-I convention, but
are seen on the aortic side of a line connecting the hinge points of the we continue to recommend the L-L convention for measurements
two visualized leaflets. An asymmetric closure line, in which the tips of of the aortic root and aorta.
the closed leaflets are closer to one of the hinge points, is an indica- Two-dimensional echocardiographic aortic diameter measure-
tion that the cross-section is not encompassing the largest root diam- ments are preferable to M-mode measurements, because cardiac
eter (Figure 12). motion may result in changes in the position of the M-mode cursor
Unfortunately, there is no uniform method of measurement of relative to the maximum diameter of the sinuses of Valsalva. This
the aortic root and aorta. Echocardiography uses the leading translational motion may result in systematic underestimation (by ap-
edge-to-leading edge (L-L) convention, but other techniques, such proximately 2 mm) of the aortic diameter by M-mode imaging in
as MDCT and CMR, use the inner edge-to-inner edge (I-I) or outer comparison with 2D echocardiographic measurements.195 The thor-
edge-to-outer edge convention. In the consensus document,194 the acic aorta can be better imaged using TEE compared with the TTE ap-
ASE and EACVI writing committee took the initiative to provide a proach, because that aortic segment is in the near field of the
common standard for measurement of the aortic root and aorta by transesophageal echocardiographic transducer. The aortic root
recommending a switch to the I-I convention for echocardiography. and ascending aorta can be best seen in the midesophageal aortic
However, this goal of achieving uniformity among modalities was valve long-axis view (three-chamber view at about 1208 –1408).3
ultimately abandoned for several reasons. First, currently used The short-axis view of the ascending aorta is best obtained using
264 R.M. Lang et al.

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Figure 12 Correct (A) and incorrect (B, C) measurements of the aortic annulus (double arrows). (A) Centrally positioned diameter and central
closure of leaflets. Thin lines correspond to the long axis of the ascending aorta and, orthogonally, to correct orientation of the annular diameter.
(B) Incorrect, eccentric annular measurement. The hinge points are slightly displaced upward and do not correspond to the nadir of the cusp attach-
ments, with incomplete opening and closing of leaflets. (C) Incorrect, oblique annular measurement. The annulus is “virtual“ and only defined by the
hinge-points of the three aortic valve leaflets. As such, much of the ring is without a visible anatomic structure. However, its location on any long-axis
two-dimensional view can be approximated since the plane of the virtual annulus is approximately perpendicular to the long-axis of the aorta. When
bisecting the maximum dimension of the annulus in the sagittal plane, one will image the right coronary cusp anteriorly and the fibrous trigone
between the left and noncoronary cusps posteriorly. Because only one anatomic marker (the RCC hinge-point) is seen, the opposing annulus
must be approximated with a measurement that is perpendicular to the long axis of the aorta. Attempting to measure what you believe to be 2
hinge-points (B and C) typically will measure within the sinuses of Valsalva and overestimate the annulus.

Figure 13 The 95% confidence intervals for aortic root diameter at sinuses of Valsalva on the basis of BSA in children and adolescents (A), adults
aged 20 to 39 years (B), and adults aged ≥40 years (C). Reprinted with permission from Roman et al.195

the midesophageal views at about 458. For measurements of the des- segments. Aortic root diameter measurements at the level of the
cending aorta, short-axis views at about 08 and long-axis views at sinuses of Valsalva is closely related to BSA and age. Therefore,
about 908 should be obtained from the level of the diaphragm up BSA may be used to predict aortic root diameter in three age
to the aortic arch. The biplane imaging function on current 3D echo- strata, ,20, 20 to 40, and .40 years, by using published equations.195
cardiographic imaging systems allows simultaneous visualization of Aortic root dilatation at the sinuses of Valsalva is defined as an aortic
both short- and long-axis views. root diameter above the upper limit of the 95% confidence interval of
the distribution in a large reference population. Aortic dilatation can
13. Identification of Aortic Root be easily detected by plotting observed aortic root diameter versus
Dilatation BSA on previously published nomograms (Figure 13).195 Equations
Aortic root dilatation is associated with the presence and progres- to determine the expected aortic diameter at the sinuses of Valsalva
sion of aortic regurgitation197 and with the occurrence of aortic dis- in relation to BSA for each of the three age strata are also shown in
section. The presence of hypertension appears to have minimal Table 14 and Figure 13. The aortic root index or ratio of observed
impact on aortic root diameter at the level of the sinuses of Valsalva to expected aortic root diameters can be calculated by dividing the
level197 but is associated with enlargement of more distal aortic observed by the expected diameter.
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults 265

presence of normal pressure.200,201 In addition, the IVC is commonly

Table 14 Aortic root dimensions in normal adults dilated and may not collapse in patients on ventilators, so it should not
Absolute values Indexed values be routinely used in such cases to estimate RA pressure.202 However,
(cm) (cm/m2) IVC diameter measured on TEE at the cavoatrial junction has been
......................... ......................... successfully used to derive central venous pressure in anesthetized
Aortic root Men Women Men Women
................................................................................ mechanically ventilated patients.203 The use of the IVC size and dy-
Annulus 2.6 + 0.3 2.3 + 0.2 1.3 + 0.1 1.3 + 0.1 namics is encouraged for estimation of RA pressure. This estimate
Sinuses of Valsalva 3.4 + 0.3 3.0 + 0.3 1.7 + 0.2 1.8 + 0.2 should be used in estimation of the pulmonary artery pressure on
Sinotubular junction 2.9 + 0.3 2.6 + 0.3 1.5 + 0.2 1.5 + 0.2 the basis of the tricuspid regurgitant jet velocity, rather than assuming
Proximal ascending 3.0 + 0.4 2.7 + 0.4 1.5 + 0.2 1.6 + 0.3 a constant RA pressure for all patients.
aorta

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Notice and Disclaimer
Adapted from Roman et al.195 and Hiratzka et al.204
This report is made available by the ASE and EACVI as a courtesy ref-
erence source for members. This report contains recommendations
Recommendations
only and should not be used as the sole basis to make medical practice
The aortic annulus should be measured at midsystole from inner edge
decisions or for disciplinary action against any employee. The statements
to inner edge. All other aortic root measurements (i.e., maximal
and recommendations contained in this report are based primarily on
diameter of the sinuses of Valsalva, the sinotubular junction, and
the opinions of experts, rather than on scientifically verified data. The
the proximal ascending aorta) should be made at end-diastole, in a
ASE and EACVI make no express or implied warranties regarding the
strictly perpendicular plane to that of the long axis of the aorta
completeness or accuracy of the information in this report, including
using the L-L convention. Measurements of maximal diameter of
the warranty of merchantability or fitness for a particular purpose. In
the aortic root at the sinuses of Valsalva should be compared with
no event shall the ASE and EACVI be liable to you, your patients, or
age- and BSA-related nomograms or to values calculated from specif-
any other third parties for any decision made or action taken by you
ic allometric equations. Accurate measurement of the aortic annulus
or such other parties in reliance on this information. Nor does your
before TAVI or TAVR is crucial. To date, there is no established gold-
use of this information constitute the offering of medical advice by the
standard technique for measuring the aortic annulus before TAVI or
ASE and EACVI or create any physician-patient relationship between
TAVR. Three-dimensional TEE and MDCT are emerging as reliable
the ASE and EACVI and your patients or anyone else.
and possibly preferred methods for aortic annulus measurements.

Abbreviations
V. The Inferior Vena Cava AP, Anteroposterior; ASE, American Society of Echocardiography;
Examination of the IVC from the subcostal view should be included as BSA, Body surface area; CMR, Cardiac magnetic resonance; DTI,
part of the routine transthoracic echocardiographic examination. It is Doppler tissue imaging; EACVI, European Association of Cardiovas-
generally agreed that the diameter of the IVC should be measured in cular Imaging; EDV, End-diastolic volume; EF, Ejection fraction; ESV,
the subcostal view with the patient in the supine position at 1.0 to End-systolic volume; FAC, Fractional area change; GLS, Global longi-
2.0 cm from the junction with the right atrium, using the long-axis tudinal strain; I-I, Inner edge-to-inner edge; IVC, Inferior vena cava;
view. For accuracy, this measurement should be made perpendicular LA, Left atrial; L-L, Leading edge-to-leading edge; LV, Left ventricular;
to the IVC long axis. The diameter of the IVC decreases in response MDCT, Multidetector computed tomography; PW, Pulsed-wave;
to inspiration when the negative intrathoracic pressure leads to an in- RA, Right atrial; RIMP, Right ventricular index of myocardial per-
crease in RV filling from the systemic veins. The diameter of the IVC formance; RV, Right ventricular; RWT, Relative wall thickness;
and the percentage decrease in the diameter during inspiration cor- STE, Speckle-tracking echocardiography; TAPSE, Tricuspid annular
relate with RA pressure. The relationship may be quantified as the plane systolic excursion; TAVI, Transcatheter aortic valve implantation;
collapsibility index.198 Evaluation of the inspiratory response often TAVR, Transcatheter aortic valve replacement; TEE, Transesophageal
requires a brief sniff, as normal inspiration may not elicit this response. echocardiography; 3D, Three-dimensional; 3DE, Three-dimensional
For simplicity and uniformity of reporting, specific values of RA echocardiography; TTE, Transthoracic echocardiography; 2D, Two-
pressure, rather than ranges, should be used in the determination dimensional; 2DE, Two-dimensional echocardiography
of systolic pulmonary artery pressure. IVC diameter ,2.1 cm that
collapses .50% with a sniff suggests normal RA pressure of Supplementary data
3 mm Hg (range, 0–5 mm Hg), whereas IVC diameter .2.1 cm
that collapses ,50% with a sniff suggests high RA pressure of Supplementary data are available at European Heart Journal – Cardio-
15 mm Hg (range, 10–20 mm Hg).199 In scenarios in which IVC diam- vascular Imaging online.
eter and collapse do not fit this paradigm, an intermediate value of
8 mm Hg (range, 5–10 mm Hg) may be used, or, preferably, other References
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266 R.M. Lang et al.

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