GUIDELINES AND STANDARDS

Recommendations for Cardiac Chamber
Quantification by Echocardiography in Adults:
An Update from the American Societyof Echocardiography and the European Associationof 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; Cre teil, France; Uppsala, Sweden; San Francisco, California;
Washington, District of Columbia; Leuven, Lie ge, and Ghent, Belgium; Boston, Massachusetts

The rapid technological developments of the past decade and the changes in echocardiographic practicebrought 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 groupassembled 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 threedimensional echocardiography and myocardial deformation, when possible, on the basis of considerablylarger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts
to eliminate several minor discrepancies that existed between previously published guidelines. (J Am Soc
Echocardiogr 2015;28:1-39.)
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^ pital Henri
Hopkins University, Baltimore, Maryland (A.A.); INSERM U955 and Ho
teil, France (L.E.); Uppsala University, Uppsala, Sweden (F.A.F.); theMondor, Cre
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ge Hospital, Liege, Belgium (P.L.); Massachusetts General Hospital andLieHarvard 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 andserves 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.
Attention ASE Members:

The ASE has gone green! Visit www.aseuniversity.org to earn free continuing
medical education credit through an online activity related to this article.
Certificates are available for immediate access upon successful completionof the activity. Nonmembers will need to join the ASE to access this great
member benefit!
Drs Lang and Badano co-chaired the Writing Group.
Reprint requests: American Society of Echocardiography, 2100 Gateway Centre
Boulevard, Suite 310, Morrisville, NC 27560 (E-mail: ase@asecho.org).
0894-7317/$36.00
Copyright 2015 by the American Society of Echocardiography.
http://dx.doi.org/10.1016/j.echo.2014.10.003

1

2 Lang et al

Abbreviations

Journal of the American Society of Echocardiography
January 2015

TABLE OF CONTENTS

AP = Anteroposterior
ASE = American Society of
Echocardiography
BSA = Body surface area
CMR = Cardiac magnetic
resonance
DTI = Doppler tissue imaging
EACVI = European
Association of Cardiovascular
Imaging
EDV = End-diastolic volume
EF = Ejection fraction
ESV = End-systolic volume
FAC = Fractional area change
GLS = Global longitudinalstrainI-I = Inner edge–to–inner edge
IVC = Inferior vena cava
LA = Left atrial
L-L = Leading edge–to–
leading edge
LV = Left ventricular
MDCT = Multidetector
computed tomography
PW = Pulsed-wave
RA = Right atrial
RIMP = Right ventricular index
of myocardial performance
RV = Right ventricular
RWT = Relative wall thickness
STE = Speckle-tracking
echocardiography
TAPSE = Tricuspid annularplane systolic excursion
TAVI = Transcatheter aortic
valve implantation
TAVR = Transcatheter aortic
valve replacement
TEE = Transesophageal
echocardiography
3D = Three-dimensional
3DE = Three-dimensional
echocardiography
TTE = Transthoracic
echocardiography
2D = Two-dimensional
2DE = Two-dimensional
echocardiography

I. The Left Ventricle 3
1. Measurementof
LV
Size 31.1. Linear
Measurements 3
1.2. Volumetric Measurements 3
1.3. Normal
Reference
Values for 2DE
6
1.4. Normal
Reference
Values for 3DE
6
Recommendation 6
2. LV Global Systolic Function 6
2.1. Fractional
Shortening 6
2.2. EF 7
2.3. Global
Longitudinal
Strain (GLS) 7
2.4. Normal
Reference
Values 7
Recommendations 10
3. LV
Regional
Function 10
3.1. Segmentation of theLeft Ventricle 10
3.2. Visual
Assessment 11
3.3. Regional Wall Motion
during Infarction andIschemia
11
3.4. Regional Abnormalities
in the Absence of Coronary Artery Disease 11
3.5. QuantificationofRegional Wall Motion
Using Doppler and
STE 11
Recommendations 12
4. LV Mass 13
Recommendations 16
II. The Right Ventricle 16
5. General
Recommendations for RV Quantification 16
6. Essential Imaging Windows and Views 16
7. RV Measurements
17
7.1. Linear
Measurements 17
7.2. Volumetric Measurements 17
Recommendations 17
8. RV
Systolic
Function 19
8.1. RIMP
19
8.2. TAPSE
19
8.3. RV 2D FAC 19
8.4. DTI-Derived Tricuspid
Lateral Annular Systolic
Velocity 20

8.5. RV Strain and Strain Rate 20
Recommendations 20
8.6. RV 3D EF 20
Recommendation 20
III. The Left and Right Atria 20
9. LA Measurements 24
9.1. General Considerations for LA Size 24
9.2. Linear Dimensions and Area Measurements
9.3. Volume Measurements 25
9.4. Normal Values of LA Measurements 25
Recommendations 28
10. Right Atrial measurements 28
Recommendations 28
IV. The Aortic Annulus and Aortic Root 28
11. The Aortic Annulus 28
12. The Aortic Root30
13. Identification of Aortic Root Dilatation 32
Recommendations 32
V. The Inferior Vena Cava 32
Notice and Disclaimer 33
References 33
Appendix 39.e1
Methods 39.e1
Echocardiographic Measurements
39.e1
Statistical Analysis 39.e1

25

The quantification of cardiac chamber size and function is the cornerstone of cardiac imaging, with echocardiography being the mostcommonly used noninvasive modality because of its unique ability
to provide real-time images of the beating heart, combined with its
availability and portability. Standardization of the methodology
used to quantify cardiac chambers is maintained by creating anddisseminating official recommendations, which when followed bypractitioners provides uniformity and facilitates communication.
Recommendations for echocardiographic chamber quantification
were last published in 2005 by the American Society of
Echocardiography (ASE) and the European Association of
Echocardiography (renamed the European Association of
Cardiovascular Imaging [EACVI]).1,2
Since then, echocardiographic technology has continued
evolving, with two major developments being real-time threedimensional (3D) echocardiography (3DE) and myocardial deformation imaging. The goal of this document is to provide an updateto the previously published guidelines, as well as recommendations
and reference values, while eliminating the minor discrepancies thatexisted between previous guidelines. The normal values in this update include 3DE and myocardial deformation, when possible.
Importantly, compared with the previous guidelines, this update isbased on considerably larger numbers of normal subjects, compiled
from multiple databases, to improve the reliability of the reference
values.
Although most issues covered in this document reflect a broadconsensus among the members of the writing group, one important
issue the group debated was partition values for severity of abnormalities. Most often, in addition to describing a parameter as normal or
abnormal (reference values), clinical echocardiographers qualify the
degree of abnormality with terms such as mildly, moderately, andLang et al 3

Journal of the American Society of Echocardiography
Volume 28 Number 1

severely abnormal, which reflect the degree to which measurements
deviate from normal. In addition to providing normative data, it
would be beneficial to standardize cutoffs for severity of abnormality
for all parameters across echocardiography laboratories, such that theterm moderately abnormal, for example, would have the same meaning universally. However, different approaches may be used for determining cutoff values for the different degrees of abnormality, all ofwhich have significant limitations.
The first approach would be to empirically define cutoffs for
mild, moderate, and severe abnormalities on the basis of SDs above
or below the reference limit derived from a group of healthy people.
The advantage of this method is that these data readily exist formost echocardiographic parameters. However, this approach isfundamentally flawed. First, not all echocardiographic parameters
are normally distributed (or Gaussian), even in a normal population.
Second, even if a particular parameter is normally distributed innormal subjects, most echocardiographic parameters, whenmeasured in the general population, have a significant asymmetric
distribution in one direction (abnormally large for size or abnormally
low for function parameters). An alternative method would be todefine abnormalities on the basis of percentile values (e.g., 95th,99th) of measurements derived from a population that includes
both healthy people and those with disease. Although these data
would still not be normally distributed, they would account for
the asymmetric distribution and the range of abnormality present
within the general population. The major limitation of this approachis that such population data sets simply do not exist for most echocardiographic variables.
Ideally, an approach that predicts outcomes or prognosis would be
preferred. That is, defining a variable as moderately deviated fromnormal would imply that there is a moderate risk for a particularadverse outcome for a patient. Although sufficient data linking risk
and cardiac chamber sizes exist for several parameters (e.g., left ventricular [LV] size and ejection fraction [EF], left atrial [LA] volume),
outcomes data are lacking for many other parameters.
Unfortunately, this approach also has limitations. The first obstacle
is how to best define risk. The cutoffs suggested for the same parameter vary broadly for different risks in different patient populations
and disease states.
Last, cutoff values may be determined by experience-based
consensus of expert opinions. An extensive debate arose among
the members of the writing group, some of whom felt thatproviding partition values on the basis of this scientifically lessthan-rigorous approach would be a disservice to the echocardiography community and that a disease-specific approach might berequired to achieve meaningful clinical categorization of theseverity of abnormality. Others felt that such cutoffs would provide a uniform reference for echocardiographic reporting, which
would be easier to interpret by referring clinicians. The compromise was to provide experience-based partition values only for
LV EF and LA volume, while suggested partition values for additional parameters of LV size and mass are listed in the
Appendix. All partition values should interpreted with caution
in this perspective.
For parameters other than LV size, function, and mass as well as
LA volume, only the mean value and the SD of gender-, age-, andbody surface area (BSA)–normalized cutoffs or upper and lower
limits are reported in the appropriate sections of this document.
For these parameters, measurements exceeding 61.96 SDs (i.e.,the 95% confidence interval) should be classified as abnormal.
Any description of the degree of deviation from normality in theechocardiographic report should remain at the discretion of the individual laboratory, and the writing group does not recommend specific partition values.
Quantification using transesophageal echocardiography (TEE)
has advantages and disadvantages compared with transthoracic
echocardiography (TTE). Although visualization of many cardiac
structures is improved with TEE, some differences in measurements have been found between TEE and TTE, particularly forchamber dimensions and thickness. These differences are primarily
attributable to the inability to obtain from the transesophageal
approach the standardized imaging planes and views used whenquantifying chamber dimensions transthoracically. It is the recommendation of this writing group that the same range of normal
values for LV and right ventricular (RV) chamber dimensions andvolumes apply for both TEE and TTE. For details on specific viewsfor optimal measurements, please refer to the recently publishedTEE guidelines.3
All measurements described in this document should be performed on more than one cardiac cycle to account for interbeat
variability. The committee suggests the average of three beats forpatients in normal sinus rhythm and a minimum of five beats inpatients with atrial fibrillation. Because the committee acknowledges that the implementation of this recommendation is time
consuming, the use of representative beats is acceptable in the clinical setting.

I. THE LEFT VENTRICLE

1. Measurement of LV Size
The most commonly used parameters to describe LV cavity size
include linear internal dimensions and volumes. Measurements arecommonly reported for end-diastole and end-systole, which arethen used to derive parameters of global LV function. To allow comparison among individuals with different body sizes, chamber measurements should be reported indexed to BSA.
1.1. Linear Measurements. It is recommended that linear internalmeasurements of the left ventricle and its walls be performed in theparasternal long-axis view. Values should be carefully obtained
perpendicular to the LV long axis and measured at or immediately
below the level of the mitral valve leaflet tips. In this regard, the electronic calipers should be positioned on the interface between the
myocardial wall and cavity and the interface between the wall andthe pericardium. Internal dimensions can be obtained with a twodimensional (2D) echocardiography (2DE)–guided M-mode
approach, although linear measurements obtained from 2D echocardiographic images are preferred to avoid oblique sections of theventricle (Table 1).
1.2. Volumetric Measurements. LV volumes are measured using
2DE or 3DE. Volume calculations derived from linear measurements
may be inaccurate, because they rely on the assumption of a fixed
geometric LV shape such as a prolate ellipsoid, which does not apply
in a variety of cardiac pathologies. Accordingly, the Teichholz andQuinones methods for calculating LV volumes from LV linear dimensions are no longer recommended for clinical use.
Volumetric measurements are usually based on tracings of theinterface between the compacted myocardium and the LV cavity.

4 Lang et al

Journal of the American Society of Echocardiography
January 2015

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

TechniqueInternal linear
dimensions.
Linear internalmeasurements of the LVshould be acquired in theparasternal long-axis
view carefully obtained
perpendicular to the LV
long axis, and measured
at the level of the mitralvalve leaflet tips.
Electronic calipers
should be positioned on
the interface between
myocardial wall andcavity and the interface
between wall andpericardium (orange
arrows).

M-mode tracing

Volumes.
Volume measurements
are usually based on
tracings of the bloodtissue interface in theapical four- and twochamber views. At themitral valve level, thecontour is closed byconnecting the two
opposite sections of themitral ring with a straightline. LV length is definedas the distance between
the middle of this line
and the most distantpoint of the LV contour.

Biplane disk summation

Advantages

Limitations

 Reproducible
 High temporal
resolution
 Wealth of publisheddata Beam orientation
frequently off axis
 Single dimension, i.e.,
representative only innormally shaped
ventricles

2D-guided linear measurements
 Facilitates orientation
perpendicular to theventricular long axis

 Lower frame rates
than M-mode Single dimension, i.e.,
representative only innormally shaped
ventricles

 Corrects for shape
distortions
 Less geometricalassumptions
compared with linear
dimensions

 Apex frequently
foreshortened
 Endocardial dropout
 Blind to shape distortions not visualized in
the apical two- andfour-chamber planes

 Partial correction forshape distortion Apex frequently
foreshortened Heavily based ongeometricalassumptions
 Limited publisheddata on normal
population

Area-length(Continued )Lang et al 5

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 1 (Continued )Parameter and method

Technique

Advantages

Limitations

Endocardial border enhancement Helpful in patients with
suboptimal acoustic
window
 Provides volumes thatare closer to thosemeasured with cardiac
magnetic resonance Same limitations as
the above noncontrast 2D
techniques Acoustic shadowing in
LV basal segmentswith excess contrast

3D data sets

 No geometricalassumption
 Unaffected byforeshortening
 More accurate andreproducible
compared to otherimaging modalities

 Lower temporal
resolution
 Less published dataon normal values
 Image quality
dependent

Global Longitudinal
Strain.
Peak value of 2D
longitudinal speckle
tracking derived strain(%).

 Angle independent
 Establishedprognostic value Vendor dependent

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.

At the mitral valve level, the contour is closed by connecting the two
opposite sections of the mitral ring with a straight line. LV length isdefined as the distance between the bisector of this line and the apicalpoint of the LV contour, which is most distant to it. The use of thelonger LV length between the apical two- and four-chamber views
is recommended.
LV volumes should be measured from the apical four- andtwo-chamber views. Two-dimensional echocardiographic image
acquisition should aim to maximize LV areas, while avoiding foreshortening of the left ventricle, which results in volume underestimation. Acquiring LV views at a reduced depth to focus on
the LV cavity will reduce the likelihood of foreshortening andminimize errors in endocardial border tracings (Table 1).
Because the issue of foreshortening is less relevant in 3D data
sets, 3D image acquisition should focus primarily on including
the entire left ventricle within the pyramidal data set. To ensure
reasonably accurate identification of end-systole, the temporal resolution of 3D imaging should be maximized without compromising spatial resolution.
Contrast agents should be used when needed to improve endocardial delineation when two or more contiguous LV endocardial
segments are poorly visualized in apical views, as per published guidelines.4 Contrast-enhanced images may provide larger volumes thanunenhanced images that are closer to those obtained with cardiac

6 Lang et al

magnetic resonance (CMR) in head-to-head comparison.5 Careshould be taken to avoid acoustic shadowing, which may occur in
LV basal segments in the presence of high concentrations of contrast.
Normal reference values for LV volumes with contrast enhancement
are not well established.
The most commonly used method for 2D echocardiographic
volume calculations is the biplane method of disks summation(modified Simpson’s rule), which is the recommended 2D echocardiographic method by consensus of this committee (Table 1). An
alternative method to calculate LV volumes when apical endocardial
definition precludes accurate tracing is the area-length method, inwhich the LV is assumed to be bullet shaped. The mid-LV crosssectional area is computed by planimetry in the parasternal shortaxis view and the length of the ventricle taken from the midpointof the annular plane to the apex in the apical four-chamber view
(Table 1). The shortcoming of this method is that the bullet-shapeassumption does not always hold true. One of the advantages of
3D echocardiographic volume measurements is that they do not
rely on geometric assumptions. In patients with good image quality,
3D echocardiographic measurements are accurate and reproducible
and should therefore be used when available and feasible.6 The advantages and disadvantages of the various methods are summarizedin Table 1.
1.3. Normal Reference Values for 2DE. Data were extracted
from seven databases, including Asklepios (year 0 and year 10),7
Flemengho,8 CARDIA5 and CARDIA25,9 Padua 3D Echo
Normal,10
andtheNormalReference
Rangesfor
Echocardiography study,11,12 to obtain reference values in normal
subjects for the left ventricle and the left atrium (see section 10).
All data were obtained without the use of contrast agents. Data
sets for all patients included age, gender, ethnicity, height, andweight. To ensure a normal population, subjects in these studies
were excluded if any of the following criteria were met: systolicblood pressure > 140 mm Hg, diastolic blood pressure > 80 mm
Hg, history of drug-treated hypertension, diagnosis of diabetes,
impaired fasting glucose > 100 mg/dL, body mass index > 30 kg/
m2, creatinine > 1.3 mg/dL, estimated glomerular filtration rate
< 60 mL/min/1.73 m2, total cholesterol > 240 mg/dL, low-density lipoprotein cholesterol > 130 mg/dL, and total triglycerides > 150 mg/dL.
Details of the statistical analysis are described in the Appendix. Becauseof varied study aims, not all echocardiographic measurements wereavailable for each database. Supplemental Table 1 summarizes the sources of the data for each measurement group and their baseline characteristics.
Table 2 shows the normal values for 2D echocardiographic parameters of LV size and function according to gender, while Supplemental
Table 2 provides expanded data for the same parameters, obtained
from different echocardiographic views, and also includes thecorresponding number of subjects used to obtain these data.
Supplemental Table 3 lists normal ranges and consensus-based partition cutoffs for LV dimensions, volumes, EF, and mass. On multivariate analysis, age, gender, and BSA were found to have a significant
independent influence on LV end-diastolic volume (EDV) and LV
end-systolic volume (ESV). The results across genders and age deciles
subdivided into absolute and BSA-normalized values are shown in
Supplemental Table 4 (see Appendix).
Because ethnicity is an important factor, results of analysis by raceand gender are presented in Supplemental Table 5. From the regression analysis, nomograms are provided for plotting observed LV
dimensions versus BSA or BSA-indexed LV volumes versus age

Journal of the American Society of Echocardiography
January 2015

(Figures 1 and 2). Nomograms for absolute LV measurements
against age (Supplemental Figures 1 and 2) and BSA (Supplemental
Figures 3 and 4) are also provided (see Appendix).
1.4. Normal Reference Values for 3DE. Several studies havepublished 3D echocardiographic reference values for healthy normotensive subjects, which are summarized in Table 3.13 The reported
variations in the normal ranges from study to study are likely due todifferences in populations, echocardiographic equipment, and analysis software, as well as variability in measurement techniques. In
patients with good image quality, the accuracy of 3DE is comparablewith that of CMR, although volumes tend to be lower on echocardiography.6
The effects of ethnicity on 3D echocardiographic LV volumes were
investigated in one study, which reported that LV volumes were smaller
among Asian Indians than white Europeans, but EF did not differ
among ethnic groups.14 In most 3D echocardiographic studies, the relationship between age and 3D echocardiographic LV volumes was
examined, and weak to moderate negative correlations were seen between age and LV volumes, while EF did not change significantly withage.10,15,16 This finding is similar to those described in the CMR
literature.17,18 On the basis of weighted averages of threestudies,16,19,20 3D echocardiographic LV volumes were larger than
2D echocardiographic values, and corresponding upper limits of thenormal range were EDVs of 79 mL/m2 for men and 71 mL/m2 forwomen and ESVs of 32 mL/m2 for men and 28 mL/m2 for women.
Ultimately, a large study in a diverse population will be needed toestablish normal reference ranges for 3DE for different ethnic groups.
Recommendation. LV size should be routinely assessed on 2DE
by calculating volumes using the biplane method of disks summation technique. In laboratories with experience in 3DE, 3D
measurement and reporting of LV volumes is recommended
when feasible depending on image quality. When reporting LV
linear dimensions, the recommended method is 2D-guided
measurements. LV size and volume measurements should bereported indexed to BSA. For general reference, 2D echocardiographic LV EDVs of 74 mL/m2 for men and 61 mL/m2 forwomen and LV ESVs of 31 mL/m2 for men and 24 mL/m2 forwomen should be used as the upper limits of the corresponding
normal range.
2. LV Global Systolic Function
Global LV function is usually assessed by measuring the difference between the end-diastolic and end-systolic value of a one-dimensional,
2D, or 3D parameter divided by its end-diastolic value. For this, enddiastole is preferably defined as the first frame after mitral valve
closure or the frame in the cardiac cycle in which the respective LV
dimension or volume measurement is the largest. End-systole is best
defined as the frame after aortic valve closure or the frame in which
the cardiac dimension or volume is smallest. In patients with regularheart rhythm, measurements of the timing of valve openings and closures derived from M-mode echocardiography, pulsed-wave (PW) or
continuous-wave Doppler may be used for accurate definitions ofventricular time intervals.
2.1. Fractional Shortening. Fractional shortening can be derived
from 2D-guided M-mode imaging or preferably from linear measurements obtained from 2D images. Deriving global LV function
parameters from linear measurements is problematic when there
are regional wall motion abnormalities due to coronary disease orLang et al 7

Journal of the American Society of Echocardiography
Volume 28 Number 1

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

Mean 6 SD

Female2-SD range

Mean 6 SD

2-SD range

LV internal dimension
Diastolic dimension (mm)50.2 6 4.1

42.0–58.4

45.0 6 3.6

37.8–52.2

Systolic dimension (mm)32.4 6 3.7

25.0–39.8

28.2 6 3.3

21.6–34.8

LV volumes (biplane)
LV EDV (mL)106 6 22

62–15076 6 15

46–106

LV ESV (mL)

41 6 10

21–61

28 6 7

14–42

LV EDV (mL/m2)

54 6 1034–74

45 6 8

29–61

LV ESV (mL/m2)

21 6 5

11–31

16 6 4

8–24

62 6 5

52–72

64 6 554–74

LV volumes normalized by BSA

LV EF (biplane)

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

conduction abnormalities. In patients with uncomplicated hypertension, obesity or valvular diseases, such regional differences are rarein the absence of clinically recognized myocardial infarction, andaccordingly, this parameter may provide useful information in clinical studies.21 In patients with normal size of the LV base but
enlarged midventricular and distal portions, LV volume would bea better marker of LV size than linear dimension measured at theLV base.
2.2. EF. EF is calculated from EDV and ESV estimates, using thefollowing formula:
EF ¼ ðEDV  ESVÞ=EDV:

LV volume estimates may be derived from 2DE or 3DE, as
described above (section 1.2). The biplane method of disks (modified
Simpson’s rule) is the currently recommended 2D method toassess LV EF by consensus of this committee. Table 4 lists 2DEderived biplane LV EF, including normal ranges and consensusbased severity partition cutoffs according to gender. In patients withgood image quality, 3DE-based EF measurements are accurate andreproducible and should be used when available andfeasible.6,10,15,16,19,20
2.3. Global Longitudinal Strain (GLS). Lagrangian strain isdefined as the change in length of an object within a certain direction
relative to its baseline length:
Strainð%Þ ¼ ðLt  L0 Þ=L0 ;where Lt is the length at time t, and L0 is the initial length at time 0. The
most commonly used strain-based measure of LV global systolic function is GLS. It is usually assessed by speckle-tracking echocardiography(STE)22-24 (Table 1). On 2DE, peak GLS describes the relative lengthchange of the LV myocardium between end-diastole and end-systole:
GLSð%Þ ¼ ðMLs  MLdÞ=MLd;

where ML is myocardial length at end-systole (MLs) and end-diastole(MLd). Because MLs is smaller than MLd, peak GLS is a negative
number. This negative nature of GLS can lead to confusion whendescribing increases or decreases in strain. We recommend that all references to strain changes specifically mention an increase or decreasein the absolute value of strain, to avoid confusion.
After optimizing image quality, maximizing frame rate, and minimizing foreshortening, which are all critical to reduce measurement
variability, GLS measurements should be made in the three standard
apical views and averaged.25 Measurements should begin with theapical long-axis view to visualize aortic valve closure, using opening
and closing clicks of the aortic valve or aortic valve opening and closing on M-mode imaging. When regional tracking is suboptimal inmore than two myocardial segments in a single view, the calculationof GLS should be avoided. In such cases, alternative indices may be
used to gain insight into longitudinal LV function, such as mitralannular plane systolic excursion or pulsed Doppler tissue imaging(DTI)–derived mitral annular peak systolic velocity (s0 ).
There are concurrent definitions as a basis for GLS calculation using endocardial, midwall, or average deformation.24 This committee
refrains from recommendations in this regard and refers to theongoing joint standardization initiative of the ASE, EACVI, and theultrasound imaging industry.24,26 Because of intervendor andintersoftware variability and age and load dependency, serial
assessment of GLS in individual patients should be performed using
the same vendor’s equipment and the same software.
The preponderance of currently available data is for midwall GLS.
Although the evidence base for its use in routine clinical echocardiography is far smaller than that for EF, measures of midwall GLS havebeen shown in several studies to be robust and reproducible27 andto offer incremental predictive value in unselected patients undergoing
echocardiography for the assessment of resting function,28,29 as well asin predicting postoperative LV function in patients with valve
disease.30,31
2.4. Normal Reference Values. Normal reference values for LV
EF derived from 2DE have been updated using the populationbased studies described in section 1.3 above. Details can be foundin Tables 2 and 4 and Supplemental Tables 2-5 (see Appendix). EF
is not significantly related to gender, age, or body size, as measured
by BSA. Normal EF was 63 6 5% using the biplane method ofdisks. Therefore, in individuals aged > 20 years, EF in the range of
53% to 73% should be classified as normal. Three-dimensional

8 Lang et al

Journal of the American Society of Echocardiography
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Figure 1 For men (left) and women (right), the 95% confidence intervals for the following measurements are presented: LV enddiastolic dimension 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.

Journal of the American Society of Echocardiography
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Lang et al 9

Figure 2 For men (left) and women (right), the 95% confidence intervals for the following measurements are presented: LV endsystolic dimensions 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).
echocardiographic normal values have been recently reported indifferent ethnic populations (Table 3).
Normal values for GLS depend on the definition of the measurement 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
committee that differences among vendors and software packages
are still too large to recommend universal normal values and lower

10 Lang et al

Journal of the American Society of Echocardiography
January 2015

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)

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 6 2 SDs.

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

LV EF (%)
2

Maximum LA volume/BSA (mL/m )FemaleNormalrange

MildlyabnormalModerately
abnormalSeverely
abnormal

Normalrange

MildlyabnormalModerately
abnormalSeverely
abnormal

52–72

41–51

30–40

<30

54–74

41–53

30–40

<30

16–34

35–41

42–48

>48

16–34

35–41

42–48

>48

limits of normal. To provide some guidance, a peak GLS in the rangeof 20% can be expected in a healthy person. A selection of recently
published data is provided in the Appendix together with the lower
normal limits (Supplemental Table 6). There is evidence that women
have slightly higher absolute values of GLS than men and that strain
values decrease with age.32,34 GLS is a valuable and sensitive tool forfollow-up examinations, provided the same equipment, tracing methodology, and software are used.
Recommendations. LV systolic function should be routinely assessed using 2DE or 3DE by calculating EF from EDV and ESV. LV
EFs of <52% for men and <54% for women are suggestive ofabnormal LV systolic function. Two-dimensional STE-derived GLS appears to be reproducible and feasible for clinical use and offers incremental prognostic data over LV EF in a variety of cardiac conditions,although measurements vary among vendors and software versions.
To provide some guidance, a peak GLS in the range of 20% canbe expected in a healthy person, and the lower the absolute valueof strain is below this value, the more likely it is to be abnormal.
3. LV Regional Function
3.1. Segmentation of the Left Ventricle. For the assessment ofregional LV function, the ventricle is divided into segments.
Segmentation schemes should reflect coronary perfusion territories,
result in segments with comparable myocardial mass, and allow
standardized communication within echocardiography and withother imaging modalities (Figure 3). Accordingly, a 17-segment
model is commonly used. Beginning at the anterior junction of
the interventricular septum and the RV free wall and continuingcounterclockwise, basal and midventricular segments should belabeled as anteroseptal, inferoseptal, inferior, inferolateral, anterolateral, and anterior. In this 17-segment model, the apex is divided into
five segments, including septal, inferior, lateral, and anterior segments, as well as the ‘‘apical cap,’’ which is defined as the myocardium beyond the end of the LV cavity (Figures 3 and 4).35 The
17-segment model may be used for myocardial perfusion studies
or when comparing between different imaging modalities, specifically single photon-emission computed tomography, positron emission tomography, and CMR. Figure 5 shows a schematic
representation of the perfusion territories of the three major coronary arteries. When using this 17-segment model to assess wallmotion or regional strain, the 17th segment (the apical cap) should
not be included.
Alternative segmentation models treat the apex differently: the 16segment model36 divides the entire apex into the same four segments(septal, inferior, lateral, and anterior; Figure 3, left). Also, some segmentation schemes divide the apex into six segments, similar to thebasal and midventricular levels, resulting in an 18-segment model(Figure 3, right) that is simple but results in a slight overrepresentationof the distal myocardium when scoring.
All segments can be visualized by 2DE. On average, the twochamber view and the apical long-axis view intersect with thefour-chamber view at angles of approximately 53 and 129 ,Journal of the American Society of Echocardiography
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Lang et al 11

Figure 3 Schematic diagram of the different LV segmentation models: 16-segment model (left),36 17-segment model (center),35 and18-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 60 . The apical myocardium in the 16- and 17-segment models is divided instead into four equal segments of 90 . 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).

respectively,37 allowing the assessment of the central region of all segments from an apical window, independent of the model used.
Although certain variability exists in the coronary artery blood supply
to myocardial segments, segments are usually attributed to the threemajor coronary arteries (Figure 5).35
3.2. Visual Assessment. In echocardiography, regional myocardial function is assessed on the basis of the observed wall thickening
and endocardial motion of the myocardial segment. Because myocardial motion may be caused by adjacent segment tethering or overall
LV displacement, regional deformation (thickening, shortening)should be the focus of the analysis. However, it must be recognizedthat deformation can also be passive and therefore may not always
accurately reflect myocardial contraction.
It is recommended that each segment be analyzed individually inmultiple views. A semiquantitative wall motion score can be assigned
to each segment to calculate the LV wall motion score index as theaverage of the scores of all segments visualized. The following scoring
system is recommended: (1) normal or hyperkinetic, (2) hypokinetic(reduced thickening), (3) akinetic (absent or negligible thickening, e.g.,scar), and (4) dyskinetic (systolic thinning or stretching, e.g., aneurysm).
An aneurysm is a morphologic entity that demonstrates focal dilatation and thinning (remodeling) with either akinetic or dyskinetic systolic deformation.38 In contrast to the recommendation of previous
guidelines,1,2 this committee refrains from assigning a separate wallmotion score for aneurysm.
3.3. Regional Wall Motion during Infarction andIschemia. Depending on the regional coronary flow reserve, stressechocardiography may reveal significant coronary artery stenoses bymeans of inducing a wall motion abnormality. Myocardial scar
may also result in regional dysfunction of variable severity.

Echocardiography can over- or underestimate the amount of ischemic
or infarcted myocardium, depending on the function of adjacent regions, regional loading conditions, and stunning.39 In stress echocardiography, visual recognition of regional dysfunction can be improved
with a synchronized side-by-side comparison of baseline and stressimages using digital technology.40
3.4. Regional Abnormalities in the Absence of Coronary Artery Disease. Regional wall motion abnormalities may also occur inthe absence of coronary artery disease, in a variety of conditions, suchas myocarditis, sarcoidosis, and stress-induced (takotsubo) cardiomyopathy. Abnormal motion patterns of the interventricular septum
may be found postoperatively or in the presence of a left bundle
branch block or RV epicardial pacing, as well as RV dysfunction
caused by RV pressure or volume overload. Furthermore, some conduction delays can cause regional wall motion abnormalities in theabsence of primary myocardial dysfunction. This regional dysfunctionis due to the abnormal sequence of myocardial activation, whichcauses heterogeneous loading conditions and remodeling.41 Ideally,
the temporal sequence of activation and motion should be described.
Characteristic motion patterns, which result from abnormal activation
sequences, such as septal bounce (‘‘beaking,’’ ‘‘flash’’) or lateral apicalmotion during systole (‘‘apical rocking’’) should be reported.42-45
3.5. Quantification of Regional Wall Motion Using Doppler
and STE. Echocardiographic quantification of regional myocardial
function is currently based on DTI or speckle-tracking echocardiographic techniques.46-48 Both techniques provide comparable data
quality, although DTI is known to be angle dependent and prone tounderestimating motion that is not parallel to the ultrasound beam.
Commonly used parameters include velocity, motion, deformation,and deformation rate. Because velocity and motion are measured
relative to the transducer, measurements may be influenced by

12 Lang et al

Journal of the American Society of Echocardiography
January 2015

Figure 4 Orientation of apical four-chamber (A4C), apical two-chamber (A2C), and apical long-axis (ALX) views in relation to thebull’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.
tethering or overall heart motion. Accordingly, the use of deformation
parameters, such as strain and strain rate, is preferable.
The most commonly used deformation parameter is longitudinalstrain during LV systole. Similar to global strain, with current technology, regional deformation measurements may vary in amplitude,
depending on the myocardial region being investigated, the measurement methodology, the vendor, and sample volume definition.
Therefore, no specific normal ranges are provided in this document.
These values await the upcoming consensus document of the jointtask force of the ASE, EACVI, and the industry for the standardizationof quantitative function imaging.23,25
Independent of strain magnitude, characteristic changes in temporal pattern of myocardial deformation can be assessed as well.
Longitudinal shortening or radial thickening of the myocardium after
aortic valve closure (postsystolic shortening or thickening, sometimes
referred to as tardokinesis) of >20% of the total deformation during
the cardiac cycle is a consistent sign of regional functional inhomogeneity (e.g., ischemia, scar).44 The development of postsystolic

shortening during a stress test has been proposed as an indicator ofregional ischemia.49 The value of regional deformation parameters
and temporal patterns of strain derived by speckle-tracking fromeither 2D or 3D echocardiographic data sets is the subject of ongoing
research and remains to be determined.50,51
Recommendations. Different LV segmentation models are usedin clinical practice. The 17-segment model is recommended to assess
myocardial perfusion with echocardiography and other imaging techniques. The 16-segment model is recommended for routine studies
assessing wall motion, because endocardial excursion and thickeningof the tip of the apex are imperceptible. To assess wall motion, eachsegment should be evaluated in multiple views and a four-grade
scoring should be applied: (1) normal or hyperkinetic, (2) hypokinetic(reduced thickening), (3) akinetic (absent or negligible thickening),and (4) dyskinetic (systolic thinning or stretching). Despite promisingdata, quantitative assessment of the magnitude of regional LV deformation cannot be recommended at this stage because of lack ofJournal of the American Society of Echocardiography
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Lang et al 13

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.

reference values, suboptimal reproducibility, and considerable intervendor measurement variability.
4. LV Mass
LV mass is an important risk factor for, and a strong predictor of, cardiovascular events.52-55 There are several methods that effectively
calculate LV mass from M-mode echocardiography, 2DE, and 3DE(Table 5). All measurements should be performed at the end of diastole (the frame before mitral valve closure or the frame in the cardiac
cycle in which the ventricular dimension or volume is largest). Thosethat use M-mode (either blinded or 2D-guided) and 2D echocardiographic linear measurements of LV diastolic diameter and wall thickness rely on geometric formulas to calculate the volume of LV
myocardium, while 3DE can measure it directly. All methods thenconvert the volume to mass by multiplying the volume of myocardium by the myocardial density (approximately 1.05 g/mL).
When the entire ventricle is measured from 2D echocardiographic
images, either the area-length or truncated ellipsoid technique isused.1 Each method for LV mass measurement has advantages, disadvantages, and value in specific situations (Table 5).
To measure LV mass in an individual patient over time, especiallythose with cardiac disease, the 2D echocardiographic methods haveadvantages compared with the linear dimension technique.1 There
are, however, fewer studies of the prognostic value of LV mass calculated by these methods compared with the linear dimension method
described below. Unlike the linear dimension or M-mode method, the2D echocardiographic methods can accommodate for the shape ofthe ventricle and account for changes in LV size that might occur
along the long axis of the chamber. This is an important consideration,
because changes in LV geometry are common in various cardiac diseases.
However, when there is a need to screen or study large populations, the M-mode method has advantages, because it is simple, quick,and subject to less measurement variability. There is a large body ofevidence to support the accuracy of this method. Most studies that
relate LV mass to prognosis are based on this method.56 However,

several caveats need to be mentioned. First, it is critical that the wall
thickness and LV dimensions measured be truly perpendicular tothe long axis of the left ventricle. Therefore, 2D-guided M-mode imaging or measurements from 2D echocardiographic images are
preferred over blind M-mode imaging. Second, the formula includes
a correction for the 20% overestimation that was found during theoriginal validation studies of the M-mode technique. Because direct
2D measures of wall thickness may yield smaller values than the
M-mode technique, LV mass calculated using this formula may not
be directly interchangeable (Table 5). This may be a less importantconsideration if the method is being used to identify cutoff values
for prognosis. It is also important to note that the formula raises thelinear dimensions to the power of 3, and thus even small errors in dimensions can have significant effects on the calculated LV mass.
Most studies that have compared 2D-guided M-mode measurements of LV mass with the 2D echocardiographic area-length or truncated ellipsoid methods in normally shaped ventricles have shown
subtle differences but no clear advantage of one technique over theother.57 However, comparison studies have not been performed in
the current era, when tremendous gains in 2D echocardiographic image quality have been made. In fact, large population studies confirming or reestablishing normal values for LV mass with harmonic
imaging are limited.58,59
Because 3DE is the only echocardiographic method that directly
measures myocardial volume, it is an appropriate approach.
Numerous validation studies have been performed.60 However, todate, there have been few studies assessing its practical use, feasibility,
variability, or prognostic value in large-scale clinical environments.61
Accordingly, 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 notedthat continuous improvements in the spatial and temporal resolutionof 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 overestimation of the true mass, because the thickest region of theParameter and method

Linear method:
Cube formula
LV mass ¼ 0:8$1:04$½ðIVS

Echocardiographic imaging

M-mode tracingiþLVID þ PWTÞ3 LVID3 þ 0:6g

Where IVS is interventricular septum; LVID
is LV internal diameter, and PWT is
inferolateral wall thickness.
Linear internal measurements of the LVshould be acquired from the parasternal
approach and carefully obtained
perpendicular to the LV long axis, andmeasured at the level of the mitral valve
leaflet tips. M-mode measurements should
be obtained from a targeted SAX or aparasternal LAX view. All measurements
should be performed at end-diastole.
2D

LV mass ¼ 1:05p ðb þ tÞ2"#2d3
ða þ tÞ þ d 
33ða þ tÞ2
b2


)
2
d3
aþd 23
3aLimitations

 Fast and widely used
 Wealth of published data
 Demonstrated prognostic value Fairly accurate in normally shaped ventricles (i.e., systemic hypertension, aortic
stenosis)
 Simple for screening large populations

 Based on the assumption that the left
ventricle is a prolate ellipsoid with a 2:1
long/short axis ratio and symmetric distribution of hypertrophy Beam orientation frequently off axis
 Since linear measurements are cubed,
even small measurement errors in dimensions or thickness have an impact on
accuracy Overestimates LV mass
 Inaccurate in the presence of asymmetric
hypertrophy, dilated ventricles and otherdiseases with regional variations in wall
thickness

 Facilitates orientation perpendicular to
the LV long axis

 Based on the same geometrical assumptions as M-mode Same limitations as M-mode in patientswith abnormal LV geometry
 Impact of harmonic imaging on the masscalculations and normal values remains
to be defined Normal values are less well establishedthan for M-mode measurements

 Partial correction for shape distortions
 Less dependent on geometrical assumptions than the linear measurements

 Good image quality and properly oriented
parasternal short-axis views (no obliqueplanes) are required Good epicardial definition is required Cumbersome methodology
 Higher measurement variability
 Few published normative data Limited prognostic data

(Continued )Journal of the American Society of Echocardiography
January 2015

2D based formulas.
Truncated ellipsoid:(

Advantages

14 Lang et al

Table 5 Recommendations for the echocardiographic assessment of LV mass

Table 5 (Continued )Echocardiographic imaging

Advantages

Limitations

Area-length:
LV mass ¼ 1:05

5
A1 ða þ d þ tÞ65
 A2 ða þ dÞ
6
Mean wall thickness is calculated from
epicardial (A1) and endocardial (A2) crosssectional areas in short-axis view at thepapillary muscle level (top panel, green line)with the papillary muscles considered partof the LV cavity. The short axis radius iscalculated as:
qﬃﬃﬃﬃ
b Ap2

Journal of the American Society of Echocardiography
Volume 28 Number 1

Parameter and method

Then, mean wall thickness t is calculated as:
!
qﬃﬃﬃﬃ
A1
t¼
b
p
and the cross sectional area of the
myocardium (Am) in short-axis view is:
Am ¼ A 1  A2
LV mass is calculated from thesemeasurements plus the LV length measured
from the level of the short axis plane to thebase (d) and to the apex (a).
Key: a - distance from the minor axis to theendocardium at the LV apex; b = LV minor
radius; d - distance from the minor axis tothe mitral valve plane; t - mean wall
thickness.
LV mass = (LV epicardial volume  LV
endocardial volume). 1.05 = LV myocardial
volume. 1.05
LV mass = (LV epicardial volume  LV
endocardial volume). 1.05 = LV myocardial
volume. 1.05
3D based formula.

3D data set

 Normal values less well established Dependent on image quality
 Patient’s cooperation required

Lang et al 15

 Direct measurement without geometricalassumptions about cavity shape and hypertrophy distribution
 More accurate than the linear or the 2D
measurements
 Higher inter-measurement and test/retest reproducibility
 Better discriminates small changes withina patient16 Lang et alinterventricular septum is incorporated in the measurement. In
contrast, the area-length method, which uses mid-ventricular measurements, underestimates LV mass, because the thickest part ofthe interventricular septum is not included in the measurement. In
the setting of discrete upper septal or asymmetric hypertrophy, if
these methods are used to serially assess LV mass in a patient, it iscritical 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 regional differences in wall thickness and therefore can provide the most accurate measurements of
LV mass in this setting.
The values for LV mass vary according to gender, age, body size,
obesity, and region of the world. Therefore, uniform reference values
are difficult to define. LV mass is higher in men independent of bodysize and increases with body size. Since the publication of the 2005 recommendations, several studies, mostly using linear measurements, havereported normal values of LV mass in normal populations.59,62-66 Thelarger studies reported values close to those recommended in theprevious guidelines.62,65,66 Therefore, the same reference values andabnormality partition cutoffs as reported in the previous guidelines
continue to be recommended (Table 6). However, characterization of
the population being studied, and differences in mass between different
ethnic populations should be taken into account when determining
normal values.10,16,67-69
The indexing of LV mass allows comparisons in subjects withdifferent body sizes. However, whether to use height, weight, or
BSA as the indexing term remains controversial. Studies suggestthat indexing to height raised to allometric powers such as 1.7, 2.13,
and 2.7 has advantages over indexing to BSA, especially when attempting to predict events in obese patients.65,70 However mostlarge population studies reporting LV mass have indexed to BSA.
Finally, calculation of relative wall thickness (RWT) with the formula (2  posterior wall thickness)/(LV internal diameter at enddiastole) permits categorization of an increase in LV mass as either
concentric (RWT > 0.42) or eccentric (RWT # 0.42) hypertrophy
and allows the identification of concentric remodeling (normal LV
mass with increased RWT) (Figure 6).
Recommendations. In the normally shaped left ventricle, both
M-mode and 2D echocardiographic formulas to calculate LV masscan be used. Normal values for these techniques remain unchanged
from the previous guidelines and should be reported indexed to
BSA. Reference upper limits of normal LV mass by linear measurements are 95 g/m2 in women and 115 g/m2 in men. Reference upper limits of normal LV mass by 2D measurements are 88 g/m2 inwomen and 102 g/m2 in men with 2D methods. Because 3DE isthe only echocardiographic technique that measures myocardial volume directly, without geometric assumptions regarding LV shapeand distribution of wall thickening, this technique is promising andmay be used in abnormally shaped ventricles or in patients withasymmetric or localized hypertrophy. Limited upper normal limitsof 3D echocardiographic LV mass data are currently available in
the literature but are insufficient to substantiate recommendations
for reference values.

Journal of the American Society of Echocardiography
January 2015

senting with signs and symptoms of cardiopulmonary disease. Until
recently, little uniformity in echocardiographic imaging of the rightheart existed because of a lack of familiarity with various techniques,
and the enormous attention directed toward left heart quantification.
The ASE has recently published a guidelines document, endorsed by
the EACVI and the Canadian Society of Echocardiography, standardizing the approach for the evaluation of right heart dimensions andfunction during echocardiographic assessment of the right heart inadults.71 Compared with that document, this section provides updated reference values for RV dimensions and most parameters ofsystolic and diastolic function, which should replace the previously
published guideline.
5. General Recommendations for RV Quantification
In all clinical studies, a comprehensive examination of the rightventricle should be performed, taking into account the study indication and available clinical information. The operator should examine
the right ventricle using multiple acoustic windows, and the report
should present an assessment based on both qualitative and quantitative parameters. Parameters that can be measured include RV andright atrial (RA) size, a measure of RV systolic function, as assessedby at least one or a combination of the following: fractional areachange (FAC), DTI-derived tricuspid lateral annular systolic velocity
wave (S0 ), tricuspid annular plane systolic excursion (TAPSE), and
RV index of myocardial performance (RIMP). RV systolic pressure,typically calculated using the tricuspid regurgitation jet and an estimation of RA pressure based on inferior vena cava (IVC) size and collapsibility, should be reported when a complete TR Doppler velocity
envelope is present.71 When feasible, additional parameters such as
RV volumes and EF using 3DE should complement the basic 2D
echocardiographic measurements listed above. The recommended
methods, as well as the advantages and limitations of each parameter,are summarized in Tables 7 and 9, whereas the new reference values
are displayed in Tables 8 and 10. These reference values are based on
published mean and SD data obtained from normal adult individuals
without any histories of heart or pulmonary disease (Supplemental
Table 7). This document uses the same methodology as in the previous RV guidelines, whereby a meta-analysis was performed for eachparameter.
Not all of the recommended values are identical to those publishedin the previous guidelines.71 On the basis of the inclusion of new data
published in recent reports, minor changes were made in the cutoff
values for RV dimension, S0 , TAPSE, and RIMP. New publications
since the last guidelines have resulted in changes in the reference
values for 3DE-derived RV EF and volumes (Tables 8 and 10). It is
important for the reader to recognize that most of the values
proposed are not indexed to gender, BSA, or height, despite datasuggesting the advantages of indexing.72-75 As a result, it is possiblethat patients at either extreme of height or BSA may be
misclassified as having values outside the reference ranges, and it isrecommended that the interpreting physician consider theseparameters when generating the report. This potential
misclassification also applies to other groups, such as patients withcongenital heart disease and endurance athletes, for whom specificreference values are nonexistent.76

II. THE RIGHT VENTRICLE
The right ventricle has a unique crescent shape, which adds
complexity to the quantification of its size and function. This chamberplays an important role in the morbidity and mortality of patients pre-6. Essential Imaging Windows and Views
Apical four-chamber, RV-focused apical four-chamber and modified
apical four-chamber (Figure 7A), left parasternal long- andLang et al 17

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 6 Normal ranges for LV mass indices
Women

Men

LV mass (g)

67–162

88–224

LV mass/BSA (g/m2)

43–95

49–1150.22–0.42

0.24–0.42

Linear method

Relative wall thickness (cm)Septal thickness (cm)

0.6–0.9

0.6–1.0

Posterior wall thickness (cm)

0.6–0.9

0.6–1.0

2D method
LV mass (g)2

LV mass/BSA (g/m )66–150

96–200

44–88

50–102

Bold italic values: recommended and best validated.

short-axis, left parasternal RV inflow, and subcostal views provide theimages required for a comprehensive assessment of RV size, systolicand diastolic function, and RV systolic pressures.71 In most cases, in
the RV-focused view, visualization of the entire RV free wall is better
than in a standard four-chamber view, which is centered on the left
ventricle. It is therefore recommended that to measure the rightventricle, a dedicated view focused on the right ventricle be used.
Figure 7A and Table 7 show the different RV views and recommendations for measurements.
7. RV Measurements
7.1. Linear Measurements. Quantitation of RV dimensions is
critical and reduces interreader variability compared with visualassessment alone.77 Measurements by 2DE are challenging becauseof the complex geometry of the right ventricle and the lack of specific right-sided anatomic landmarks to be used as reference points.
The conventional apical four-chamber view (i.e., focused on the left
ventricle) results in considerable variability in how the right heart issectioned, and consequently, RV linear dimensions and areas mayvary widely in the same patient with relatively minor rotations intransducer position (Figure 7B). RV dimensions are best estimatedfrom a RV-focused apical four-chamber view obtained with either
lateral or medial transducer orientation (Figure 7A and Table 7).
Care should be taken to obtain the image with the LV apex at thecenter of the scanning sector, while displaying the largest basal RV
diameter and thus avoiding foreshortening. Of note, the accuracy
of RV measurements may be limited when the RV free wall is
not well defined because of the dimension of the ventricle itself
or its position behind the sternum. Recent data have suggested
that indexing RV ‘‘size’’ to BSA may be relevant in some circumstances, but the measurements used in those studies lacked thereference points of the RV-focused view and frequently used RV
areas, rather than linear dimensions.73,74 Reference values for RV
dimensions are listed in Table 8. In general, a diameter >41 mm
at the base and >35 mm at the midlevel in the RV-focused view indicates RV dilatation.
7.2. Volumetric Measurements. Three-dimensional echocardiography allows measurements of RV volumes (Figure 8), thereby
overcoming the limitations of conventional 2DE RV views withrespect to orientation and reference points. Although technically challenging, particularly in patients with imperfect image quality or

Figure 6 Comparison of RWT. Patients with normal LV mass
can have either concentric remodeling (normal LV mass withincreased RWT $ 0.42) or normal geometry (RWT # 0.42) andnormal LV mass. Patients with increased LV mass can have
either concentric (RWT $ 0.42) or eccentric (RWT # 0.42) hypertrophy. These LV mass measurements are based on linear measurements.
severely enlarged right ventricles, a reasonably accurate estimate of
RV EDV and ESV can be obtained, and RV EF can be calculated.
Practical recommendations regarding RV 3D imaging and analysis
have been recently published by the European Association of
Echocardiography and the ASE.61 During analysis of RV volume, it
is critically important to manually define end-diastolic and endsystolic frames using maximal and minimal RV volumes, respectively,
rather than LV chamber changes (Table 7). Myocardial trabeculae andthe moderator band should be included in the cavity, and RV contours on dynamic images should closely follow endocardial displacement and excursion of the tricuspid annulus throughout the cardiac
cycle.
Even though 3DE tends to underestimate RV volumes compared
CMR,78 3DE has identified relationships between RV volumes and
EF to age and gender, which are very similar to those described by
CMR.72 Overall, women have smaller 3D echocardiographic RV volumes, despite indexing to BSA, and higher EFs.75 Also, older age is associated with smaller volumes (expected decrements of 5 mL/decadefor EDV and 3 mL/decade for ESV) and higher EF (an expected
increment of 1% per decade).75 Reference values of 3DE-derived
RV volumes (indexed to BSA) and EF obtained from the metaanalyses of all studies are summarized in Tables 8 and 10. Detailsof the above-described study factoring in age, gender, and BSA
are listed in Supplemental Table 8.75 Although RV volumes by
CMR appear to be significantly influenced by race,72 no 3D echocardiographic data are yet available.
Recommendations. RV size should be routinely assessed by conventional 2DE using multiple acoustic windows, and the report
should include both qualitative 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 normal 3D echocardiographic values of RV
volumes need to be established in larger groups of subjects, current
published data suggest RV EDVs of 87 mL/m2 in men and 74 mL/m2

18 Lang et al

Journal of the American Society of Echocardiography
January 2015

Table 7 Recommendations for the echocardiographic assessment of RV size
Echocardiographic imaging

Recommended methods

Advantages

Limitations

RV linear dimensions (inflow)* Basal RV linear dimension(RVD1) = maximal transversal
dimension in the basal one
third of RV inflow at enddiastole in the RV-focusedview Mid-cavity RV linear dimension (RVD2) = transversal RV
diameter in the middle third of
RV inflow, approximately
halfway between the maximalbasal diameter and the apex,
at the level of papillary muscles at end-diastole.

 Easily obtainable Simple Fast Wealth of published data

 RV size may be underestimated due to the crescent RV
shape RV linear dimensions are
dependent on probe rotationand different RV views; in order to permit inter-study
comparison, theechocardiography report
should state the window fromwhich the measurement was
performed.

RV linear dimensions(outflow)* Proximal RV outflow diameter(RVOT prox) = linear dimension measured from theanterior RV wall to the interventricular septal-aortic
junction (in parasternal longaxis view) or to the aortic
valve (in parasternal shortaxis) at end-diastole Distal RV outflow diameter(RVOT distal) = linear transversal dimension measured
just proximal to the pulmonary valve at end-diastole Easily obtainable Simple Fast RVOT prox is dependent on
imaging plane position andless reproducible than RVOT
distal Risk of underestimation oroverestimation if the RV view
is obliquely oriented withrespect to RV outflow tract
 RV outflow dimensions canbe inaccurate in case of chestand spine deformities Endocardial definition of the
RV anterior wall is often suboptimal
 Limited normative data isavailable
 Regional measure; may notreflect global RV size (underestimation or overestimation)

RV areas (inflow)

 Manual tracing of RV endocardial border from the lateraltricuspid annulus along thefree wall to the apex and backto medial tricuspid annulus,
along the interventricular
septum at end-diastole and at
end-systole Trabeculations, papillarymuscles and moderator bandare included in the cavity area

 Relatively easy to measure Challenging in case of suboptimal image quality of RV
free wall Challenging in the presenceof trabeculation
 RV size underestimation if RV
cavity is foreshortened Due to the LV twisting motion
and the crescent RV shape,
the end-diastolic RV image
may not be in the same
tomographic plane as theend-systolic one
 May not accurately reflectglobal RV size (underestimation or overestimation)(Continued )Lang et al 19

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 7 (Continued )Echocardiographic imaging

Recommended methods

Advantages

Limitations

3DE RV volumes

 Dedicated multibeat 3D
acquisition, with minimal
depth and sector angle (for a
temporal resolution > 20–25
volumes/sec) that encompasses entire RV cavity
 Automatically identified
timing of end-diastole andend-systole should be verified Myocardial trabeculae andmoderator band should be
included in the cavity

 Unique measures of RV
global size that includes
inflow, outflow and apical regions
 Independent of geometricassumptions
 Validated against cardiac
magnetic resonance Dependent on image quality,
regular rhythm, patient cooperation
 Needs specific 3D echocardiographic equipment andtraining
 Reference values establishedin few publications

RV wall thickness

 Linear measurement of RV
free wall thickness (either by
M-mode or 2DE) performed at
end-diastole, below thetricuspid annulus at a
distance approximating thelength of anterior tricuspid
leaflet, when it is fully open
and parallel to the RV freewall.
 Trabeculae, papillary muscles
and epicardial fat should be
excluded Zoomed imaging with focus
on the RV mid-wall andrespiratory maneuvers may
improve endocardial borderdefinition

 Easy to perform Single-site measurement
 Harmonic imaging and oblique M-mode sampling may
overestimate RV wall thickness
 Challenging in case of thickening of visceral pericardium There is no criterion for
defining an abnormally thin
RV wall*All linear dimensions should be obtained using inner-edge-to-inner-edge method.

in women, and RV ESVs of 44 mL/m2 for men and 36 mL/m2 forwomen as the upper limits of the corresponding normal ranges.

associated with elevated RA pressures, which will shorten the
IVRT. RIMP > 0.43 by PW Doppler and > 0.54 by DTI indicate
RV dysfunction.

8. RV Systolic Function
RV systolic function has been evaluated using multiple parameters(Table 9), including RIMP, TAPSE, 2D FAC, 3DE EF, S0 , and longitudinal strain and strain rate by DTI and 2D STE.25 Multiple
studies have demonstrated the clinical utility and value of RIMP,TAPSE, 2D FAC, and S0 of the tricuspid annulus, as well as longitudinal speckle-tracking echocardiographic strain. RV EF by 3DE
seems to be more reliable and have better reproducibility whenproperly performed, and a growing body of data are currently
available to provide normal reference values (Table 10 and
Supplemental Table 8).

8.2. TAPSE. TAPSE is easily obtainable and represents a measure of
RV longitudinal function. It is measured by M-mode echocardiography with the cursor optimally aligned along the direction of thetricuspid lateral annulus in the apical four-chamber view (Table 9).
Although this index predominantly reflects RV longitudinal function,it has shown good correlations with parameters estimating RV global
systolic function, such as radionuclide-derived RV EF, 2D echocardiographic RV FAC, and 2D echocardiographic EF. As a one-dimensional
measurement relative to the transducer position, TAPSE may over- or
underestimate RV function because of cardiac translation.79
Although there may be minor variations in TAPSE values according
to gender and BSA, generally, TAPSE < 17 mm is highly suggestiveof RV systolic dysfunction.

8.1. RIMP. RIMP is an index of global RV performance. The isovolumic contraction time, the isovolumic relaxation time, and ejection
time intervals should be measured from the same heartbeat using
either PW spectral Doppler or DTI velocity of the lateral tricuspid
annulus (Table 9). When using PW spectral Doppler to calculate
RIMP, it important to ensure that the nonconsecutive beats have
similar RR intervals. This limitation does not apply to the DTI-based
RIMP measurements. RIMP can be falsely low in conditions

8.3. RV 2D FAC. FAC provides an estimate of global RV systolic
function. It is important to ensure that the entire right ventricle be contained in the imaging sector, including the apex and the free wall, during both systole and diastole. While tracing the RV area, care must be
taken to include the trabeculae in the RV cavity (Table 9). RV FAC< 35% indicates RV systolic dysfunction.

20 Lang et al

Journal of the American Society of Echocardiography
January 2015

Table 8 Normal values for RV chamber size
Mean 6 SD

Normal range

RV basal diameter (mm)33 6 425-41

RV mid diameter (mm)27 6 419-35

RV longitudinal diameter (mm)71 6 659-83

RVOT PLAX diameter (mm)25 6 2.5

20-30

RVOT proximal diameter (mm)28 6 3.5

21-35

RVOT distal diameter (mm)22 6 2.5

17-27

RV wall thickness (mm)

361

1-5

Parameter

RVOT EDA (cm2)Men

17 6 3.5

10-24

Women

14 6 3

8-20

RV EDA indexed to BSA (cm2/m2)
Men

8.8 6 1.9

5-12.6Women

8.0 6 1.75

4.5-11.5

RV ESA (cm2)
Men

963

3-15

Women

762

3-11

Men

4.7 6 1.35

2.0-7.4Women

4.0 6 1.2

1.6-6.4

RV ESA indexed to BSA (cm2/m2)

RV EDV indexed to BSA (mL/m2)
Men

61 6 13

35-87

Women

53 6 10.5

32-74

Men

27 6 8.5

10-44

Women

22 6 7

8-36

RV ESV indexed to BSA (mL/m2)

EDA, end-diastolic area; ESA, end-systolic area; PLAX, parasternal
long-axis view; RVOT, RV outflow tract.

8.4. DTI-Derived Tricuspid Lateral Annular Systolic
Velocity. DTI-derived S0 -wave velocity is easy to measure, reliable,
and reproducible, and it has been shown to correlate well with othermeasures of global RV systolic function. Specific age-related cutoff
values have been reported in a large sample of healthy subjects.80 It
is important to keep the basal segment and the annulus alignedwith the Doppler cursor to avoid velocity underestimation(Table 9). Similar to TAPSE, S0 is measured relative to the transducer
and may therefore be influenced by overall heart motion. An S0 velocity < 9.5 cm/sec measured on the free-wall side indicates RV systolic
dysfunction.
8.5. RV Strain and Strain Rate. Strain and strain rate are usefulparameters for estimating RV global and regional systolic function.
Longitudinal strain is calculated as the percentage of systolic shortening of the RV free wall from base to apex, while longitudinalstrain rate is the rate of this shortening. RV longitudinal strain isless confounded by overall heart motion79,81 but depends on RV
loading conditions as well as RV size and shape. RV longitudinalstrain should be measured in the RV-focused four-chamber view.
Compared with STE-derived strain, the angle dependency of DTI
strain is a disadvantage. RV speckle-tracking echocardiographic
strain is influenced by image quality, reverberation and other artifacts, as well as attenuation. Placing the basal reference points toolow (i.e., on the atrial side of the tricuspid annulus) might result in

artifactually low basal strain values. The width of the region of interest should be limited to the myocardium, excluding the pericardium, which may be difficult given the usually thin RV free wall
(Table 9).
In the context of the right ventricle, GLS is a parameter borrowed
from LV measurements, and software currently used to measure RV
GLS from most manufacturers has been designed for LV measurements and later adapted for the right ventricle. The term RV GLS usually refers to either the average of the RV free wall and the septal
segments or the RV free wall segments alone (Figure 9). Peak global
longitudinal RV strain excluding the interventricular septum has
been recently reported to have prognostic value in various diseasestates, such as heart failure,82,83 acute myocardial infarction,84 pulmonary hypertension,85,86 and amyloidosis,87 and to predict RV failure
after LV assist device implantation.88
The largest body of evidence comes from the single-center studies
cited above, which involved predominantly imaging equipment andsoftware from two vendors, where pooled data were derived fromlimited number of subjects. Current reference values for global RV
free wall speckle-tracking echocardiographic strain are reported inTable 10. Pooled data (though heavily weighted by a single vendor)
suggest that global longitudinal RV free wall strain > 20% (i.e.,<20% in absolute value) is likely abnormal.
Recommendations. Two-dimensional STE-derived strain, particularly of the RV free wall, appears to be reproducible and feasible forclinical use. Because of the need for additional normative data fromlarge studies involving multivendor equipment, no definite reference
ranges are currently recommended for either global or regional RV
strain or strain rate.
8.6. RV 3D EF. Three-dimensional echocardiographic RV EF is a
global measure of RV systolic performance. Although RV EF does
not directly reflect RV contractile function per se, it provides an integrated view of the interaction between RV contractility and load. RV
EF can be of particular clinical value in patients after cardiac surgery(in the absence of marked septal shift), when conventional indicesof longitudinal RV function (i.e., TAPSE, S0 wave) are generally
reduced and no longer representative of overall RV performance.81,89,90 Three-dimensional echocardiography has been extensively validated against CMR,78,91 and the volumetric semiautomatedborder detection approach is the recommended method for theassessment of RV EF.
The limitations of 3D assessment of RV EF are load dependency,
interventricular changes affecting septal motion, poor acoustic windows, and irregular rhythms. As described above in the section on
RV volume, the RV EF is slightly higher in women than in men,because of smaller volumes, and it is recommended to refer togender-specific values (Supplemental Table 8).
Recommendation. In laboratories with appropriate 3D platforms
and experience, 3DE-derived RV EF should be considered as amethod of quantifying RV systolic function, with the limitations
mentioned above. Roughly, an RV EF of <45% usually reflectsabnormal RV systolic function, though laboratories may choose torefer to age- and gender-specific values.

III. THE LEFT AND RIGHT ATRIAThe left atrium fulfills three major physiologic roles that influence LV
filling and performance. The left atrium acts as a (1) contractile pumpLang et al 21

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 9 Recommendations for the echocardiographic assessment of RV function
Echocardiographic imaging

RV global function
Pulsed Doppler RIMP

Tissue Doppler RIMP

RV global systolic function
FAC

EF

Recommended methods

Advantages

Limitations

RIMP (Tei index) by pulsed
Doppler:
RIMP = (TCO  ET)/ET Prognostic value
 Less affected by heart rate Requires matching for R-R
intervals when measurements are performed on
separate recordings
 Unreliable when RA pressure is elevated Less affected by heart rate
 Single-beat recording withno need for R-R interval
matching

 Unreliable when RA pressure is elevated

RIMP by tissue Doppler:
RIMP = (IVRT + IVCT)/ET =(TCO  ET)/ET

RV FAC in RV-focused
 Established prognostic
apical four-chamber view:
value
RV FAC (%) = 100  (EDA   Reflects both longitudinal
ESA)/EDA
and radial components of
RV contraction
 Correlates with RV EF by
CMR

Fractional RV volume
change by 3D TTE:
RV EF (%) = 100  (EDV 
ESV)/EDV

 Includes RV outflow tract
contribution to overall function
 Correlates with RV EF by
CMR Neglects the contribution of
RV outflow tract to overallsystolic function
 Only fair inter-observer
reproducibility Dependent on adequate
image quality
 Load dependency
 Requires offline analysis andexperience Prognostic value not established(Continued )22 Lang et al

Journal of the American Society of Echocardiography
January 2015

Table 9 (Continued )Echocardiographic imaging

RV longitudinal systolic function
TAPSE

Pulsed tissue Doppler S wave

Recommended methods

Advantages

Limitations

 Tricuspid annular longitudi-  Established prognostic
nal excursion by M-mode
value(mm), measured between
 Validated against radionuend-diastole and peak sysclide EF
tole
 Proper alignment of Mmode cursor with the direction of RV longitudinal
excursion should beachieved from the apicalapproach.

 Angle dependency
 Partially representative of
RV global function*

 Peak systolic velocity of
tricuspid annulus by pulsedwave DTI (cm/sec), obtained
from the apical approach, inthe view that achieves parallel alignment of Doppler
beam with RV free wall longitudinal excursion

 Easy to perform Reproducible
 Validated against radionuclide EF Established prognosticvalue Angle dependent Not fully representative of
RV global function, particularly after thoracotomy,
pulmonary thromboendarterectomy or hearttransplantation

 Peak systolic velocity of
tricuspid annulus by color
DTI (cm/sec) Sampling is performed after  Angle dependent Not fully representative ofimage acquisition
RV global function, particu Allows multisite sampling on
larly after thoracotomy,
the same beatpulmonary thrombendarterectomy or hearttransplantation
 Lower absolute values andreference ranges thanpulsed DTI S0 wave
 Requires offline analysis

Color tissue Doppler S wave

GLS

 Peak value of 2D longitudi-  Angle independent
nal speckle tracking derived  Established prognostic
strain, averaged over thevaluethree segments of the RV
free wall in RV-focused apical four-chamber view (%)

 Vendor dependent

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.

Lang et al 23

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 10 Normal values for parameters of RV function
Parameter

TAPSE (mm)Mean 6 SD

Abnormality threshold

24 6 3.5<17

Pulsed Doppler S wave (cm/sec)

14.1 6 2.3<9.5

Color Doppler S wave (cm/sec)

9.7 6 1.85

<6.0

RV fractional area change (%)
RV free wall 2D strain* (%)
RV 3D EF (%)

49 6 7
29 6 4.5<35
>20 (<20 in magnitude with thenegative sign)

58 6 6.5<45

Pulsed Doppler MPI

0.26 6 0.085>0.43

Tissue Doppler MPI

0.38 6 0.08

>0.54

E wave deceleration time (msec)

180 6 31<119 or >242

E/A

1.4 6 0.3

<0.8 or >2.0

e0 /a01.18 6 0.33

<0.52

e0

14.0 6 3.1

<7.8

E/e0

4.0 6 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.

24 Lang et al

Journal of the American Society of Echocardiography
January 2015

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

Figure 9 Measurement of RV systolic strain by 2D STE. The upper panel demonstrates RV ‘‘global’’ free wall strain whereby the threesegments of the free wall are averaged, and the lower panel demonstrates ‘‘global’’ longitudinal strain of the six segments of the apicalfour-chamber view: three free wall and three septal segments. Note that RV longitudinal strain is significantly higher (as an absolutevalue) 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.
that delivers 15% to 30% of the entire LV filling, (2) reservoir that collects pulmonary venous return during ventricular systole, and (3)conduit for the passage of stored blood from the left atrium to theleft ventricle during early ventricular diastole.92,93 An enlarged left
atrium is associated with adverse cardiovascular outcomes.94-99 In
the absence of mitral valve disease, an increase in LA size mostcommonly reflects increased wall tension as a result of increased
LA pressure,100-103 as well as impairment in LA function secondary
to an atrial myopathy.104,105 A clear relationship exists between
an enlarged left atrium and the incidence of atrial fibrillationand stroke,92,106-115 risk for overall mortality after myocardial

infarction,104,105,116,117 risk for death and hospitalization in patientswith dilated cardiomyopathy,118-122 and major cardiac events ordeath in patients with diabetes mellitus.123 LA enlargement is amarker of both the severity and chronicity of diastolic dysfunction
and magnitude of LA pressure elevation.98,100-103

9. LA Measurements
9.1. General Considerations for LA Size. TTE is the recommended approach for assessing LA size. Recommendations for LA

Journal of the American Society of Echocardiography
Volume 28 Number 1

quantification are summarized in Table 11. With TEE, the entire left
atrium frequently cannot be fit in the image sector. Accordingly,
TEE should not be used to assess LA size. LA size should be measured
at the end of LV systole, when the LA chamber is at its greatest dimension. While acquiring images to measure LA size and volumes, careshould be taken to avoid foreshortening of the left atrium. Because
the longitudinal axes of the left ventricle and left atrium frequently
lie in different planes, dedicated acquisitions of the left atrium fromthe apical approach should be obtained for optimal LA volume measurements. The base of the left atrium should be at its largest size, indicating that the imaging plane passes through the maximal short-axisarea. LA length should also be maximized to ensure alignment along
the true long axis of the left atrium. When using the biplane disk summation method to calculate LA volumes, the lengths of the long axes
measured in the two- and four-chamber views should be similar.
When tracing the borders of the left atrium, the confluences of thepulmonary veins and the LA appendage should be excluded. The
atrioventricular interface should be represented by the mitral annulus
plane, not by the tip of the mitral leaflets.
9.2. Linear Dimensions and Area Measurements. The mostwidely used linear dimension is the LA anteroposterior (AP) measurement in the parasternal long-axis view using M-mode echocardiography or, preferably, 2DE.92,107,109,110,114,118,120,121,124,125 Although thismeasurement has been used extensively in clinical practice andresearch, it has become clear that frequently it may not represent an
accurate picture of LA size.126,127 Traditionally, the AP dimension
was widely used because it was known to be the most reproducible
measurement. However, assessment of LA size using only the APdiameter assumes that when the left atrium enlarges, all its
dimensions change similarly, which is often not the case during LA
remodeling.128-130 Therefore, AP linear dimension should not be
used as the sole measure of LA size. LA area can be planimetered in
the apical four- and two-chamber views and normal values for theseparameters have been reported.12 Optimal contours should be obtained orthogonally around the long axis of the left atrium fromgood quality images while avoiding foreshortening.1 The ease withwhich LA volumes can be obtained in clinical practice in conjunction
with the existing robust literature on normal values and the prognostic
value of LA volumes renders reporting of LA area unnecessary.
9.3. Volume Measurements. When assessing the LA size and remodeling, the measurement of LA volume is recommended.
Evaluation of volume takes into account alterations in LA chamber
size in all directions. LA volume has been shown to be a powerfulprognostic variable in a variety of cardiac diseasestates.99,106,112,113,115-117,122,131-136 Compared with AP diameter, LA
volume has a stronger association with outcomes in cardiac
patients.113,137 Two-dimensional echocardiographic LA volumes are
typically smaller than those reported from computed tomography
or CMR.138-142 Measurements of LA volumes are important,because they reflect the burden and chronicity of elevated LV fillingpressures and are a strong predictor of outcomes.
Different methods exist for measuring LA volumes. Although thethree linear measurements have been used to calculate LA volume using an ellipsoid model,131,137,143 the relative inaccuracy of these linear
measurements limits this method. LA volume should be measured
using the disk summation algorithm, similar to that used to measure
LV volume (Table 11).144,145
The LA endocardial borders should be traced in both the apicalfour- and two-chamber views. A single-plane approach can also beLang et al 25

used, but this method is based on the geometric assumption thatthe left atrium is circular in the short-axis cut plane, which may not
be always accurate.146 Although not recommended for routine use,
this approach could be used in cases when planimetry in both views
is difficult. Single-plane apical four-chamber indexed LA volumes are
typically 1 to 2 mL/m2 smaller than apical two-chamber volumes.12,146
Alternatively, a biplane calculation could also be performed using
the LA areas and lengths measured from both the apical four- andtwo-chamber views (Table 11). Although the area-length method stillassumes an ellipsoidal LA shape, it has the advantage of reducing
linear dimensions to only two measurements of atrial length, of which
the shorter one is selected.98,147
9.4. Normal Values of LA Measurements. Since the publicationof the 2005 chamber quantification guidelines, two articles have reported normal values for LA linear measurements.12,143 These
values were in keeping with prior recommendations, andaccordingly, no modifications have been made to the normal valuesof LA AP diameters (Supplemental Table 9). Although not recommended for routine clinical use, normal values for apical four- andtwo-chamber linear measurements and nonindexed LA area and volume measurements have been reported.12
LA size is dependent on gender. However the gender differences in
LA size are generally accounted for when adjusting for body size.12
Several indexing methods have been proposed,137,148 but indexing
to BSA has yielded the most available data and is recommended by
the writing group. Indexing by BSA accounts for the genderdifferences in LA size, such that only the indexed value should bereported.93,137,149,150
In the prior chamber quantification guideline document, the reported BSA-indexed LA volume normal values were based on two
studies performed in a small number of subjects.98,144 Since thepublication of that document, eight additional studies (1,234
patients) describing normal values of LA volumes using the arealength ellipsoid or the disk summation techniques have beenreported.11,12,145,147,151-155 This has resulted in a change in therecommended upper normal indexed LA volume to 34 mL/m2(previously 28 mL/m2). In addition, LA volume data became
available in 1,331 patients from the five databases described earlier
in this document, wherein the mean calculated LA volume was
25 mL/m2. This upper normal revised value of 34 mL/m2 also
seems to fit in well 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 also consistent with the ASE and European
Association of Echocardiography guideline document on evaluationof diastolic function.156 The 2DE-derived biplane LA volumes arelisted in Table 4, including normal ranges and severity partition cutoffs.
Of note, LA volume can be increased in elite athletes, which needs tobe taken into account to avoid misinterpretation as abnormal.146
Three-dimensional echocardiography holds promise for assessing
LA volume and correlates with cardiac computed tomography157,158 and magnetic resonance imaging.159,160 Compared with
2D assessment of LA volume, 3DE is more accurate comparedwith CMR159,160 and has superior prognostic ability.161,162 Threedimensional echocardiographic LA volumes are typically larger
than 2D echocardiographic volumes in most studies.160,163
Despite these advantages, the lack of a standardized methodology
and limited normative data164 prevent this committee from recommending the use of 3D echocardiographic normal values at thistime.

26 Lang et al

Journal of the American Society of Echocardiography
January 2015

Table 11 Recommendations for the echocardiographic assessment of LA size
Parameter and method

Internal linear
dimensions.
The anteroposterior
diameter of the left atrium
can be measured in theparasternal long-axis view
perpendicular to the aortic
root long axis, andmeasured at the level of theaortic sinuses by using theleading-edge to leadingedge convention.

Area.
Measured in four-chamber
apical view, at end-systole,on the frame just prior to
mitral valve opening bytracing the LA inner border,
excluding the area underthe mitral valve annulus
and the inlet of thepulmonary veins.

Echocardiographic imaging

Advantages

Limitations

M-mode tracing Reproducible
 High temporal resolution
 Wealth of published data

Single dimension not representative of actual LA
size (particularly in dilated
atria)

2D-guided linear measurements

 Facilitates orientation
perpendicular to LA
posterior wall

 Lower frame rates than in
M-mode Single dimension only

2D images

 More representative of
actual LA size than anteroposterior diameter only

 Need for a dedicatedview to avoid LA foreshortening Assumes a symmetricshape of the atrium(Continued )Lang et al 27

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 11 (Continued )Parameter and method

Volume.
2D volumetricmeasurements are basedon tracings of the bloodtissue interface on apicalfour- and two-chamber
views. At the mitral valve
level, the contour is closed
by connecting the two
opposite sections of themitral annulus with astraight line. Endocardial
tracing should exclude
atrial appendage andpulmonary veins. LA length
L is defined as the shortestof the two long axes
measured in the apicaltwo- and four-chamber
views (to provide reliablecalculations the twolengths should not differ
more than 5 mm). Volumes
can be computed by using
the area-length
approximation:
Echocardiographic imaging

2DE
Area-length technique

Advantages

Limitations

 Enables accurate
assessment of theasymmetric remodelingof the left atrium
 More robust predictor of
cardiovascular events
than linear or area measurements

 Geometric assumptions
about LA shape Few accumulated dataon normal population
 Single plane volume calculations are inaccurate
since they are based on
the assumption that A1 =A2 No geometrical assumption about LA shape More accurate whencompared to 2D measurements Dependent on adequate
image quality
 Lower temporal resolution
 Limited data on normal
values Patient’s cooperation
required

Biplane method of disks

8 ðA1 $A2 ÞL
3pwhere A1 and A2 are thecorresponding LA areas.
Alternatively LA volume
can be calculated using thedisk summation techniqueby adding the volume of a
stack of cylinders of heighth and area calculated byorthogonal minor andmajor transverse axes (D1and D2) assuming an oval
shape: P
p=4ðhÞ ðD1ÞðD2Þ
3D data sets are usuallyobtained from the apicalapproach using a multibeat
full-volume acquisition
3D data sets

28 Lang et al

Recommendations. Because it is theoretically more accurate than
the area-length method, the biplane disk summation technique,which incorporates fewer geometric assumptions, should be thepreferred method to measure LA volume in clinical practice. The upper normal limit for 2D echocardiographic LA volume is 34 mL/m2
for both genders.
10. Right Atrial measurements
Less research and fewer clinical outcomes data are available on thequantification of RA size. Although the right atrium can be assessedfrom different views, quantification of RA size is most commonly performed from the apical four-chamber view (Table 12). The minor-axis
dimension should be taken from a plane perpendicular to the longaxis of the right atrium, extending from the lateral border of the rightatrium to the interatrial septum. In contrast to the left atrium, RA size
appears to be gender dependent, but prior ASE guidelines did nothave sufficient data to provide normative data by gender.1,71
Recent data obtained from three cohorts of >2,400 patients now
provide normal values of RA dimensions for men andwomen.12,73,165
As with the left atrium, RA volumes are likely to be more robust
and accurate for determination of RA size compared with linear dimensions. At the time of the prior guideline document, limited data
were available for the determination of normative RA volumes.
Because there are no standard orthogonal RA views to use for anapical biplane calculation, a single-view area-length and/or disksummation techniques has been proposed for RA volume
determination.150,153,165-167 Of note, normal RA volumes for men
are slightly larger than those for women, with indexing to BSA
failing to equalize values between genders for reasons that are notfully understood.150,165 Recommendations for RA volume
normative data are made from the two largest most contemporary
data sets12,165 (Table 13). RA volumes are underestimated with 2D
echocardiographic techniques compared with 3DE.164,165,168 RA
volumes in adult subjects appear to be smaller than LAvolumes.12,150,153,165 This is because the RA volumes were obtainedusing a single-plane method of disks, in contrast to the LA volumes,
which were established using the biplane technique.
Recommendations. The recommended parameter to assess RA
size is RA volume, calculated using single-plane area-length or disksummation techniques in a dedicated apical four-chamber view.
The normal ranges for 2D echocardiographic RA volume are
25 6 7 mL/m2 in men and 21 6 6 mL/m2 in women.

IV. THE AORTIC ANNULUS AND AORTIC ROOT
Detailed knowledge and quantification of the aortic root and aortic
valve morphology has become even more crucial with the increasinguse of transcatheter aortic valve implantation (TAVI) and transcatheter aortic valve replacement (TAVR) procedures. This knowledge iscritically important for preprocedural planning, intraprocedural guidance, and postprocedural assessment.
The aortic root extends from the basal attachments of the aortic
valve leaflets within the LV outflow tract to their distal attachment
at the tubular portion of the aorta (the sinotubular junction).169 The
aortic root is a geometrically complex structure that includes (1) the
aortic valve annulus, (2) the interleaflet triangles, (3) the semilunar

Journal of the American Society of Echocardiography
January 2015aortic leaflets and their attachments, (4) the aortic sinuses of
Valsalva, and (5) the sinotubular junction.170-172 Aortic
measurements should be made at the following sites: (1) the aortic
valve annulus, (2) the maximal diameter of the sinuses of Valsalva,(3) the sinotubular junction (usually a demarcated transition
between the sinuses of Valsalva and the tubular portion of theascending aorta), and (4) the maximal diameter of the proximal
ascending aorta, including a notation of the distance between themeasurement site and the sinotubular junction (Figure 10A).
11. The Aortic Annulus
The ‘‘aortic annulus’’ is not a true or distinct anatomic structure but is avirtual ring that may be defined by joining the basal attachments, ornadirs, of the three aortic leaflets. The distal (uppermost) attachmentsof the leaflets, in the shape of a crown, form a true anatomic
ring169,173 (Figure 10B). Approximately two-thirds of the circumference of the lower part of the aortic root is attached to the muscularinterventricular septum, while the remaining one-third is in fibrouscontinuity with the anterior mitral valve leaflet.174 Measurement of
the aortic valve annulus before TAVI or TAVR is a challenge, andthe ideal modality for its measurement has yet to be established.
During the initial TAVI and TAVR experience, aortic annular measurements were routinely performed using 2DE.174,175 Although thestandard approach during the early years of TAVI and TAVR was
echocardiography using a one-dimensional measurement, thismethod has clear limitations for TAVI and TAVR valve sizing. At present, the two most commonly used imaging techniques used formeasuring the aortic annulus before TAVI or TAVR are echocardiography and multidetector computed tomography (MDCT).
With echocardiography, measurements of the aortic annulus
should be made in the zoom mode using standard electronic calipers
in midsystole, when the annulus is slightly larger and rounder than indiastole, between the hinge points of the aortic valve leaflets (usually
between the hinge point of the right coronary cusp and the edge ofthe sinus at the side of the commissures between the left coronary
cusp and the noncoronary cusp) from inner edge to inner edge. Allother aortic measurements should be made at end-diastole, in astrictly perpendicular plane to that of the long axis of the aorta.
Aortic annular measurements may be difficult in patients with acoustic blooming caused by a calcified aortic annulus.176-179 As a generalrule, calcium protuberances should be considered as part of thelumen, not of the aortic wall, and therefore excluded from thediameter measurement.
The anteroposterior diameter is commonly measured by both 2D
TTE (from the parasternal long-axis view) and 3D TEE (from the longitudinal view of the proximal aortic root, usually 110 –130 ) and approximates the minor dimension of the annulus measured by
MDCT.3,176,180 However, because the annulus is often elliptical,
with variable diameters, it is preferable to measure the annulus in across-sectional view, using 3D imaging, as recommended by theEuropean Association of Echocardiography and ASE guidelines181;
the American College of Cardiology Foundation, American
Association for Thoracic Surgery, Society for Cardiac Angiography
and Interventions, and Society of Thoracic Surgeons consensus document on TAVR182; the Society of Cardiovascular Computed
Tomography expert consensus document on MDCT183; andothers.184-187 Using 3D TEE, both the smaller (anteroposterior,sagittal) and larger (medial-lateral, coronal) diameters, as well as theperimeter and annular area, should be measured in a cross-sectional

Lang et al 29

Journal of the American Society of Echocardiography
Volume 28 Number 1

Table 12 Recommendations for the echocardiographic assessment of RA size
Parameter and method

Echocardiographic imaging

Linear dimensions.
The minor axis of the right atrium
should be measured in the apicalfour-chamber view as the
distance between the lateral RA
wall and interatrial septum, at the
midatrial level defined by half of
RA long axis

2D-guided linear measurements

 Easy to obtain Established normal values Single dimension only Assumes that RA enlargement
is symmetrical View dependent

Area.
Measured in the apical fourchamber view at end-systole, on
the frame just prior to tricuspid
valve opening, by tracing the RA
blood-tissue interface, excluding
the area under the tricuspid valve
annulus.

2D view

 More representative of actual
RA size than linear dimensions
 Established normal values Need of a dedicated view to
avoid RA foreshortening Assumes a symmetrical shapeof the cavity
 View dependent

Volume.
2D volumetric measurements areusually based on tracings of theblood-tissue interface on theapical four-chamber view. At thetricuspid valve level, the contour isclosed by connecting the two
opposite sections of the tricuspid
ring with a straight line. Volumes
can be computed by using either
the single plane area-length:" #2D view

 More representative of actual
RA size than linear dimensions

 Assumes a symmetrical shapeof the cavity
 Single plane volume calculation
may be inaccurate since it assumes that RA enlargement issymmetrical Normal values not well established

3D data sets

 No geometrical assumption
 Established normal values

 Dependent on image quality
 Lower temporal resolution
 Patient’s cooperation required

83pAdvantages

Limitations

ðAÞ2
Lor the disks summation technique.
3D data sets are usually obtained
from the apical approach using afull-volume acquisition

30 Lang et alview in midsystole (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 referred to four recent publications.184-187 By using thesetechniques, 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 thesemethods 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. Threedimensional TEE also has limitations. First, the software required
to use the methodology 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 the level of the annulus may hinder the ability todetermine boundary definition and may make its shape irregular.
Third, the plane formed by the nadirs of the three cusps is often
not orthogonal to the LV outflow tract or aortic root; frequently
the insertion of the right coronary cusp is inferior to that of theleft and noncoronary cusps.183 Fourth, both the spatial and temporal
resolution of 3D echocardiography is currently limited. Last, thistechnique is operator dependent and may be difficult at times,
even in experienced hands.173,174 Because of these potential
limitations, it is desirable to use a multimodality approach foraortic annular measurement.

Journal of the American Society of Echocardiography
January 2015

Table 13 Normal RA size obtained from 2D
echocardiographic studies
Women

Men

2

RA minor axis dimension (cm/m )1.9 6 0.3

1.9 6 0.3

RA major axis dimension (cm/m2)

2.5 6 0.3

2.4 6 0.3

2D echocardiographic RA volume (mL/m2)

21 6 625 6 7

Data are expressed as mean 6 SD.

12. The Aortic RootWith 2D TTE, the diameter of the aortic root (at the maximal diameter of the sinuses of Valsalva) should be obtained from the parasternal long-axis view, which depicts the aortic root and the proximal
ascending aorta. This plane is slightly different from that of the longaxis of the left ventricle (Figure 10A). Acquisition of this LV longaxis view may be performed from different intercostal spaces andat various distances from the left sternal border. Use of simultaneous
biplane orthogonal images provided by matrix transducers may be
helpful. The tubular ascending aorta is often not adequately visualized
from a standard parasternal window. In these instances, moving thetransducer closer to the sternum may allow visualization of a longer
portion of the ascending aorta. In addition, the ascending aorta may
sometimes be well visualized from right parasternal windows in thesecond or third intercostal space, especially when the aorta is dilated.
Measurements should be made in the view that depicts the
maximum aortic diameter perpendicular to the long axis of the aorta.
In patients with tricuspid aortic valves, the closure line of the leaflets(typically the right coronary cusp and the noncoronary cusp) is in thecenter of the aortic root lumen, and the closed leaflets are seen on theaortic side of a line connecting the hinge points of the two visualized
leaflets. An asymmetric closure line, in which the tips of the closed
leaflets are closer to one of the hinge points, is an indication thatthe cross-section is not encompassing the largest root diameter(Figure 12).
Unfortunately, there is no uniform method of measurement of theaortic root and aorta. Echocardiography uses the leading edge–to–
leading edge (L-L) convention, but other techniques, such as
MDCT and CMR, use the inner edge–to–inner edge (I-I) or outeredge–to–outer edge convention. In the consensus document,194
the ASE and EACVI writing committee took the initiative to provide

Figure 10 (A) Sites for measurements of the aortic root andascending aorta. This diagram illustrates the four sites at whichmeasurements are recommended (light blue arrows): (1) the aortic
valve annulus (hinge point of aortic leaflets), (2) the sinuses of
Valsalva (maximal diameter, usually the midpoint), (3) the sinotubular junction, and (4) the proximal ascending aorta (the distance
between the measurement site and the annular plane [purple arrowheads] should always be reported). The aortic annulus shouldbe measured at peak systole, in contrast to the other dimensions,which are measured at end-diastole. The dashed lines, depicting
the longitudinal axis of the left ventricle (LV) and that of the aortic
root and proximal ascending aorta, are different. Note that theangle between these two axes varies from individual to individual
and with age and pathology. (B) Normal anatomy of the aortic
annulus. The aortic annulus accounts for the tightest part of theaortic root and is defined as a virtual ring (shaded) with three
anatomic anchor points at the nadir of each of the attachmentsof the three aortic leaflets. Reproduced with permission from
Kasel et al.184 Ao, Aorta; LA, left atrium.

a common standard for measurement of the aortic root and aorta byrecommending a switch to the I-I convention for echocardiography.
However, this goal of achieving uniformity among modalities was ultimately abandoned for several reasons. First, currently used longstanding reference values for the aorta were obtained using the L-L
convention.195,196 Second, the L-L convention provides statisticallyJournal of the American Society of Echocardiography
Volume 28 Number 1

Lang et al 31

Figure 11 The smaller (antero-posterior, sagittal) aortic root diameter is measured using CT (A) or 3D TEE (C, zoomed cross sectionalview) 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 pointof 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 multiplanarreconstruction. 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.

Figure 12 Correct (A) and incorrect (B, C) measurements of the aortic annulus (double arrows). (A) Centrally positioned diameter andcentral closure of leaflets. Thin lines correspond to the long axis of the ascending aorta and, orthogonally, to correct orientation of theannular diameter. (B) Incorrect, eccentric annular measurement. The hinge points are slightly displaced upward and do not correspond to the nadir of the cusp attachments, 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 theplane of the virtual annulus is approximately perpendicular to the long-axis of the aorta. When bisecting the maximum dimensionof the annulus in the sagittal plane, one will image the right coronary cusp anteriorly and the fibrous trigone between the left andnoncoronary 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.
larger diameters than the I-I convention (by 2–4 mm), and switching
to the I-I convention raised a concern that patients at potential risk fordeveloping life-threatening complications such as aortic dissection
and/or rupture would fall below a threshold for intervention recommendation by current guidelines. Accordingly, the aortic annulus
should be measured using the I-I convention, but we continue torecommend the L-L convention for measurements of the aortic
root and aorta.
Two-dimensional echocardiographic aortic diameter measurements are preferable to M-mode measurements, because cardiac motion may result in changes in the position of the M-mode cursor
relative to the maximum diameter of the sinuses of Valsalva. This

32 Lang et al

Journal of the American Society of Echocardiography
January 2015

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
Table 14 Aortic root dimensions in normal adults
Indexed values (cm/m2)

Absolute values (cm)Aortic Root

Men

Women

Men

Women

Annulus2.6 6 0.3

2.3 6 0.2

1.3 6 0.1

1.3 6 0.1

Sinuses of Valsalva

3.4 6 0.3

3.0 6 0.3

1.7 6 0.2

1.8 6 0.2

Sinotubular junction

2.9 6 0.3

2.6 6 0.3

1.5 6 0.2

1.5 6 0.2

Proximal ascending aorta

3.0 6 0.4

2.7 6 0.4

1.5 6 0.2

1.6 6 0.3

Adapted from Roman et al.195 and Hiratzka et al.204

translational motion may result in systematic underestimation (byapproximately 2 mm) of the aortic diameter by M-mode imaging incomparison with 2D echocardiographic measurements.195 The
thoracic aorta can be better imaged using TEE compared with the
TTE approach, because that aortic segment is in the near field of
the transesophageal echocardiographic transducer. The aortic root
and ascending aorta can be best seen in the midesophageal aortic
valve long-axis view (three-chamber view at about 120 –140 ).3
The short-axis view of the ascending aorta is best obtained using
the midesophageal views at about 45 . For measurements of the descending aorta, short-axis views at about 0 and long-axis views at
about 90 should be obtained from the level of the diaphragm up
to the aortic arch. The biplane imaging function on current 3D echocardiographic imaging systems allows simultaneous visualization ofboth short- and long-axis views.
13. Identification of Aortic Root Dilatation
Aortic root dilatation is associated with the presence and progressionof aortic regurgitation197 and with the occurrence of aortic dissection.
The presence of hypertension appears to have minimal impact onaortic root diameter at the level of the sinuses of Valsalva level197
but is associated with enlargement of more distal aortic segments.
Aortic root diameter measurements at the level of the sinuses of
Valsalva is closely related to BSA and age. Therefore, BSA may be
used to predict aortic root diameter in three age strata, <20, 20 to40, and >40 years, by using published equations.195 Aortic root dilatation at the sinuses of Valsalva is defined as an aortic root diameter
above the upper limit of the 95% confidence interval of the distribu-

tion in a large reference population. Aortic dilatation can be easily detected by plotting observed aortic root diameter versus BSA on
previously published nomograms (Figure 13).195 Equations to determine the expected aortic diameter at the sinuses of Valsalva in relation
to BSA for each of the three age strata are also shown in Table 14 andFigure 13. The aortic root index or ratio of observed to expected
aortic root diameters can be calculated by dividing the observed by
the expected diameter.
Recommendations. The aortic annulus should be measured at
midsystole from inner edge to inner edge. All other aortic root measurements (i.e., maximal diameter of the sinuses of Valsalva, the sinotubular junction, and the proximal ascending aorta) should be madeat end-diastole, in a strictly perpendicular plane to that of the long axisof the aorta using the L-L convention. Measurements of maximal
diameter of the aortic root at the sinuses of Valsalva should becompared with age- and BSA-related nomograms or to values calculated from specific allometric equations. Accurate measurement of
the aortic annulus before TAVI or TAVR is crucial. To date, there isno established gold-standard technique for measuring the aortic
annulus before TAVI or TAVR. Three-dimensional TEE and MDCT
are emerging as reliable and possibly preferred methods for aortic
annulus measurements.

V. THE INFERIOR VENA CAVA
Examination of the IVC from the subcostal view should be included
as part of the routine transthoracic echocardiographic examination. ItJournal of the American Society of Echocardiography
Volume 28 Number 1

is generally agreed that the diameter of the IVC should be measured
in the subcostal view with the patient in the supine position at 1.0 to
2.0 cm from the junction with the right atrium, using the long-axis
view. For accuracy, this measurement should be made perpendicular
to the IVC long axis. The diameter of the IVC decreases in response toinspiration when the negative intrathoracic pressure leads to anincrease in RV filling from the systemic veins. The diameter of the
IVC and the percentage decrease in the diameter during inspiration
correlate with RA pressure. The relationship may be quantified as
the collapsibility index.198 Evaluation of the inspiratory response
often requires a brief sniff, as normal inspiration may not elicit this
response.
For simplicity and uniformity of reporting, specific values of RA
pressure, rather than ranges, should be used in the determination ofsystolic pulmonary artery pressure. IVC diameter < 2.1 cm that collapses >50% with a sniff suggests normal RA pressure of 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 15 mm Hg(range, 10–20 mm Hg).199 In scenarios in which IVC diameter andcollapse do not fit this paradigm, an intermediate value of 8 mm
Hg (range, 5–10 mm Hg) may be used, or, preferably, other indicesof RA pressure should be integrated to downgrade or upgrade to
the normal or high values of RA pressure. It should be noted that innormal young athletes, the IVC may be dilated in the presence of
normal pressure.200,201 In addition, the IVC is commonly dilated
and may not collapse in patients on ventilators, so it should not beroutinely used in such cases to estimate RA pressure.202 However,
IVC diameter measured on TEE at the cavoatrial junction has beensuccessfully used to derive central venous pressure in anesthetizedmechanically ventilated patients.203 The use of the IVC size and dynamics is encouraged for estimation of RA pressure. This estimate
should be used in estimation of the pulmonary artery pressure on
the basis of the tricuspid regurgitant jet velocity, rather than assuming
a constant RA pressure for all patients.

NOTICE AND DISCLAIMER
This report is made available by the ASE and EACVI as a courtesy
reference source for members. This report contains recommendations only and should not be used as the sole basis to make medical
practice decisions or for disciplinary action against any employee.
The statements and recommendations contained in this report are
based primarily on the opinions of experts, rather than on scientifically verified data. The ASE and EACVI make no express or implied
warranties regarding the completeness or accuracy of the informationin this report, including the warranty of merchantability or fitness for aparticular purpose. In no event shall the ASE and EACVI be liable toyou, your patients, or any other third parties for any decision made or
action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of
medical advice by the ASE and EACVI or create any physician-patient
relationship between the ASE and EACVI and your patients oranyone else.

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39.e1 Lang et al

APPENDIX
Methods
When possible, data on systolic blood pressure, diastolic blood pressure, diagnosis of hypertension, treatment of hypertension, diagnosis
of diabetes, fasting glucose levels, creatinine levels, total cholesterollevel, low-density lipoprotein cholesterol levels, and triglyceride levels
were obtained. BSA was calculated using the Mosteller formula.205
Body mass index was calculated by dividing the weight in kilogramsby the height in meters squared.
Echocardiographic Measurements
Transthoracic echocardiographic measurements were performed foreach of the studies as per available published guidelines.1 Values forthe following measurements were provided from the following 2D

Journal of the American Society of Echocardiography
January 2015transthoracic echocardiographic views: LV end-diastolic diameterand LV end-systolic diameter from the parasternal long-axis view;
LV EDV, LV ESV, and LV EF from the apical four- and twochamber views; and LV EDV, LV ESV, LV stroke volume, and LV
EF from the biplane view.

Statistical Analysis
All studied parameters were found to satisfy a normal distribution using the Kolmogorov-Smirnov test, and summary data for these variables are expressed as mean 6 SD. Multivariate analysis was used
to determine the dependence of the measured parameters on age,gender, and BSA. Simple univariate linear regression against age
was then used to construct the presented nomograms normalized
for BSA and divided by gender as mean and 95% confidence intervals. P values < .05 were considered significant.

Journal of the American Society of Echocardiography
Volume 28 Number 1

Lang et al 39.e2

Supplemental Figure 1 For men (left column) and women (right column), the 95% confidence intervals for apical four-chamber view
(top row), apical two-chamber view (middle row) and the biplane (bottom row) LV EDV on the basis of age.

39.e3 Lang et al

Journal of the American Society of Echocardiography
January 2015

Supplemental Figure 2 For men (left column) and women (right column), the 95% confidence intervals for apical four-chamber view
(top row), apical two-chamber view (middle row), and the biplane (bottom row) LV ESVs on the basis of age.

Journal of the American Society of Echocardiography
Volume 28 Number 1

Lang et al 39.e4

Supplemental Figure 3 For men (left column) and women (right column), the 95% confidence intervals for apical four-chamber view
(top row), apical two-chamber view (middle row), and the biplane (bottom row) LV EDVs on the basis of BSA.

39.e5 Lang et al

Journal of the American Society of Echocardiography
January 2015

Supplemental Figure 4 For men (left column) and women (right column), the 95% confidence intervals for apical four-chamber view
(top row), apical two-chamber view (middle row), and the biplane (bottom row) LV ESVs on the basis of BSA.

Lang et al 39.e6

Journal of the American Society of Echocardiography
Volume 28 Number 1

Supplemental Table 1 Sources of the data from which LV measurements were obtained, grouped by echocardiographic view,
gender, and baseline characteristics

Data Sources (n)Parasternal Long-axis view

Apical four-chamber view

Apical two-chamber view

Biplane viewAsklepios (1,019)
Flemengho (252)

CARDIA5 (1,027)
Asklepios (1,006)
Flemengho (245)

CARDIA25 (588)
Asklepios10 (161)
Flemengho (244)Padua (111)Asklepios10 (161)
Flemengho (248)

Men
n

502

962

410

201

Race white (n)

502

770

345

201

Race black (n)

0

192

65

0

Age (y)45 6 837 6 1050 6 847 6 14177 6 8Height (cm)177 6 7

178 6 7

178 6 7Weight (kg)

78 6 1077 6 1080 6 1079 6 11

BSA (m2)

1.96 6 0.14

1.94 6 0.15

1.99 6 0.15

1.97 6 0.17

BMI (kg/m2)

25 6 324 6 325 6 325 6 3

n

769

1,316

583

319

Race white (n)

769

244

509

319

Women

Race black (n)

0

1,072

74

0

Age (y)45 6 737 6 1050 6 748 6 12164 6 7Height (cm)

164 6 6

164 6 6165 6 6Weight (kg)

63 6 862 6 966 6 963 6 9

BSA (m2)

1.69 6 0.13

1.68 6 0.13

1.73 6 0.15

1.70 6 0.14

BMI (kg/m2)

23 6 323 6 324 6 324 6 3

39.e7 Lang et al

Journal of the American Society of Echocardiography
January 2015

Supplemental Table 2 Normal values for LV size and function parameters for men and women obtained from different
echocardiographic views, listed with the number of subjects used to derive them
Male
ParameternMean 6 SD

Female2-SD rangenMean 6 SD

2-SD range

Parasternal long-axis view*
Diastolic LV internal dimension (mm)502

50.2 6 4.1

42.0–58.4

769

45.0 6 3.6

37.8–52.2

Systolic LV internal dimension (mm)389

32.4 6 3.7

25.0–39.8

630

28.2 6 3.3

21.6–34.8

Apical two-chamber view†
LV EF (%)

410

62 6 7

48–76

583

64 6 6

52–76

LV EDV (mL)410

117 6 29

59–175583

87 6 23

41–133

LV ESV (mL)410

45 6 15

15–75

583

32 6 11

10–54

Apical four-chamber view‡
LV EF (%)

962

60 6 7

46–74

1316

62 6 8

46–78

LV EDV (mL)962

127 6 29

69–1851316

94 6 23

48–140

LV ESV (mL)962

50 6 14

22–78

1316

36 6 12

12–60

Biplane§
LV EF (%)

201

62 6 552–72

319

64 6 554–74

LV EDV (mL)201

106 6 22

62–150319

76 6 15

46–106

LV ESV (mL)201

41 6 10

21–61

319

28 6 7

14–42

LV EDV (mL/m2)

410

59 6 14

31–87

583

50 6 12

26–74

2

410

23 6 7

9–37

583

18 6 6

6–30

LV EDV (mL/m2)

962

65 6 14

37–93

1316

56 6 13

30–82

LV ESV (mL/m2)

962

26 6 7

12–40

1316

21 6 7

7–35

LV EDV (mL/m2)

201

54 6 10

34–74

319

45 6 8

29–61

LV ESV (mL/m2)

201

21 6 5

11–31

319

16 6 4

8–24

Normalized to BSA
Apical two-chamber view†
LV ESV (mL/m )Apical four-chamber view‡§

Biplane

Data Sources.
*Asklepios, Flemengho.
†
Asklepios, CARDIA5, Flemengho.
‡
Flemengho, CARDIA25; Asklepios10.
§
Asklepios10, Flemehgho, Padua.

Lang et al 39.e8

Journal of the American Society of Echocardiography
Volume 28 Number 1

Supplemental Table 3 Normal ranges and severity partition cutoff values for 2DE-derived LV size, function and mass
Male

FemaleNormalrange

MildlyabnormalModerately
abnormalSeverely
abnormal

Normalrange

MildlyabnormalModerately
abnormalSeverely
abnormal

LV diastolic diameter (cm)

4.2–5.8

5.9–6.3

6.4–6.8>6.8

3.8–5.2

5.3–5.6

5.7–6.1>6.1

LV diastolic diameter/BSA (cm/m2)

2.2–3.0

3.1–3.3

3.4–3.6>3.6

2.3–3.1

3.2–3.4

3.5–3.7>3.7

LV systolic diameter (cm)

2.5–4.0

4.1–4.3

4.4–4.5>4.5

2.2–3.5

3.6–3.8

3.9–4.1>4.1

LV systolic diameter/BSA (cm/m2)

1.3–2.1

2.2–2.3

2.4–2.5>2.5

1.3–2.1

2.2–2.3

2.4–2.6>2.6

62–150

151–174

175–200>200

46–106

107–120

121–130

LV dimension

LV volume
LV diastolic volume (mL)
2

>130

LV diastolic volume/BSA (mL/m )

34–74

75–89

90–100

>100

29–61

62–70

71–80

>80

LV systolic volume (mL)

21–61

62–73

74–85

>85

14–42

43–55

56–67

>67

LV systolic volume/BSA (mL/m2)

11–31

32–38

39–45

>45

8–24

25–32

33–40

>40

52–72

41–51

30–40

<30

54–74

41–53

30–40

<30

Septal wall thickness (cm)

0.6–1.0

1.1–1.3

1.4–1.6>1.6

0.6–0.9

1.0–1.2

1.3–1.5>1.5

Posterior wall thickness (cm)

0.6–1.0

1.1–1.3

1.4–1.6>1.6

0.6–0.9

1.0–1.2

1.3–1.5>1.5

LV mass (g)88–224

225–258

259–292>292

67–162

163–186

187–210>210

LV mass/BSA (g/m2)

49–115

116–131

132–148

>148

43–95

96–108

109–121>121

96–200

201–227

228–254>254

66–150

151–171

172–193>193

50–102

103–116

117–130

>130

44–88

89–100

101–112>112

LV function
LV EF (%)
LV mass by linear method

LV mass by 2D method
LV mass (g)2

LV mass/BSA (g/m )Age 20–29 yMaleParameternMean 6 SD

Age 30–39 yFemalenMean 6 SD

Malen

Mean 6 SD

62 6 5

Age 40–49 yFemalenMean 6 SD

Malen

Mean 6 SD

144

62 6 6

Age 30–59

FemalenMean 6 SD

Malen

Mean 6 SD

191

61 6 8

Age 60Femalen

MaleFemaleMean 6 SD n Mean 6 SD n Mean 6 SD

39.e9 Lang et al

Supplemental Table 4 LV function by age decile and gender (mean and 2 SDs)

Apical two-chamber view*
LV EF (%)

14

62 6 416

62 6 627

LV EDV (mL)

14 122 6 1816

88 6 2127 111 6 27

LV ESV (mL)14

46 6 716

33 6 1027

63 6 6274

63 6 6363

18 65 6 5

223 63 6 6

290 64 6 6

34

63 6 636 65 6 618 88 6 14 144 121 6 25 223 90 6 22 191 119 6 30 290 87 6 23 34

88 6 22 36 63 6 1242 6 1118 31 6 7144

46 6 14 223 34 6 11 191

46 6 16 290 32 6 11 34

32 6 836 22 6 6

61 6 7478 62 6 8

235

58 6 760 6 759 6 518 60 6 6Apical four-chamber view†383 60 6 9

LV EF (%)

247

LV EDV (mL)

247 136 6 29 274 106 6 23 363 131 6 28 478 99 6 23 235 118 6 28 383 84 6 20

LV ESV (mL)247

51 6 13 274

LV EF (%)

29

62 6 5

LV EDV (mL)

29 118 6 25

39 6 11 363

51 6 14 478 37 6 11 235

50 6 16 383 34 6 1239

63 6 434

61 6 434 63 6 445

62 6 539

87 6 18

34 114 6 2234 82 6 13

45 107 6 2096

163 60 6 8

21

96 115 6 29 163 82 6 18 21 110 6 24 18 74 6 1596

47 6 16 163 33 6 12 21

82 64 6 4

55

63 6 582 77 6 13

55 101 6 21 116 73 6 14 38

45 6 12 18 29 6 7

Biplane‡116 64 6 5116 26 6 6

38

63 6 548 65 6 6

98 6 21 48 68 6 11

LV ESV (mL)29

46 6 1139

32 6 834

44 6 1034 31 6 645

41 6 1082 28 6 655

38 6 9

LV stroke volume (mL)29

73 6 1739

55 6 1234

69 6 1534 52 6 845

66 6 1282 49 6 955

64 6 15 116 46 6 10 38

LV EDV (mL/m2)

14

59 6 81650 6 927

56 6 1418 50 6 8144

61 6 13 223 52 6 12 191

60 6 14 290 51 6 13 34

45 6 11 36 37 6 7

LV ESV (mL/m2)

14

22 6 416

19 6 527

21 6 618 18 6 4144

23 6 723 6 816 6 438

36 6 948 24 6 6

62 6 14 48 44 6 8Normalized to BSA
Apical two-chamber view*223 19 6 6191

290 19 6 634

36 13 6 3

Apical four-chamber view†
LV EDV (mL/m2)

247

70 6 14 274

63 6 13 363

67 6 13 478 59 6 13 235

60 6 13 383 50 6 1196

59 6 13 163 49 6 10 21

56 6 11 18 44 6 8

LV ESV (mL/m2)

247

26 6 623 6 626 6 726 6 896

24 6 14 163 20 6 7

22 6 5

LV EDV (mL/m2)

29

62 6 1039

52 6 934

57 6 1134 49 6 645

54 6 982 45 6 755

52 6 9116 43 6 7

38

50 6 10 48 40 6 7

LV ESV (mL/m2)

29

24 6 539

19 6 434

22 6 534 18 6 445

21 6 582 16 6 355

19 6 4116 15 6 3

38

18 6 4274

363

478 22 6 6235383 20 6 7

21

18 17 6 4

Biplane‡Journal of the American Society of Echocardiography
January 2015

Data sources.
*Asklepios, CARDIA5, Flemehgho.
†
Flemehgho, CARDIA25; Asklepios10.
‡
Asklepios10, Flemehgho, Padua.

48 14 6 3

Lang et al 39.e10

Journal of the American Society of Echocardiography
Volume 28 Number 1

Supplemental Table 5 LV size and function by race and gender
Black

White

Male
ParameternMean 6 SD

FemalenMean 6 SD

Malen

Mean 6 SD

FemalenMean 6 SD

Apical two-chamber view*
LV EF (%)

65

61 6 774

64 6 6345

62 6 7509

64 6 6

LV EDV (mL)65

130 6 2874

99 6 23345

114 6 28509

85 6 22

LV ESV (mL)

65

51 6 1674

36 6 10345

44 6 14509

31 6 11

Apical four-chamber view†
LV EF (%)

244

63 6 6

192

64 6 6770

60 6 71072

61 6 8LV EDV (mL)244

135 6 29192

106 6 23770

125 6 291072

91 6 23

LV ESV (mL)244

50 6 12192

38 6 11770

50 6 151072

36 6 12

LV EDV (mL/m2)

65

66 6 1374

55 6 11345

57 6 14509

50 6 12

LV ESV (mL/m2)

65

26 6 874

20 6 6345

22 6 7509

18 6 6

LV EDV (mL/m2)

244

70 6 14192

62 6 13770

64 6 141072

54 6 13

LV ESV (mL/m2)

244

26 6 6

192

22 6 6770

26 6 71072

21 6 7

Normalized to BSA
Apical two-chamber view*

Apical two-chamber view†

Data sources.
*Asklepios, CARDIA5, Flemengho.
†
Flemengho, CARDIA25; Asklepios10.

39.e11 Lang et al

Journal of the American Society of Echocardiography
January 2015

Supplemental Table 6 Normal LV strain values from meta-analysis and individual recent publications using specific vendors’
equipment and software
vendorSoftwaren

Mean

Varying
GE

SD

LLN

Reference

Meta-analysis

2597

19.7%

NA

26

EchoPAC BT 12247

21.5%

2.0%

18%

31

EchoPAC BT 12207

21.2%

1.6%

18%

*

EchoPAC BT 12

13121.2%

2.4%

17%

†

EchoPAC 110.1.3

333

21.3%

2.1%

17%

32

Philips

QLAB 7.1

330

18.9%

2.5%

14%

32

Toshiba

Ultra Extend

337

19.9%

2.4%

15%

32

Siemens

VVI

116

19.8

4.6

11%

197

VVI

82

17.3

2.3

13%

198

EsaoteMylab 50

30

19.5

3.1

13%

199

LLN, Lower limit of normal range.
*T. Kouznetsova and J. Staessen, Department of Cardiology, Catholic University Leuven, personal communication.
†
P. Barbier, University Milano, personal communication.

Lang et al 39.e12

Journal of the American Society of Echocardiography
Volume 28 Number 1

Supplemental Table 7 Numbers of studies and subjects
used to derive the reference values for RV chamber size andfunction
Parameter

Studiesn

RV basal diameter (mm)

12

695

RV mid diameter (mm)

14

1938

RV longitudinal diameter (mm)

10

537

RVOT PLAX diameter (mm)

11

380

RVOT proximal diameter (mm)5193

RVOT distal diameter (mm)4159

RV wall thickness (mm)9527

RVOT EDA (cm2)
Men

2

909

Women

2

971

Men

2

909

Women

2

971

RV EDA indexed to BSA (cm2/m2)

RV ESA (cm2)
Men

1

533

Women

1

600

RV ESA indexed to BSA (cm2/m2)
Men

1

533

Women

1

600

RV EDV indexed to BSA (mL/m2)
Men

2

257

Women

2

285

RV ESV indexed to BSA (mL/m2)
Men

2

257

Women

2

285

TAPSE (mm)

68

4803

Pulsed Doppler S wave (cm/s)

69

4752

Color Doppler S wave (cm/s)

9409

RV fractional area change (%)

57

3606

RV free wall 2D strain (%)

18

782

RV 3D EF (%)

15

1162

Pulsed Doppler MPI

23

853

Tissue Doppler MPI

13

746

E wave deceleration time (ms)

30

1637

E/A

56

2829

e0 /a0

33

1230

e0

43

3081

E/e0

8

545

CI, Confidence interval; EDA, end-diastolic area; ESA, end-systolicarea; PLAX, parasternal long-axis view; RVOT, RV outflow tract;
MPI, myocardial performance index.
Values are expressed as mean (95% CI), while normal limit is expressed as lower reference value (95% CI) and/or *upper reference
value (95% CI) where appropriate.

39.e13 Lang et al

Journal of the American Society of Echocardiography
January 2015

Supplemental Table 8 Normal ranges for 3D echocardiographic RV size and function by gender and age decade (fromMaffessanti et al.75)
RV EDV (mL/m2)

RV EF (%)

Men

Women

53 (38, 78)

66 (42, 100)

20 (8, 45)

28 (16, 52)

60 (43, 82)

56 (42, 68)

50 (38, 77)

58 (35, 85)

18 (11, 38)

23 (12, 38)

63 (50, 78)

60 (47, 74)

50 (34, 65)

54 (36, 78)

18 (8, 27)

21 (11, 33)

65 (49, 80)

59 (51, 75)

49 (37, 69)

53 (36, 76)

18 (11, 29)

19 (10, 37)

62 (46, 76)

62 (45, 74)

69 (39, 30)

46 (26, 64)

52 (37, 86)

17 (8, 26)

19 (10, 36)

61 (50, 79)

63 (49, 79)

37 (23, 14)

43 (25, 62)

54 (31, 68)

12 (7, 21)

18 (7, 28)

71 (57, 82)

65 (55, 76)

Age (y)n (women, men)<30

102 (45, 57)

30–39

96 (50, 46)

40–49

96 (53, 43)

50–59

88 (47, 41)

60–69
$70

Women

RV ESV (mL/m2)

Data are expressed as median (5th, 95th percentile).

Men

Women

Men

Lang et al 39.e14

Journal of the American Society of Echocardiography
Volume 28 Number 1

Supplemental Table 9 Normal values of LA size
Women

Men

AP dimension (cm)

2.7–3.8

3.0–4.0

AP dimension index (cm/m2)

1.5–2.3

1.5–2.3

A4C area index (cm2/m2)

9.3 6 1.7

8.9 6 1.5

A2C area index (cm2/m2)

9.6 6 1.4

9.3 6 1.6

A4C volume index MOD (mL/m2)

25.1 6 7.2

24.5 6 6.4

A4C volume index AL (mL/m2)

27.3 6 7.9

27.0 6 7.0

A2C volume index MOD (mL/m2)

26.1 6 6.7

27.1 6 7.9

A2C volume index AL (mL/m2)

28.0 6 7.3

28.9 6 8.5