Thansthorasic Echocardiographic Normal Values

1. Normal Values of TTE

2. Contents
•1 Left Ventricle
• 1.1 Left Ventricular Systolic Function
• 1.2 Left Ventricular Diastolic Function
• 1.3 Left Ventricular Mass and Geometry
• 1.4 Left Ventricular Size
•2 Right Ventricle
• 2.1 Right Ventricular and Pulmonary Artery Size
• 2.2 Right Ventricular Size and Function
•3 Atria
• 3.1 Left Atrial Dimensions / Volumes
• 3.2 Left Atrial Pressure
•4 Aortic Valve
• 4.1 Aortic valve stenosis - severity
• 4.2 Aortic regurgitation - severity
•5 Mitral Valve
• 5.1 Mitral regurgitation - severity
• 5.2 Mitral stenosis - severity
• 5.3 Mitral valve stenosis - Wilkins score
• 5.4 Mitral stenosis - routine measurements
•6 Tricuspid Valve
• 6.1 Tricuspid regurgitation - severity
• 6.2 Tricuspid stenosis - severity
•7 Pulmonary Valve
• 7.1 Pulmonary regurgitaion - severity
• 7.2 Pulmonary stenosis - severity
•8 References

3. Reference limits and values and partition values of left ventricular function<ref>ASE</ref>
Women Men
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Linear method
Endocardi
al
fractional
shortening
, %
27–45 22–26 17–21 ≤16 25–43 20–24 15–19 ≤14
Midwall
fractional
shortening
, %
15–23 13–14 11–12 ≤10 14–22 12–13 10–11 ≤10
2D Method
Ejection
fraction, %
≥55 45–54 30–44 <30 ≥55 45–54 30–44 <30
•2D, Two-dimensional.
•Green values: Recommended and best validated.
Left Ventricular Systolic Function

4. Left Ventricular Diastolic Function
Practical approach to LV diastolic function grading. Ater [1]

5. Normal values for Doppler-derived diastolic measurements[1]
Age group (y)
Measurement 16-20 21-40 41-60 >60
IVRT (ms) 50 ± 9 (32-68) 67 ± 8 (51-83) 74 ± 7 (60-88) 87 ± 7 (73-101)
E/A ratio
1.88 ± 0.45 (0.98-
2.78)
1.53 ± 0.40 (0.73-
2.33)
1.28 ± 0.25 (0.78-
1.78)
0.96 ± 0.18 (0.6-
1.32)
DT (ms) 142 ± 19 (104-180) 166 ± 14 (138-194) 181 ± 19 (143-219) 200 ± 29 (142-258)
A duration (ms) 113 ± 17 (79-147) 127 ± 13 (101-153) 133 ± 13 (107-159) 138 ± 19 (100-176)
PV S/D ratio
0.82 ± 0.18 (0.46-
1.18)
0.98 ± 0.32 (0.34-
1.62)
1.21 ± 0.2 (0.81-
1.61)
1.39 ± 0.47 (0.45-
2.33)
PV Ar (cm/s) 16 ± 10 (1-36) 21 ± 8 (5-37) 23 ± 3 (17-29) 25 ± 9 (11-39)
PV Ar duration (ms) 66 ± 39 (1-144) 96 ± 33 (30-162) 112 ± 15 (82-142) 113 ± 30 (53-173)
Septal e´ (cm/s)
14.9 ± 2.4 (10.1-
19.7)
15.5 ± 2.7 (10.1-
20.9)
12.2 ± 2.3 (7.6-16.8) 10.4 ± 2.1 (6.2-14.6)
Septal e´/a´ ratio 2.4∗
1.6 ± 0.5 (0.6-2.6) 1.1 ± 0.3 (0.5-1.7)
0.85 ± 0.2 (0.45-
1.25)
Lateral e´ (cm/s) 20.6 ± 3.8 (13-28.2) 19.8 ± 2.9 (14-25.6)
16.1 ± 2.3 (11.5-
20.7)
12.9 ± 3.5 (5.9-19.9)
Lateral e´/a´ ratio 3.1∗
1.9 ± 0.6 (0.7-3.1) 1.5 ± 0.5 (0.5-2.5) 0.9 ± 0.4 (0.1-1.7)
•Data are expressed as mean ± SD (95% confidence interval). Note that for e´ velocity in subjects aged 16 to 20 years,
values overlap with those for subjects aged 21 to 40 years. This is because e´ increases progressively with age in children
and adolescents. Therefore, the e´ velocity is higher in a normal 20-year-old than in a normal 16-year-old, which results in
a somewhat lower average e´ value when subjects aged 16 to 20 years are considered.
•∗
Standard deviations are not included because these data were computed, not directly provided in the original articles
from which they were derived.

6. Reference limits and partition values of left ventricular mass and geometry[2]
Women Men
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Linear Method
LV mass, g 67–162 163–186 187–210 ≥211 88–224 225–258 259–292 ≥293
LV mass/BSA, g/m2
43–95 96–108 109–121 ≥122 49–115 116–131 132–148 ≥149
LV mass/height, g/m 41–99 100–115 116–128 ≥129 52–126 127–144 145–162 ≥163
LV mass/height2
, g/m2
18–44 45–51 52–58 ≥59 20–48 49–55 56–63 ≥64
Relative wall
thickness, cm
0.22–0.42 0.43–0.47 0.48–0.52 ≥0.53 0.24–0.42 0.43–0.46 0.47–0.51 ≥0.52
Septal thickness, cm 0.6–0.9 1.0–1.2 1.3–1.5 ≥1.6 0.6–1.0 1.1–1.3 1.4–1.6 ≥1.7
Posterior wall
thickness, cm
0.6–0.9 1.0–1.2 1.3–1.5 ≥1.6 0.6–1.0 1.1–1.3 1.4–1.6 ≥1.7
2D Method
LV mass, g 66–150 151–171 172–182 >193 96–200 201–227 228–254 >255
LV mass/BSA, g/m2
44–88 89–100 101–112 ≥113 50–102 103–116 117–130 ≥131
•BSA, Body surface area; LV, left ventricular; 2D, 2-dimensional.
•Green values: Recommended and best validated.
Left Ventricular Mass and Geometry

7. Reference limits and partition values of left ventricular size[2]
Women Men
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
LV dimension
LV diastolic diameter 3.9–5.3 5.4–5.7 5.8–6.1 ≥6.2 4.2–5.9 6.0–6.3 6.4–6.8 ≥6.9
LV diastolic
diameter/BSA, cm/m2
2.4–3.2 3.3–3.4 3.5–3.7 ≥3.8 2.2–3.1 3.2–3.4 3.5–3.6 ≥3.7
LV diastolic
diameter/height,
cm/m
2.5–3.2 3.3–3.4 3.5–3.6 ≥3.7 2.4–3.3 3.4–3.5 3.6–3.7 ≥3.8
LV volume
LV diastolic volume,
mL
56–104 105–117 118–130 ≥131 67–155 156–178 179–201 ≥201
LV diastolic
volume/BSA, mL/m2
35–75 76–86 87–96 ≥97 35–75 76–86 87–96 ≥97
LV systolic volume, mL 19–49 50–59 60–69 ≥70 22–58 59–70 71–82 ≥83
LV systolic
volume/BSA, mL/m2
12–30 31–36 37–42 ≥43 12–30 31–36 37–42 ≥43
•BSA, body surface area; LV, left ventricular.
•Green values: Recommended and best validated.
Left Ventricular Size

8. Reference limits and partition values of right ventricular and pulmonary artery size[2]
Reference range Mildly abnormal
Moderately
abnormal
Seve
abno
RV dimensions
Basal RV diameter (RVD 1), cm 2.0–2.8 2.9–3.3 3.4–3.8 ≥3
Mid-RV diameter (RVD 2), cm 2.7–3.3 3.4–3.7 3.8–4.1 ≥4
Base-to-apex length (RVD 3), cm 7.1–7.9 8.0–8.5 8.6–9.1 ≥9
RVOT diameters
Above aortic valve (RVOT 1), cm 2.5–2.9 3.0–3.2 3.3–3.5 ≥3
Above pulmonic valve (RVOT 2), cm 1.7–2.3 2.4–2.7 2.8–3.1 ≥3
PA diameter
Below pulmonic valve (PA 1), cm 1.5–2.1 2.2–2.5 2.6–2.9 ≥3
•RV, Right ventricular; RVOT, right ventricular outflow tract; PA, pulmonary artery.
•Data from Foale et al.[3]
Right Ventricular and Pulmonary Artery Size Right Ventricle

9. Reference limits and partition values of right ventricular size and function as
measured in the apical 4-chamber view[2]
Reference
range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
RV diastolic area,
cm2
11–28 29–32 33–37 ≥38
RV systolic area,
cm2
7.5–16 17–19 20–22 ≥23
RV fractional
area change, %
32–60 25–31 18–24 ≤17
TAPSE, (cm) 1.5-2.0[2]
1.3-1.5[4]
1.0-1.2[4]
<1.0[4]
•RV, Right ventricular.
•Data from Weyman.[5]
Right Ventricular Size and Function

10. Reference limits and partition values for left atrial dimensions/volumes[2]
Women Men
Referenc
e range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Referenc
e range
Mildly
abnormal
Moderately
abnormal
Severely
abnormal
Atrial dimensions
LA diameter, cm 2.7–3.8 3.9–4.2 4.3–4.6 ≥4.7 3.0–4.0 4.1–4.6 4.7–5.2 ≥5.2
LA diameter/BSA, cm/m2
1.5–2.3 2.4–2.6 2.7–2.9 ≥3.0 1.5–2.3 2.4–2.6 2.7–2.9 ≥3.0
RA minor-axis
dimension, cm
2.9–4.5 4.6–4.9 5.0–5.4 ≥5.5 2.9–4.5 4.6–4.9 5.0–5.4 ≥5.5
RA minor-axis
dimension/BSA, cm/m2
1.7–2.5 2.6–2.8 2.9–3.1 ≥3.2 1.7–2.5 2.6–2.8 2.9–3.1 ≥3.2
Atrial area
LA area, cm2
≤20 20–30 30–40 >40 ≤20 20–30 30–40 >40
Atrial volumes
LA volume, mL 22–52 53–62 63–72 ≥73 18–58 59–68 69–78 ≥79
LA volume/BSA, mL/m2
22 ± 6 29–33 34–39 ≥40 22 ± 6 29–33 34–39 ≥40
•BSA, Body surface area; LA, left atrial; RA, right atrial.
•Green values: Recommended and best validated.
Atria Left Atrial Dimensions / Volumes

11. Left Atrial Pressure
Estimation of left atrial pressure in normal LVEF. After

12. Estimation of left atrial pressure in reduced LVEF. After
Left Atrial Pressure

13. Recommendations for classification of AS severity[6]
Aortic
sclerosis
Mild Moderate Severe
Aortic jet velocity (m/s) ≤2.5 m/s 2.6-2.9 3.0-4.0 >4.0
Mean gradient (mmHg) - <20 (<30a
)
20-40b
(30-
50a
)
>40b
(>50a
)
AVA (cm2
) - >1.5 1.0-1.5 <1
Indexed AVA (cm2
/m2
) >0.85 0.60-0.85 <0.6
Velocity ratio >0.50 0.25-0.50 <0.25
•a
ESC Guidelines.[7]
•b
AHA/ACC Guidelines.[8]
Aortic Valve
Aortic valve stenosis - severity

14. Application of specific and supportive signs, and quantitative parameters in the grading of aortic
regurgitation severity[9]
Mild Moderate Severe
Specific signs for
AR severity
•Central Jet, width < 25% of
LVOTς
•Vena contracta < 0.3 cmς
•No or brief early diastolic
flow reversal in descending
aorta
•Signs of AR>mild present
but no criteria for severe AR
•Central Jet, width ≥ 65% of
LVOTς
•Vena contracta > 0.6cmς
Supportive signs
•Pressure half-time > 500
ms
•Normal LV size∗
•Intermediate values •Pressure half-time < 200
ms
•Holodiastolic aortic flow
reversal in descending aorta
•Moderate or greater LV
enlargement∗∗
Quantitative parametersψ
R Vol, ml/beat < 30 30-44 45-59 ≥ 60
RF % < 30 30-39 40-49 ≥ 50
EROA, cm2
< 0.10 0.10-0.19 0.20-0.29 ≥ 0.30
•AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, left ventricular outflow tract; R
Vol, regurgitant volume; RF, regurgitant fraction.
•∗
LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis ≤ 2.8 cm/m2
, LV end-diastolic volume ≤
82 ml/m2
(2).
•ς
At a Nyquist limit of 50–60 cm/s.
•∗∗
In the absence of other etiologies of LV dilatation.
•ψ
Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-
Aortic regurgitation - severity

15. Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity[9]
Mild Moderate Severe
Specific signs of severity
•Small central jet <4 cm2
or <20%
of LA areaψ
•Vena contracta width <0.3 cm
•No or minimal flow
convergence
•Signs of MR>mild present, but
no criteria for severe MR
•Vena contracta width ≥
0.7cm with large central MR jet
(area < 40% of LA) or with a wall-
impinging jet of any size, swirling
in LAψ
•Large flow convergenceς
•Systolic reversal in pulmonary
veins
•Prominent flail MV leaflet or
ruptured papillary muscle
Supportive signs
•Systolic dominant flow in
pulmonary veins
•A-wave dominant mitral inflowΦ
•Soft density, parabolic CW
Doppler MR signal
•Normal LV size∗
•Intermediate signs/findings •Dense, triangular CW Doppler
MR jet
•E-wave dominant mitral inflow
(E >1.2 m/s)Φ
Enlarged LV and LA
size∗∗
, (particularly when normal
LV function is present).
Quantitative parametersφ
R Vol (ml/beat) < 30 30-44 45-59 ≥ 60
RF (%) < 30 30-39 40-49 ≥ 50
EROA (cm2
) < 0.20 0.20-0.29 0.30-0.39 ≥ 0.40
•CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MV, mitral valve; MR, mitral regurgitation; R
Vol, regurgitant volume; RF, regurgitant fraction.
•∗
LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis ≤ 2.8 cm/m2
, LV end-diastolic volume ≤ 82 ml/m2
, maximal LA
antero-posterior diameter ≤ 2.8 cm/m2
, maximal LA volume ≤ 36 ml/m2
(2;33;35).
•∗∗
In the absence of other etiologies of LV and LA dilatation and acute MR.
•ψ
At a Nyquist limit of 50-60 cm/s.
•Φ
Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA
pressure.
•ς
Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and ≤ 0.9 cm for central jets, respectively, with a baseline
shift at a Nyquist of 40 cm/s; Cut-offs for eccentric jets are higher, and should be angle corrected (see text).
Mitral Valve
Mitral
regurgitation -
severity

16. Recommendations for classification of mitral stenosis severity[6]
Mild Moderate Severe
Specific findings
Valve area (cm2
) >1.5 1.0-1.5 <1.0
Supportive findings
Mean gradient (mmHg)a
<5 5-10 >10
Pulmonary artery pressure
(mmHg)
<30 30-50 >50
•a
At heart rates between 60 and 80 bpm and in sinus rhythm.
Mitral stenosis - severity

18. Assessment of mitral valve anatomy according to the Wilkins score[10]
Grad
e
Mobility Thickening Calcification
Subvalvular
Thickening
1 Highly mobile valve
with only leaflet tips
restricted
Leaflets near normal
in thickness (4-5 mm)
A single area of
increased echo
brightness
Minimal thickening
just below the mitral
leaflets
2 Leaflet mid and base
portions have normal
mobility
Midleaflets normal,
considerable
thickening of margins
(5-8 mm)
Scattered areas of
brightness confined
to leaflet margins
Thickening of chordal
structures extending
to one-third of the
chordal length
3 Valve continues to
move forward in
diastole, mainly from
the base
Thickening extending
through the entire
leaflet (5-8mm)
Brightness extending
into the mid-portions
of the leaflets
Thickening extended
to distal third of the
chords
4 No or minimal
forward movement
of the leaflets in
diastole
Considerable
thickening of all
leaflet tissue (>8-
10mm)
Extensive brightness
throughout much of
the leaflet tissue
Extensive thickening
and shortening of all
chordal structures
extending down to
the papillary muscles
•The total score is the sum of the four items and ranges between 4 and 16.
Mitral valve stenosis - Wilkins score

19. Recommendations for data recording and measurement in routine use for mitral stenosis quantitation[6]
Data element Recording Measurement
Planimetry
- 2D parasternal short-axis view - contour of the inner mitral orifice
- determine the smallest orifice by scanning
from apex to base
- include commissures when opened
- positioning of measurement plan can be
oriented by 3D echo
- in mid-diastole (use cine-loop)
- lowest gain setting to visualize the whole
mitral orifice
- average measurements if atrial fibrillation
Mitral flow
- continuous-wave Doppler - mean gradient from the traced contour of the
diastolic mitral flow
- apical windows often suitable (optimize
intercept angle)
- pressure half-time from the descending sLope of the
E-wave (mid-diastole slope if not linear)
- adjust gain setting to obtain well-defined
flow contour
- average measurements if atrial fibrillation
Systolic
pulmonary artery
pressure
- continuous-wave Doppler - maximum velocity of tricuspid regurgitant flow
- multiple acoustic windows to optimize
intercept angle
- estimation of right atrial pressure according to
inferior vena cava diameter
Valve anatomy
- parasternal short-axis view - valve thickness (maximum and heterogeneity)
- commissural fusion
- extension and location of localized bright zones
(fibrous nodutes or calcification)
- parasternal long-axis view - valve thickness
- extension of calcification
- valve pliability
- subvalvular apparatus (chordal thickening, fusion, or
shortening)
- apical two-chamber view - subvalvular apparatus (chordal thickening, fusion, or
Mitral stenosis - routine measurements

20. Echocardiographic and Doppler parameters used in grading tricuspid regurgitation severity[9]
Parameter Mild Moderate Severe
Tricuspid valve Usually normal Normal or abnormal
Abnormal/Flail
leaflet/Poor coaptation
RV/RA/IVC size Normal∗
Normal or dilated Usually dilated∗∗
Jet area-central jets
(cm2
)§
< 5 5-10 > 10
VC width (cm)Φ
Not defined Not defined, but < 0.7 > 0.7
PISA radius (cm)ψ
≤ 0.5 0.6-0.9 > 0.9
Jet density and contour–
CW
Soft and parabolic Dense, variable contour
Dense, triangular with
early peaking
Hepatic vein flow† Systolic dominance Systolic blunting Systolic reversal
•CW, Continuous wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena
contracta width.
•∗
Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical 4-
chamber view: RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2
,
maximal RA medio-lateral and supero-inferior dimensions ≤ 4.6 cm and 4.9 cm respectively, maximal RA
volume ≤ 33 ml/m2
(35;89).
•∗∗
Exception: acute TR.
•§
At a Nyquist limit of 50-60 cm/s. Not valid in eccentric jets. Jet area is not recommended as the sole
parameter of TR severity due to its dependence on hemodynamic and technical factors.
•Φ
At a Nyquist limit of 50-60 cm/s.
•ψ
Baseline shift with Nyquist limit of 28 cm/s.
•† Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated RA pressure).
Tricuspid Valve
Tricuspid regurgitation - severity

21. Findings indicative of haemodynamically significant tricuspid stenosis[6]
Specific findings
Mean pressure gradient ≥5 mmHg
Inflow time-velocity integral >60 cm
T1/2 ≥190 ms
Valve area by continuity equationa
≤1 cm2
Supportive findings
Enlarged right atrium ≥moderate
Dilated inferior vena cava
•a
Stroke volume derived from left or right ventricular outflow. In the presence of
more than mild TR, the derived valve area will be underestimated. Nevertheless,
a value ≤1 cm2
implies a significant haemodynamic burden imposed by the
combined lesion.
Tricuspid stenosis - severity

22. Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity[9]
Parameter Mild Moderate Severe
Pulmonic valve Normal Normal or abnormal Abnormal
RV size Normal∗
Normal or dilated Dilated
Jet size by color Doppler§
Thin (usually < 10 mm in
length) with a narrow
origin
Intermediate
Usually large, with a
wide origin; May be brief
in duration
Jet density and
deceleration rate –CW†
Soft; Slow deceleration
Dense; variable
deceleration
Dense; steep
deceleration, early
termination of diastolic
flow
Pulmonic systolic flow
compared to systemic
flow –PWφ
Slightly increased Intermediate Greatly increased
•CW, Continuous wave Doppler; PR, pulmonic regurgitation; PW, pulsed wave Doppler; RA, right
atrium; RF, regurgitant fraction; RV, right ventricle.
•∗
Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-
chamber view; RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2
(89).
•∗∗
Exception: acute PR
•§
At a Nyquist limit of 50-60 cm/s.
•φ
Cut-off values for regurgitant volume and fraction are not well validated.
•† Steep deceleration is not specific for severe PR.
Pulmonary Valve Pulmonary regurgitaion - severity

23. Grading of pulmonary stenosis[6]
Mild Moderate Severe
Peak velocity (m/s) <3 3-4 >4
Peak gradient
(mmHg)
<36 36-64 >64
Pulmonary stenosis - severity

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