Normal Values of TTE

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

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 methodEndocardial 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 MethodEjection 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

Left Ventricular Diastolic Function

Practical approach to LV diastolic function grading. Ater [1]

Normal values for Doppler-derived diastolic measurements[1] Age group (y)

Measurement 16-20 21-40 41-60 >60IVRT (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.

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 MethodLV mass, g 67–162 163–186 187–210 ≥211 88–224 225–258 259–292 ≥293LV mass/BSA, g/m2 43–95 96–108 109–121 ≥122 49–115 116–131 132–148 ≥149LV mass/height, g/m 41–99 100–115 116–128 ≥129 52–126 127–144 145–162 ≥163LV mass/height2, g/m2 18–44 45–51 52–58 ≥59 20–48 49–55 56–63 ≥64Relative 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 ≥1.7Posterior 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 MethodLV mass, g 66–150 151–171 172–182 >193 96–200 201–227 228–254 >255LV 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

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 dimensionLV 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 ≥6.9LV 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 volumeLV 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 ≥83LV 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

Reference limits and partition values of right ventricular and pulmonary artery size[2]

Reference range Mildly abnormal Moderately abnormal

Severely abnormal

RV dimensionsBasal RV diameter (RVD 1), cm 2.0–2.8 2.9–3.3 3.4–3.8 ≥3.9Mid-RV diameter (RVD 2), cm 2.7–3.3 3.4–3.7 3.8–4.1 ≥4.2

Base-to-apex length (RVD 3), cm 7.1–7.9 8.0–8.5 8.6–9.1 ≥9.2

RVOT diameters

Above aortic valve (RVOT 1), cm 2.5–2.9 3.0–3.2 3.3–3.5 ≥3.6

Above pulmonic valve (RVOT 2), cm 1.7–2.3 2.4–2.7 2.8–3.1 ≥3.2

PA diameterBelow pulmonic valve (PA 1), cm 1.5–2.1 2.2–2.5 2.6–2.9 ≥3.0•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

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

Reference limits and partition values for left atrial dimensions/volumes[2]

Women Men

Reference range

Mildly abnormal

Moderately abnormal

Severely abnormal

Reference range

Mildly abnormal

Moderately abnormal

Severely abnormal

Atrial dimensionsLA 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 ≥3.0RA 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 areaLA area, cm2 ≤20 20–30 30–40 >40 ≤20 20–30 30–40 >40Atrial volumesLA volume, mL 22–52 53–62 63–72 ≥73 18–58 59–68 69–78 ≥79LA 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

Left Atrial Pressure

Estimation of left atrial pressure in normal LVEF. After 

Estimation of left atrial pressure in reduced LVEF. After

Left Atrial Pressure

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

•aESC Guidelines.[7]

•bAHA/ACC Guidelines.[8]

Aortic ValveAortic valve stenosis - severity

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 ≥ 60RF % < 30 30-39 40-49 ≥ 50EROA, 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-to-severe regurgitation as shown.

Aortic regurgitation - severity

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)ΦEnlarged LV and LA size∗∗, (particularly when normal LV function is present).

Quantitative parametersφ

R Vol (ml/beat) < 30 30-44 45-59 ≥ 60RF (%) < 30 30-39 40-49 ≥ 50EROA (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/m 2, 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).•φ Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.

Mitral ValveMitral regurgitation - severity

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

•aAt heart rates between 60 and 80 bpm and in sinus rhythm.

Mitral stenosis - severity

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

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 shortening)

Detail each component and summarize in a score

Mitral stenosis - routine measurements

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 > 0.7PISA radius (cm)ψ ≤ 0.5 0.6-0.9 > 0.9Jet density and contour–CW Soft and parabolic Dense, variable contour Dense, triangular with

early peakingHepatic 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 ValveTricuspid regurgitation - severity

Findings indicative of haemodynamically significant tricuspid stenosis[6]

Specific findingsMean pressure gradient ≥5 mmHgInflow time-velocity integral >60 cmT1/2 ≥190 msValve area by continuity equationa ≤1 cm2

Supportive findingsEnlarged right atrium ≥moderateDilated inferior vena cava•aStroke 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

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

IntermediateUsually 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

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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