Normal Values of TTE

From Echopedia
Revision as of 14:22, 9 January 2021 by 77.234.244.30 (talk) (→‎References)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search

Below an up-to-date list of echocardiographic normal values.

Left Ventricle[edit]

Left Ventricular Systolic Function[edit]

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
Endocardial 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 Diastolic Function[edit]

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 >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.

Left Ventricular Mass and Geometry[edit]

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 Size[edit]

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.

Right Ventricle[edit]

Right Ventricular and Pulmonary Artery Size[edit]

Reference limits and partition values of right ventricular and pulmonary artery size[2]
  Reference range Mildly abnormal Moderately abnormal Severely abnormal
RV dimensions
Basal RV diameter (RVD 1), cm 2.0–2.8 2.9–3.3 3.4–3.8 ≥3.9
Mid-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 diameter
Below 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 Size and Function[edit]

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]

Atria[edit]

Left Atrial Dimensions / Volumes[edit]

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 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.

Left Atrial Pressure[edit]

Estimation of left atrial pressure in normal LVEF. After [1]
Estimation of left atrial pressure in reduced LVEF. After [1]


Aortic Valve[edit]

Aortic valve stenosis - severity[edit]

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 regurgitation - severity[edit]

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-to-severe regurgitation as shown.


Mitral Valve[edit]

Mitral regurgitation - severity[edit]

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

Mitral stenosis - severity[edit]

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 valve stenosis - Wilkins score[edit]

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

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


Tricuspid Valve[edit]

Tricuspid regurgitation - severity[edit]

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 stenosis - severity[edit]

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
  • 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.

Pulmonary Valve[edit]

Pulmonary regurgitaion - severity[edit]

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 stenosis - severity[edit]

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

Inferior Caval Vein[edit]

Estimate of central veinous pressure using ICV echo
CVP IVC collaps on inspiration IVC diameter
CVP 0-5 cm total collaps < 1.5 cm
CVP 5-10 cm >50% 1.5 to 2.5 cm
CVP 11-15 cm <50% 1.5 to 2.5 cm
CVP 16-20 cm <50% > 2.5 cm
CVP > 20 cm no change > 2.5 cm

References[edit]

Click on the reference to link directly to the manuscript

Error fetching PMID 3730205:
Error fetching PMID 16458610:
Error fetching PMID 19130998:
Error fetching PMID 3190958:
Error fetching PMID 17259184:
Error fetching PMID 18848134:
Error fetching PMID 12835667:
Error fetching PMID 19187853:
  1. Error fetching PMID 19187853: [ASEDF]
  2. Error fetching PMID 16458610: [ASE]
  3. Error fetching PMID 3730205: [Foale]
  4. ISBN:9031362352 [Hamer]
  5. ISBN:0812112075 [Weyman]
  6. Error fetching PMID 19130998: [ASEVS]
  7. Error fetching PMID 17259184: [ESCAS]
  8. Error fetching PMID 12835667: [ASERE]
  9. Error fetching PMID 3190958: [Wilkins]
  10. Error fetching PMID 18848134: [ACCAS]

All Medline abstracts: PubMed | HubMed

External links[edit]