Recommendations for chamber quantiﬁcation · Quantiﬁcation of cardiac chamber size, ventricular...

Eur J Echocardiography (2006) 7, 79e108

GUIDELINES

Recommendations for chamber quantification*

Roberto M. Lang, Michelle Bierig, Richard B. Devereux,Frank A. Flachskampf *, Elyse Foster, Patricia A. Pellikka,Michael H. Picard, Mary J. Roman, James Seward,Jack Shanewise, Scott Solomon, Kirk T. Spencer,Martin St. John Sutton, William Stewart

Med. Klinik 2, Erlangen University, Ulmenweg 18, 91054 Erlangen, Germany

Received 7 November 2005; accepted 23 December 2005Available online 2 February 2006

KEYWORDSStandards;Measurements;Volumes;Linear dimensions;Quantification

Abstract Quantification of cardiac chamber size, ventricular mass and functionranks among the most clinically important and most frequently requested tasks ofechocardiography. Over the last decades, echocardiographic methods and techniqueshave improvedandexpandeddramatically, due to the introductionofhigher frequencytransducers, harmonic imaging, fully digital machines, left-sided contrast agents, andother technological advancements. Furthermore, echocardiography due to its porta-bility and versatility is now used in emergency rooms, operating rooms, and intensivecare units. Standardization of measurements in echocardiography has been inconsis-tent and less successful, compared to other imaging techniques and consequently,echocardiographic measurements are sometimes perceived as less reliable. There-fore, the American Society of Echocardiography, working together with the EuropeanAssociation of Echocardiography, a branch of the European Society of Cardiology, hascritically reviewed the literature and updated the recommendations for quantifyingcardiac chambers using echocardiography. This document reviews the technicalaspects on how to perform quantitative chamber measurements of morphology andfunction, which is a component of every complete echocardiographic examination.ª 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rightsreserved.

Abbreviations: LV, left ventricle; LA, left atrium; RA, right atrium; RV, right ventricle; LVID, left ventricular internal dimension;LVIDd, left ventricular internal dimension at end diastole; LVIDs, left ventricular internal dimension at end systole; SWTd, septal wallthickness at end-diastole; PWTd, posterior wall thickness at end-diastole; EBD, endocardial border delineation; TEE, transesophagealechocardiography; MI, myocardial infarction.* A report from the American Society of Echocardiography’s Nomenclature and Standards Committee and the Task Force on Cham-ber Quantification, developed in conjunction with the American College of Cardiology Echocardiography Committee, the AmericanHeart Association, and the European Association of Echocardiography, a branch of the European Society of Cardiology.* Corresponding author. Tel.: þ49 9131 853 5301; fax: þ49 9131 853 5303.E-mail address: [email protected] (F.A. Flachskampf).

1525-2167/$32 ª 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.euje.2005.12.014

mailto:[email protected]

80 R.M. Lang et al.

Introduction

Quantification of cardiac chamber size, ventricularmass and function ranks among the most clinicallyimportant and most frequently requested tasks ofechocardiography. Standardization of chamberquantification has been an early concern in echo-cardiography and recommendations on how tomeasure such fundamental parameters are amongthe most often cited papers in the field.1,2 Overthe last decades, echocardiographic methods andtechniques have improved and expanded dramati-cally. Improvements in image quality have beensignificant, due to the introduction of higher fre-quency transducers, harmonic imaging, fully digi-tal machines, left-sided contrast agents, andother technological advancements.

Furthermore, echocardiography has become thedominant cardiac imaging technique, which due toits portability and versatility is now used inemergency rooms, operating rooms, and intensivecare units. Standardization of measurements inechocardiography has been inconsistent and lesssuccessful, compared to other imaging techniquesand consequently, echocardiographic measure-ments are sometimes perceived as less reliable.Therefore, the American Society of Echocardiog-raphy, working together with the European Asso-ciation of Echocardiography, a branch of theEuropean Society of Cardiology, has criticallyreviewed the literature and updated the recom-mendations for quantifying cardiac chambers usingechocardiography. Not all the measurements de-scribed in this document can be performed in allpatients due to technical limitations. In addition,specific measurements may be clinically pertinentor conversely irrelevant in different clinic scenar-ios. This document reviews the technical aspectson how to perform quantitative chamber measure-ments and is not intended to describe the standardof care of which measurements should be per-formed in individual clinical studies. However,evaluation of chamber size and function is a com-ponent of every complete echocardiographicexamination and these measurements may havean impact on clinical management.

General overview

Enhancements in imaging have followed techno-logical improvements such as broadband trans-ducers, harmonic imaging and left-sided contrastagents. Nonetheless, image optimization stillrequires considerable expertise and attention tocertain details that are specific to each view

(Table 1). In general, images optimized for quanti-tation of one chamber may not necessarily be op-timal for visualization or measurement of othercardiac structures. The position of the patient dur-ing image acquisition is important. Optimal viewsare usually obtained with the patient in the steepleft-lateral decubitus position using a cut-out mat-tress to permit visualization of the true apex whileavoiding LV foreshortening. The patient’s left armshould be raised to spread the ribs. Excessivetranslational motion can be avoided by acquiringimages during quiet respiration. If images areobtained during held end-expiration, care mustbe taken to avoid a Valsalva maneuver, whichcan degrade image quality.

Digital capture and display of images on theechocardiographic system or on a workstationshould optimally display images at a rate of atleast �30 frames/second. In routine clinical prac-tice a representative cardiac cycle can be used formeasurement as long as the patient is in sinusrhythm. In atrial fibrillation, particularly whenthere is marked RR variation, multiple beatsshould be used for measurements. Averaging mea-surements from additional cycles may be particu-larly useful when R-R intervals are highly irregular.When premature atrial or ventricular contractionsare present, measurements should be avoided inthe post-ectopic beat since the length of the

Table 1 Elements of image acquisition andmeasurement for two-dimensional quantitation

Aim Method

Minimize translationalmotion

Quiet or suspendedrespiration (at end-expiration)

Maximize imageresolution

Image at minimum depthnecessaryHighest possible transducerfrequencyAdjust gains, dynamic range,transmit and lateral gaincontrols appropriatelyFrame rate �30/sHarmonic imagingB-color imaging

Avoid apicalforeshortening

Steep lateral decubituspositionCut-out mattressAvoid reliance on palpableapical impulse

Maximize endocardialborder

Contrast enhancementdelineation

Identifyend-diastoleand end-systole

Mitral valve motion andcavity size rather thanreliance on ECG

Recommendations for chamber quantification 81

preceding cardiac cycle can influence ventricularvolume and fiber shortening.

Harmonic imaging is now widely employed inclinical laboratories to enhance the images espe-cially in patients with poor acoustic windows.While this technology reduces the ‘‘drop-out’’ ofendocardial borders, the literature suggests thatthere is a systemic tendency for higher measure-ments of LV wall thickness and mass and smallermeasurements of internal dimensions and vol-umes.3,4 When analyzing serial studies on a givenpatient, differences in chamber dimension poten-tially attributable to imaging changes from thefundamental to the harmonic modality are probablysmaller than the inter and intra-observer variabil-ity of these measurements. The best techniquefor comparing serial changes in quantitation is todisplay similar serial images side-by-side andmake the same measurement on both images bythe same person, at the same time.5 It is importantto note that most measurements presented in thismanuscript are derived from fundamental imagingas normative values have not been establishedusing harmonic imaging.

Left-sided contrast agents used for endocardialborder delineation (EBD) are helpful and improvemeasurement reproducibility for suboptimal stud-ies and correlation with other imaging techniques.While the use of contrast agents has beenreviewed elsewhere in detail,6 a few caveats re-garding their use deserve mention. The mechanicalindex should be lowered to decrease the acousticpower of the ultrasound beam, which reduces bub-ble destruction. The image should be ‘‘focused’’on the structure of interest. Excessive shadowingmay be present during the initial phase of bubbletransit and often the best image can be recordedseveral cardiac cycles following the appearanceof contrast in the left ventricle. When less than80% of the endocardial border is adequately visual-ized, the use of contrast agents for EBD is stronglyrecommended.7 By improving visualization of theLV apex, the problem of ventricular foreshorteningis reduced and correlation with other techniquesimproved. Contrast enhanced images should belabeled to facilitate the reader identification ofthe imaging planes.

Quantitation using transesophageal echocardi-ography (TEE) has advantages and disadvantagescompared to transthoracic echocardiography(TTE). Although visualization of many cardiacstructures is improved with TEE some differencesin measurements have been found between TEEand TTE. These differences are primarily attribut-able to the inability to obtain from the trans-esophageal approach the standardized imaging

planes/views used when quantifying chamber di-mensions transthoracically.8,9 It is the recommen-dation of this writing group that the same rangeof normal values for chamber dimensions and vol-umes apply for both TEE and TTE. In this manu-script, recommendations for quantification usingTEE will primarily focus on acquisition of imagesthat allow measurement of cardiac structuresalong imaging planes that are analogous to TTE.

In addition to describing a parameter as normalor abnormal (reference values), clinical echocar-diographers most often qualify the degree ofabnormality with terms such as ‘‘mildly’’, ‘‘mod-erately’’ or ‘‘severely’’ abnormal. Such a descrip-tion allows the clinician to not only understandthat the parameter is abnormal but also thedegree to which their patient’s measurementsdeviate from normal. In addition to providingnormative data it would be beneficial to standard-ize cutoffs for severity of abnormality acrossechocardiographic laboratories, such that moder-ately abnormal had the same implication in alllaboratories. However, multiple statistical tech-niques exist for determining thresholds values, allof which have significant limitations.10

The first approach would be to define cutoffsempirically for mild, moderate and severe abnor-malities based on standard deviations above/below the reference limit derived from a groupof normal subjects. The advantage of this methodis that this data readily exists for most echocar-diographic parameters. However, this approachhas several disadvantages. Firstly, not all echocar-diographic parameters are normally distributed, orGaussian in nature, making the use of standarddeviation questionable. Secondly, even if a partic-ular parameter is normally distributed in controlsubjects, most echocardiographic parameterswhen measured in the general population havea significant asymmetric distribution in one di-rection (abnormally large for size or abnormallylow for function parameters). Using the standarddeviation derived from normal subjects leads toabnormally low cutoff values which are inconsis-tent with clinical experience, as the standarddeviation inadequately represents the magnitudeof asymmetry (or range of values) towards abnor-mality. This is the case with LV ejection fraction(EF) where 4 standard deviations below the mean(64 G 6.5) results in a cutoff for severely abnormalof 38%.

An alternative method would be to defineabnormalities based on percentile values (95th,99th, etc.) of measurements derived from a pop-ulation that includes both normal subjects andthose with disease states.11 Although this data may

82 R.M. Lang et al.

still not be Gaussian, it accounts for the asymmet-ric distribution and range of abnormality presentwithin the general population. The major limita-tion of this approach is that large enough popula-tion data sets simply do not exist for mostechocardiographic variables.

Ideally, an approach that would predict out-comes or prognosis would be preferred. That isdefining a variable as moderately deviated fromnormal would imply that there is a moderate riskof a particular adverse outcome for that patient.Although sufficient data linking risk and cardiacchamber sizes exist for several parameters (i.e.,EF, LV size, LA volume); risk data are lacking formany other parameters. Unfortunately, this ap-proach continues to have several limitations. Thefirst obstacle is how to best define ‘‘risk’’. Thecutoffs suggested for a single parameter varybroadly for the risk of death, myocardial infarction(MI), atrial fibrillation etc. In addition, much of therisk literature applies to specific populations (post-MI, elderly), and not general cardiovascular riskreadily applicable to consecutive patients studiedin an echocardiography laboratory. Lastly, al-though having data specifically related to risk isideal, it is not clear that this is necessary. Perhapscardiac risk rises inherently as echocardiographicparameters become more abnormal. This has beenshown for several echocardiographic parameters(LA dimension, wall thickness, LV size and LV mass)which, when partitioned based on populationestimates, demonstrated graduated risk, which isoften non-linear.11

Lastly cutoffs values may be determined fromexpert opinion. Although scientifically least rigor-ous, this method takes into account the collectiveexperience of having read and measured tens ofthousands of echocardiograms.

No single methodology could be used for allparameters. The tables of cutoffs represent a con-sensus of a panel of experts using a combination ofthe methods described above (Table 2). The con-sensus values are more robust for some parametersthan others and future research may redefine thecutoff values. Despite the limitations, these parti-tion values represent a leap forward towards thestandardization of clinical echocardiography.

Quantification of the left ventricle

Left ventricular dimensions, volumes and wallthicknesses are echocardiographic measurementswidely used in clinical practice and research.12,13

LV size and performance are still frequently visu-ally estimated. However, qualitative assessment

of LV size and function may have significant in-ter-observer variability and is a function of inter-preter skill. Therefore, it should regularly becompared to quantitative measurements, espe-cially when different views qualitatively suggestdifferent degrees of LV dysfunction. Similarly, itis also important to cross-check quantitative datausing the ‘‘eye-ball’’ method, to avoid overempha-sis on process-related measurements, which attimes may depend on structures seen in a singlestill-frame. It is important to account for the inte-gration over time of moving structures seen in oneplane, and the integration of three-dimensionalspace obtained from viewing a structure in multi-ple orthogonal planes. Methods for quantitationof LV size, mass and function using two-dimen-sional imaging have been validated.14e17

There are distinct advantages and disadvan-tages to each of the accepted quantitativemethods (Table 3). For example, linear LV mea-surements have been widely validated in the man-agement of valvular heart disease, but maymisrepresent dilatation and dysfunction in pa-tients with regional wall motion abnormalitiesdue to coronary artery disease. Thus, laboratoriesshould be familiar with all available techniquesand peer review literature and should apply themon a selective basis.

General principles for linear andvolumetric LV measurements

To obtain accurate linear measurements of in-terventricular septal and posterior wall thick-nesses and LV internal dimension, recordings

Table 2 Methods used to establish cutoff values ofdifferent echocardiographic parameters

Standarddeviation

Percentile Risk Expertopinion

Septal wallthickness

U U

LV mass U U

LV dimensions U U

LV volumes U

LV functionlinear method

U

Ejection fraction U U

RV dimensions U

PA diameters U

RV areas U

RV function U

LA dimensions U

LA volumes U U U

RA dimensions U


Table 3 LV quantification methods: utility, advantages and limitations

Dimension/volumes Utility/advantages Limitations

LinearM-mode Reproducible

e High frame rates e Beam orientation frequently off-axise Wealth of accumulated

datae Single dimension may not berepresentative in ‘‘distorted’’ ventricles

e Most representative in ‘‘normally’’shaped ventricles

2-D guided e Assures orientation perpendicularto ventricular long-axis

e Lower frame rates than in M-modee Single dimension only

VolumetricBiplane Simpson’s e Corrects for shape distortions e Apex frequently foreshortened

e Minimizes mathematical assumptions e Endocardial dropoute Relies on only two planese Little accumulated data on normalpopulation

Area length e Partial correction for shape distortion e Based on mathematical assumptionse Little accumulated data

MassM-mode or 2-D guided e Wealth of accumulated data e Inaccurate in ventricles with regional

abnormalitiese Beam orientation (M-mode)e Small errors magnifiede Overestimates LV mass

Area length e Allows for contribution ofpapillary muscles

e Insensitive to distortion inventricular shape

Truncated ellipsoid e More sensitive to distortions inventricular shape

e Based on a number or mathematicalassumptions

e Minimal \normal data

should be made from the parasternal long-axisacoustic window. It is recommended that LV in-ternal diameters (LVIDd and LVIDs, respectively)and wall thicknesses be measured at the level ofthe LV minor axis, approximately at the mitralvalve leaflet tips. These linear measurements canbe made directly from 2D images or using 2D-targeted M-mode echocardiography.

By virtue of their high pulse rate, M-moderecordings have excellent temporal resolutionand may complement 2-D images in separatingstructures such as trabeculae adjacent to theposterior wall, false tendons on the left side ofthe septum, and tricuspid apparatus or moderatorband on the right side of the septum from theadjacent endocardium. However, it should berecognized that even with 2D guidance, it maynot be possible to align the M-mode cursor per-pendicular to the long axis of the ventricle which ismandatory to obtain a true minor axis dimensionmeasurement. Alternatively, chamber dimensionand wall thicknesses can be acquired from theparasternal short-axis view using direct 2D mea-surements or targeted M-mode echocardiography

provided that the M-mode cursor can be positionedperpendicular to the septum and LV posterior wall.

A 2D method, useful for assessing patients withcoronary artery disease has been proposed. Whenusing this method, it is recommended that LVinternal diameters (LVIDd and LVIDs, respectively)and wall thicknesses be measured at the level ofthe LV minor dimension, at the mitral chordaelevel. These linear measurements can also bemade directly from 2D images or using 2D-targetedM-mode echocardiography. Direct 2D minor axismeasurements at the chordae level intersect theinterventricular septum below the left ventricularoutflow tract,2,5,18 and thus provides a global as-sessment in a symmetrically contracting LV, andalso evaluates basal regional function in a chamberwith regional wall motion abnormalities. Thedirect 2D minor axis dimensions are smaller thanthe M-mode measurements with the upper limitsof normal of LVIDd being 5.2 cm vs 5.5 cm andthe lower limits of normal for fractional shorteningbeing 0.18 vs 0.25. Normal systolic and diastolicmeasurements reported for this parameter are4.7 G 0.4 cm and 3.3 G 0.5 cm, respectively.2,18

84 R.M. Lang et al.

LVID and septal and posterior wall thicknesses(SWT and PWT, respectively) are measured at end-diastole (d) and end-systole (s) from 2-D or M-moderecordings,1,2 preferably on several cardiac cycles(Fig. 1).1,2 Refinements in image processing haveallowed improved resolution of cardiac structures.Consequently, it is now possible to measure the ac-tual visualized thickness of the ventricular septumand other chamber dimensions as defined by theactual tissueeblood interface, rather than the dis-tance between the leading edge echoes which hadpreviously been recommended.5 Use of 2-D echo-derived linear dimensions overcomes the commonproblem of oblique parasternal images resultingin overestimation of cavity and wall dimensionsfrom M mode. If manual calibration of images isrequired, 6 cm or larger distances should be usedto minimize errors due to imprecise placement ofcalibration points.

In order to obtain volumetric measurements themost important views for 2-D quantitation are themid-papillary short-axis view and the apical four-and two-chamber views. Volumetric measurementsrequire manual tracing of the endocardial border.The papillary muscles should be excluded from thecavity in the tracing. Accurate measurementsrequire optimal visualization of the endocardialborder in order to minimize the need for extrapo-lation. It is recommended that the basal border ofthe LV cavity area be delineated by a straight line

connecting the mitral valve insertions at the lateraland septal borders of the annulus on the four-chamber view and the anterior and inferior annularborders on the two-chamber view.

End-diastole can be defined at the onset of theQRS, but is preferably defined as the framefollowing mitral valve closure or the frame in thecardiac cycle in which the cardiac dimension islargest. In sinus rhythm, this follows atrial con-traction. End-systole is best defined as the framepreceding mitral valve opening or the time in thecardiac cycle in which the cardiac dimension issmallest in a normal heart. In the two-chamberview, mitral valve motion is not always clearlydiscernible and the frames with the largest andsmallest volumes should be identified as end-diastole and end-systole, respectively.

The recommended TEE views for measurementof LV diameters are the mid esophageal two-chamber view (Fig. 2) and the transgastric (TG)two- chamber views (Fig. 3). LV diameters aremeasured from the endocardium of the anteriorwall to the endocardium of the inferior wall ina line perpendicular to the long-axis of the ventri-cle at the junction of the basal and middle thirdsof the long-axis. The recommended TEE view formeasurement of LV wall thicknesses is the TGmid short-axis view (Fig. 4). With TEE, the long-axis dimension of the LV is often foreshortened inthe mid-esophageal four-chamber and long-axis

Figure 1 Measurement of left ventricular end-diastolic diameter (EDD) and end-systolic diameter (ESD) fromM-mode, guided by a parasternal short axis image (upper left) to optimize medial-lateral beam orientation.


Figure 2 Transesophageal measurements of left ventricular length (L) and minor diameter (LVD) from the mid-esophageal two-chamber view, usually best imaged at a multiplane angle of approximately 60e90 degrees.

views; therefore the mid-esophageal two-chamberview is preferred for this measurement. Care mustbe made to avoid foreshortening TEE views, by re-cording the image plane which shows the maxi-mum obtainable chamber size, finding the anglefor diameter measurement which is perpendicularto the long-axis of that chamber, then measuringthe maximum obtainable short-axis diameter.

Calculation of left ventricular mass

In clinical practice, LV chamber dimensions arecommonly used to derive measures of LV systolicfunction, whereas in epidemiologic studies andtreatment trials, the single largest application ofechocardiography has been the estimation of LVmass in populations and its change with antihy-pertensive therapy.13,19 All LV mass algorithms,

whether utilizing M-mode, 2-D or 3-D echocardio-graphic measurements, are based upon subtrac-tion of the LV cavity volume from the volumeenclosed by the LV epicardium to obtain LV muscleor ‘‘shell’’ volume. This shell volume is then con-verted to mass by multiplying by myocardial den-sity. Hence, quantitation of LV mass requiresaccurate identification of interfaces between thecardiac blood pool and endocardium and betweenepicardium and pericardium.

To date, most LV mass calculations have beenmade using linear measurements derived from 2-D-targeted M-mode or, more recently, from 2-Dlinear LV measurements.20 The ASE recommendedformula for estimation of LV mass from LV lineardimensions (validated with necropsy r ¼ 0.90,p < 0.00121) is based on modeling the LV as aprolate ellipse of revolution:

Figure 3 Transesophageal echo measurements of left ventricular minor axis diameter (LVD) from the trans-gastrictwo-chamber view of the left ventricle, usually best imaged at an angle of approximately 90e110 degrees after op-timizing the maximum obtainable LV size by adjustment of medial-lateral rotation.

86 R.M. Lang et al.

Figure 4 Transesophageal echo measurements of wall thickness of the left ventricular septal wall (SWT) and theposterior wall (PWT), from the trans-gastric short axis view of the left ventricle, at the papillary muscle level, usuallybest imaged at angle of approximately 0e30 degrees.

LV mass¼ 0:8� ð1:04½ðLVIDdþ PWTd

þSWTdÞ3�ðLVIDdÞ3�Þ þ 0:6 g

This formula is appropriate for evaluating pa-tients without major distortions of LV geometry,e.g., patients with hypertension. Since this for-mula requires cubing primary measurements, evensmall errors in these measurements are magnified.Calculation of relative wall thickness (RWT) by theformula, (2 � PWTd)/LVIDd, permits categoriza-tion of an increase in LV mass as either concentric(RWT � 0.42) or eccentric (RWT � 0.42) hypertro-phy and allows identification of concentric

remodeling (normal LV mass with increased RWT)(Fig. 5).22

The most commonly employed 2-D methods formeasuring LV mass are based on the areaelengthformula and the truncated ellipsoid model, asdescribed in detail in the 1989 ASE document onLV quantitation.2 Both methods were validated inthe early 1980s in animal models and by comparingpre-morbid echocardiograms with measured LVweight at autopsy in humans. Both methods relyon measurements of myocardial area at the mid-papillary muscle level. The epicardium is tracedto obtain the total area (A1) and the endocardiumis traced to obtain the cavity area (A2). Myocardial

Figure 5 Comparison of relative wall thickness (RWT). Patients with normal LV mass can have either concentricremodeling (normal LV mass with increased RWT > 0.42) or normal (RWT � 0.42) and normal LV mass. Patients withincreased LV mass can have either concentric (RWT > 0.42) or eccentric (RWT � 0.42) hypertrophy. These LV massmeasurements are based on linear measurements.


area (Am) is computed as the difference:Am ¼ A1 � A2. Assuming a circular area, the radiusis computed (b ¼ A2/p) and a mean wall thickness(t) derived (Fig. 6). Left ventricular mass can becalculated by one of the two formulae shown inFig. 6. In the presence of extensive regional wallmotion abnormalities (e.g. myocardial infarction),the biplane Simpson’s method may be used,although this method is dependent on adequateendocardial and epicardial definition of the LVwhich often is challenging from this window. Mostlaboratories obtain the measurement at end-diastole and exclude the papillary muscles in trac-ing the myocardial area.

TEE evaluation of LV mass is also highly accu-rate, but has minor systematic differences in LVposterior wall thickness. In particular LV massderived from TEE wall thickness measurements ishigher by an average of 6 g/m2.8

Left ventricular systolic function: linearand volumetric measurement

Many echocardiographic laboratories rely on M-mode measurements or linear dimensions derivedfrom the two-dimensional image for quantifica-tion. Linear measurements from M-mode and 2-D

images have proven to be reproducible with lowintra- and inter-observer variability.20,23e26 Al-though linear measures of LV function are prob-lematic when there is a marked regionaldifference in function, in patients with uncompli-cated hypertension, obesity or valvular diseases,such regional differences are rare in the absenceof clinically recognized myocardial infarction.Hence fractional shortening and its relationshipto end-systolic stress often provide useful informa-tion in clinical studies.27 The previously usedTeichholz or Quinones methods of calculating LVejection fraction from LV linear dimensions mayresult in inaccuracies due to the geometric as-sumptions required to convert a linear measure-ment to a 3-D volume.28,29 Accordingly, the useof linear measurements to calculate LV EF is notrecommended for clinic practice.

Contraction of muscle fibers in the LV midwallmay better reflect intrinsic contractility thancontraction of fibers at the endocardium. Calcula-tion of midwall, rather than endocardial fractionalshortening is particularly useful in revealingunderlying systolic dysfunction in the setting ofconcentric hypertrophy.30 Mid-wall fractionalshortening (MWFS) may be computed from linearmeasures of diastolic and systolic cavity sizes and

Figure 6 Two methods for estimating LV mass based on the areaelength (AL) formula and the truncated ellipsoid(TE) formula, from short axis (left) and apical four-chamber (right) 2-D echo views. A1 ¼ total LV area; A2 ¼ LV cavityarea; Am ¼myocardial area, a is the long or semi-major axis from widest minor axis radius to apex, b is the short-axisradius (back calculated from the short-axis cavity area) and d is the truncated semi-major axis from widest short-axisdiameter to mitral anulus plane. Assuming a circular area, the radius (b) is computed and mean wall thickness (t)derived from the short-axis epicardial and cavity areas. See text for explanation.

88 R.M. Lang et al.

wall thicknesses based on mathematicalmodels,30,31 according to the following formulas:

Inner shell¼�h

LVIDdþ SWTd=2þ PWTd=2�3

�LVIDd3 þ LVIDs3�1=3

�LVIDs

MWFS¼ ð½LVIDdþ SWTd=2þ PWTd=2� � ½LVIDsþ inner shell�ÞðLVIDdþ SWTd=2þ PWTd=2Þ � 100

The most commonly used 2-D measurement forvolume measurements is the biplane method ofdiscs (modified Simpson’s rule) and is the currentlyrecommended method of choice by consensus ofthis committee (Fig. 7). The principle underlyingthis method is that the total LV volume is calculatedfrom the summation of a stack of elliptical discs.The height of each disc is calculated as a fraction(usually one-twentieth) of the LV long axis basedon the longer of the two lengths from the two-and four-chamber views. The cross-sectional area

of the disk is based on the two diameters obtainedfrom the two- and four-chamber views. When twoadequate orthogonal views are not available, a sin-gle plane can be used and the area of the disc isthen assumed to be circular. The limitations of

using a single plane are greatest when extensivewall motion abnormalities are present.

An alternative method to calculate LV volumeswhen apical endocardial definition precludes ac-curate tracing is the areaelength method wherethe LV is assumed to be bullet-shaped (Fig. 6). Themid LV cross-sectional area is computed by planim-etry in the parasternal short-axis view andthe length of the ventricle taken from the midpoint of the annulus to the apex in the apicalfour-chamber view. These measurements are

Figure 7 2-D measurements for volume calculations using the biplane method of discs (modified Simpson’s rule), inthe apical four-chamber (A4C) and apical two-chamber (A2C) views at end diastole (LV EDD) and at end-systole (LVESD). The papillary muscles should be excluded from the cavity in the tracing.


repeated at end-diastole and end-systole and thevolume is computed according to the formula:volume ¼ [5(area)(length)] O 6. The most widelyused parameter for indexing volumes is the bodysurface area (BSA) in m2.

The end-diastolic and end-systolic volumes(EDV, ESV) are calculated by either of the twomethods described above and the ejection fractionis calculated as follows:

Ejection fraction¼ ðEDV� ESVÞ=EDV

Partition values for recognizing depressed LVsystolic function in Table 6 follow the conventionalpractice of using the same cut-offs in women andmen; however, emerging echocardiographic and MRIdata suggests that LV ejection fraction and otherindices are somewhat higher in apparently normalwomen than in men.32,33 Quantitation of LV vol-umes using TEE is challenging due to difficulties inobtaining a non-foreshortened LV cavity from theesophageal approach. However when carefullyacquired, direct comparisons between TEE andTTE volumes and ejection fraction have shownminor or no significant differences.8,9

Reference values for left ventricularmeasurements (Tables 4e6)

Reference values for LV linear dimensions havebeen obtained from an ethnically diverse populationof 510 normal-weight, normotensive, non-diabeticwhite, African-American and American-Indianadults without recognized cardiovascular disease(unpublished data). The populations from whichthese data has been derived have been describedin detail previously.20,34e36 Reference values forvolumetric measurements have also been obtainedin a normal adult population.37

Normal values for LV mass differ between menand women even when indexed for body surfacearea (Table 4). The best method for normalizing LVmass measurements in adults is still debated.While body surface area (BSA) has been most oftenemployed in clinical trials, this method will under-estimate the prevalence of LV hypertrophy in over-weight and obese individuals. The ability to detectLV hypertrophy related to obesity as well as tocardiovascular diseases is enhanced by indexingLV mass for the power of its allometric or growthrelation with height (height2.7). Data are inconclu-sive as to whether such indexing of LV mass mayimprove or attenuate prediction of cardiovascularevents. Of note, the reference limits for LV massin Table 4 are lower than those published insome previous echocardiographic studies, yet are

Table

4Reference

limitsandpartitionva

luesofleft

ventricularmass

andge

ometry

Women

Men

Reference

range

Mildly

abnorm

al

Moderately

abnorm

al

Seve

rely

abnorm

al

Reference

range

Mildly

abnorm

al

Moderately

abnorm

al

Seve

rely

abnorm

al

Linearmethod

LVmass

(g)

67e16

216

3e18

618

7e21

0�21

188

e22

422

5e25

825

9e29

2�29

3LV

mass/B

SA(g/m

2)

43e95

96e108

109e121

‡122

49e115

116e131

132e148

‡149

LVmass/h

eight(g/m

)41

e99

100e

115

116e

128

�12

952

e12

612

7e14

414

5e16

2�16

3LV

mass/h

eight(g/m

)2,7

18e44

45e51

52e58

�59

20e48

49e55

56e63

�64

Relative

wallthickn

ess

(cm)

0.22

e0.42

0.43

e0.47

0.48

e0.52

�0.53

0.24

e0.42

0.43

e0.46

0.47

e0.51

�0.52

Septalthickn

ess

(cm)

0.6e0.9

1.0e1.2

1.3e1.5

‡1.6

0.6e1.0

1.1e1.3

1.4e1.6

‡1.7

Posteriorwallthickn

ess

(cm)

0.6e0.9

1.0e1.2

1.3e1.5

‡1.6

0.6e1.0

1.1e1.3

1.4e1.6

‡1.7

2-Dmethod

LVmass

(g)

66e15

015

1e17

117

2e18

2>18

396

e20

020

1e22

722

8e25

4�25

5LV

mass/B

SA(g/m

2)

44e88

89e100

101e112

�113

50e102

103e116

117e130

�131

Valuesin

bold

are

reco

mmendedandbest

validated.

90 R.M. Lang et al.

Table

5Reference


luesofleft

ventricularsize

Women

Men

Reference

range

Mildly

abnorm

al

Moderately

abnorm

al

Seve

rely

abnorm

al

Reference

range

Mildly

abnorm

al

Moderately

abnorm

al

Seve

rely

abnorm

al

LVdim

ension

LVdiastolicdiameter

3.9e

5.3

5.4e

5.7

5.8e6.1

�6.2

4.2e

5.9

6.0e

6.3

6.4e

6.8

�6.9

LVdiastolicdiameter/BSA

(cm/m

2)

2.4e

3.2

3.3e

3.4

3.5e3.7

�3.8

2.2e

3.1

3.2e

3.4

3.5e

3.6

�3.7

LVdiastolicdiameter/height(cm/m

)2.5e

3.2

3.3e

3.4

3.5e3.6

�3.7

2.4e

3.3

3.4e

3.5

3.6e

3.7

�3.8

LVvo

lume

LVdiastolicvo

lume(m

l)56

e10

410

5e11

711

8e13

0�13

167

e15

515

6e17

817

9e20

1�20

1LVdiastolicvolume/BSA

(ml/m

2)

35e75

76e86

87e96

‡97

35e75

76e86

87e96

‡97

LVsystolicvo

lume(m

l)19

e49

50e59

60e69

�70

22e58

59e70

71e82

�83

LVsystolicvolume/BSA

(ml/m

2)

12e30

31e36

37e42

‡43

12e30

31e36

37e42

‡43

Valuesin

bold

are

reco

mmendedandbest

validated.

virtually identical to those based on direct nec-ropsy measurement and cutoff values used in clin-ical trials.19,20,36,38,39 Although some prior studieshave suggested racial differences in LV mass mea-surement, the consensus of the literature avail-able indicates that no significant differencesexist between clinically normal black and whitesubjects. In contrast, a recent study has shownracial-ethnic differences in left ventricular structurein hypertensive adults.40 Although the sensitivity,specificity and predictive value of LV wall thick-ness measurements for detection of LV hypertro-phy are lower than for calculated LV mass, it issometimes easiest in clinical practice to identifyLV hypertrophy by measuring an increased LVposterior and septal thickness.41

The use of LV mass in children is complicated bythe need for indexing the measurement relative topatient body size. The intent of indexing is toaccount for normal childhood growth of lean bodymass without discounting the pathologic effects ofoverweight and obesity. In this way, an indexed LVmass measurement in early childhood can bedirectly compared to a subsequent measurementduring adolescence and adulthood. Dividing LVmass by height raised to a power of 2.5e3.0 isthe most widely accepted indexing method inolder children and adolescents since it correlatesbest to indexing LV mass to lean body mass.42 Cur-rently an intermediate value of 2.7 is generallyused.43,44 In younger children (<8 years), themost ideal indexing factor remains an area of re-search, but height raised to a power of 2.0 appearsto be the most appropriate.45

Three-dimensional assessmentof volume and mass

Three-dimensional chamber volume and mass areincompletely characterized by one-dimensional ortwo-dimensional approaches, which are based ongeometric assumptions. While these inaccuracieshave been considered inevitable and of minorclinical importance in the past, in most situationsaccurate measurements are required, particularlywhen following the course of a disease with serialexaminations. Over the last decade, several three-dimensional echocardiographic techniques becameavailable to measure LV volumes and mass.46e59

These can be conceptually divided into tech-niques, which are based on off-line reconstructionfrom a set of 2-D cross-sections, or on-line dataacquisition using a matrix array transducer, alsoknown as real-time 3-D echocardiography. Afteracquisition of the raw data, calculation of LVvolumes and mass requires identification of


Table 6 Reference limits and values and partition values of left ventricular function

Women Men

Referencerange

Mildlyabnormal

Moderatelyabnormal

Severelyabnormal

Referencerange

Mildlyabnormal

Moderatelyabnormal

Severelyabnormal

Linear methodEndocardialfractionalshortening (%)

27e45 22e26 17e21 �16 25e43 20e24 15e19 �14

Midwallfractionalshortening (%)

15e23 13e14 11e12 �10 14e22 12e13 10e11 �10

2-D methodEjectionfraction (%)

‡55 45e54 30e44 <30 ‡55 45e54 30e44 <30

Values in bold are recommended and best validated.

endocardial borders (and for mass epicardial bor-der) using manual or semi-automated algorithms.These borders are then processed to calculatethe cavity or myocardial volume by summation ofdiscs54,56 or other methods.46e48

Regardless of which acquisition or analysismethod is used, 3-D echocardiography does notrely on geometric assumptions for volume/masscalculations and is not subject to plane positioningerrors, which can lead to chamber foreshortening.Studies comparing 3-D echocardiographic LV vol-umes or mass to other gold-standards such asmagnetic resonance imaging, have confirmed 3-Dechocardiography to be accurate. Compared tomagnetic resonance data, LV and RV volumescalculated from 3-D echocardiography showedsignificantly better agreement (smaller bias), lowerscatter and lower intra- and inter-observer vari-ability than 2-D echocardiography.46,54,57,60 Thesuperiority of 3-D echocardiographic LV mass calcu-lations over values calculated fromM-mode derivedor 2-D echocardiography has been convincinglyshown.55,57,59 Right ventricular volume and masshave also been measured by 3-D echocardiographywith good agreement with magnetic resonancedata.58,61 Current limitations include the require-ment of regular rhythm, relative inferior imagequality of real-time 3-D echocardiography com-pared to 2-D images, and the time necessary foroff-line data analysis. However, the greater numberof acquired data points, the lack of geometricassumptions, increasingly sophisticated 3-D imageand measurements solutions offset theselimitations.

Regional left ventricular function

In 1989, the American Society of Echocardiographyrecommended a 16 segment model for LV

segmentation.2 This model consists of six segmentsat both basal and mid-ventricular levels and foursegments at the apex (Fig. 8). The attachment ofthe right ventricular wall to the left ventricle de-fines the septum, which is divided at basal andmid LV levels into anteroseptum and inferoseptum.Continuing counterclockwise, the remaining seg-ments at both basal and mid ventricular levelsare labeled as inferior, inferolateral, anterolateraland anterior. The apex includes septal, inferior,lateral, and anterior segments. This model hasbecome widely utilized in echocardiography. Incontrast, nuclear perfusion imaging, cardiovascularmagnetic resonance and cardiac computedtomography have commonly used a larger numberof segments.

In 2002, the American Heart Association WritingGroup on Myocardial Segmentation and Registra-tion for Cardiac Imaging, in an attempt to establishsegmentation standards applicable to all typesof imaging, recommended a 17-segment model(Fig. 8).62 This differs from the previous 16-segment model predominantly by the addition ofa 17th segment, the ‘‘apical cap.’’ The apicalcap is the segment beyond the end of the LVcavity. Refinements in echocardiographic imaging,including harmonics and contrast imaging arebelieved to permit improved imaging of the apex.Either model is practical for clinical applicationyet sufficiently detailed for semi-quantitativeanalysis. The 17-segment model should be predom-inantly used for myocardial perfusion studies oranytime efforts are made to compare betweenimaging modalities. The 16-segment model isappropriate for studies assessing wall motionabnormalities as the tip of the normal apex(segment 17) does not move.

The mass and size of the myocardium asassessed at autopsy is the basis for determining

92 R.M. Lang et al.

Figure 8 Segmental analysis of LV walls based on schematic views, in a parasternal short and long axis orientation,at three different levels. The ‘‘apex segments’’ are usually visualized from apical four-chamber, apical two- andthree-chamber views. The apical cap can only be appreciated on some contrast studies. A 16 segment model canbe used, without the apical cap, as described in an ASE 1989 document.2 A 17 segment model, including the apicalcap, has been suggested by the American Heart Association Writing Group on Myocardial Segmentation and Registra-tion for Cardiac Imaging.62

the distribution of segments. Sectioned into basal,mid ventricular and apical thirds, perpendicular tothe LV long-axis, with the mid ventricular thirddefined by the papillary muscles, the measuredmyocardial mass in adults without cardiac diseasewas 43% for the base, 36% for the mid cavity and21% for the apex.63 The 16-segment model closelyapproximates this, creating a distribution of 37.5%for both the basal and mid portions and 25% for theapical portion. The 17-segment model createsa distribution of 35.3%, 35.3% and 29.4% for thebasal, mid and apical portions (including the apicalcap) of the heart, respectively.

Variability exists in the coronary artery bloodsupply to myocardial segments. Nevertheless, thesegments are usually attributed to the three majorcoronary arteries are shown in the TTE G dis-tributions of Fig. 9.62

Since the 1970s, echocardiography has beenused for the evaluation of LV regional wall motionduring infarction and ischemia.64e66 It is recog-nized that regional myocardial blood flow andregional LV systolic function are related overa wide range of blood flows.67 Although regionalwall motion abnormalities at rest may not beseen until the luminal diameter stenosis exceeds85%, with exercise, a coronary lesion of 50% can re-sult in regional dysfunction. It is recognized that

echocardiography can overestimate the amountof ischemic or infarcted myocardium, as wallmotion of adjacent regions may be affected bytethering, disturbance of regional loading condi-tions and stunning.68 Therefore, wall thickeningas well as motion should be considered. Moreover,it should be remembered that regional wall motionabnormalities may occur in the absence of coro-nary artery disease.

It is recommended that each segment be ana-lyzed individually and scored on the basis of itsmotion and systolic thickening. Ideally, the functionof each segment should be confirmed in multipleviews. A segment which is normal or hyperkineticis assigned a score of 1, hypokinesis ¼ 2, akinesis(negligible thickening) ¼ 3, dyskinesis (paradoxicalsystolic motion) ¼ 4, and aneurysmal (diastolicdeformation) ¼ 5.1 Wall motion score index can bederived as a sum of all scores divided by the numberof segments visualized.

Assessment of LV remodeling and the useof echocardiography in clinical trials

Left ventricular remodeling describes the processby which the heart changes its size, geometry andfunction over time. Quantitative 2-D transthoracic


Figure 9 Artist’s diagram showing the position of three long axis views and one short axis view of the left ventricle,showing the typical distributions of the right coronary artery (RCA), the left anterior descending (LAD), and thecircumflex (Cx) coronary arteries. The arterial distribution varies between patients. Some segments have variablecoronary perfusion.

echocardiography enables characterization of LVremodeling that occurs in normal subjects and ina variety of heart diseases. LV remodeling may bephysiological when the heart increases in size butmaintains normal function during growth, physicaltraining and pregnancy. Several studies have dem-onstrated that both isometric and isotonic exercisecause remodeling of the left and right ventricularchamber sizes and wall thicknesses.69e73 Thesechanges in the highly-trained, elite ‘‘athletehearts’’ are directly related to the type and dura-tion of exercise and have been characterized echo-cardiographically. With isometric exercise, adisproportionate increase occurs in LV mass com-pared to the increase in LV diastolic volume result-ing in significantly greater wall thickness to cavitysize ratio (h/R ratio) than take place in normalnon-athletic subjects with no change in ejectionphase indices of LV contractile function.69e73 Thisphysiologic hypertrophic remodeling of the athleteheart is reversible with cessation of endurancetraining and is related to the total increase inlean body weight70 and triggered by enhanced car-diac sympathetic activity.74 Remodeling may becompensatory in chronic pressure overload due tosystemic hypertension or aortic stenosis resultingin concentric hypertrophy (increased wall thick-ness, normal cavity volume and preserved ejectionfraction) (Fig. 5). Compensatory LV remodelingalso occurs in chronic volume overload associated

with mitral or aortic regurgitation, which inducesa ventricular architecture characterized by eccen-tric hypertrophy, LV chamber dilatation and ini-tially normal contractile function. Pressure andvolume overload may remain compensated by ap-propriate hypertrophy which normalizes wallstress such that hemodynamics and ejection frac-tion remain stable long term. However, in somepatients chronically increased afterload cannotbe normalized indefinitely and the remodelingprocess becomes pathologic.

Transition to pathologic remodeling is heraldedby progressive ventricular dilatation, distortion ofcavity shape and disruption of the normal geome-try of the mitral annulus and subvalvular apparatusresulting in mitral regurgitation. The additionalvolume load from mitral regurgitation escalatesthe deterioration in systolic function and develop-ment of heart failure. LV dilatation begets mitralregurgitation and mitral regurgitation begets fur-ther LV dilatation, progressive remodeling andcontractile dysfunction.

Changes in LV size and geometry due to hyper-tension (Fig. 5) reflect the dominant underlyinghemodynamic alterations associated with bloodpressure elevation.22,75 The pressure-overloadpattern of concentric hypertrophy is uncommonin otherwise healthy hypertensive individuals andis associated with high systolic blood pressureand high peripheral resistance. In contrast, eccentric

94 R.M. Lang et al.

LV hypertrophy is associated with normal periph-eral resistance but high cardiac index consistentwith excess circulating blood volume. Concentricremodeling (normal LV mass with increased rela-tive wall thickness) is characterized by high pe-ripheral resistance, low cardiac index, andincreased arterial stiffness.76,77

A unique form of remodeling occurs followingmyocardial infarction due to the abrupt loss ofcontracting myocytes.22,78 Early expansion of theinfarct zone is associated with early LV dilatationas the increased regional wall stress is redistrib-uted to preserve stroke volume. The extent ofearly and late post-infarction remodeling is deter-mined by a number of factors, including size andlocation of infarction, activation of the sympa-thetic nervous system, and up-regulation of therenin/angiotensin/aldosterone system and natri-uretic peptides. Between one-half and one-thirdof post-infarction patients experience progressivedilatation79,80 with distortion of ventricular geom-etry and secondary mitral regurgitation. Mitralregurgitation further increases the propensity fordeterioration in LV function and development ofcongestive heart failure. Pathologic LV remodelingis the final common pathway to heart failure,whether the initial stimulus is chronic pressure orchronic volume overload, genetically determinedcardiomyopathy or myocardial infarction. The eti-ology of LV dysfunction in approximately two thirdsof the 4.9 million patients with heart failure in theUSA is coronary artery disease.81

While LV remodeling in patients with chronicsystemic hypertension, chronic valvular regurgita-tion and primary cardiomyopathies has been de-scribed, the transition to heart failure is less wellknown because the time course is so prolonged. Bycontrast, the time course from myocardial infarc-tion to heart failure is shorter and has been clearlydocumented.

The traditional quantitative echocardiographicmeasurements recommended to evaluate LV re-modeling included estimates of LV volumes eitherfrom biplane or single plane images as advocatedby the American Society of Echocardiography.Although biplane and single-plane volume estima-tions are not interchangeable, both estimates areequally sensitive for detecting time-dependent LVremodeling and deteriorating contractile func-tion.77 LV volumes and derived ejection fractionhave been demonstrated to predict adversecardiovascular events at follow-up, includingdeath, recurrent infarction, heart failure, ventric-ular arrhythmias and mitral regurgitation innumerous post-infarction and heart failuretrials.78e81 This committee recommends the use

of quantitative estimation of LV volumes, LVEF,LV mass and shape as (described in the respectivesections above) to follow LV remodeling induced byphysiologic and pathologic stimuli. In addition,these measurements provide prognostic informa-tion incremental to that of baseline clinicaldemographics.

Quantification of the RV and RVOT

The normal right ventricle (RV) is a complexcrescent-shaped structure wrapped around theleft ventricle and is incompletely visualized inany single 2-D echocardiographic view. Thus,accurate assessment of RV morphology and func-tion requires integration of multiple echocardio-graphic views, including the parasternal long andshort-axis views, the RV inflow view, the apicalfour-chamber and the subcostal views. Whilemultiple methods for quantitative echocardio-graphic RV assessment have been described, inclinical practice assessment of RV structure andfunction remains mostly qualitative. Nevertheless,numerous studies have recently emphasized theimportance of RV function in the prognosis ofa variety of cardio-pulmonary diseases suggestingthat more routine quantification of RV functionis warranted under most clinical circumstances.

Compared to the left ventricle, the right ven-tricle is a thin-walled structure under normalconditions. The normal right ventricle is accus-tomed to a low pulmonary resistance and hencelow afterload; thus, normal RV pressure is low andright ventricular compliance high. The right ven-tricle is therefore sensitive to changes in after-load, and alterations in RV size and function areindicators of increased pulmonary vascular resis-tance and load transmitted from the left-sidedchambers. Elevations in RV afterload in adults aremanifested acutely by RV dilatation and chroni-cally by concentric RV hypertrophy. In addition,intrinsic RV abnormalities, such as infarction or RVdysplasia82 can cause RV dilatation or reduced RVwall thickness. Thus, assessment of RV size andwall thickness is integral to the assessment of RVfunction.

Right ventricular free wall thickness, normallyless than 0.5 cm, is measured using either M-modeor 2-D imaging. Although RV free wall thickness canbe assessed from the apical and parasternal long-axis views, the subcostal view measured at thepeak of the R wave at the level of the tricuspidvalve chordae tendinae provides less variationand closely correlates with RV peak systolic pres-sure (Fig. 10).75 Care must be taken to avoid over


measurement due to the presence of epicardial fatdeposition as well as coarse trabeculations withinthe right ventricle.

Qualitative assessment of RV size is easilyaccomplished from the apical four-chamber view(Fig. 11). In this view, RV area or mid cavity diam-eter should be smaller than that of the left ventri-cle. In cases of moderate enlargement, the RVcavity area is similar to that of the LV and it mayshare the apex of the heart. As RV dilation prog-resses, the cavity area will exceed that of the LVand the RV will be ‘‘apex forming’’. Quantitativeassessment of RV size is also best performed inthe apical four-chamber view. Care must be takento obtain a true non-foreshortened apical four-chamber view, oriented to obtain the maximumRV dimension, prior to making these measure-ments. Measurement of the mid-cavity and basalRV diameter in the apical four-chamber view atend-diastole is a simple method to quantify RVsize (Fig. 11). In addition, RV longitudinal diameter

Figure 10 Methods of measuring right ventricular wallthickness (arrows) from an M-mode echo (left) and asubcostal transthoracic echo (right).

can be measured from this view. Table 7 providesnormal RV dimensions from the apical four-cham-ber view.76,80,83

Right ventricular size may be assessed may beassessed with TEE in the mid-esophageal four-chamber view (Fig. 12). The mid-esophagealfour- chamber view, which generally parallelswhat is obtainable from the apical four-chamberview, should originate at the mid-left atrial leveland pass through the LV apex with the multiplaneangle adjusted to maximize the tricuspid annulusdiameter, usually between 10 and 20 degrees.

Right ventricular systolic function is generallyestimated qualitatively in clinical practice. Whenthe evaluation is based on a qualitative assess-ment, the displacement of the tricuspid annulusshould be observed. In systole, the tricuspidannulus will normally descend toward the apex1.5e2.0 cm. Tricuspid annular excursion of lessthan 1.5 cm has been associated with poor progno-sis in a variety of cardiovascular diseases.84 Al-though a number of techniques exist for accuratequantitation, direct calculation of RV volumesand ejection fraction remains problematic giventhe complex geometry of the right ventricle andthe lack of standard methods for assessing RVvolumes. Nevertheless, a number of echocardio-graphic techniques may be used to assess RV func-tion. Right ventricular fractional area change (FAC)measured in the apical four-chamber view is a sim-ple method for assessment of RV function that hascorrelated with RV ejection fractions measured byMRI (r ¼ 0.88) and has been related to outcome ina number of disease states.81,85 Normal RV areasand fractional area changes are shown in Table 8.Additional assessment of the RV systolic functionincludes tissue imaging of tricuspid annular

Figure 11 Mid right-ventricular diameter measured in the apical four-chamber view at level of left ventricularpapillary muscles.

96 R.M. Lang et al.

Table 7 Reference limits and partition values of right ventricular and pulmonary artery size76

Referencerange

Mildlyabnormal

Moderatelyabnormal

Severelyabnormal

RV dimensionsBasal RV diameter (RVD#1) (cm) 2.0e2.8 2.9e3.3 3.4e3.8 �3.9Mid RV diameter (RVD#2) (cm) 2.7e3.3 3.4e3.7 3.8e4.1 �4.2Base-to-apex length (RVD#3) (cm) 7.1e7.9 8.0e8.5 8.6e9.1 �9.2

RVOT diametersAbove aortic valve (RVOT#1) (cm) 2.5e2.9 3.0e3.2 3.3e3.5 �3.6Above pulmonic valve (RVOT#2) (cm) 1.7e2.3 2.4e2.7 2.8e3.1 �3.2

PA diameterBelow pulmonic valve (PA#1) (cm) 1.5e2.1 2.2e2.5 2.6e2.9 �3.0

velocity or right ventricular index of myocardialperformance (Tei Index).86

The RV outflow tract (RVOT) extends from theanterosuperior aspect of the right ventricle to thepulmonary artery, and includes the pulmonaryvalve. It is best imaged from the parasternallong-axis view angled superiorly, and the para-sternal short-axis at the base of the heart. It canadditionally be imaged from the subcostal long andtransverse windows as well as the apical window.Measurement of the RV outflow tract is mostaccurate from the parasternal short-axis (Fig. 13)just proximal to the pulmonary valve. Mean RVOTmeasurements are shown in Table 7.75 With TEE,the mid-esophageal RV inflow-outflow view usuallyprovides the best image of the RVOT just proximalto the pulmonary valve (Fig. 14).

Quantification of LA/RA size

The left atrium (LA) fulfills three major physiologicroles that impact on LV filling and performance.

The left atrium acts as a contractile pump thatdelivers 15e30% of the LV filling, as a reservoir thatcollects pulmonary venous return during ventricu-lar systole and as a conduit for the passage ofstored blood from the LA to the LV during earlyventricular diastole.87 Increased left atrial size isassociated with adverse cardiovascular outcom-es.88e90 An increase in atrial size most commonlyis related to increased wall tension due to in-creased filling pressure.91,92 Although increasedfilling volumes can cause an increase in LA size,the adverse outcomes associated with increaseddimension and volume are more strongly associ-ated with increased filling pressure. Relationshipsexist between increased left atrial size and the in-cidence of atrial fibrillation and stroke,93e101 riskof overall mortality after MI,102,103 and the risk ofdeath and hospitalization in subjects with dilatedcardiomyopathy.104e108 LA enlargement is a markerof both the severity and chronicity of diastolicdysfunction and magnitude of LA pressureelevation.88,91,92

Figure 12 Transesophageal echo measurements of right ventricular diameters from the mid-esophageal four-chamber view, best imaged after optimizing the maximum obtainable RV size by varying angles from approximately0e20 degrees.


Table 8 Reference limits and partition values of right ventricular size and function as measured in the apicalfour-chamber view 80

Referencerange

Mildlyabnormal

Moderatelyabnormal

Severelyabnormal

RV diastolic area (cm2) 11e28 29e32 33e37 �38RV systolic area (cm2) 7.5e16 17e19 20e22 �23RV fractional area change (%) 32e60 25e31 18e24 �17

The LA size is measured at the end-ventricularsystole when the LA chamber is at its greatestdimension. While recording images for computingLA volume, care should be taken to avoid fore-shortening of the LA. The base of the LA should beat its largest size indicating that the imaging planepasses through the maximal short-axis area. TheLA length should also be maximized ensuringalignment along the true long-axis of the LA.When performing planimetry the LA, the conflu-ences of the pulmonary veins and LA appendageshould be excluded.

With TEE, the LA frequently cannot fit in itsentirety into the image sector. Measurements of LAvolume from this approach cannot be reliablyperformed however; LA dimension can be

estimated combining measurements from differ-ent imaging planes.

LA linear dimension

The LA can be visualized from multiple echocar-diographic views from which several potential LAdimensions can be measured. However, the largevolume of prior clinical and research work used theM-mode or 2-D derived anteroposterior (AP) lineardimension obtained from the parasternal long-axisview making this the standard for linear LAmeasurement (Fig. 15).93,95,96,98,104,105 The con-vention for M-mode measurement is to measurefrom the leading edge of the posterior aortic wallto the leading edge of the posterior LA wall.

Figure 13 Measurement of the right ventricular outflow tract diameter at the subpulmonary region (RVOT1) and atthe pulmonic valve annulus (RVOT2), in the mid-esophageal aortic valve short axis view, using a multiplane angle ofapproximately 45e70 degrees.

98 R.M. Lang et al.

Figure 14 Measurement of the right ventricular outflow tract at the pulmonic valve annulus (RVOT2), and at andmain pulmonary artery from the midesophageal RV inflow-outflow view.

However, to avoid the variable extent of spacebetween the LA and aortic root, the trailing edgeof the posterior aortic is recommended.

Although these linear measurements have beenshown to correlate with angiographic measure-ments and have been widely used in clinicalpractice and research, they inaccurately representtrue LA size.109,110 Evaluation of the LA in the APdimension assumes that a consistent relationshipis maintained between the AP dimension and allother LA dimensions as the atrium enlarges, whichis often not the case.111,112 Expansion of the leftatrium in the AP dimension may be constrainedby the thoracic cavity between the sternumand the spine. Predominant enlargement in thesuperior-inferior and medial-lateral dimensionswill alter LA geometry such that the AP dimensionmay not be representative of LA size. For thesereasons, AP linear dimensions of the left atriumas the sole measure of left atrial size may be mis-leading and should be accompanied by left atrialvolume determination in both clinical practiceand research.

LA volume measurements

When LA size is measured in clinical practice,volume determinations are preferred over lineardimensions because they allow accurate assess-ment of the asymmetric remodeling of the LAchamber.111 In addition, the strength of therelationship between cardiovascular disease isstronger for LA volume than for LA linear dimen-sions.97,113 Echocardiographic measures of LA vol-ume have been compared with cine-computedtomography, biplane contrast ventriculographyand MRI.109,114e116 These studies have showneither good agreement or a tendency for echocar-diographic measurements to underestimate com-parative LA volumes.

The simplest method for estimating LA volume isthe cube formula, which assumes that the LAvolume is that of a sphere with a diameter equalto the LA antero-posterior dimension. However,this method has proven to be inferior to othervolume techniques.109,111,117 Left atrial volumesare best calculated using either an ellipsoid modelor Simpson’s rule.88,89,97,101,102,109e111,115e117

The ellipsoid model assumes that the LA can beadequately represented as a prolate ellipse witha volume of 4p/3(L/2)(D1/2)(D2/2), where L is thelong-axis (ellipsoid) and D1 and D2 are orthogonalshort-axis dimensions. LA volume can be estimatedusing this biplane dimension-length formula bysubstituting the LA antero-posterior diameteracquired from the parasternal long-axis as D1, LAmedial-lateral dimension from the parasternalshort-axis as D2 and the LA long-axis from the apicalfour-chamber for L.117e119 Simplified methodsusing non-orthogonal linear measurements for

Figure 15 Measurement of left atrial diameter (LAD)from M-mode, guided by a parasternal short axis image(upper right) at the level of the aortic valve. This linearmethod is not recommended.


estimation of LA volume have been proposed.113

Volume determined using linear dimensions isvery dependent on careful selection of the loca-tion and direction of the minor axis dimensionsand has been shown to significantly underestimateLA volume.117

In order to estimate the LA minor axis dimensionof the ellipsoid more reliably, the long-axis LA areascan be traced and a composite dimension derived.This dimension takes into account the entire LAborder, rather than a single linear measurement.When long-axis-area is substituted for minor axisdimension, the biplane areaelength formula isused: 8(A1)(A2)/3p(L), where A1 and A2 representthe maximal planimetered LA area acquired fromthe apical four- and two-chamber-views, respec-tively. The length (L) remains the LA long-axislength determined as the distance of the perpen-dicular line measured from the middle of the planeof the mitral annulus to the superior aspect of theleft atrium (Fig. 16). In the areaelength formulathe length (L) is measured in both the four- andtwo-chamber views and the shortest of these twoL measurements is used in the formula.

The areaelength formula can be computed froma single plane, typically the apical four-chamber,by assuming A1 ¼A2, such that volume ¼ 8(A1)

2/3p(L).120 However, this method makes geometricassumptions that may be inaccurate. In older sub-jects the diaphragm lifts the cardiac apex upwardwhich increases the angle between ventricle andatrium. Thus the apical four-chamber view willcommonly intersect the atria tangentially in oldersubjects and result in underestimation of volumeusing a single plane technique. Since the majorityof prior research and clinical studies have used thebiplane areaelength formula, it is the recommen-ded ellipsoid method (Figs. 15 and 16).

LA volumemay also bemeasured using Simpson’srule, similar to its application for LV measure-ments, which states that the volume of a geomet-rical figure can be calculated from the sum of thevolumes of smaller figures of similar shape. Mostcommonly, Simpson’s algorithm divides the LA intoa series of stacked oval disks whose height is h andwhose orthogonal minor and major axes are D1 andD2 (method of disks). The volume of the entireleft atrium can be derived from the sum of the

Figure 16 Measurement of left atrial volume from the areaelength method using the apical four-chamber (A4C) andapical two-chamber (A2C) views at ventricular end-systole (maximum LA size). The length (L) is measured from theback wall to the line across the hinge points of the mitral valve. The shorter (L) from either the A4C or A2C isused in the equation.

100 R.M. Lang et al.

volume of the individual disks. Volume ¼ p/4(h)

P(D1)(D2). The formula is integrated with the

aid of a computer and the calculated volumeprovided by the software package online (Fig. 17).

The use of the Simpson’s method in this wayrequires the input of biplane LA planimetry toderive the diameters. Optimal contours should beobtained orthogonally around the long-axis of theleft atrium using TTE apical views. Care should betaken to exclude the pulmonary veins from the LAtracing. The inferior border should be representedby the plane of the mitral annulus. A single planemethod of disks could be used to estimate LAvolume by assuming the stacked disks are circularV ¼ p/4(h)

P(D1).

2 However, as noted above, thismakes the assumption that the LA width in the api-cal two- and four-chamber are identical, which isoften not the case and therefore this formula isnot preferred.

Three-dimensional echocardiography shouldprovide the most accurate evaluation of LA volumeand has shown promise, however to date noconsensus exists on the specific method that shouldbe used for data acquisition and there is nocomparison with established normal values.121e123

Normal values of LA measurements

The non-indexed LA linear measurements aretaken from a Framingham Heart Study cohort of

1099 subjects between the ages of 20 and45 years old who were not obese, were of averageheight and were without cardiovascular disease(Table 9).11 Slightly higher values have beenreported in a cohort of 767 subjects withoutcardiovascular disease in which obesity and heightwere not exclusion criteria.113 Both body sizeand aging have been noted to influence LAsize.10,87,113 There are also gender differences inLA size, however, these are nearly completely ac-counted for by variation in body size.87,113,120,124

The influence of subject size on LA size is typicallycorrected by indexing to some measure of bodysize. In fact, from childhood onward the indexedatrial volume changes very little.125 Several index-ing methods have been proposed, such as height,weight, estimated lean body mass and body sur-face area.10,113 The most commonly used conven-tion, and that recommended by this committee,is indexing LA size by dividing by body surfacearea.

Normal indexed LA volume has been determinedusing the preferred biplane techniques (areaelength or method of disks) in a number of studiesinvolving several hundred patients to be22 G 6 ml/m2.88,120,126,127 Absolute LA volume hasalso been reported however in clinical practiceindexing to body surface area accounts for varia-tions in body size and should therefore be used.As cardiac risk and LA size are closely linked,

Figure 17 Measurement of left atrial volume from the biplane method of discs (modified Simpson’s rule), using theapical four-chamber (A4C) and apical two-chamber (A2C) views at ventricular end-systole (maximum LA size).


Table

9Reference


luesforleft

atrialdim

ensions/vo

lumes

Women

Men

Reference

Range

Mildly

Abnorm

al

Moderately

Abnorm

al

Seve

rely

Abnorm

al

Reference

Range

Mildly

Abnorm

al

Moderately

Abnorm

al

Seve

rely

Abnorm

al

Atrialdim

ensions

LAdiameter(cm)

2.7e

3.8

3.9e4.2

4.3e

4.6

�4.7

3.0e

4.0

4.1e4.6

4.7e

5.2

�5.2

LAdiameter/BSA

(cm/m

2)

1.5e

2.3

2.4e2.6

2.7e

2.9

�3.0

1.5e

2.3

2.4e2.6

2.7e

2.9

�3.0

RAminoraxisdim

ension(cm)

2.9e

4.5

4.6e4.9

5.0e

5.4

�5.5

2.9e

4.5

4.6e4.9

5.0e

5.4

�5.5

RAminoraxisdim

ension/B

SA(cm/m

2)

1.7e

2.5

2.6e2.8

2.9e

3.1

�3.2

1.7e

2.5

2.6e2.8

2.9e

3.1

�3.2

Atrialarea

LAarea(cm

2)

�20

20e30

30e40

>40

�20

20e30

30e40

>40

Atrialvo

lumes

LAvo

lume(m

l)22

e52

53e62

63e72

�73

18e58

59e68

69e78

�79

LAvo

lume/B

SA(m

l/m

2)

22G

629e33

34e39

‡40

22G

629e33

34e39

‡40

Valuesin

bold

are

reco

mmendedandbest

validated.

more importantly than simply characterizing thedegree of LA enlargement, normal referencevalues for LA volume allow prediction of cardiacrisk. There are now multiple peer reviewed arti-cles which validate the progressive increase inrisk associated with having LA volumes greaterthan these normative values.89,97,99e103,106e108,128

Consequently, indexed LA volume measurementsshould become a routine laboratory measure sinceit reflects the burden and chronicity of elevated LVfilling pressure and is a strong predictor ofoutcome.

Right atrium

Much less research and clinical data are availableon quantifying right atrial size. Although the RAcan be assessed from many different views, quan-tification of RA size is most commonly performedfrom the apical four-chamber view. The minor axisdimension should be taken in a plane perpendicu-lar to the long-axis of the RA and extends from thelateral border of the RA to the interatrial septum.Normative values for the RA minor axis are shownin Table 9.80,129 Although RA dimension may varyby gender, no separate reference values for maleand females can be recommended at this time.

Although, limited data are available for RAvolumes, assessment of RA volumes would bemore robust and accurate for determination ofRA size than linear dimensions. As there are nostandard orthogonal RA views to use an apicalbiplane calculation, the single plane areaelengthand method of discs formulae have been applied toRA volume determination in several small stud-ies.120,130,131 We believe there is too little peer re-viewed validated literature to recommend normalRA volumetric values at this time. However, lim-ited data on small number of normal subjectsrevealed that indexed RA volumes are similar toLA normal values in men (21 ml/m2) but appearto be slightly smaller in women.120

Quantification of the aorta and IVC

Aortic measurements

Recordings should be made from the parasternallong-axis acoustic window to visualize the aorticroot and proximal ascending aorta. Two-dimen-sional images should be used to visualize the LVoutflow tract and the aortic root should be re-corded in different views in varying intercostalspaces and at different distances from the leftsternal border. Right parasternal views, recorded


with the patient in a right lateral decubitusposition are also useful. Measurements are usuallytaken at: (1) aortic valve annulus (hinge point ofaortic leaflets); (2) the maximal diameter in thesinuses of Valsalva; and (3) sinotubular junction(transition between the sinuses of Valsalva and thetubular portion of the ascending aorta).

Views used for measurement should be thosethat show the largest diameter of the aortic root.When measuring the aortic diameter, it is partic-ularly important, to use the maximum obtainableshort-axis diameter measured perpendicular to thelong-axis of the vessel in that view. Some expertsfavor inner edge-to-inner edge techniques tomatch those used by other methods of imagingthe aorta, such as MRI and CT scanning. Howeverthe normative data for echocardiography wereobtained using the leading edge technique(Fig. 18). Advances in ultrasound instrumentationwhich have resulted in improved image resolutionshould minimize the difference between thesemeasurement methods.

Reliability of aortic root measurements bythis method yielded an intra-class correlationcoefficient of 0.79 (p < 0.001) in a study of 183hypertensive patients (unpublished data). Two-dimensional aortic diameter measurements arepreferable to M-mode measurements, as cyclicmotion of the heart and resultant changes inM-mode cursor location relative to the maximumdiameter of the sinuses of Valsalva result insystematic underestimation (by w2 mm) of aorticdiameter by M-mode in comparison to the 2-Daortic diameter.132 The aortic annular diameter ismeasured between the hinge points of the aorticvalve leaflets (inner edgeeinner edge) in the para-sternal or apical long-axis views that reveal thelargest aortic annular diameter with color flow

mapping to clarify tissueeblood interfaces ifnecessary.132

The thoracic aorta can be better imaged usingTEE than, as most of it is in the near field of thetransducer. The ascending aorta can be seen inlong-axis, using the mid-esophageal aortic valvelong-axis view at about 130 degrees and the mid-esophageal ascending aorta long-axis view. Theshort-axis view of the ascending aorta is obtainedusing the mid-esophageal views at about 45 de-grees. For measurements of the descending aorta,short-axis views at about 0 degrees, and long-axisviews at about 90 degrees, can be recorded fromthe level of the diaphragm up to the aortic arch(Fig. 19). The arch itself and origins of two of thegreat vessels can be seen in most patients. Thereis a ‘‘blind spot’’ in the upper ascending aortaand the proximal arch that is not seen by TEEdue to the interposed tracheal bifurcation.

Identification of aortic root dilatation

Aortic root diameter at the sinuses of Valsalva isrelated most strongly to body surface area andage. Therefore, body surface area may be used topredict aortic root diameter in three age-strata:<20 years, 20e40 and >40 years, by publishedequations.132 Aortic root dilatation at the sinusesof Valsalva is defined as an aortic root diameterabove the upper limit of the 95% confidence inter-val of the distribution in a large reference popula-tion.132 Aortic dilatation can be easily detected byplotting observed aortic root diameter versus bodysurface area on previously-published nomograms(Fig. 20).132 Aortic dilatation is strongly associatedwith the presence and progression of aortic regur-gitation133 and with the occurrence of aorticdissection.134 The presence of hypertension

Figure 18 Measurement of aortic root diameters at the aortic valve annulus (AV ann) level, the sinuses of Valsalva(Sinus Val), and the Sino-tubular junction (ST J � n) from the mid-esophageal long axis view of the aortic valve, usu-ally at an angle of approximately 110e150 degrees. The annulus is measured by convention at the base of the aorticleaflets. Although leading edge to leading edge technique is demonstrated for the sinuses of Valsalva and sinotubularjunction, some prefer the inner edge to inner edge method (see text for further discussion).


Figure 19 Measurement of aortic root diameter at the sinuses of Valsava from 2-D parasternal long-axis image.Although leading edge to leading edge technique is shown, some prefer the inner edge to inner edge method(see text for further discussion).

appears to have minimal impact on aortic rootdiameter at the sinuses of Valsalva133,135 but isassociated with enlargement of more distal aorticsegments.135

Evaluation of the inferior vena cava

Examination of the inferior vena cava (IVC) fromthe subcostal view should be included as part ofthe routine TTE examination. It is generally agreedthat the diameter of the inferior vena cava shouldbe measured with the patient in the left decubitusposition at 1.0e2.0 cm from the junction with theright atrium, using the long-axis view. For accu-racy, this measurement should be made perpen-dicular to the IVC long-axis. The diameter of the

inferior vena cava decreases in response to inspira-tion when the negative intrathoracic pressureleads to an increase in right ventricular fillingfrom the systemic veins. The diameter of the IVCand the percent decrease in the diameter duringinspiration correlate with right atrial pressure.The relationship has been called the ‘‘collapsibil-ity index’’.136 Evaluation of the inspiratory re-sponse often requires a brief ‘‘sniff’’ as normalinspiration may not elicit this response.

The normal IVC diameter is <1.7 cm. There isa 50% decrease in the diameter when the rightatrial pressure is normal (0e5 mmHg). A dilatedIVC (>1.7 cm) with normal inspiratory collapse(�50%) is suggestive of a mildly elevated RA pres-sure (6e10 mmHg). When the inspiratory collapse

Figure 20 95% confidence intervals for aortic root diameter at the sinuses of Valsalva based on body surface area in:children and adolescents (A), adults aged 20e39 years (B), and adults aged 40 years or more (C).132


is <50%, the RA pressure is usually between 10 and15 mmHg. Finally, a dilated IVC without any col-lapse suggests a markedly increased RA pressureof >15 mmHg. In contrast, a small IVC (usually<1.2 cm) with spontaneous collapse often is seenin the presence of intravascular volumedepletion.137

There are several additional conditions to beconsidered in evaluating the inferior vena cava.Athletes have been shown to have dilated inferiorvena cavae with normal collapsibility index. Stud-ies137,138 have found that the mean IVC diameter inathletes was 2.31 G 0.46 compared to 1.14 G 0.13in aged-matched normals. The highest diameterswere seen in highly trained swimmers.

One study showed that a dilated IVC in themechanically ventilated patient did not alwaysindicate a high right atrial pressure. However,a small IVC (<1.2 cm) had a 100% specificity fora RA pressure of less than 10 mmHg with a low sen-sitivity.139 A more recent study suggested thatthere was a better correlation when the IVC diam-eter was measured at end-expiration and end-diastole using M-mode echocardiography.140

The use of the inferior vena cava size anddynamics is encouraged for estimation of the rightatrial pressure. This estimate should be used inestimation of the pulmonary artery pressure basedon the tricuspid regurgitant jet velocity.

Acknowledgments

The authors wish to thank Harvey Feigenbaum,MD, and Nelson B. Schiller for their careful reviewand thoughtful comments.

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