Normal Values of TTE

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

Left Ventricle

Left Ventricular Systolic Function

Reference limits and values and partition values of left ventricular function[1]

	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

Practical approach to LV diastolic function grading. Ater [2]

Normal values for Doppler-derived diastolic measurements[2]

	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

Reference limits and partition values of left ventricular mass and geometry[1]

	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

Reference limits and partition values of left ventricular size[1]

	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

Right Ventricular and Pulmonary Artery Size

Reference limits and partition values of right ventricular and pulmonary artery size[1]

	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

Reference limits and partition values of right ventricular size and function as measured in the apical 4-chamber view[1]

	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[1]	1.3-1.5[4]	1.0-1.2[4]	<1.0[4]
RV, Right ventricular. Data from Weyman.[5]

Atria

Left Atrial Dimensions / Volumes

Reference limits and partition values for left atrial dimensions/volumes[1]

	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

Estimation of left atrial pressure in normal LVEF. After [2]

Estimation of left atrial pressure in reduced LVEF. After [2]

Aortic Valve

Aortic valve stenosis - severity

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

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

Mitral regurgitation - severity

Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity[9]

	Mild	Moderate		Severe
Specific signs of severity	Small central jet <4 cm2 or <20% of LA areaψ Vena contracta width <0.3 cm No or minimal flow convergence	Signs of MR>mild present, but no criteria for severe MR		Vena contracta width ≥ 0.7cm with large central MR jet (area < 40% of LA) or with a wall-impinging jet of any size, swirling in LAψ Large flow convergenceς Systolic reversal in pulmonary veins Prominent flail MV leaflet or ruptured papillary muscle
Supportive signs	Systolic dominant flow in pulmonary veins A-wave dominant mitral inflowΦ Soft density, parabolic CW Doppler MR signal Normal LV size∗	Intermediate signs/findings		Dense, triangular CW Doppler MR jet E-wave dominant mitral inflow (E >1.2 m/s)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

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

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

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

Tricuspid regurgitation - severity

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

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

Pulmonary regurgitaion - severity

Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity[9]

Parameter	Mild	Moderate	Severe
Pulmonic valve	Normal	Normal or abnormal	Abnormal
RV size	Normal∗	Normal or dilated	Dilated
Jet size by color Doppler§	Thin (usually < 10 mm in length) with a narrow origin	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

Grading of pulmonary stenosis[6]

	Mild	Moderate	Severe
Peak velocity (m/s)	<3	3-4	>4
Peak gradient (mmHg)	<36	36-64	>64

References

Click on the reference to link directly to the manuscript <biblio>

1. Foale pmid=3730205
2. Weyman isbn=0812112075
3. ASE pmid=16458610
4. ASEVS pmid=19130998
5. Wilkins pmid=3190958
6. ESCAS pmid=17259184
7. ACCAS pmid=18848134
8. ASERE pmid=12835667
9. ASEDF pmid=19187853
10. Hamer isbn=9031362352

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