Left ventricle

Left ventricle (Size)

Male Female

Normal Mildly Moderately Severely Normal Mildly Moderately Severely

range abnormal abnormal abnormal range abnormal abnormal abnormal

LVIDd (cm)
Left ventricular
4,2 - 5,8 5,9 - 6,3 6,4 - 6,8 >6,8 3,8 - 5,2 5,3 - 5,6 5,7 - 6,1 >6,1
internal dimension at
end-diastole

LVIDd (cm/m2)
Left ventricular
internal dimension at
2,2 - 3,0 3,1 - 3,3 3,4 - 3,6 >3,6 2,3 - 3,1 3,2 - 3,4 3,5 - 3,7 >3,7
end-diastole

LVIDs (cm)
Left ventricular
internal dimension at
2,5 - 4,0 4,1 - 4,3 4,4 - 4,5 >4,5 2,2 - 3,5 3,6 - 3,8 3,9 - 4,1 >4,1
end-systole

LVIDs (cm/m2)
Left ventricular
1,3 - 2,1 2,2 - 2,3 2,4 - 2,5 >2,5 1,3 - 2,1 2,2 - 2,3 2,4 - 2,6 >2,6
internal dimension at
end-systole

IVSd (cm)
Interventricular
septum thickness at
0,6 - 1,0 1,1 - 1,3 1,4 - 1,6 >1,6 0,6 - 0,9 1,0 - 1,2 1,3 - 1,5 >1,5
end-diastole

PWd (cm)
Left ventricular
posterior wall 0,6 - 1,0 1,1 - 1,3 1,4 - 1,6 >1,6 0,6 - 0,9 1,0 - 1,2 1,3 - 1,5 >1,5
thickness at end-
diastole

RWT
Relative wall 0,24 - 0,42 0,43 - 0,46 0,47 - 0,51 >0,52 0,22 - 0,42 0,43 - 0,47 0,48 - 0,52 >0,53
thickness

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Left ventricle (Mass)

Male Female

Normal Mildly Moderately Severely Normal Mildly Moderately Severely

range abnormal abnormal abnormal range abnormal abnormal abnormal

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 LV mass (g)
88 - 224 225 - 258 259 - 292 >292 67 - 162 163 - 186 187 - 210 >210
Left ventricular mass

LV mass (g/m2)
49 - 115 116 - 131 132 - 148 >148 43 - 95 96 - 108 109 - 121 >121
Left ventricular mass

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Left ventricle (Volume)

Male Female

Normal Mildly Moderately Severely Normal Mildly Moderately Severely

range abnormal abnormal abnormal range abnormal abnormal abnormal

LVEDV (ml)
Left ventricular end-diastole 62 - 150 151 - 174 175 - 200 >200 46 - 106 107 - 120 121 - 130 >130
volume (Biplane)

LVEDV (ml/m2)
Left ventricular end-diastole 34 - 74 75 - 89 90 - 100 >100 29 - 61 62 - 70 71 - 80 >80
volume (Biplane)

LVESV (ml)
Left ventricular end-systole 21 - 61 62 - 73 74 - 85 >85 14 - 42 43 - 55 56 - 67 >67
volume (Biplane)

LVESV (ml/m2)
Left ventricular end-systole 11 - 31 32 - 38 39 - 45 >45 8 - 24 25 - 32 33 - 40 >40
volume (Biplane)

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Left ventricle (Ejection fraction)

Male Female

Normal Mildly Moderately Severely Normal Mildly Moderately Severely

range abnormal abnormal abnormal range abnormal abnormal abnormal

LV EF (%)
Left ventricular ejection 52 - 72 41 - 51 30 - 40 <30 54 - 74 41 - 53 30 - 40 <30
fraction (Biplane)

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

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 What is ‘normal’ left ventricular ejection fraction? (heart.bmj.com)

Left ventricle (Geometry)

LV mass(g/m2) RWT
Relative wall
Left ventricular mass
thickness

Normal left ≤115 ≤95

<0,42
ventricle (Male) (Female)

Concentric >115 >95

>0,42
hypertrophy (Male) (Female)

Eccentric >115 >95

<0,42
hypertrophy (Male) (Female)

Concentric ≤115 ≤95

>0,42
remodeling (Male) (Female)

Description of LV geometry, using at the minimum the four categories of normal geometry, concentric remodelling,
and concentric and eccentric hypertrophy, should be a standard component of the echocardiography report.

Recommendations on the use of echocardiography in adult hypertension: a report from the EACVI and the ASE (2015)

Left ventricle (Geometry)

LVEDV(ml/m2) LV mass(g/m2) RWT

Left ventricular mass Relative wall thickness

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 Left ventricular end-
diastole volume (Biplane)

Normal left ventricle ≤75 ≤115 (Male) ≤95 (Female) 0,32-0,42

Physiological hypertrophy >75 >115 (Male) >95 (Female) 0,32-0,42

Concentric remodeling ≤75 ≤115 (Male) ≤95 (Female) >0,42

Eccentric remodelling >75 ≤115 (Male) ≤95 (Female) <0,32

Concentric hypertrophy ≤75 >115 (Male) >95 (Female) >0,42

Mixed hypertrophy >75 >115 (Male) >95 (Female) >0,42

Dilated hypertrophy >75 >115 (Male) >95 (Female) 0,32-0,42

Eccentric hypertrophy >75 >115 (Male) >95 (Female) <0,32

Recommendations on the use of echocardiography in adult hypertension: a report from the EACVI and the ASE (2015)

RWT = 0,42

RWT = 0,32
Mixed Dilated
hypertrophy hypertrophy
Concentric
hypertrophy
LV mass (g/m2)

Physiological Eccentric
hypertrophy hypertrophy

Concentric
remodeling
Normal LV
Eccentric
remodeling

LVEDV (ml/m2)

The red horizontal line separates LV hypertrophy from normal LV mass.

The black vertical line separates dilated from nondilated ventricles.
The two oblique blue lines delimit the upper (0.42) and lower (0.32) limit of normal RWT.
This leads to eight categories of ventricles.
The green ellipse indicates the area of normal ventricles including physiological LV enlargement.

Recommendations on the use of echocardiography in adult hypertension: a report from the EACVI and the ASE (2015)

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 Left ventricular diastolic function
Normal ejection fraction Abnormal ejection fraction
(male >52%, female >54%) or myocardial disease

1. MV E/e´ >14
2. Septal e´ <7cm/s or
1 positive Lateral e´ <10cm/s 3, 4 positive
3. Vmax TR >2,8m/s
4. LA volume >34ml/m2

2 positive

Normal diastolic Diastolic

Indeterminate
function dysfunction

Mitral inflow

E/A ≤0.8 + E >50 cm/s

E/A ≤0.8 + E ≤50 cm/s or E/A ≥2
E/A >0.8 - <2

1. MV E/e´ >14
2/3 or 3/3 2/3 or 3/3
2. Vmax TR >2,8m/s
negative positive
3. LA volume >34ml/m2

Only 2 criteria available1

1 positive and
2 negative 2 positive
1 negative

Grade I diastolic Cannot determine Grade II diastolic Grade III diastolic

dysfunction LAP and diastolic dysfunction dysfunction
Normal LAP dysfunction grade ↑ LAP ↑ LAP

If symptomatic

Consider CAD, or
proceed to diastolic
stress test

1. LAP indeterminate if only 1 of 3 parameters available. Pulmonary vein S/D ratio <1 applicable to conclude elevated LAP in patients
with depressed LV EF.

Recommendations for the Evaluation of LV Diastolic Function by Echocardiography: An Update from the ASE and EACVI (2016)

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 Assessment of LV filling pressures in special populations

Disease Echocardiographic measurements and cutoff values

Peak acceleration rate of mitral E velocity (≥1,900 cm/sec 2)

IVRT (≤65 msec)
Atrial fibrillation DT of pulmonary venous diastolic velocity (≤220 msec)
E/Vp ratio (≥1.4)
Septal E/e´ ratio (≥11)

Mitral inflow pattern with predominant early LV filling in patients with EFs <50%
IVRT ≤70 msec is specific (79%)
Pulmonary vein systolic filling fraction ≤40% is specific (88%)
Sinus tachycardia Average E/e´ >14 (this cutoff has highest specificity but low sensitivity)
When E and A velocities are partially or completely fused, the presence of a
compensatory period after premature beats often leads to separation of E and A
velocities which can be used for assessment of diastolic function

Average E/e´ (>14)

Hypertrophic Ar-A (≥30 msec)
cardiomyopathy TR peak velocity (>2.8 m/sec)
LA volume (>34 mL/m2).

DT (<140 msec)
Restrictive Mitral E/A (>2.5)
cardiomyopathy IVRT (<50 msec has high specificity)
Average E/e´ (>14)

Lateral E/e´ can be applied to determine whether a cardiac etiology is the

Noncardiac pulmonary underlying reason for the increased pulmonary artery pressures
hypertension When cardiac etiology is present, lateral E/e´ is >13, whereas in patients with
pulmonary hypertension due to a noncardiac etiology, lateral E/e´ is <8

IVRT (<60 msec has high specificity)

Mitral stenosis IVRT/TE-e´ (<4.2)
Mitral A velocity (>1.5 m/sec)

Ar-A (≥30 msec)

IVRT (<60 msec has high specificity)
Mitral regurgitation IVRT/TE-e´ (<5.6) may be applied for the prediction of LV filling pressures in patients
with MR and normal EFs
Average E/e´ (>14) may be considered only in patients with depressed EFs

Recommendations for the Evaluation of LV Diastolic Function by Echocardiography: An Update from the ASE and EACVI (2016)

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 Hypertrophic cardiomyopathy

1 - Averate E/e´ ratio >14

1 - Presence of a restrictive filling pattern
2 - LA volume >34ml/m2 2 - Abnormallz reduced mitral annular e´ velocity
3 - Pulmonary vein atrial reversal velocity Ar-A ≥30ms (Septal e´ <7cm/s, Lateral e´ <10cm/s)
4 - Peak TR jet velocity (CW) >2.8m/s

<50% positive >50% positive

Grade I diastolic dysfunction Grade II diastolic dysfunction

Grade III diastolic dysfunction
Normal LAP Elevated LAP

Restrictive cardiomyopathy

Early disease Constrictive pericarditis Advanced disease

Grade I-II 1 - Septal e´ > Lateral e´ 1 - DT of E velocity < 150ms

diastolic (annulus reversus) 2 - E/A >2.5
dysfunction 2 - E/e´ should not be used to 3 - IVRT <50ms
estimate LV filling pressures 4 - Average E/e´ >14, decreased
septal and lateral e´ (3-4cm/s)
5 - LA volume >50ml/m2

Grade III
diastolic dysfunction

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 Valvular heart disease

Aortic
Mitral Mitral Mitral annular
stenosis,
senosis regurgitation calcification
regurgitation

1 - Ar-A ≥ 30ms (with normal EF) 1 - Increased transmitral

Aortic stenosis:
1 - IVRT <60ms 2 - IVRT <60ms (with normal EF) velocities
Apply the GL regardless of
2 - IVRT/TT-e´ <4.2 3 - IVRT/TT-e´ <5,6 (with normal EF) 2 - Decreased e´ due to
severity, unless severe MAC
3 - Mitral A >1.5m/s 4 - Average E/e´ >14 (consider only decreased excursion
Aortic regurgitation:
in patients with depressed EF) 3 - Increase in E/e´ ratio
LA enlargement,
average E/e´ ratio >14, and
TR peak velocity >2.8m/s
support the presence of
increased LV filling pressures

Heart transplant

1 - Patients with preserved EFs and normal diastolic function commonly have restrictive appearing filling.
2 - No single diastolic parameter appears reliable enough predict graft rejection.
3 - PASP estimation using the TR jet can be helpful as a surrogate measurement of mean LAP in the absence of pulmonary disease.

Atrioventrcular block and paced

1 - In patients with first degree AV block, the variables used to evaluate diastolic function and filling pressures likely remain valid as
long as there is no fusion of mitrel E and A velocities.
2 - The accuracy of mitral annular velocities and E/e´ ratio is less in the presence of LBBB, RV pacing, and in patients who have
received cardiac resynchronization therapy.
3 -If only mitral A velocity is present, only TR peak velocity >2.8m/s can be used as an indicator of LV filling pressures.

Atrial fibrillation (with impaired EF)

1 - Peak acceleration rate of mitral E velocity (≥1900 cm/s2)

2 - IVRT (≤65ms)
3 - DT of pulmonary venous diastolic velocity (≤220ms)
4 - E/Vp ratio (≥1,4)
5 - Septal E/e´ (≥11)

Recommendations for the Evaluation of LV Diastolic Function by Echocardiography: An Update from the ASE and EACVI (2016)
ASE recommendations for the evaluation of LV diastolic function by echocardiography: Quick reference (2016)

Right ventricle

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 Right ventricle (Size)

RVD1basal
Right ventricular basal diameter at end-diastole
25 - 41mm

RVD2mid
Right ventricular mid diameter at end-diastole
19 - 35mm

RVD3long
Right ventricular longitudinal diameter at end-diastole
59 - 83mm

RVOTprox(PLAX)
20 - 30mm
Right ventricular outflow tract at proximal (PLAX)

RVOTprox(PSAX)
Right ventricular outflow tract at proximal (PSAX)
21 - 35mm

RVOTdistal(PSAX)
Right ventricular outflow tract at distal (PSAX)
17 - 27mm

PAdiameter
15 - 25mm
Main pulmonary artery diameter

RVWT
Right ventricular wall thickness
1 - 5mm

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: ASE, EACVI, ESC, CSE (2010)
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)
Guidelines for the diagnosis and management of acute pulmonary embolism ESC, ERS (2019)

Right ventricle (Area, Volume)

Male Female

RV EDA (cm2)
Right ventricular end-diastolic area
10 - 24 8 - 20

RV EDA (cm2/m2)
Right ventricular end-diastolic area
5 - 12,6 4,5 - 11,5

RV ESA (cm2)
3 - 15 3 - 11
Right ventricular end-systolic area

RV ESA (cm2/m2)
Right ventricular end-systolic area
2 - 7,4 1,6 - 6,4

RV EDV (ml/m2)
Right ventricular end-diastolic volume
35 - 87 32 - 74

RV ESV (ml/m2)
Right ventricular end-systolic volume
10 - 44 8 - 36

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

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 Right ventricle (Function)

Variable Abnormal

TAPSE
Tricuspid annular plane systolic excursion
<17mm

S’ WavepulsedTDI
Peak systolic velocity tricuspid annulus (Pulsed TDI)
<9,5cm/s

S’ WavecolorTDI
<6cm/s
Peak systolic velocity tricuspid annulus (Color TDI)

FAC
Fractional Area Change
<35%

RV EF
Right ventricular ejection fraction
<45%

RIMPTDI
Right Ventricular Index of Myocardial Performance >0,54
(TDI)

RIMPPWd
Right Ventricular Index of Myocardial Performance >0,43
(PWd)

IVARV
Myocardial acceleration during isovolumic <1,1m/s2
contraction

PVR
>3WU
Pulmonary vascular ressistance

RV dP/dt
Rate of rise of right ventricle pressure
<400mmHg/s

E/ATrV <0,8
Tricuspid valve E / A wave ratio >2

DT TrV <119ms
Tricuspid valve deceleration time >242ms

e´ waveTrV
eak velocity in early diastole of tricuspid annulus <7,8cm/s
(TDI)

e´/a´TrV
<0,52
Tricuspid valve e´ / a´ ratio (TDI)

E/e´TrV
Tricuspid valve E / e´ ratio
>6

PAAT
Pulmonary artery acceleration time
<100ms

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: ASE, EACVI, ESC, CSE (2010)

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 Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)
Guidelines for the diagnosis and management of acute pulmonary embolism ESC, ERS (2019)

Right ventricle (Pressure)

Variable Abnormal

RVSP(SPAP)
Right ventricular systolic pressure
>35mmHg

mPAP
>25mmHg
Mean pulmonar arterial pressure

PADP
Pulmonary artery diastolic pressure
>15mmHg

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: ASE, EACVI, ESC, CSE (2010)

Right ventricle (Pressure overload)

Variable Abnormal

RVOTprox(PLAX)
Right ventricular outflow tract at proximal (PLAX)
>30mm

Basal RV/LV
Basal right/left ventricle ratio
>1

D septum
D shaped septum
Yes

IVCdiameter
>2,1cm
Inferior vena cava diameter

IVCcollaps
Inferior vena cava collapsibility
<50%

60/60 sign
60/60 Echo sign
Yes

McConnel´s sign
Yes
Mid wall hypokinesia and apical hyperkinesia

Trombus RV
Yes
Right heart mobile trombus

TAPSE
Tricuspid annular plane systolic excursion
<16mm

S’ wavepulsedTDI
Peak systolic velocity tricuspid annulus (Pulsed TDI)
<9,5cm/s

Guidelines for the diagnosis and management of acute pulmonary embolism ESC, ERS (2019)

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 Regional wall motion abnormality and
segments

Distal septum infarct Supraapical infarct

LAD (distal, mid., prox.) LAD (distal, mid., prox.)
Low remodeling risk Small supraapical aneurysm
A4C, A2C, A3C (Echo views) Low remodeling risk

Supraapical and distal septal infarcts can also occur in proximal LAD occlusion after rapid reperfusion.

Proximal LAD type AMI Small basal inferior infarct

LAD (before 1st septal branch, left main) RCA
Always remodeling Difficult region to interpret
Poor prognosis Low remodeling risk

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 Inferior Infarct Infero-Posterior Infarct
RCA RCA (dominant) or Cx (large, prox.)
Low-moderate remodeling risk Moderate remodeling risk
Inferolateral (also called posterior)

Posterolateral Infarct Infero-Posterior-Lateral Infarct

CX, RCA Dominant RCA, CX (large, prox.)
Moderate remodeling risk High remodeling risk
Inferolateral (also called posterior) Inferolateral (also called posterior)

Inferior/ posterior/ postero-lateral infarcts pose an elevated risk for restrictive MR!

Lateral Infarct
CX, LAD (diagonal branch, difficult to
interpret)
Low remodeling risk

When assessing the patterns of myocardial infarction, always consider the possibility of multiple/sequential
infarcts!

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 Coronary Artery Territories (Echocardiography Illustrated Book 4)

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 ESSENTIAL ECHOCARDIOGRAPHY A Companion to Braunwald’s Heart Disease

Atria

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 Left atrium (Size)

Female Male

LA AP (cm)
2,7 - 3,8 3,0 - 4,0
Left atrium anterior-posterior dimension

LA AP (cm/m2)
Left atrium anterior-posterior dimension
1,5 - 2,3 1,5 - 2,3

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Left atrium (Volume)

Male Female

Normal Mildly Moderately Severely Normal Mildly Moderately Severely

range abnormal abnormal abnormal range abnormal abnormal abnormal

LA volume (ml/m2)
16 - 34 35 - 41 42 - 48 >48 16 - 34 35 - 41 42 - 48 >48
Left atrial volume (Biplane)

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Right atrium (Size)

Variable Abnormal

RA major (mm)
Right atrium major axis dimension
>53

RA minor (mm)
>44
Right atrium minor axis dimension

RA area (cm2)
>18
Right atrial area

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Right atrium (Size, Volume)

Male Female

RA major (cm/m2) 2,4 ±0,3 2,5 ±0,3

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 Right atrium major axis dimension

RA minor (cm/m2)
1,9 ±0,3 1,9 ±0,3
Right atrium minor axis dimension

RA volume (ml/m2)
25 ±7 21 ±6
Right atrium volume (Single plane)

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Right atrium (Pressure)

Normal Intermediate Intermediate High

3mmHg 8mmHg 8mmHg 15mmHg
(0 - 5mmHg) (5 - 10mmHg) (5 - 10mmHg) (10 - 20mmHg)

IVCdiameter
<2,1cm <2,1cm >2,1cm >2,1cm
Inferior vena cava diameter

IVCcollaps
Inferior vena cava collapsibility
>50% <50% >50% <50%

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Pericardial effusion
Pericardial effusion (Quantification)

Small <1mm 300ml

Moderate 10 - 20mm 500 - 700ml

Large >20mm >700ml

Very large >30mm Compression

Inferior vena cava

Inferior vena cava (Size)

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 Variable Abnormal

IVCdiameter
>2,1cm
Inferior vena cava diameter

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Aorta
Aorta (Size)

mm mm/m2

AoA
20 - 31 13 ± 1
Aortic annulus diameter

AoSV
29 - 45 19 ± 1
Aortic sinuses of valsalva diameter

AoSTJ 22 - 36 15 ± 1
Aortic sinotubular junction diameter

AoPxA
22 - 36 15 ± 2
Proximal ascending aorta diameter

AoArch
22 - 36
Aortic arch diameter

AoDesc 20 - 30
Descending aorta diameter

Echocardiography in aortic diseases: EAE recommendations for clinical practice (2010)

Aortic valve
Aortic stenosis

Aortic sclerosis Mild Moderate Severe

Vmax AoV (m/s)

≤2,5 2,6 - 2,9 3,0 - 4,0 ≥4,0
Aortic valve maximum velocity

meanPG AoV (mmHg)

<20 20 - 40 ≥40
Aortic valve mean pressure gradient

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 AVA (cm2) >1,5 1,0 - 1,5 <1,0
Aortic valve area (continuity equation)

AVA (cm2/m2)
>0,85 0,60 - 0,85 <0,60
Aortic valve area (continuity equation)

Velocity ratio
>0,5 0,25 - 0,5 <0,25
Aortic valve velocity ratio (Dimensionless index)

Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the EACVI and the ASE (2017)

Aortic regurgitation

Mild Moderate Severe

Structural parameters

Abnormal/flail, or
Aortic leaflets Normal or abnormal Normal or abnormal wide coaptation
defect

Normal1 Usually dilated2

Left ventricle (Size) (LVEDV ≤150ml male, Normal or mild dilated (LVEDV >150ml male,
≤106ml female) >106ml female)

Qualitative doppler

Large in central jets;

RegJetwidht Small in central jets Intermediate variable in eccentric
Regurgitation jet witdh (Width in LVOT <25%) jets
(Width in LVOT >65%)

None or very small Large

Flow convergence (PISAr) Intermediate
(<0,3cm) (≥1cm)

RegJetdensity
Regurgitant jet density Incomplete or faint Dense Dense
(CW doppler)

PHTRegJet3 Incomplete or faint

Medium Steep
Pressure half time of regurgitant Slow (200-500ms) <200ms
jet (>500ms)

Diastolic reversal flow

Brief, early diastolic Prominent
in descending aorta (PW Intermediate
reversal holodiastolic reversal
doppler)

Semiquantitative parameters4

VCW (cm) <0,3 0,3 - 0,6 >0,6

Vena contracta width

RegJetwidth in LVOT (%)

Regurgitation jet width in LVOT <25 25-45 46-64 ≥65
(centrel jets)

CSARegJet in CSA LVOT (%) <5 5-20 21-59 ≥60

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 Regurgitation jet CSA in LVOT
CSA (centrel jets)

Quantitative parameters4

Grade I Grade II Grade III Grade IV

EROA (cm2)
Effective regurgitant orifice area
<0,1 0,1 - 0,19 0,2 - 0,29 ≥0,3

RegVol (ml)
Regurgitant volume of aortic <30 30 - 44 45 - 59 ≥60
regurgitation

RF (%)
Regurgitant fraction of aortic <30 30 - 39 40 - 49 ≥50
valve

Bolded qualitative and semiquantitative signs are considered specific for their AR grade. Color Doppler usually
performed at a Nyquist limit of 50-70 cm/sec.

1. Unless there are other reasons for LV dilation.

2. Specific in normal LV function, in absence of causes of volume overload. Exception: acute AR, in which chambers
have not had time to dilate.
3. PHT is shortened with increasing LV diastolic pressure and may be lengthened in chronic adaptation to severe
AR.
4. Quantitative parameters can subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

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 Chronic aortic regurgitation

Does AR meet specific criteria of mild or severe AR?

Specific Criteria for Mild AR Specific Criteria for Severe AR

1. VCW <0,3cm 1. Flail Valve
2-3 criteria
2. Central jet (<25% of LVOT) 2. VCW >0,6cm
3. PISAr ≤0,3cm (Nyquist 30-40cm/s) 3. Central jet (≥65% in LVOT)
4. Soft or incomplete jet by CW doppler 4. PISAr >1cm (Nyquist 30-40cm/s)
5. PHT RegJet >500ms 5. PHT RegJet <200ms
6. Normal LV size 6. Holodiastolic reversal flow in DescAo
(LVEDV≤150ml male, ≤106ml Perform quantitative 7. Enlarged LV with normal function
female) methods whenever possible (LVEDV >150ml male, >106ml
to refine assessment female, EF LV >50%)

≥4 criteria ≥4 criteria
Definitively mild Definitively severe
(quantitation not needed) (may still quantitate)

Grade I AR Grade II AR Grade III AR Grade IV AR

EROA <0,1cm2 EROA 0,1-0,19cm2 EROA 0,2-0,29cm2 EROA ≥0,3cm2
RegVol <30ml RegVol 30-44ml RegVol 45-59ml RegVol ≥60ml
RF <30% RF 30-39% RF 40-49% RF ≥50%

3 specific criteria
for severe AR

Mild AR Moderate AR Severe AR

Poor TTE quality or low confidence in measured Doppler parameters Indeterminate AR

Consider further testing:
Discordant quantitative and qualitative parameters and/or clinical data TEE or CMR for quantitation

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Mitral valve
Mitral stenosis

Mild Moderate Severe

MVA (cm2)*
Mitral valve area
>1,5 1 - 1,5 <1

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 meanPG MV (mmHg) <5 5 - 10 >10
Mitral valve mean pressure gradient

RVSP(SPAP) (mmHg)
<30 30 - 50 >50
Right ventricular systolic pressure

* Specific findings

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Chronic mitral regurgitation

Mild Moderate Severe

Structural

Severe valve lesions

None or mild leaflet (primary: flail leaflet,
abnormality Moderate leaflet abnormality or ruptured papillary muscle,
Mitral valve morphology (e.g., mild thickening, severe retraction, large
moderate tenting
calcifications or prolapse, perforation; secondary:
mild tenting) severe tenting, poor leaflet
coaptation)

Usually normal Dilated2

Left ventricle (Size)1 (LVEDV ≤150ml male, Normal or mild dilated (LVEDV >150ml male,
≤106ml female) >106ml female)

Usually normal
Left atrium (Size)1 Normal or mild dilated Dilated2
(LA volume ≤34ml/m2)

Qualitative doppler

Large central jet

RegJetarea Small, central, narrow,
(RegJet/LA area >50%) or
Regurgitation jet area. often brief Variable
eccentric wall-impinging jet
(Nyquist limit 50-70cm/s) (RegJet/LA area <20%)
of variable size

Not visible, transient Large throughout

Flow convergence (PISAr) Intermediate in size and duration
or small systole
(Nyquist limit 30-40cm/s)
(PISAr <0,3cm) (PISAr ≥1cm)

Regurgitant jet Faint/ partial/ Holosystolic/ dense/

Dense but partial or parabolic
(CW doppler) parabolic triangular

Semiquantitative

VCW (cm) <0,3cm 0,3 - 0,7cm >0,7cm (>0,8cm)3

Vena contracta width

Systolic dominance Minimal to no systolic

Pulmonary vein flow4 (may be blunted in LV Normal or systolic blunting flow/ systolic flow
dysfunction or AF) reversal

Mitral inflow5 A wave dominant Variable E wave dominant

(A wave > E wave) (E wave >1,2m/s)

Quantitative6

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 Grade I Grade II Grade III Grade IV

EROA (cm2)
<0,2 0,2 - 0,3 0,3 - 0,39 ≥0,4
Effective regurgitant orifice area

RegVol (ml)
Regurgitant volume of mitral <30 30 - 44 45 - 59 ≥60
regurgitation

RF (%)
Regurgitant fraction of mitral <30 30 - 39 40 - 49 ≥50
valve

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each
echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that
accounts for body size, sex, and all other patient characteristics.

1. This pertains mostly to patients with primary

2. LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who
have small body size, particularly women, or with small LV size preceding the occurrence of MR.
3. For average between apical two- and four-chamber views (Biplane).
4. Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
5. Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
6. Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative
parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

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 Chronic mitral regurgitation

Does MR meet specific criteria for mild or severe MR?

Specific Criteria for Mild MR Specific Criteria for Severe MR

1. Small, narrow central jet 1. Flail leaflet
2-3 criteria
(RegJet/LA area <20%) 2. VCW ≥0,7cm
2. VCW ≤0,3cm 3. PISAr ≥1cm (Nyquist 30-40cm/s)
3. PISAr ≤0,3cm (Nyquist 30-40cm/s) 4. Central large jet
4. Mitral A wave dominant inflow (RegJet/LA area >50%)
5. Soft or incomplete jet (CW doppler) 5. Pulmonary vein systolic flow reversal
6. Normal LV and LA size Perform quantitative 6. Enlarged LV with normal function
(LA volume ≤34ml/m2, LVEDV (LVEDV >150ml male, >106ml
methods whenever
≤150ml male, ≤106ml female) female, LV EF >50%)
possible

≥4 criteria ≥4 criteria
Definitely mild Definitely severe

Grade I MR Grade II MR Grade III MR Grade IV MR

EROA <0,2cm2 EROA 0,2-0,29cm2 EROA 0,3-0,39cm2 EROA ≥0,4cm2
RegVol <30ml RegVol 30-44ml RegVol 44-59ml RegVol ≥60ml
RF <30% RF 30-39% RF 40-49% RF ≥50%

3 specific criteria
for severe MR or
elliptical orifice

Mild MR Moderate MR Severe MR

Poor TTE quality or low confidence in measured Doppler parameters Indeterminate MR

Consider further testing:
Discordant quantitative and qualitative parameters and/or clinical data TEE or CMR for quantitation

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Tricuspid valve
Tricuspid stenosis

Variable Abnormal

meanPG TrV*
≥5mmHg
Mean pressure gradient tricuspidal valve

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 VTI TrV*
>60cm
Velocity time integral of tricuspid valve (inflow)

PHT TrV*
≥190ms
Pressure half time of tricuspidal valve

TrVA*
≤1cm2
Tricuspid valve area (continuity equation)

RA major
>50mm
Right atrium major axis dimension

IVCdiameter
>2,1cm
Inferior vena cava diameter

* Specific findings

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Chronic tricuspid regurgitation

Mild Moderate Severe

Structural

Severe valve lesions

Normal or mildly Moderately abnormal
Tricuspid valve morphology (e.g., flail leaflet, severe
abnormal leaflets leaflets
retraction, large perforation)

Usually normal Usually dilated1

Right atrium (Size) Normal or mild dilatation
(RA major <45mm) (RA major >45mm)

Usually normal Usually dilated1

Right ventricle (Size) Normal or mild dilatation
(RVD1basal <41mm) (RVD1basal >41mm)

IVCdiameter Normal Normal or mildly dilated Dilated

Inferior vena cava diameter (IVCdiameter <2cm) (IVCdiameter 2,1 - 2,5cm) (IVCdiameter >2,5cm)

Qualitative doppler

Large central jet

RegJetarea
Small, narrow, central (RegJet/RA area >50%) or
Regurgitation jet area. Moderate central
(RegJet/RA area <20%) eccentric wall-impinging jet of
(Nyquist limit 50-70cm/s)
variable size

Not visible, transient or

Flow convergence (PISAr) Intermediate in size and Large throughout systole
small
(Nyquist limit 30-40cm/s) duration (PISAr ≥1cm)
(PISAr <0,3cm)

Regurgitant jet Dense but partial or

Faint/ partial/ parabolic Dense, often triangular
(CW doppler) parabolic

Semiquantitative

RegJetarea (cm2)
Regurgitation jet area Not defined Not defined >10
(Nyquist limit 50-70cm/s)

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 VCW (cm)
Vena contracta width <0,3 0,3 - 0,69 ≥0,7
(Nyquist limit 50-70cm/s)

PISAr (cm)
≤0,5 0,6 - 0,9 >0,9
(Nyquist limit 30-40cm/s)

Hepatic vein flow2 Systolic dominance Systolic blunting Systolic flow reversal

A wave dominant E wave

Tricuspid inflow2 Variable
(A wave > E wave) (E wave >1m/s)

Quantitative

EROA (cm2)
<0,2 0,2 - 0,393 ≥0,4
Effective regurgitant orifice area

RegVol (ml)
Regurgitant volume of tricuspid <30 30 - 443 ≥45
regurgitation

Bolded signs are considered specific for their tricuspid regurgitation grade.

1. RV and RA size can be within the ‘‘normal’’ range in patients with acute severe TR.
2. Signs are nonspecific and are influenced by many other factors (RV diastolic function, atrial fibrillation, RA
pressure).
3. There are little data to support further separation of these values.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

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 Chronic tricuspid regurgitation

Does TR meet most specific criteria for mild or severe TR?

2-3 criteria
Specific Criteria for Mild TR Specific Criteria for Severe TR
1. Dilated TV annulus (>35mm) with
1. Thin, small central color jet no valve coaptation or flail leaflet
Minority of criteria or
(RegJet/RA area <20%) 2. Large central jet (RegJet/RA
2. VCW <0,3cm Intermediate Values:
area >50%)
3. PISAr <0,4cm (Nyquist 30-40cm/s) TR Probably Moderate 3. VCW ≥0,7cm
4. Incomplete or faint jet (CW doppler) 4. PISAr >0,9cm (Nyquist 30-40cm/s)
5. Systolic dominant Hepatic vein flow 5. Dense, triangular jet (CW doppler)
6. Tricuspid A-wave dominant inflow Perform VC measurement, and or sine wave pattern
7. Normal RV/RA (RA major <45mm, May perform quantitative PISA 6. Systolic reversal of Hepatic vein flow
RVD1basal <41mm) method, whenever possible. 7. Dilated RV with preserved EF
Clinical experience in quantitation of (RVD1basal >41mm, EF RV >45%)
TR is much less than that with mitral
and aortic regurgitation.
≥4 criteria ≥4 criteria

Grade I TR Grade II TR Grade III TR

VCW <0,3cm VCW 0,3-0,69cm VCW ≥0,7cm
EROA <0,2cm2 EROA 0,2-0,4cm2 EROA ≥0,4cm2
RegVol <30ml RegVol 30-44ml RegVol ≥45ml

Mild TR Moderate TR Severe TR

Poor TTE quality or low confidence in measured Doppler parameters Indeterminate TR

Consider further testing:
Discordant quantitative and qualitative parameters and/or clinical data TEE or CMR for quantitation

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Pulmonary valve
Pulmonary stenosis

Mild Moderate Severe

Vmax PV (m/s)
<3 3-4 >4
Maximal (peak) velocity pulmonary valve

maxPG PV (mmHg) <36 36 - 64 >64

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 Pulmonary valve maximal pressure
gradient

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Pulmonary regurgitation

Mild Moderate Severe

Abnormal and may

Pulmonic valve Normal Normal or abnormal
not be visible

Normal1 Dilated2
Right ventricle (Size) Normal or dilated
(RVD1basal <41mm) (RVD1basal >41mm)

RegJetlength Thin with a narrow

Broad origin; variable
Regurgitant jet length origin Intermediate
depth of penetration
(Nyquist limit 50-70cm/s) (usually <10 mm in length)

RatioRegJet/PV
Ratio regurgitant jet width / pulmonary valve >70%3
annulus

RegJetdensity Dense; early

Regurgitant jet density Soft Dense termination of
(CW doppler) diastolic flow

DTRegJet Short4
Deceleration time of pulmonary regurgitant jet (<260ms)

PHTRegJet
Pressure half time of pulmonary regurgitant jet
<100ms5

PR index6
<0,77 <0,77
Pulmonory regurgitation index

PAreversal flow
Yes
Reversal flow in the branch pulmonary artery

PV VTI / LVOT VTI7

Pulmonic systolic VTI compered to LVOT VTI
Slightly increased Intermediate Greatly increased

RF8
<20% 20-40% >40%
Regurgitant fraction of pulmonary valve

1. Unless there are other reasons for RV enlargement.

2. Exception: acute PR.
3. Identifies a CMR-derived PR fraction >40%.
4. Steep deceleration is not specific for severe PR.
5. Not reliable in the presence of high RV end diastolic pressure.
6. Defined as the duration of the PR signal divided by the total duration of diastole, with this cutoff identifying a
CMR-derived PR fraction > 25%.
7. Cutoff values for regurgitant volume and fraction are not well validated.
8. RF data primarily derived from CMR with limited application with echocardiography.

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 Chronic pulmonic regurgitation

Does PR meet most specific criteria for mild or severe PR?

1-2 criteria
Specific Criteria for mild PR Specific Criteria for Severe PR
1. Small Jet (RegJet length <10mm) Minority of criteria or Intermediate 1. Ratio RegJet / PV annulus (>70%)
2. Soft or faint jet (CW doppler) Values: 2. RegJet hart density
3. Slow deceleration time (>260ms) PR Probably Moderate 3. Pressure half time (<100ms)
4. Normal RV size 4. Diastolic flow reversal in PA
(RVD1basal <41mm) branches
May Perform volumetric 5. Dilated RV with NL function
quantitative methods, (RVD1basal >41mm)
if possible, whenever
significant PR is suspected
(Clinical experience in quantitation
of PR is sparse.)

≥2 criteria ≥3 criteria

Grade I PR Grade II PR Grade III PR

RF <20% RF 20-40% RF >40%

Mild PR Moderate PR Severe PR

Poor TTE quality or discordant parameters with clinical data, Indeterminate PR

particularly when significant PR may be suspected Consider CMR for quantitation

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

References:

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from

the ASE and EACVI (2015)

Recommendations for the Evaluation of LV Diastolic Function by Echocardiography: An Update from the
ASE and EACVI (2016)

Recommendations on the use of echocardiography in adult hypertension: a report from the EACVI and
the ASE (2015)

Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update

from the EACVI and the ASE (2017)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

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 Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE
(2018)

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: ASE, EACVI, ESC, CSE
(2010)

Guidelines for the diagnosis and management of acute pulmonary embolism ESC, ERS (2019)

Echocardiography in aortic diseases: EAE recommendations for clinical practice (2010)

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

ESSENTIAL ECHOCARDIOGRAPHY A Companion to Braunwald’s Heart Disease

Coronary Artery Territories (Echocardiography Illustrated Book 4)

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