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GUIDELINES
KEYWORDS Abstract Quantification of cardiac chamber size, ventricular mass and function
Standards; ranks among the most clinically important and most frequently requested tasks of
Measurements; echocardiography. Over the last decades, echocardiographic methods and techniques
Volumes; have improved and expanded dramatically, due to the introduction of higher frequency
Linear dimensions; transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and
Quantification other technological advancements. Furthermore, echocardiography due to its porta-
bility and versatility is now used in emergency rooms, operating rooms, and intensive
care 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 European
Association of Echocardiography, a branch of the European Society of Cardiology, has
critically reviewed the literature and updated the recommendations for quantifying
cardiac chambers using echocardiography. This document reviews the technical
aspects on how to perform quantitative chamber measurements of morphology and
function, which is a component of every complete echocardiographic examination.
ª 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rights
reserved.
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 wall
thickness at end-diastole; PWTd, posterior wall thickness at end-diastole; EBD, endocardial border delineation; TEE, transesophageal
echocardiography; 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 American
Heart 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: frank.flachskampf@rzmail.uni-erlangen.de (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
80 R.M. Lang et al.
preceding cardiac cycle can influence ventricular planes/views used when quantifying chamber di-
volume and fiber shortening. mensions transthoracically.8,9 It is the recommen-
Harmonic imaging is now widely employed in dation of this writing group that the same range
clinical laboratories to enhance the images espe- of normal values for chamber dimensions and vol-
cially in patients with poor acoustic windows. umes apply for both TEE and TTE. In this manu-
While this technology reduces the ‘‘drop-out’’ of script, recommendations for quantification using
endocardial borders, the literature suggests that TEE will primarily focus on acquisition of images
there is a systemic tendency for higher measure- that allow measurement of cardiac structures
ments of LV wall thickness and mass and smaller along imaging planes that are analogous to TTE.
measurements of internal dimensions and vol- In addition to describing a parameter as normal
umes.3,4 When analyzing serial studies on a given or abnormal (reference values), clinical echocar-
patient, differences in chamber dimension poten- diographers most often qualify the degree of
tially attributable to imaging changes from the abnormality with terms such as ‘‘mildly’’, ‘‘mod-
fundamental to the harmonic modality are probably erately’’ or ‘‘severely’’ abnormal. Such a descrip-
smaller than the inter and intra-observer variabil- tion allows the clinician to not only understand
ity of these measurements. The best technique that the parameter is abnormal but also the
for comparing serial changes in quantitation is to degree to which their patient’s measurements
display similar serial images side-by-side and deviate from normal. In addition to providing
make the same measurement on both images by normative data it would be beneficial to standard-
the same person, at the same time.5 It is important ize cutoffs for severity of abnormality across
to note that most measurements presented in this echocardiographic laboratories, such that moder-
manuscript are derived from fundamental imaging ately abnormal had the same implication in all
as normative values have not been established laboratories. However, multiple statistical tech-
using harmonic imaging. niques exist for determining thresholds values, all
Left-sided contrast agents used for endocardial of which have significant limitations.10
border delineation (EBD) are helpful and improve The first approach would be to define cutoffs
measurement reproducibility for suboptimal stud- empirically for mild, moderate and severe abnor-
ies and correlation with other imaging techniques. malities based on standard deviations above/
While the use of contrast agents has been below the reference limit derived from a group
reviewed elsewhere in detail,6 a few caveats re- of normal subjects. The advantage of this method
garding their use deserve mention. The mechanical is that this data readily exists for most echocar-
index should be lowered to decrease the acoustic diographic parameters. However, this approach
power of the ultrasound beam, which reduces bub- has several disadvantages. Firstly, not all echocar-
ble destruction. The image should be ‘‘focused’’ diographic parameters are normally distributed, or
on the structure of interest. Excessive shadowing Gaussian in nature, making the use of standard
may be present during the initial phase of bubble deviation questionable. Secondly, even if a partic-
transit and often the best image can be recorded ular parameter is normally distributed in control
several cardiac cycles following the appearance subjects, most echocardiographic parameters
of contrast in the left ventricle. When less than when measured in the general population have
80% of the endocardial border is adequately visual- a significant asymmetric distribution in one di-
ized, the use of contrast agents for EBD is strongly rection (abnormally large for size or abnormally
recommended.7 By improving visualization of the low for function parameters). Using the standard
LV apex, the problem of ventricular foreshortening deviation derived from normal subjects leads to
is reduced and correlation with other techniques abnormally low cutoff values which are inconsis-
improved. Contrast enhanced images should be tent with clinical experience, as the standard
labeled to facilitate the reader identification of deviation inadequately represents the magnitude
the imaging planes. of asymmetry (or range of values) towards abnor-
Quantitation using transesophageal echocardi- mality. This is the case with LV ejection fraction
ography (TEE) has advantages and disadvantages (EF) where 4 standard deviations below the mean
compared to transthoracic echocardiography (64 G 6.5) results in a cutoff for severely abnormal
(TTE). Although visualization of many cardiac of 38%.
structures is improved with TEE some differences An alternative method would be to define
in measurements have been found between TEE abnormalities based on percentile values (95th,
and TTE. These differences are primarily attribut- 99th, etc.) of measurements derived from a pop-
able to the inability to obtain from the trans- ulation that includes both normal subjects and
esophageal approach the standardized imaging those with disease states.11 Although this data may
82 R.M. Lang et al.
should be made from the parasternal long-axis provided that the M-mode cursor can be positioned
acoustic window. It is recommended that LV in- perpendicular to the septum and LV posterior wall.
ternal diameters (LVIDd and LVIDs, respectively) A 2D method, useful for assessing patients with
and wall thicknesses be measured at the level of coronary artery disease has been proposed. When
the LV minor axis, approximately at the mitral using this method, it is recommended that LV
valve leaflet tips. These linear measurements can internal diameters (LVIDd and LVIDs, respectively)
be made directly from 2D images or using 2D- and wall thicknesses be measured at the level of
targeted M-mode echocardiography. the LV minor dimension, at the mitral chordae
By virtue of their high pulse rate, M-mode level. These linear measurements can also be
recordings have excellent temporal resolution made directly from 2D images or using 2D-targeted
and may complement 2-D images in separating M-mode echocardiography. Direct 2D minor axis
structures such as trabeculae adjacent to the measurements at the chordae level intersect the
posterior wall, false tendons on the left side of interventricular septum below the left ventricular
the septum, and tricuspid apparatus or moderator outflow tract,2,5,18 and thus provides a global as-
band on the right side of the septum from the sessment in a symmetrically contracting LV, and
adjacent endocardium. However, it should be also evaluates basal regional function in a chamber
recognized that even with 2D guidance, it may with regional wall motion abnormalities. The
not be possible to align the M-mode cursor per- direct 2D minor axis dimensions are smaller than
pendicular to the long axis of the ventricle which is the M-mode measurements with the upper limits
mandatory to obtain a true minor axis dimension of normal of LVIDd being 5.2 cm vs 5.5 cm and
measurement. Alternatively, chamber dimension the lower limits of normal for fractional shortening
and wall thicknesses can be acquired from the being 0.18 vs 0.25. Normal systolic and diastolic
parasternal short-axis view using direct 2D mea- measurements reported for this parameter are
surements or targeted M-mode echocardiography 4.7 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 connecting the mitral valve insertions at the lateral
(SWT and PWT, respectively) are measured at end- and septal borders of the annulus on the four-
diastole (d) and end-systole (s) from 2-D or M-mode chamber view and the anterior and inferior annular
recordings,1,2 preferably on several cardiac cycles borders on the two-chamber view.
(Fig. 1).1,2 Refinements in image processing have End-diastole can be defined at the onset of the
allowed improved resolution of cardiac structures. QRS, but is preferably defined as the frame
Consequently, it is now possible to measure the ac- following mitral valve closure or the frame in the
tual visualized thickness of the ventricular septum cardiac cycle in which the cardiac dimension is
and other chamber dimensions as defined by the largest. In sinus rhythm, this follows atrial con-
actual tissueeblood interface, rather than the dis- traction. End-systole is best defined as the frame
tance between the leading edge echoes which had preceding mitral valve opening or the time in the
previously been recommended.5 Use of 2-D echo- cardiac cycle in which the cardiac dimension is
derived linear dimensions overcomes the common smallest in a normal heart. In the two-chamber
problem of oblique parasternal images resulting view, mitral valve motion is not always clearly
in overestimation of cavity and wall dimensions discernible and the frames with the largest and
from M mode. If manual calibration of images is smallest volumes should be identified as end-
required, 6 cm or larger distances should be used diastole and end-systole, respectively.
to minimize errors due to imprecise placement of The recommended TEE views for measurement
calibration points. of LV diameters are the mid esophageal two-
In order to obtain volumetric measurements the chamber view (Fig. 2) and the transgastric (TG)
most important views for 2-D quantitation are the two- chamber views (Fig. 3). LV diameters are
mid-papillary short-axis view and the apical four- measured from the endocardium of the anterior
and two-chamber views. Volumetric measurements wall to the endocardium of the inferior wall in
require manual tracing of the endocardial border. a line perpendicular to the long-axis of the ventri-
The papillary muscles should be excluded from the cle at the junction of the basal and middle thirds
cavity in the tracing. Accurate measurements of the long-axis. The recommended TEE view for
require optimal visualization of the endocardial measurement of LV wall thicknesses is the TG
border in order to minimize the need for extrapo- mid short-axis view (Fig. 4). With TEE, the long-
lation. It is recommended that the basal border of axis dimension of the LV is often foreshortened in
the LV cavity area be delineated by a straight line the mid-esophageal four-chamber and long-axis
Figure 1 Measurement of left ventricular end-diastolic diameter (EDD) and end-systolic diameter (ESD) from
M-mode, guided by a parasternal short axis image (upper left) to optimize medial-lateral beam orientation.
Recommendations for chamber quantification 85
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-chamber whether utilizing M-mode, 2-D or 3-D echocardio-
view is preferred for this measurement. Care must graphic measurements, are based upon subtrac-
be made to avoid foreshortening TEE views, by re- tion of the LV cavity volume from the volume
cording the image plane which shows the maxi- enclosed by the LV epicardium to obtain LV muscle
mum obtainable chamber size, finding the angle or ‘‘shell’’ volume. This shell volume is then con-
for diameter measurement which is perpendicular verted to mass by multiplying by myocardial den-
to the long-axis of that chamber, then measuring sity. Hence, quantitation of LV mass requires
the maximum obtainable short-axis diameter. accurate identification of interfaces between the
cardiac blood pool and endocardium and between
Calculation of left ventricular mass epicardium and pericardium.
To date, most LV mass calculations have been
In clinical practice, LV chamber dimensions are made using linear measurements derived from 2-D-
commonly used to derive measures of LV systolic targeted M-mode or, more recently, from 2-D
function, whereas in epidemiologic studies and linear LV measurements.20 The ASE recommended
treatment trials, the single largest application of formula for estimation of LV mass from LV linear
echocardiography has been the estimation of LV dimensions (validated with necropsy r ¼ 0.90,
mass in populations and its change with antihy- p < 0.00121) is based on modeling the LV as a
pertensive therapy.13,19 All LV mass algorithms, prolate ellipse of revolution:
Figure 3 Transesophageal echo measurements of left ventricular minor axis diameter (LVD) from the trans-gastric
two-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 the
posterior wall (PWT), from the trans-gastric short axis view of the left ventricle, at the papillary muscle level, usually
best imaged at angle of approximately 0e30 degrees.
Figure 5 Comparison of relative wall thickness (RWT). Patients with normal LV mass can have either concentric
remodeling (normal LV mass with increased RWT > 0.42) or normal (RWT 0.42) and normal LV mass. Patients with
increased LV mass can have either concentric (RWT > 0.42) or eccentric (RWT 0.42) hypertrophy. These LV mass
measurements are based on linear measurements.
Recommendations for chamber quantification 87
area (Am) is computed as the difference: images have proven to be reproducible with low
Am ¼ A1 A2. Assuming a circular area, the radius intra- and inter-observer variability.20,23e26 Al-
is computed (b ¼ A2/p) and a mean wall thickness though linear measures of LV function are prob-
(t) derived (Fig. 6). Left ventricular mass can be lematic when there is a marked regional
calculated by one of the two formulae shown in difference in function, in patients with uncompli-
Fig. 6. In the presence of extensive regional wall cated hypertension, obesity or valvular diseases,
motion abnormalities (e.g. myocardial infarction), such regional differences are rare in the absence
the biplane Simpson’s method may be used, of clinically recognized myocardial infarction.
although this method is dependent on adequate Hence fractional shortening and its relationship
endocardial and epicardial definition of the LV to end-systolic stress often provide useful informa-
which often is challenging from this window. Most tion in clinical studies.27 The previously used
laboratories obtain the measurement at end- Teichholz or Quinones methods of calculating LV
diastole and exclude the papillary muscles in trac- ejection fraction from LV linear dimensions may
ing the myocardial area. result in inaccuracies due to the geometric as-
TEE evaluation of LV mass is also highly accu- sumptions required to convert a linear measure-
rate, but has minor systematic differences in LV ment to a 3-D volume.28,29 Accordingly, the use
posterior wall thickness. In particular LV mass of linear measurements to calculate LV EF is not
derived from TEE wall thickness measurements is recommended for clinic practice.
higher by an average of 6 g/m2.8 Contraction of muscle fibers in the LV midwall
may better reflect intrinsic contractility than
Left ventricular systolic function: linear contraction of fibers at the endocardium. Calcula-
and volumetric measurement tion of midwall, rather than endocardial fractional
shortening is particularly useful in revealing
Many echocardiographic laboratories rely on M- underlying systolic dysfunction in the setting of
mode measurements or linear dimensions derived concentric hypertrophy.30 Mid-wall fractional
from the two-dimensional image for quantifica- shortening (MWFS) may be computed from linear
tion. Linear measurements from M-mode and 2-D measures 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 cavity
area; Am ¼ myocardial area, a is the long or semi-major axis from widest minor axis radius to apex, b is the short-axis
radius (back calculated from the short-axis cavity area) and d is the truncated semi-major axis from widest short-axis
diameter 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 mathematical of the disk is based on the two diameters obtained
models,30,31 according to the following formulas: from the two- and four-chamber views. When two
adequate orthogonal views are not available, a sin-
h
Inner shell ¼ LVIDd þ SWTd=2 þ PWTd=23 gle plane can be used and the area of the disc is
then assumed to be circular. The limitations of
1=3
LVIDd3 þ LVIDs3 LVIDs
The most commonly used 2-D measurement for using a single plane are greatest when extensive
volume measurements is the biplane method of wall motion abnormalities are present.
discs (modified Simpson’s rule) and is the currently An alternative method to calculate LV volumes
recommended method of choice by consensus of when apical endocardial definition precludes ac-
this committee (Fig. 7). The principle underlying curate tracing is the areaelength method where
this method is that the total LV volume is calculated the LV is assumed to be bullet-shaped (Fig. 6). The
from the summation of a stack of elliptical discs. mid LV cross-sectional area is computed by planim-
The height of each disc is calculated as a fraction etry in the parasternal short-axis view and
(usually one-twentieth) of the LV long axis based the length of the ventricle taken from the mid
on the longer of the two lengths from the two- point of the annulus to the apex in the apical
and four-chamber views. The cross-sectional area four-chamber view. These measurements are
Figure 7 2-D measurements for volume calculations using the biplane method of discs (modified Simpson’s rule), in
the apical four-chamber (A4C) and apical two-chamber (A2C) views at end diastole (LV EDD) and at end-systole (LV
ESD). The papillary muscles should be excluded from the cavity in the tracing.
Recommendations for chamber quantification 89
abnormal
Severely
volume is computed according to the formula:
0.52
‡149
293
163
255
131
volume ¼ [5(area)(length)] O 6. The most widely
‡1.7
‡1.7
64
used parameter for indexing volumes is the body
surface area (BSA) in m2.
The end-diastolic and end-systolic volumes
Moderately
(EDV, ESV) are calculated by either of the two
0.47e0.51
132e148
117e130
259e292
145e162
228e254
abnormal
1.4e1.6
1.4e1.6
56e63
methods described above and the ejection fraction
is calculated as follows:
0.43e0.46
116e131
103e116
225e258
127e144
201e227
abnormal
Partition values for recognizing depressed LV
1.1e1.3
1.1e1.3
49e55
systolic function in Table 6 follow the conventional
Mildly
practice of using the same cut-offs in women and
men; however, emerging echocardiographic and MRI
data suggests that LV ejection fraction and other
indices are somewhat higher in apparently normal
0.24e0.42
Reference
49e115
50e102
88e224
52e126
96e200
0.6e1.0
0.6e1.0
women than in men.32,33 Quantitation of LV vol-
20e48
range
umes using TEE is challenging due to difficulties in
Men
obtaining a non-foreshortened LV cavity from the
esophageal approach. However when carefully
acquired, direct comparisons between TEE and
abnormal
TTE volumes and ejection fraction have shown
Severely
minor or no significant differences.8,9
0.53
‡122
211
129
>183
113
‡1.6
‡1.6
59
Reference limits and partition values of left ventricular mass and geometry
0.48e0.52
109e121
101e112
187e210
116e128
172e182
abnormal
1.3e1.5
1.3e1.5
52e58
Reference values for LV linear dimensions have
been obtained from an ethnically diverse population
of 510 normal-weight, normotensive, non-diabetic
white, African-American and American-Indian
adults without recognized cardiovascular disease
0.43e0.47
96e108
89e100
163e186
100e115
151e171
abnormal
1.0e1.2
1.0e1.2
(unpublished data). The populations from which
45e51
66e150
0.6e0.9
0.6e0.9
43e95
44e88
41e99
18e44
Women
LV mass/BSA (g/m2)
LV mass (g)
abnormal
Severely
ropsy measurement and cutoff values used in clin-
ical trials.19,20,36,38,39 Although some prior studies
201
6.9
3.7
3.8
83
‡97
‡43
have suggested racial differences in LV mass mea-
surement, the consensus of the literature avail-
able indicates that no significant differences
Moderately
exist between clinically normal black and white
abnormal
179e201
6.4e6.8
3.5e3.6
3.6e3.7
87e96
37e42
71e82
subjects. In contrast, a recent study has shown
racial-ethnic differences in left ventricular structure
in hypertensive adults.40 Although the sensitivity,
specificity and predictive value of LV wall thick-
ness measurements for detection of LV hypertro-
abnormal
156e178
6.0e6.3
3.2e3.4
3.4e3.5
76e86
31e36
59e70
phy are lower than for calculated LV mass, it is
Mildly
35e75
12e30
the need for indexing the measurement relative to
22e58
range
‡43
87e96
37e42
60e69
abnormal
105e117
76e86
31e36
50e59
Three-dimensional assessment
of volume and mass
Reference
56e104
3.9e5.3
2.4e3.2
2.5e3.2
35e75
12e30
Women
19e49
Table 6 Reference limits and values and partition values of left ventricular function
Women Men
Reference Mildly Moderately Severely Reference Mildly Moderately Severely
range abnormal abnormal abnormal range abnormal abnormal abnormal
Linear method
Endocardial 27e45 22e26 17e21 16 25e43 20e24 15e19 14
fractional
shortening (%)
Midwall 15e23 13e14 11e12 10 14e22 12e13 10e11 10
fractional
shortening (%)
2-D method
Ejection ‡55 45e54 30e44 <30 ‡55 45e54 30e44 <30
fraction (%)
Values in bold are recommended and best validated.
endocardial borders (and for mass epicardial bor- segmentation.2 This model consists of six segments
der) using manual or semi-automated algorithms. at both basal and mid-ventricular levels and four
These borders are then processed to calculate segments at the apex (Fig. 8). The attachment of
the cavity or myocardial volume by summation of the right ventricular wall to the left ventricle de-
discs54,56 or other methods.46e48 fines the septum, which is divided at basal and
Regardless of which acquisition or analysis mid LV levels into anteroseptum and inferoseptum.
method is used, 3-D echocardiography does not Continuing counterclockwise, the remaining seg-
rely on geometric assumptions for volume/mass ments at both basal and mid ventricular levels
calculations and is not subject to plane positioning are labeled as inferior, inferolateral, anterolateral
errors, which can lead to chamber foreshortening. and anterior. The apex includes septal, inferior,
Studies comparing 3-D echocardiographic LV vol- lateral, and anterior segments. This model has
umes or mass to other gold-standards such as become widely utilized in echocardiography. In
magnetic resonance imaging, have confirmed 3-D contrast, nuclear perfusion imaging, cardiovascular
echocardiography to be accurate. Compared to magnetic resonance and cardiac computed
magnetic resonance data, LV and RV volumes tomography have commonly used a larger number
calculated from 3-D echocardiography showed of segments.
significantly better agreement (smaller bias), lower In 2002, the American Heart Association Writing
scatter and lower intra- and inter-observer vari- Group on Myocardial Segmentation and Registra-
ability than 2-D echocardiography.46,54,57,60 The tion for Cardiac Imaging, in an attempt to establish
superiority of 3-D echocardiographic LV mass calcu- segmentation standards applicable to all types
lations over values calculated from M-mode derived of imaging, recommended a 17-segment model
or 2-D echocardiography has been convincingly (Fig. 8).62 This differs from the previous 16-
shown.55,57,59 Right ventricular volume and mass segment model predominantly by the addition of
have also been measured by 3-D echocardiography a 17th segment, the ‘‘apical cap.’’ The apical
with good agreement with magnetic resonance cap is the segment beyond the end of the LV
data.58,61 Current limitations include the require- cavity. Refinements in echocardiographic imaging,
ment of regular rhythm, relative inferior image including harmonics and contrast imaging are
quality of real-time 3-D echocardiography com- believed to permit improved imaging of the apex.
pared to 2-D images, and the time necessary for Either model is practical for clinical application
off-line data analysis. However, the greater number yet sufficiently detailed for semi-quantitative
of acquired data points, the lack of geometric analysis. The 17-segment model should be predom-
assumptions, increasingly sophisticated 3-D image inantly used for myocardial perfusion studies or
and measurements solutions offset these anytime efforts are made to compare between
limitations. imaging modalities. The 16-segment model is
appropriate for studies assessing wall motion
Regional left ventricular function abnormalities as the tip of the normal apex
(segment 17) does not move.
In 1989, the American Society of Echocardiography The mass and size of the myocardium as
recommended a 16 segment model for LV assessed 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- and
three-chamber views. The apical cap can only be appreciated on some contrast studies. A 16 segment model can
be used, without the apical cap, as described in an ASE 1989 document.2 A 17 segment model, including the apical
cap, 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, echocardiography can overestimate the amount
mid ventricular and apical thirds, perpendicular to of ischemic or infarcted myocardium, as wall
the LV long-axis, with the mid ventricular third motion of adjacent regions may be affected by
defined by the papillary muscles, the measured tethering, disturbance of regional loading condi-
myocardial mass in adults without cardiac disease tions and stunning.68 Therefore, wall thickening
was 43% for the base, 36% for the mid cavity and as well as motion should be considered. Moreover,
21% for the apex.63 The 16-segment model closely it should be remembered that regional wall motion
approximates this, creating a distribution of 37.5% abnormalities may occur in the absence of coro-
for both the basal and mid portions and 25% for the nary artery disease.
apical portion. The 17-segment model creates It is recommended that each segment be ana-
a distribution of 35.3%, 35.3% and 29.4% for the lyzed individually and scored on the basis of its
basal, mid and apical portions (including the apical motion and systolic thickening. Ideally, the function
cap) of the heart, respectively. of each segment should be confirmed in multiple
Variability exists in the coronary artery blood views. A segment which is normal or hyperkinetic
supply to myocardial segments. Nevertheless, the is assigned a score of 1, hypokinesis ¼ 2, akinesis
segments are usually attributed to the three major (negligible thickening) ¼ 3, dyskinesis (paradoxical
coronary arteries are shown in the TTE G dis- systolic motion) ¼ 4, and aneurysmal (diastolic
tributions of Fig. 9.62 deformation) ¼ 5.1 Wall motion score index can be
Since the 1970s, echocardiography has been derived as a sum of all scores divided by the number
used for the evaluation of LV regional wall motion of segments visualized.
during infarction and ischemia.64e66 It is recog-
nized that regional myocardial blood flow and
regional LV systolic function are related over Assessment of LV remodeling and the use
a wide range of blood flows.67 Although regional of echocardiography in clinical trials
wall motion abnormalities at rest may not be
seen until the luminal diameter stenosis exceeds Left ventricular remodeling describes the process
85%, with exercise, a coronary lesion of 50% can re- by which the heart changes its size, geometry and
sult in regional dysfunction. It is recognized that function over time. Quantitative 2-D transthoracic
Recommendations for chamber quantification 93
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 the
circumflex (Cx) coronary arteries. The arterial distribution varies between patients. Some segments have variable
coronary perfusion.
Figure 11 Mid right-ventricular diameter measured in the apical four-chamber view at level of left ventricular
papillary muscles.
96 R.M. Lang et al.
Table 7 Reference limits and partition values of right ventricular and pulmonary artery size76
Reference Mildly Moderately Severely
range abnormal abnormal abnormal
RV dimensions
Basal RV diameter (RVD#1) (cm) 2.0e2.8 2.9e3.3 3.4e3.8 3.9
Mid RV diameter (RVD#2) (cm) 2.7e3.3 3.4e3.7 3.8e4.1 4.2
Base-to-apex length (RVD#3) (cm) 7.1e7.9 8.0e8.5 8.6e9.1 9.2
RVOT diameters
Above aortic valve (RVOT#1) (cm) 2.5e2.9 3.0e3.2 3.3e3.5 3.6
Above pulmonic valve (RVOT#2) (cm) 1.7e2.3 2.4e2.7 2.8e3.1 3.2
PA diameter
Below pulmonic valve (PA#1) (cm) 1.5e2.1 2.2e2.5 2.6e2.9 3.0
velocity or right ventricular index of myocardial The left atrium acts as a contractile pump that
performance (Tei Index).86 delivers 15e30% of the LV filling, as a reservoir that
The RV outflow tract (RVOT) extends from the collects pulmonary venous return during ventricu-
anterosuperior aspect of the right ventricle to the lar systole and as a conduit for the passage of
pulmonary artery, and includes the pulmonary stored blood from the LA to the LV during early
valve. It is best imaged from the parasternal ventricular diastole.87 Increased left atrial size is
long-axis view angled superiorly, and the para- associated with adverse cardiovascular outcom-
sternal short-axis at the base of the heart. It can es.88e90 An increase in atrial size most commonly
additionally be imaged from the subcostal long and is related to increased wall tension due to in-
transverse windows as well as the apical window. creased filling pressure.91,92 Although increased
Measurement of the RV outflow tract is most filling volumes can cause an increase in LA size,
accurate from the parasternal short-axis (Fig. 13) the adverse outcomes associated with increased
just proximal to the pulmonary valve. Mean RVOT dimension and volume are more strongly associ-
measurements are shown in Table 7.75 With TEE, ated with increased filling pressure. Relationships
the mid-esophageal RV inflow-outflow view usually exist between increased left atrial size and the in-
provides the best image of the RVOT just proximal cidence of atrial fibrillation and stroke,93e101 risk
to the pulmonary valve (Fig. 14). of overall mortality after MI,102,103 and the risk of
death and hospitalization in subjects with dilated
Quantification of LA/RA size cardiomyopathy.104e108 LA enlargement is a marker
of both the severity and chronicity of diastolic
The left atrium (LA) fulfills three major physiologic dysfunction and magnitude of LA pressure
roles that impact on LV filling and performance. elevation.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 approximately
0e20 degrees.
Recommendations for chamber quantification 97
Table 8 Reference limits and partition values of right ventricular size and function as measured in the apical
four-chamber view 80
Reference Mildly Moderately Severely
range abnormal abnormal abnormal
RV diastolic area (cm2) 11e28 29e32 33e37 38
RV systolic area (cm2) 7.5e16 17e19 20e22 23
RV fractional area change (%) 32e60 25e31 18e24 17
The LA size is measured at the end-ventricular estimated combining measurements from differ-
systole when the LA chamber is at its greatest ent imaging planes.
dimension. While recording images for computing
LA volume, care should be taken to avoid fore- LA linear dimension
shortening of the LA. The base of the LA should be
at its largest size indicating that the imaging plane The LA can be visualized from multiple echocar-
passes through the maximal short-axis area. The diographic views from which several potential LA
LA length should also be maximized ensuring dimensions can be measured. However, the large
alignment along the true long-axis of the LA. volume of prior clinical and research work used the
When performing planimetry the LA, the conflu- M-mode or 2-D derived anteroposterior (AP) linear
ences of the pulmonary veins and LA appendage dimension obtained from the parasternal long-axis
should be excluded. view making this the standard for linear LA
With TEE, the LA frequently cannot fit in its measurement (Fig. 15).93,95,96,98,104,105 The con-
entirety into the image sector. Measurements of LA vention for M-mode measurement is to measure
volume from this approach cannot be reliably from the leading edge of the posterior aortic wall
performed however; LA dimension can be to the leading edge of the posterior LA wall.
Figure 13 Measurement of the right ventricular outflow tract diameter at the subpulmonary region (RVOT1) and at
the pulmonic valve annulus (RVOT2), in the mid-esophageal aortic valve short axis view, using a multiplane angle of
approximately 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 and
main pulmonary artery from the midesophageal RV inflow-outflow view.
However, to avoid the variable extent of space The simplest method for estimating LA volume is
between the LA and aortic root, the trailing edge the cube formula, which assumes that the LA
of the posterior aortic is recommended. volume is that of a sphere with a diameter equal
Although these linear measurements have been to the LA antero-posterior dimension. However,
shown to correlate with angiographic measure- this method has proven to be inferior to other
ments and have been widely used in clinical volume techniques.109,111,117 Left atrial volumes
practice and research, they inaccurately represent are best calculated using either an ellipsoid model
true LA size.109,110 Evaluation of the LA in the AP or Simpson’s rule.88,89,97,101,102,109e111,115e117
dimension assumes that a consistent relationship The ellipsoid model assumes that the LA can be
is maintained between the AP dimension and all adequately represented as a prolate ellipse with
other LA dimensions as the atrium enlarges, which a volume of 4p/3(L/2)(D1/2)(D2/2), where L is the
is often not the case.111,112 Expansion of the left long-axis (ellipsoid) and D1 and D2 are orthogonal
atrium in the AP dimension may be constrained short-axis dimensions. LA volume can be estimated
by the thoracic cavity between the sternum using this biplane dimension-length formula by
and the spine. Predominant enlargement in the substituting the LA antero-posterior diameter
superior-inferior and medial-lateral dimensions acquired from the parasternal long-axis as D1, LA
will alter LA geometry such that the AP dimension medial-lateral dimension from the parasternal
may not be representative of LA size. For these short-axis as D2 and the LA long-axis from the apical
reasons, AP linear dimensions of the left atrium four-chamber for L.117e119 Simplified methods
as the sole measure of left atrial size may be mis- using non-orthogonal linear measurements for
leading and should be accompanied by left atrial
volume determination in both clinical practice
and research.
LA volume measurements
estimation of LA volume have been proposed.113 The areaelength formula can be computed from
Volume determined using linear dimensions is a single plane, typically the apical four-chamber,
very dependent on careful selection of the loca- by assuming A1 ¼A2, such that volume ¼ 8(A1)2/
tion and direction of the minor axis dimensions 3p(L).120 However, this method makes geometric
and has been shown to significantly underestimate assumptions that may be inaccurate. In older sub-
LA volume.117 jects the diaphragm lifts the cardiac apex upward
In order to estimate the LA minor axis dimension which increases the angle between ventricle and
of the ellipsoid more reliably, the long-axis LA areas atrium. Thus the apical four-chamber view will
can be traced and a composite dimension derived. commonly intersect the atria tangentially in older
This dimension takes into account the entire LA subjects and result in underestimation of volume
border, rather than a single linear measurement. using a single plane technique. Since the majority
When long-axis-area is substituted for minor axis of prior research and clinical studies have used the
dimension, the biplane areaelength formula is biplane areaelength formula, it is the recommen-
used: 8(A1)(A2)/3p(L), where A1 and A2 represent ded ellipsoid method (Figs. 15 and 16).
the maximal planimetered LA area acquired from LA volume may also be measured using Simpson’s
the apical four- and two-chamber-views, respec- rule, similar to its application for LV measure-
tively. The length (L) remains the LA long-axis ments, which states that the volume of a geomet-
length determined as the distance of the perpen- rical figure can be calculated from the sum of the
dicular line measured from the middle of the plane volumes of smaller figures of similar shape. Most
of the mitral annulus to the superior aspect of the commonly, Simpson’s algorithm divides the LA into
left atrium (Fig. 16). In the areaelength formula a series of stacked oval disks whose height is h and
the length (L) is measured in both the four- and whose orthogonal minor and major axes are D1 and
two-chamber views and the shortest of these two D2 (method of disks). The volume of the entire
L measurements is used in the formula. left 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) and
apical two-chamber (A2C) views at ventricular end-systole (maximum LA size). The length (L) is measured from the
back wall to the line across the hinge points of the mitral valve. The shorter (L) from either the A4C or A2C is
used in the equation.
100 R.M. Lang et al.
Figure 17 Measurement of left atrial volume from the biplane method of discs (modified Simpson’s rule), using the
apical four-chamber (A4C) and apical two-chamber (A2C) views at ventricular end-systole (maximum LA size).
Recommendations for chamber quantification 101
Abnormal
Severely
degree of LA enlargement, normal reference
5.2
3.0
5.5
3.2
values for LA volume allow prediction of cardiac
>40
79
‡40
risk. There are now multiple peer reviewed arti-
cles which validate the progressive increase in
risk associated with having LA volumes greater
Moderately
Abnormal
than these normative values.89,97,99e103,106e108,128
4.7e5.2
2.7e2.9
5.0e5.4
2.9e3.1
34e39
30e40
69e78
Consequently, indexed LA volume measurements
should become a routine laboratory measure since
it reflects the burden and chronicity of elevated LV
filling pressure and is a strong predictor of
Abnormal
outcome.
4.1e4.6
2.4e2.6
4.6e4.9
2.6e2.8
29e33
20e30
59e68
Mildly
Right atrium
22 G 6
18e58
Range
20
>40
73
‡40
4.3e4.6
2.7e2.9
5.0e5.4
2.9e3.1
34e39
Reference limits and partition values for left atrial dimensions/volumes
63e72
3.9e4.2
2.4e2.6
4.6e4.9
2.6e2.8
29e33
20e30
53e62
2.7e3.8
1.5e2.3
2.9e4.5
1.7e2.5
22e52
22 G 6
Range
Aortic measurements
LA volume/BSA (ml/m2)
LA area (cm2)
with the patient in a right lateral decubitus mapping to clarify tissueeblood interfaces if
position are also useful. Measurements are usually necessary.132
taken at: (1) aortic valve annulus (hinge point of The thoracic aorta can be better imaged using
aortic leaflets); (2) the maximal diameter in the TEE than, as most of it is in the near field of the
sinuses of Valsalva; and (3) sinotubular junction transducer. The ascending aorta can be seen in
(transition between the sinuses of Valsalva and the long-axis, using the mid-esophageal aortic valve
tubular portion of the ascending aorta). long-axis view at about 130 degrees and the mid-
Views used for measurement should be those esophageal ascending aorta long-axis view. The
that show the largest diameter of the aortic root. short-axis view of the ascending aorta is obtained
When measuring the aortic diameter, it is partic- using the mid-esophageal views at about 45 de-
ularly important, to use the maximum obtainable grees. For measurements of the descending aorta,
short-axis diameter measured perpendicular to the short-axis views at about 0 degrees, and long-axis
long-axis of the vessel in that view. Some experts views at about 90 degrees, can be recorded from
favor inner edge-to-inner edge techniques to the level of the diaphragm up to the aortic arch
match those used by other methods of imaging (Fig. 19). The arch itself and origins of two of the
the aorta, such as MRI and CT scanning. However great vessels can be seen in most patients. There
the normative data for echocardiography were is a ‘‘blind spot’’ in the upper ascending aorta
obtained using the leading edge technique and the proximal arch that is not seen by TEE
(Fig. 18). Advances in ultrasound instrumentation due to the interposed tracheal bifurcation.
which have resulted in improved image resolution
should minimize the difference between these Identification of aortic root dilatation
measurement methods.
Reliability of aortic root measurements by Aortic root diameter at the sinuses of Valsalva is
this method yielded an intra-class correlation related most strongly to body surface area and
coefficient of 0.79 (p < 0.001) in a study of 183 age. Therefore, body surface area may be used to
hypertensive patients (unpublished data). Two- predict aortic root diameter in three age-strata:
dimensional aortic diameter measurements are <20 years, 20e40 and >40 years, by published
preferable to M-mode measurements, as cyclic equations.132 Aortic root dilatation at the sinuses
motion of the heart and resultant changes in of Valsalva is defined as an aortic root diameter
M-mode cursor location relative to the maximum above the upper limit of the 95% confidence inter-
diameter of the sinuses of Valsalva result in val of the distribution in a large reference popula-
systematic underestimation (by w2 mm) of aortic tion.132 Aortic dilatation can be easily detected by
diameter by M-mode in comparison to the 2-D plotting observed aortic root diameter versus body
aortic diameter.132 The aortic annular diameter is surface area on previously-published nomograms
measured between the hinge points of the aortic (Fig. 20).132 Aortic dilatation is strongly associated
valve leaflets (inner edgeeinner edge) in the para- with the presence and progression of aortic regur-
sternal or apical long-axis views that reveal the gitation133 and with the occurrence of aortic
largest aortic annular diameter with color flow dissection.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 aortic
leaflets. Although leading edge to leading edge technique is demonstrated for the sinuses of Valsalva and sinotubular
junction, some prefer the inner edge to inner edge method (see text for further discussion).
Recommendations for chamber quantification 103
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 root inferior vena cava decreases in response to inspira-
diameter at the sinuses of Valsalva133,135 but is tion when the negative intrathoracic pressure
associated with enlargement of more distal aortic leads to an increase in right ventricular filling
segments.135 from the systemic veins. The diameter of the IVC
and the percent decrease in the diameter during
Evaluation of the inferior vena cava inspiration correlate with right atrial pressure.
The relationship has been called the ‘‘collapsibil-
Examination of the inferior vena cava (IVC) from ity index’’.136 Evaluation of the inspiratory re-
the subcostal view should be included as part of sponse often requires a brief ‘‘sniff’’ as normal
the routine TTE examination. It is generally agreed inspiration may not elicit this response.
that the diameter of the inferior vena cava should The normal IVC diameter is <1.7 cm. There is
be measured with the patient in the left decubitus a 50% decrease in the diameter when the right
position at 1.0e2.0 cm from the junction with the atrial pressure is normal (0e5 mmHg). A dilated
right atrium, using the long-axis view. For accu- IVC (>1.7 cm) with normal inspiratory collapse
racy, this measurement should be made perpen- (50%) is suggestive of a mildly elevated RA pres-
dicular to the IVC long-axis. The diameter of the 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
104 R.M. Lang et al.
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<1.2 cm) with spontaneous collapse often is seen Henzlova M, et al. Comparison of four echocardiographic
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depletion.137 tion. Am J Cardiol 2000;86:1358e62.
8. Colombo PC, Municino A, Brofferio A, Kholdarova L,
There are several additional conditions to be Nanna M, Ilercil A, et al. Cross-sectional multiplane trans-
considered in evaluating the inferior vena cava. esophageal echocardiographic measurements: comparison
Athletes have been shown to have dilated inferior with standard transthoracic values obtained in the same
vena cavae with normal collapsibility index. Stud- setting. Echocardiography 2002;19:383e90.
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tricular volumes and ejection fraction by biplane transeso-
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Distribution and categorization of echocardiographic mea-
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