Search Results
SONODESK: Echo Reference Guide
LV Systolic Function & EF
Volumes, EF grading, biplane & 3D
LV Diastolic Function
LAP algorithm, filling pressures
Aortic Stenosis
Velocity, gradient, AVA, DSI
Aortic Root
Annulus, sinuses, STJ, ascending
Mitral Regurgitation
Qual, quant, Carpentier
RV Systolic Function
TAPSE, FAC, DTI S', strain
Right Heart Haemo
PASP, mPAP, PAEDP, PVR
Prosthetic Aortic
DPI, EOA, PPM, algorithm
Calculator
RVSP, AVA, PISA, DSI, mPAP
LV Systolic Function & Ejection Fraction
Simpson's biplane, 3D volumes, EF grading by sex
Simpson's Biplane — LV Volumes indexed (ml/m²)▼
| MEN | WOMEN | |||||||
|---|---|---|---|---|---|---|---|---|
| Measure | Normal | Mild | Mod | Severe | Normal | Mild | Mod | Severe |
| LVEDV | 34–74 | 75–89 | 90–100 | >100 | 29–61 | 62–70 | 71–80 | >80 |
| LVESV | 11–31 | 32–38 | 39–45 | >45 | 8–24 | 25–32 | 33–40 | >40 |
Female partition values may be too small — interpret with other measurements and visual impression
3D Volumes — Upper Limit of Normal▼
| MEN | WOMEN | |||
|---|---|---|---|---|
| LVEDV (ml/m²) | LVESV (ml/m²) | LVEDV (ml/m²) | LVESV (ml/m²) | |
| Upper normal | 79 | 32 | 71 | 28 |
LV Ejection Fraction (%)▼
| MEN | WOMEN | |||||||
|---|---|---|---|---|---|---|---|---|
| Normal | Mild ↓ | Mod ↓ | Severe ↓ | Normal | Mild ↓ | Mod ↓ | Severe ↓ | |
| EF (%) | 52–72 | 41–51 | 30–40 | <30 | 54–74 | 41–53 | 30–40 | <30 |
Significant MR: EF <60% is abnormal regardless of sex
LV Diastolic Function
Diastolic function grading & LAP estimation — standard algorithm
Algorithm Exceptions — Use Special Populations Table Instead▼
This algorithm does not apply to the following:
- MAC (moderate–severe)
- Mitral regurgitation (significant)
- Mitral stenosis (any degree)
- Atrial fibrillation
- LVAD (Left Ventricular Assist Device)
- Non-cardiac pulmonary hypertension
- Heart transplant (HTX)
- Pericardial constriction
For alternative parameters in these populations, see Special Populations Diastolic Function →
Step 1 — The Three Variables▼
| # | Variable | Abnormal Threshold |
|---|---|---|
| 1 | Reduced e' velocity * | Septal ≤6 cm/s · Lateral ≤7 cm/s · Average ≤6.5 cm/s |
| 2 | Increased E/e' | Septal ≥15 · Lateral ≥13 · Average ≥14 |
| 3 | Increased TR velocity / PASP | TR velocity ≥2.8 m/s · PASP ≥35 mmHg |
* Per ASE 2025: fixed cut-offs apply irrespective of age. Age-specific lower limits of normal may be applied as an alternative where clinically appropriate.
Diastolic Function Grading Flowchart▼
All 3 variables normal
↓
Normal LAP
↓
Normal Diastolic Function
Reduced e' only
↓
E/A ≤ 0.8
↓
Grade 1
If symptomatic → consider diastolic exercise echo
E/A > 0.8
↓
proceed to secondary parameters →
Increased TR/PASP only · or Increased E/e' only · or any 2 abnormal variables
↓
Secondary Parameters — need ≥1 of 3
Pulmonary vein S/D ≤0.67
LA reservoir strain (LARS) ≤18%
LAVi >34 ml/m²
LA reservoir strain (LARS) ≤18%
LAVi >34 ml/m²
Alternatively: IVRT ≤70 ms
If none available/reliable, use Special Populations methods →
None positive
↓
Normal LAP
≥1 present
↓
Increased LAP
(Grade 2 if E/A <2)
3 of the above abnormal
↓
Increased LAP
↓
E/A < 2
↓
Grade 2
(Mild/Mod ↑LAP)
E/A ≥ 2
↓
Grade 3
(Marked ↑LAP)
For the full alternate-pathway table (MAC, significant MR, MS, AF, LVAD, HTX, constriction, non-cardiac PH) see Special Populations Diastolic Function →
Grade Summary▼
| Grade | Description | LAP |
|---|---|---|
| Normal DF | All 3 variables normal | Normal |
| Grade 1 | Impaired relaxation, E/A ≤0.8, no secondary criteria positive | Normal |
| Grade 2 | Pseudonormal pattern, E/A <2 with elevated LAP | Mild–Moderately elevated |
| Grade 3 | Restrictive pattern, E/A ≥2 with elevated LAP | Markedly elevated |
Grade 1 with symptoms → consider diastolic exercise echocardiography to unmask exertional LAP elevation
Special Populations — Diastolic Function
Use this table instead of the standard algorithm when any of the listed conditions apply
← Back to Standard Algorithm▼
Why the Standard Algorithm Doesn't Apply▼
The 3-variable LAP estimation algorithm (e', E/e', TR velocity/PASP) assumes a structurally typical mitral valve and LV in sinus rhythm. The following conditions invalidate one or more of its inputs and require alternative or adjunctive parameters:
- MAC (moderate–severe): annular calcification artificially elevates e' measurement reliability and distorts inflow patterns
- Significant MR: volume loading elevates LA pressure independent of diastolic relaxation; E velocity dominated by regurgitant volume
- Mitral stenosis (any degree): transmitral gradient reflects valve obstruction, not LV diastolic properties
- Atrial fibrillation: no distinct A wave; E/e' and deceleration time-based methods used instead with AF-specific cut-offs
- LVAD: mechanical unloading alters loading conditions independent of native diastolic function
- Heart transplant (HTX): altered atrial mechanics and possible rejection-related changes confound standard cut-offs
- Pericardial constriction: respirophasic ventricular interdependence and septal bounce dominate the physiology
- Non-cardiac pulmonary hypertension: elevated TR velocity/PASP reflects pulmonary vascular disease, not LAP
Atrial Fibrillation — Alternative Parameters▼
| Parameter | Elevated LAP Suggested |
|---|---|
| E/e' (septal) | ≥11–13 |
| IVRT (ms) | <65 ms |
| Deceleration time (ms) | <160 ms |
| Pulmonary vein AR duration | Shortened systolic fraction |
| LA reservoir strain | Reduced |
Average over ≥5 cardiac cycles due to beat-to-beat variability in AF
Significant MR — Alternative Parameters▼
| Parameter | Elevated LAP Suggested |
|---|---|
| Pulmonary vein systolic fraction | ≤40% |
| LA reservoir strain | Reduced (severity-dependent) |
| Vena contracta-adjusted E velocity | Interpret with caution — E often elevated from regurgitant volume alone |
e' velocity and E/e' remain relatively load-independent but lose diagnostic precision as MR severity increases
Mitral Stenosis — Approach▼
Standard diastolic function grading is not applicable. LA pressure is presumed elevated proportional to mean transmitral gradient and MVA — see Mitral Stenosis → for grading by mean gradient, MVA and PHT.
MAC, LVAD, HTX, Constriction, Non-cardiac PH▼
| Population | Recommended Approach |
|---|---|
| MAC (mod–severe) | Rely on LA volume/strain and clinical context over annular e' or E/e' |
| LVAD | Diastolic indices not validated; assess via right heart catheterisation if needed clinically |
| Heart transplant | Use serial trends rather than single cut-offs; correlate with biopsy/rejection status |
| Pericardial constriction | Assess respirophasic septal shift, hepatic vein expiratory flow reversal, medial e' > lateral e' (annulus reversus) |
| Non-cardiac PH | TR velocity/PASP unreliable for LAP — rely on e', E/e', LA volume/strain instead |
LV Dimensions & Mass
Linear method, indexed values
LV Cavity Dimensions — Indexed (cm/m²)▼
| MEN | WOMEN | |||||||
|---|---|---|---|---|---|---|---|---|
| Normal | Mild | Mod | Severe | Normal | Mild | Mod | Severe | |
| LVEDD | 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 |
| LVESD | 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 |
LV Wall Thickness & Mass▼
| MEN | WOMEN | |||||||
|---|---|---|---|---|---|---|---|---|
| Normal | Mild | Mod | Severe | Normal | Mild | Mod | Severe | |
| IVS (cm) | 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 |
| PW (cm) | 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 |
| Linear ILVM (g/m²) | 49–115 | 116–131 | 132–148 | >148 | 43–95 | 96–108 | 109–121 | >121 |
| 2D ILVM (g/m²) | 50–102 | 103–116 | 117–130 | >130 | 44–88 | 89–100 | 101–112 | >112 |
🧮 LV Geometry Calculator — Classify Hypertrophy Pattern▼
RWT = (2 × PW) / LVEDD · LVMI = LV Mass / BSA · LV Mass (g) = 0.8 × [1.04 × (LVEDD + IVS + PW)³ − LVEDD³] + 0.6
Measurements
IVS (cm)cm
LVEDD (cm)cm
PW (cm)cm
Patient Details
Sex
BSA (m²)m²
BSA = √(Height(cm) × Weight(kg) / 3600) (Mosteller)
Height (cm)cm
Weight (kg)kg
Enter measurements above
LV Geometric Pattern Classification▼
LV geometry is classified by combining LV Mass Index (LVMI) and Relative Wall Thickness (RWT). The ASE recommends reporting geometry pattern as a standard component of every echo report.
RWT = (2 × PW) / LVEDD · Normal RWT: 0.32–0.42 · Concentric threshold: >0.42
RWT ≤ 0.42
RWT > 0.42
LVMI
Normal
Normal
Normal Geometry
Normal mass
Normal wall thickness
Normal wall thickness
Low cardiovascular risk
Concentric Remodelling
Normal mass
Increased wall thickness
Increased wall thickness
Early pressure adaptation
Often hypertension-related
Often hypertension-related
LVMI
Increased
Increased
Eccentric LVH
Increased mass
Normal wall thickness
Normal wall thickness
Volume overload pattern
(e.g. AR, MR, dilated CMP)
(e.g. AR, MR, dilated CMP)
Concentric LVH
Increased mass
Increased wall thickness
Increased wall thickness
Highest CV risk
(e.g. HTN, AS, HCM)
(e.g. HTN, AS, HCM)
← Relative Wall Thickness →
Men: LVMI >115 g/m² = LVH · Women: LVMI >95 g/m² = LVH (linear method)
RWT = 2×PW / LVEDD · Concentric geometry = RWT >0.42 regardless of sex or BSA
RWT = 2×PW / LVEDD · Concentric geometry = RWT >0.42 regardless of sex or BSA
Source: Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults. J Am Soc Echocardiogr. 2015;28(1):1–39. Fig. 10 & Table 5.
Left Atrial Volume
Indexed LAV — biplane disc summation preferred
ILAV (ml/m²)▼
| Normal | Mildly Abnormal | Moderately Abnormal | Severely Abnormal |
|---|---|---|---|
| 16–34 | 35–41 | 42–48 | >48 |
RV Size
Quantitative parameters; mean ± SD
RV Linear Dimensions (mean ± SD)▼
RV Focused
| Basal RV (mm) | Mid RV (mm) | RV Length (mm) |
|---|---|---|
| 25–41 (33±4) · Indexed <24 mm/m² | 19–35 (27±4) | 59–83 (71±6) |
RVOT
| PLAX (mm) | Proximal (mm) | Distal (mm) |
|---|---|---|
| 20–30 (25±2.5) | 25–35 (28±3.5) | 17–27 (22±2.5) |
RV Wall Thickness (subcostal)
1–5 mm (3±1 mm)
2D Area (cm²/m²)
| MEN | WOMEN | |||
|---|---|---|---|---|
| RVEDA | RVESA | RVEDA | RVESA | |
| Range | 5–12.6 (8.8±1.9) | 3–15 (9±3) | 4.5–11.5 (8.0±1.75) | 1.6–6.4 (4.0±1.2) |
3D Volume (ml/m²)
| MEN | WOMEN | |||
|---|---|---|---|---|
| RVEDV | RVESV | RVEDV | RVESV | |
| Range | 35–87 (61±13) | 10–44 (27±8.5) | 32–74 (53±10.5) | 8–36 (22±7) |
±1.96 SD = 95% CI cutoff for abnormal; +2 SD above mean ≈ dilated/thickened
RV Systolic Function
Use multiple parameters in combination
RV Systolic Parameters▼
| Parameter | Normal | Abnormal |
|---|---|---|
| RVFAC (%) | ≥35 (49±7) | <35 |
| TAPSE (mm) | ≥17 (24±3.5) | <17 |
| Pulsed DTI S' (cm/s) | ≥9.5 (14.1±2.3) | <9.5 |
| 3D RVEF (%) | ≥45 (58±6.5) | <45 |
| MPI (PW) | ≤0.43 (0.26±0.085) | >0.43 |
| MPI (DTI) | ≤0.54 (0.38±0.08) | >0.54 |
| RV Free Wall Strain (%) | −29±4.5 | <−20 |
Values may vary by vendor and software version
RV Diastolic Function
RV Diastolic Parameters▼
Normal Values
| E/A | DT (ms) | E/e' | E' (cm/s) |
|---|---|---|---|
| 1.4±0.3 (range 0.8–2.0) | 180±31 (range 119–242) | 4.0±1.0 (abnormal >6.0) | 14.0±3.1 (abnormal <7.8) |
Grading
| Grade | Criteria |
|---|---|
| Impaired Relaxation | Tricuspid E/A <0.8 |
| Pseudonormal | E/A 0.8–2.1 + E/e' >6 or hepatic vein diastolic predominance |
| Restrictive | E/A >2.1 + deceleration time <120 ms |
RV diastolic function influenced by LH systolic and diastolic function. Report systemic BP also.
Right Atrium & RAP Estimation
Right Atrial Volume (ml/m²)▼
| Men | Women | |||
|---|---|---|---|---|
| Normal | Dilated | Normal | Dilated | |
| RAV index (ml/m²) | <39 (25±7) | ≥39 | <33 (21±6) | ≥33 |
| 2D area (cm²) | <18 | ≥18 | <18 | ≥18 |
2D planimetry area ≥18 cm² is an alternative marker of RA enlargement when volumetric indexing is not available · Measured in apical 4-chamber at end-systole (maximum RA size)
RAP Estimation — IVC Method▼
| Normal 3 mmHg | Intermediate 8 mmHg | High 15 mmHg | ||
|---|---|---|---|---|
| IVC diameter (cm) | ≤2.1 | ≤2.1 | >2.1 | >2.1 |
| Collapse with sniff | >50% | <50% | >50% | <50% |
Secondary indices of ↑ RAP
- Restrictive filling (right heart)
- Tricuspid E/e' >6
- SSF ratio <55%
Athletes: IVC may be dilated with normal RAP · Ventilated patients: IVC unreliable
Aortic Root Measurements
Leading edge to leading edge at end diastole (except annulus: mid-systole, inner edge to inner edge)
Aortic Dimensions▼
| Location | Men | Women | ||
|---|---|---|---|---|
| Absolute (cm) | Indexed (cm/m²) | Absolute (cm) | Indexed (cm/m²) | |
| Aortic Annulus | 2.6±0.3 (dil >3.2) | 1.3±0.1 (dil >1.5) | 2.3±0.2 (dil >2.7) | 1.3±0.1 (dil >1.5) |
| Sinus of Valsalva | 3.4±0.3 (dil >4.0) | 1.7±0.2 (dil >2.1) | 3.0±0.3 (dil >3.6) | 1.8±0.2 (dil >2.2) |
| Sinotubular Junction | 2.9±0.3 (dil >3.5) | 1.5±0.2 (dil >1.9) | 2.6±0.3 (dil >3.2) | 1.5±0.2 (dil >1.9) |
| Prox Ascending | 3.0±0.4 (dil >3.8) | 1.5±0.2 (dil >1.9) | 2.7±0.4 (dil >3.5) | 1.6±0.3 (dil >2.2) |
| Aortic Arch | 2.2–3.6 cm | 2.2–3.6 cm | ||
| Descending Aorta | 2.0–3.0 cm | 2.0–3.0 cm | ||
Dilation defined as above upper 95% CI · Values only valid when measured by the specified technique
Rule of +2 Standard Deviations: Dilation is defined as exceeding mean + 2SD for sex (upper 95% CI). The "dil" threshold shown in each cell = mean + (2 × SD). Example: Men's sinus of Valsalva mean 3.4 ± 0.3 cm → dilation threshold = 3.4 + (2 × 0.3) = 4.0 cm. Apply the same rule to all locations — a result above this value is dilated regardless of absolute size alone.
Z-Score — Age & BSA Adjusted Aortic Root▼
Absolute and indexed measurements may be insufficient in young patients, small adults, or suspected connective tissue disorders (Marfan syndrome, Loeys-Dietz, Ehlers-Danlos). Z-scores normalise aortic root measurements to age, sex, and BSA simultaneously.
Predicted SoV = 2.423 + (Age × 0.009) + (BSA × 0.461) − (Sex × 0.267)
Sex: Men = 1, Women = 2 · SEE = 0.261 cm · BSA by DuBois method
Z-score = (Measured SoV − Predicted SoV) / 0.261
Sex: Men = 1, Women = 2 · SEE = 0.261 cm · BSA by DuBois method
Z-score = (Measured SoV − Predicted SoV) / 0.261
Age (years)yrs
Sex
BSA (m²)m²
Measured SoV (cm)cm
Sinuses of Valsalva (SoV) measured at end diastole, leading edge to leading edge (PLAX)
Enter all values above
| Z-Score | Interpretation |
|---|---|
| Z < 1.96 | Normal for age and body size |
| Z ≥ 1.96 | Dilated — required criterion for aortic root dilation in Ghent nosology (Marfan diagnosis) |
| Z ≥ 3 | Borderline threshold for Marfan in absence of FBN1 mutation — monitor closely |
| Z ≥ 4.5 | Severe dilation — significant aneurysm phenotype, surgical consideration |
Marfan Foundation Adult Z-Score Calculator (Devereux / Roman nomograms · Sinuses of Valsalva · Age ≥15 years · BSA by DuBois method)
→ marfan.org/dx/z-score-adults/
→ marfan.org/dx/z-score-adults/
Paediatric Z-Score Calculator (Colan nomograms · Age <15 years)
→ marfan.org/dx/zscore-children/
→ marfan.org/dx/zscore-children/
Ghent Nosology — Revised Marfan Diagnostic Criteria (2010)
| Aortic Root (Z) | Additional Feature | Diagnosis |
|---|---|---|
| Z ≥ 1.96 | Ectopia lentis | Marfan syndrome |
| Z ≥ 1.96 | FBN1 mutation (bona fide) | Marfan syndrome |
| Z ≥ 1.96 | Systemic score ≥ 7 points | Marfan syndrome |
| Z < 2 | FBN1 + systemic features | Potential MFS — monitor |
| Z < 2 | Systemic score <7, no FBN1 | Non-specific CTD |
Loeys BL et al. Revised Ghent nosology for Marfan syndrome. J Med Genet. 2010;47:476–485
Aortic Stenosis
AHA/ACC and ESC gradient thresholds differ — note which guideline applies
AS Grading Parameters▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Peak velocity (m/s) | 2.6–2.9 | 3.0–4.0 | >4.0 |
| Mean gradient AHA/ACC (mmHg) | <20 | 20–40 | >40 |
| Mean gradient ESC (mmHg) | <30 | 30–50 | >50 |
| AVA (cm²) | >1.5 | 1.0–1.5 | <1.0 |
| AVA indexed (cm²/m²) | >0.85 | 0.6–0.85 | <0.6 |
| DSI | >0.5 | 0.25–0.5 | <0.25 |
Index AVA for BSA when BSA <1.6 m² or >2.0 m²
🧮 Stroke Volume Index (SVi) Calculator▼
Calculate SVi to determine flow status. SVi ≤35 ml/m² = low flow — consider low-flow, low-gradient AS subtype.
SV = CSALVOT × VTILVOT · SVi = SV / BSA
LVOT Ø (cm)cm
LVOT VTI (cm)cm
BSA (m²)m²
BSA can be calculated from height + weight in the LV Geometry Calculator
Enter values above
AS Flow & Gradient Classification Flowchart▼
Full ESC/EACTS algorithm for discordant AS parameters (AVA ≤1 cm² with low gradient). Begin at the top and follow the branching logic.
MG <40 mmHg & AVA <1 cm²
AVA-gradient discordance → assess SVi
MG ≥40 mmHg & AVA <1 cm²
High-Gradient Severe AS
↓
↓
SVi ≤35 ml/m²
Low Flow
SVi >35 ml/m²
Normal-Flow, Low-Gradient AS
HIGH GRADIENT SEVERE AS
AVA <1 cm²
MG ≥40 mmHg
SVi >/<35 ml/m²
LVEF >/<50%
MG ≥40 mmHg
SVi >/<35 ml/m²
LVEF >/<50%
↓
Check LVEF
LVEF <50%
LVEF ≥50%
NORMAL-FLOW LOW-GRADIENT AS
AVA <1 cm²
MG <40 mmHg
SVi >35 ml/m²
LVEF ≥50%
MG <40 mmHg
SVi >35 ml/m²
LVEF ≥50%
Verify echo sources of error
LVOT underestimation: compare measured vs predicted LVOTD; corroborate LVOT area (3D, MDCT)
Confirm low-flow: Teicholz, biplane Simpson, or 3D volumetric
Causes of low-flow: LV concentric remodelling, impaired longitudinal function, AF, amyloidosis, MR/MS, TR, RV dysfunction
Confirm low-gradient: multi-window interrogation (apical, right parasternal, suprasternal)
Confirm low-flow: Teicholz, biplane Simpson, or 3D volumetric
Causes of low-flow: LV concentric remodelling, impaired longitudinal function, AF, amyloidosis, MR/MS, TR, RV dysfunction
Confirm low-gradient: multi-window interrogation (apical, right parasternal, suprasternal)
↓
↓
↓
CLASSIC LF-LG AS
AVA <1 cm²
MG <40 mmHg
SVi ≤35 ml/m²
LVEF <50%
MG <40 mmHg
SVi ≤35 ml/m²
LVEF <50%
PARADOXICAL LF-LG AS
AVA <1 cm²
MG <40 mmHg
SVi ≤35 ml/m²
LVEF ≥50%
MG <40 mmHg
SVi ≤35 ml/m²
LVEF ≥50%
Usually moderate AS — reassess carefully, exclude measurement error
↓
↓
DSE — Dobutamine Stress Echo
Low dose: up to 20 µg/kg/min
AVA ≥1 cm²
MG <40 mmHg
MG <40 mmHg
Pseudo-severe AS
AVA <1 cm²
MG ≥40 mmHg
MG ≥40 mmHg
Severe AS
AVA <1 cm²
MG <40 or ΔSV <20%
MG <40 or ΔSV <20%
Indeterminate → AVAproj
If ΔSV 10–20%: Calculate AVAproj
AVAproj <1 cm² → Severe AS · AVAproj ≥1 cm² → Pseudo-severe AS
AVAproj <1 cm² → Severe AS · AVAproj ≥1 cm² → Pseudo-severe AS
Non-Contrast MDCT — AV Calcium Score
For paradoxical LF-LG AS and normal-flow LG AS
Below threshold
Men <2,000 AU
Women <1,200 AU
Women <1,200 AU
Non-severe AS
Above threshold
Men ≥2,000 AU
Women ≥1,200 AU
Women ≥1,200 AU
Severe AS
CT calcium thresholds above are from ESC/EACTS 2021 guidelines. Note: AHA/ACC 2021 uses slightly different thresholds (≥1600 AU men / ≥800 AU women for severe AS). Some centres use ≥3000 AU for very high likelihood.
Sources: ESC/EACTS 2021 VHD Guidelines (Vahanian et al.) · AHA/ACC 2021 VHD Guidelines · Baumgartner H et al. Eur Heart J. 2017;38:2739–91
Aortic Regurgitation
AR — Qualitative▼
| Parameter | Mild 1/4 | Moderate 2–3/4 | Severe 4/4 |
|---|---|---|---|
| CW signal intensity | Incomplete/faint | Dense | Dense |
| Flow reversal – Desc Ao | Brief, early diastolic | Intermediate | Pan-diastolic |
| Flow reversal – Abdo Ao | — | — | Pan-diastolic |
| AR pressure half-time (ms) | >500 | 200–500 | <200 |
| Jet width of LVOT (%) ** | <25 | Intermediate | ≥65 |
| VC-W (cm) ** | <0.30 | Intermediate | ≥0.6 |
PHT dependent on LV compliance · ** Nyquist limit 50–60 cm/s
AR — Quantitative▼
| Parameter | 1/4 | 2/4 | 3/4 | 4/4 |
|---|---|---|---|---|
| RV (ml) | <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 |
Mitral Stenosis
MS Grading▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Mean gradient (mmHg)* | <5 | 5–9 | ≥10 |
| MVA (cm²) | >2.5 | 1.6–2.5 | <1.5 |
| RVSP (mmHg) | <30 | 30–50 | >50 |
| PHT (ms) | <100 | 100–149 | ≥150 |
* At heart rates 60–80 bpm in sinus rhythm
Wilkins Score▼
Score ≤8 → likely good result · Score >8 → less likely good result (balloon valvuloplasty)
| Grade | Mobility | Subvalvular | Thickening | Calcification |
|---|---|---|---|---|
| 1 | Highly mobile, tips only restricted | Minimal below leaflets | Near normal 4–5 mm | Single bright area |
| 2 | Mid/base normal mobility | Up to 1/3 chordal length | Mid normal; margins 5–8 mm | Scattered at margins |
| 3 | Forward mainly from base | To distal 1/3 chords | Entire leaflet 5–8 mm | Into mid-portion |
| 4 | No/minimal forward movement | Extensive to papillary muscles | All tissue >8–10 mm | Extensive throughout |
Padial Score▼
Score ≥10 → likely to develop severe MR post-valvuloplasty
| Grade | Leaflet Thickening (each scored separately) | Commissural Calcification | Subvalvular |
|---|---|---|---|
| 1 | Near normal (4–5 mm) or one thick segment | Fibrosis/calcium in one commissure | Minimal just below valve |
| 2 | Evenly fibrotic/calcified; no thin areas | Both commissures mildly affected | Up to 1/3 chordal length |
| 3 | Uneven; thinner segments mildly thickened 5–8 mm | Calcium in both; one markedly affected | Distal 1/3 chordae |
| 4 | Uneven; thinner segments near normal 4–5 mm | Both commissures markedly affected | Extensive to papillary muscle |
Mitral Regurgitation
MR — Qualitative▼
| Parameter | Mild 1/4 | Moderate 2–3/4 | Severe 4/4 |
|---|---|---|---|
| Transmitral PW | A-dominant | Variable | E-dominant >1.5 m/s |
| Pulmonary venous PW | Systolic dominance | Systolic blunting | Systolic reversal |
| MR CW intensity | Incomplete/faint | Dense | Dense |
| MR jet contour CW | Parabolic | Usually parabolic | Early peaking / triangular |
| Jet area ratio (%) | <4 cm² or <20% LAA | Variable | >10 cm² or >40% LAA |
| VC-W (cm) | <0.30 | 0.30–0.69 | ≥0.7 |
| PISA radius (cm) | No/minimal <0.4 | Variable | Large ≥0.9 |
Nyquist 50–60 cm/s for colour · PISA: baseline shift at Nyquist 40 cm/s · Higher VC cut-offs for eccentric jets (angle-correct)
MR — Quantitative▼
| Parameter | 1/4 | 2/4 | 3/4 | 4/4 |
|---|---|---|---|---|
| RV (ml) | <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 |
Carpentier Functional Classification▼
| Type | Leaflet Motion | Anatomical Lesion |
|---|---|---|
| Type I | Normal | Annular dilation · Leaflet perforation · Cleft leaflet |
| Type II (Prolapse) | Increased | Chordal/PM rupture · Chordal/PM elongation |
| Type IIIa (Rheumatic) | Restricted systole & diastole | Leaflet thickening/retraction/calcification · Chordal/commissural fusion |
| Type IIIb (Ischaemic) | Restricted systole only | PM displacement · LV dilation · Leaflet tethering · Chordal thickening |
Pulmonary Stenosis
PS Grading▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Peak velocity (m/s) | <3 | 3–4 | >4 |
| Max gradient (mmHg) | <36 | 36–64 | >64 |
PASP from RVSP
| Obstruction | Formula |
|---|---|
| Mild–moderate | PASP = RVSP − mean PV gradient |
| Critical (rounded signal) | PASP = RVSP − max PV gradient |
Pulmonary Regurgitation
PR — Qualitative▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Signal intensity | Incomplete/faint | Dense | Dense |
| Jet width (mm) | <10 mm | Intermediate | Wide at origin |
Pan-diastolic branch PA reversal → moderate or more PR · P½t <100 ms → haemodynamically significant · Jet/RVOT annulus >40% → moderate or more
PR — Quantitative RF (%)▼
| Mild <20 | Moderate 20–40 | Severe >40 |
|---|
Tricuspid Stenosis
TS Grading▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Mean Gradient (m/s) | <2 | 2–4 | ≥5 |
| TVA (cm²) | — | — | ≤1.0 |
Tricuspid Regurgitation
TR — Qualitative▼
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Forward E velocity | — | — | ≥65 cm/s |
| Signal intensity | Incomplete/faint | Dense | Dense |
| Contour | Parabolic | Usually parabolic | Early peaking (V cut-off) |
| Hepatic vein | Systolic dominance | Systolic blunting | Systolic flow reversal |
| Jet area (cm²) Nyquist 50–60 | <5 | 5–10 | >10 |
| Flow convergence radius (cm) Nyquist 28 | ≤0.5 | 0.6–0.9 | >0.9 |
| Vena contracta (cm) Nyquist 50–60 | — | — | ≥0.7 |
TR — Quantitative▼
| Parameter | 1/4 | 2/4 | 3/4 | 4/4 |
|---|---|---|---|---|
| RV (ml) | <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 |
Prosthetic Aortic Valve
Doppler Parameters — Mechanical & Bioprosthetic AVR▼
| Parameter | Normal | Possible Stenosis | Significant Stenosis |
|---|---|---|---|
| Peak velocity (m/s) | <3 | 3–4 | >4 |
| Mean gradient (mmHg) | <20 | 20–35 | >35 |
| DPI | ≥0.30 | 0.25–0.29 | <0.25 |
| EOA (cm²) | >1.2 | 0.8–1.2 | <0.8 |
| Jet contour | Triangular, early peaking | Triangular → intermediate | Rounded, symmetrical |
| Acceleration time (ms) | <80 | 80–100 | >100 |
Normal/near-normal stroke volume 50–70 ml assumed · More affected by flow when concomitant AR present
Patient-Prosthesis Mismatch (PPM)▼
| Indexed EOA (cm²/m²) | Normal >0.85 | Moderate 0.65–0.85 | Severe <0.65 |
|---|
Differentiating Elevated AVR Gradients▼
| Parameter | PP Mismatch | Obstruction | Valve Geometry* | High Output |
|---|---|---|---|---|
| Valve gradients | ↑ | ↑ | ↑ | ↑ |
| DPI (DVI) | Normal | Reduced | Reduced | Normal |
| EOA | Normal | Reduced | Reduced | Normal |
| EOA Index | Reduced | Reduced | Reduced | Normal |
| Δ EOA/DPI vs baseline | No | Yes | No | No |
| Abnormal leaflet motion | No | Yes | No | No |
* Most commonly in 19 mm and 21 mm bileaflet prostheses
Elevated Peak Prosthetic Aortic Velocity — Algorithm▼
Source: Zoghbi WA, Jone PN, Chamsi-Pasha MA, et al. Guidelines for the Evaluation of Prosthetic Valve Function with Cardiovascular Imaging. J Am Soc Echocardiogr. 2024;37(2):2–63. Figure 13 — Algorithm for initial evaluation of elevated peak prosthetic aortic jet velocity incorporating DVI, jet contour, and acceleration time (AT).
Prosthetic Mitral Valve
Doppler Parameters — Prosthetic MVR▼
| Parameter | Normal | Possible Stenosis | Significant Stenosis |
|---|---|---|---|
| Peak velocity (m/s) | <1.9 | 1.9–2.5 | >2.5 |
| Mean gradient (mmHg) | ≤5 | 6–10 | >10 |
| MVR Index | <2.2 | 2.2–2.5 | >2.5 |
| EOA (cm²) | ≥2.0 | 1.0–2.0 | <1.0 |
| P½T (ms) | <130 | 130–200 | >200 |
Best specificity when majority of parameters agree · Also evaluate for ↑ flow, ↑ HR, PPM · Also abnormal with significant prosthetic MR
Prosthetic Tricuspid Valve
Doppler Parameters — Prosthetic TVR▼
| Parameter | Bioprosthetic (Abnormal ≥) | Mechanical (Abnormal ≥) |
|---|---|---|
| Peak velocity (m/s) | ≥2.1 | ≥1.9 |
| Mean gradient (mmHg) | ≥9 | ≥6 |
| P½t (ms) | ≥200 | ≥130 |
| EOA (cm²) / TVR Index | <1.5 | <2.0 |
Average ≥5 cycles due to respiratory variation
Right Heart Haemodynamics
Pulmonary Hypertension Classification▼
RVSP / PASP
| Mild | Moderate | Severe |
|---|---|---|
| 40–54 mmHg | 55–64 mmHg | ≥65 mmHg |
PVR
| Normal <2 WU | Elevated >3 WU |
|---|
PVR estimation not routinely recommended
PHTN Aetiology Differentiation▼
LH Disease
- ↑ TR velocity
- ↑ E/e'
- ePLAR <0.25 m/s
Pulmonary Disease
- ↑ TR velocity
- E/e' low or normal
- ePLAR >0.3 m/s
Formulas & Normal Values▼
| Parameter | Formula | Normal |
|---|---|---|
| RVSP / PASP | 4 × VTR² + RAP | <40 mmHg |
| mPAP | AcT>120: 79−(0.45×AcT) AcT≤120: 90−(0.62×AcT) | <25 mmHg |
| PAEDP | 4 × VPR-ED² + RAP | 4–12 mmHg |
🧮 RVSP / PASP Calculator▼
RVSP = 4 × VTR² + RAP
TR velocity (m/s)m/s
RAP (mmHg)
Enter values above
🧮 mPAP Calculator▼
AcT >120 ms: mPAP = 79 − (0.45 × AcT)
AcT ≤120 ms: mPAP = 90 − (0.62 × AcT)
AcT ≤120 ms: mPAP = 90 − (0.62 × AcT)
RV AcT (ms)ms
Enter AcT above
AcT measured from RVOT PW Doppler — onset of flow to peak velocity · Mid-systolic notch may indicate PHTN even with AcT >120 ms
🧮 PAEDP Calculator▼
PAEDP = 4 × VPR-ED² + RAP
PR end-diastolic v (m/s)m/s
RAP (mmHg)
Enter values above
Normal PAEDP: 4–12 mmHg · PR end-diastolic velocity measured from CW or PW Doppler at end-diastole
Quick Calculator
Inline calculation tools for common echo measurements
🧮 RVSP / PASP▼
RVSP = 4 × VTR² + RAP
VTR (m/s)m/s
RAP (mmHg)mmHg
Enter values above
🧮 AVA Continuity Equation▼
AVA = (LVOT CSA × LVOT VTI) / AV VTI
LVOT Ø (cm)cm
LVOT VTI (cm)cm
AV VTI (cm)cm
Enter values above
🧮 DSI (Dimensionless Severity Index)▼
DSI = LVOT VTI / AV VTI
LVOT VTI (cm)cm
AV VTI (cm)cm
Enter values above
🧮 PISA EROA (MR)▼
EROA = (2π × r² × Va) / VMR
PISA radius (cm)cm
Aliasing Va (cm/s)cm/s
Peak VMR (m/s)m/s
Enter values above
🧮 MR — Stroke Volume Method▼
SVMV = CSAMV × VTIMV
SVLVOT = CSALVOT × VTILVOT
RVol = SVMV − SVLVOT · RF = RVol / SVMV
SVLVOT = CSALVOT × VTILVOT
RVol = SVMV − SVLVOT · RF = RVol / SVMV
Mitral Annulus (total inflow)
MV annulus Ø (cm)cm
MV inflow VTI (cm)cm
LVOT (forward/systemic flow)
LVOT Ø (cm)cm
LVOT VTI (cm)cm
Enter values above
Use the larger valve annulus diameter measured in an orthogonal view; MV annulus is best measured in apical 4 or 2 chamber at annular hinge points. Assumes no concomitant AR or AS.
🧮 AR — Stroke Volume Method▼
SVLVOT = CSALVOT × VTILVOT
SVMV = CSAMV × VTIMV
RVol = SVLVOT − SVMV · RF = RVol / SVLVOT
SVMV = CSAMV × VTIMV
RVol = SVLVOT − SVMV · RF = RVol / SVLVOT
LVOT (total outflow, incl. regurgitant volume)
LVOT Ø (cm)cm
LVOT VTI (cm)cm
Mitral Annulus (forward flow)
MV annulus Ø (cm)cm
MV inflow VTI (cm)cm
Enter values above
LVOT represents total systolic outflow (forward + regurgitant volume); MV inflow represents net forward flow. Assumes no concomitant MR or MS.
🧮 Qp:Qs (Shunt Ratio)▼
Qp = CSARVOT/PA × VTIRVOT/PA (pulmonary flow)
Qs = CSALVOT × VTILVOT (systemic flow)
Qp:Qs = Qp / Qs
Qs = CSALVOT × VTILVOT (systemic flow)
Qp:Qs = Qp / Qs
Pulmonary Flow (Qp) — RVOT/PA
RVOT/PA Ø (cm)cm
RVOT/PA VTI (cm)cm
Systemic Flow (Qs) — LVOT
LVOT Ø (cm)cm
LVOT VTI (cm)cm
Enter values above
Qp:Qs >1.5 generally considered haemodynamically significant left-to-right shunt · Qp:Qs <1.0 suggests right-to-left shunt · Measure RVOT just proximal to the pulmonary valve · For a PDA with reversed (right-to-left) flow, tick "Reverse" to report as Qs:Qp
🧮 mPAP from RV AcT▼
AcT>120: 79−(0.45×AcT) AcT≤120: 90−(0.62×AcT)
RV AcT (ms)ms
Enter value above
🧮 RVSP from VSD▼
RVSP = SBP − 4 × VVSD²
SBP (mmHg)mmHg
VVSD (m/s)m/s
Enter values above
🧮 Respiratory Variation▼
Respiratory Variation (%) = (Expiration − Inspiration) / Expiration × 100
Used to assess haemodynamic significance of pericardial effusion (tamponade), constrictive physiology, or fluid responsiveness. Measure peak velocity in both expiration and inspiration.
Mitral Inflow
Expiratory E (cm/s)cm/s
Inspiratory E (cm/s)cm/s
Enter values above
Interpretation thresholds:
Mitral E: ≥25% variation → significant tamponade physiology
Constrictive pericarditis: mitral E ≥25% + septal bounce + annulus reversus
Mitral E: ≥25% variation → significant tamponade physiology
Constrictive pericarditis: mitral E ≥25% + septal bounce + annulus reversus
Mitral Annular Calcification (MAC)
Assessed from parasternal short-axis at level of mitral annulus
MAC Grading▼
| Grade | Description |
|---|---|
| Mild | Focal, limited echodensity; <1/3 annular circumference |
| Moderate | Marked echodensity involving 1/3 to 1/2 of ring circumference |
| Severe | Marked echodensity >1/2 annulus, or intrusion into LV inflow, or >4 mm thickness (AP direction, PSAX) |
References & Source Guidelines
All clinical content in this reference tool is derived from the following ASE and collaborative society guidelines
Left Ventricular Function & Diastolic Function▼
LV Diastolic Function
Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure with Preserved Ejection Fraction Diagnosis: An Update from the American Society of Echocardiography
J Am Soc Echocardiogr. 2025;38(7):537–569
Supersedes the 2016 ASE/EACVI guideline. Introduces revised 3-variable algorithm, grading (Normal DF, Grade 1–3), special population algorithms for AF, PHTN, and HTX, and new HFpEF diagnostic criteria.
View on JASE →
Prior Guideline
Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
J Am Soc Echocardiogr. 2016;29(4):277–314
Previous 4-variable algorithm (e', E/e', TR velocity, LAVi). Superseded by the 2025 ASE update.
Chamber Quantification▼
LV & RV Dimensions
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
J Am Soc Echocardiogr. 2015;28(1):1–39
Source for LV volumes (Simpson's biplane, 3D), EF grading by sex, LV cavity dimensions/mass (linear and 2D), LA volume, RV linear/area/3D dimensions, RA volume, and aortic root measurements.
View on JASE →
Right Heart & Pulmonary Hypertension▼
RV Function & PHTN
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults and Special Considerations in Pulmonary Hypertension: Recommendations from the American Society of Echocardiography
J Am Soc Echocardiogr. 2025;38(3):1–(in press)
Source for RV size (basal, mid, length, RVOT, wall thickness), RV systolic function (TAPSE, FAC, DTI S', 3D RVEF, MPI, free wall strain), RV diastolic function grading, RA volume, RAP estimation (IVC method), RVSP/PASP, mPAP formulas, PVR, and PHTN classification.
View on JASE →
Prior Guideline
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography
J Am Soc Echocardiogr. 2010;23(7):685–713
Foundational right heart guideline; superseded by the 2025 update above.
Native Valve Regurgitation▼
AR, MR, TR, PR
Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance
J Am Soc Echocardiogr. 2017;30(4):303–371
Source for qualitative and quantitative grading of AR, MR, TR, PR, PS, and TS. Includes Carpentier classification for MR, VC-W, PISA EROA, RVol, RF thresholds, flow reversal criteria, and CW signal density assessment.
View on JASE →
Aortic Stenosis▼
AS Grading
AHA/ACC 2014 Guideline for the Management of Patients with Valvular Heart Disease
J Am Coll Cardiol. 2014;63(22):e57–185 (updated 2021)
Source for AHA/ACC AS severity thresholds (peak velocity, mean gradient, AVA, indexed AVA, DSI). ESC thresholds (mean gradient >50 mmHg for severe) sourced from 2021 ESC/EACTS VHD guidelines.
Mitral Stenosis▼
MS Grading & Scoring
ASE/ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease: Echocardiographic Assessment of Mitral Stenosis
J Am Soc Echocardiogr. 2009;22(1):1–23
Source for MS grading (mean gradient, MVA, RVSP, PHT), Wilkins score (mobility, subvalvular thickening, leaflet thickening, calcification), and Padial score. Also sourced from AHA/ACC 2021 VHD guidelines for updated MVA thresholds.
Prosthetic Valve Assessment▼
AVR / MVR / TVR
Guidelines for the Evaluation of Prosthetic Valve Function with Cardiovascular Imaging: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography
J Am Soc Echocardiogr. 2024;37(2):2–63
Source for all prosthetic valve Doppler parameters (AVR: peak velocity, mean gradient, DPI/DVI, EOA, jet contour, AT; MVR: peak velocity, mean gradient, MVR index, EOA, P½T; TVR: bioprosthetic vs mechanical thresholds), PPM, differential diagnosis algorithm for elevated prosthetic aortic gradients, and paravalvular AR assessment.
View on JASE →
Aortic Root & Great Vessels▼
Aortic Measurements
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults (see above) — Aortic Root Section
Supplemented by: ASE Comprehensive Echocardiography (2nd Ed.) — Aorta Chapter
Source for aortic annulus, sinus of Valsalva, STJ, and proximal ascending aorta absolute and indexed reference values by sex. Measurement methodology (leading edge to leading edge, end diastole; except annulus: inner edge to inner edge, mid-systole).
How to Cite This Tool▼
This reference tool is a clinical summary compiled from the guidelines listed above for point-of-care use by cardiac sonographers and echocardiologists. It is not an independent publication. Users should refer to the primary source guidelines for full methodology, limitations, and clinical context before applying values in individual patient care.
Content last reviewed: June 2026 · Primary source: ASE Guidelines (various years as listed above) · For discrepancies, the most recently published ASE guideline takes precedence.