Echo Reference — Chamber Quantification
LV Volumes & Ejection Fraction
Indexed LV volumes by Simpson's biplane, 3D, and contrast methods. Ejection fraction severity grading and global longitudinal strain (GLS) reference values by sex.
Simpson's Biplane — Indexed Volumes & EF
LV volumes are measured using the biplane method of discs (modified Simpson's rule) from apical four-chamber and two-chamber views. Trace the endocardial border at end-diastole and end-systole, excluding papillary muscles from the cavity. Volumes are indexed to BSA.
Men
| Parameter | Mildly Abnormal | Moderately Abnormal | Severely Abnormal |
|---|---|---|---|
| ILVEDV (mL/m²) | 75 – 89 | 90 – 100 | > 100 |
| ILVESV (mL/m²) | 32 – 38 | 39 – 45 | > 45 |
| LVEF (%) | 41 – 51 | 30 – 40 | < 30 |
Women
| Parameter | Mildly Abnormal | Moderately Abnormal | Severely Abnormal |
|---|---|---|---|
| ILVEDV (mL/m²) | 62 – 70 | 71 – 80 | > 80 |
| ILVESV (mL/m²) | 25 – 32 | 33 – 40 | > 40 |
| LVEF (%) | 41 – 53 | 30 – 40 | < 30 |
Female partition values: The partition values for female LV volumes have been questioned as potentially too small. Consider in the context of other measurements and visual impressions.
Significant MR: In the presence of significant mitral regurgitation, an EF < 60% should be considered abnormal as the volume-loaded ventricle is expected to be hyperdynamic.
EF Classification by Heart Failure Phenotype
LVEF defines the heart failure phenotype, which directly determines guideline-directed medical therapy. These thresholds are used across ESC, AHA/ACC, and NHFA guidelines.
| LVEF | Classification | Abbreviation |
|---|---|---|
| ≤ 40% | Heart failure with reduced ejection fraction | HFrEF |
| 41 – 49% | Heart failure with mildly reduced ejection fraction | HFmrEF |
| ≥ 50% | Heart failure with preserved ejection fraction | HFpEF |
Diagnostic caveat: EF alone does not diagnose heart failure. HFmrEF and HFpEF require additional evidence of cardiac dysfunction — typically elevated filling pressures (elevated natriuretic peptides, diastolic dysfunction on echo) or other objective findings supporting the diagnosis.
Treatment implications: The strongest evidence for neurohormonal blockade (ACE inhibitors/ARNi, beta-blockers, MRAs) remains in HFrEF. SGLT2 inhibitors have the broadest evidence base across the EF spectrum, with randomised outcome data supporting their use in HFrEF, HFmrEF, and HFpEF.
Pitfalls of EF by Simpson's Biplane
| Pitfall | Effect |
|---|---|
| Foreshortened apical views | Underestimates true LV length → underestimates volumes → may overestimate EF |
| Poor endocardial definition (≥ 2 contiguous segments) | Inaccurate tracing → unreliable volumes. Use contrast or 3D instead |
| Inconsistent endocardial tracing convention | Papillary muscle and trabecular handling varies by operator and software → affects cavity volume and EF reproducibility |
| Limited representation of regional dysfunction | Biplane method samples only 2 planes — abnormal geometry or wall motion outside these planes is not captured |
| 2D vs 3D vs CMR discrepancy | 2D Simpson's systematically underestimates volumes compared to 3D and CMR |
When to Use Which Method
| Method | When to Use |
|---|---|
| 2D Simpson's biplane | Standard method when image quality is adequate and endocardial borders are well seen |
| Contrast-enhanced 2D | When ≥ 2 contiguous endocardial segments are not visualised. Improves accuracy and reproducibility |
| 3D echocardiography | Preferred when available — less geometric assumptions, better reproducibility, closer agreement with CMR. Recommended for serial monitoring |
| CMR | Gold standard for LV volumes and EF. Use when echo is suboptimal or discrepant with clinical picture. When EF is borderline around major management cut-points — particularly device decisions — CMR may be useful for more reproducible quantification |
3D and Contrast LV Volumes
3D echocardiography and contrast-enhanced volumes provide more accurate and reproducible LV volumes than 2D methods, with less geometric assumptions. Note the different upper limits of normal compared to Simpson's biplane.
| Parameter | Men | Women |
|---|---|---|
| 3D LVEDVI (mL/m²) | < 79 | < 71 |
| 3D LVESVI (mL/m²) | < 32.2 | < 28 |
| Contrast LVEDVI (mL/m²) * | < 98 | < 83 |
* Contrast volumes: These are proposed cutoff values only — larger prospective studies are needed. Contrast-enhanced volumes are systematically larger than non-contrast 2D and 3D volumes due to improved endocardial border delineation.
Global Longitudinal Strain (GLS)
GLS is measured by speckle-tracking echocardiography from apical four-chamber, two-chamber, and three-chamber (long-axis) views. Reported as a negative value (more negative = better function), but absolute values are used for grading. Vendor-specific differences exist — use the same platform for serial studies.
| GLS (absolute value) | Normal | Borderline | Abnormal |
|---|---|---|---|
| Threshold | > 18% | 16 – 18% | < 16% |
Clinical context: GLS detects subclinical systolic dysfunction before EF declines and is particularly valuable in cardio-oncology surveillance, HFpEF assessment, infiltrative cardiomyopathies, and valvular heart disease. A relative reduction of > 15% from baseline is considered clinically significant in serial monitoring (e.g. cancer therapeutics).
Vendor variability: Normal GLS values vary by vendor and software version. The thresholds above are consensus values from the ASE/EACVI 2015 guidelines. Always compare serial studies using the same vendor platform and software version.
GLS Regional Patterns — Clinical Significance
GLS is not just a global number — the regional strain pattern provides diagnostic clues. The bull's-eye plot should be reviewed for characteristic distributions.
| Pattern | Description | Consider |
|---|---|---|
| Apical sparing | Reduced basal and mid-ventricular strain with preserved apical strain | Cardiac amyloidosis — highly suggestive pattern |
| Basal-to-mid predominant reduction | Reduced strain in basal and mid segments with relatively preserved apical function | Hypertensive heart disease / pressure-loading phenotype |
| Territorial pattern | Reduced strain confined to a single coronary artery territory | Coronary artery disease — regional ischaemia or prior infarction |
| Globally reduced, preserved EF | Diffusely reduced strain (< 16–18%) with LVEF ≥ 50% | Subclinical LV systolic dysfunction — early chemotherapy cardiotoxicity, HFpEF, early cardiomyopathy |
| Septal systolic stretch / septal flash | Early septal shortening with delayed lateral wall contraction on strain curves | LBBB-related mechanical dyssynchrony — relevant to CRT evaluation rather than routine aetiologic interpretation |
Cardio-oncology: In patients receiving potentially cardiotoxic cancer therapy, a relative GLS reduction of > 15% from baseline — even if the absolute GLS remains above 16% — should prompt cardiology review. GLS decline typically precedes EF reduction by weeks to months, providing a window for early intervention.
References
- Lang RM, et al. 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;28:1–39.
- Asch FM, et al; WASE Investigators. Similarities and Differences in Left Ventricular Size and Function among Races and Nationalities: Results of the World Alliance Societies of Echocardiography Normal Values Study. J Am Soc Echocardiogr. 2019;32(11):1396–1406.
- Addetia K, et al; WASE Investigators. Normal Values of Left Ventricular Size and Function on Three-Dimensional Echocardiography: Results of the World Alliance Societies of Echocardiography Study. J Am Soc Echocardiogr. 2022;35(5):449–459.