LV Volume Normal Values, Ejection Fraction & GLS
Adult LVEDVi, LVESVi and LVEF normal ranges and severity partitions by sex, with 3D and ultrasound-enhancing-agent values, global longitudinal strain cut-offs, and practical measurement pitfalls.
Left ventricular end-diastolic volume index (LVEDVi), left ventricular end-systolic volume index (LVESVi) and left ventricular ejection fraction (LVEF) are most commonly measured by the biplane method of discs, or modified Simpson's method. The tables below give adult normal reference ranges and severity partitions by sex, followed by 3D and ultrasound-enhancing-agent (contrast) values, global longitudinal strain reference values, and the measurement pitfalls that most often distort them.
Normal LVEDVi, LVESVi and LVEF by Simpson's Biplane Method
Volumes are traced from apical four-chamber and two-chamber views, then indexed to body surface area. Trace the compacted endocardial border, excluding papillary muscles and trabeculae from the blood-pool cavity. Values below are the ASE/EACVI 2015 adult 2D biplane reference ranges. For linear dimensions, wall thickness and LV mass, see LV dimensions and mass reference values.
Men
| Parameter | Normal | Mildly abnormal | Moderately abnormal | Severely abnormal |
|---|---|---|---|---|
| LVEDVi (mL/m²) | 34 – 74 | 75 – 89 | 90 – 100 | > 100 |
| LVESVi (mL/m²) | 11 – 31 | 32 – 38 | 39 – 45 | > 45 |
| LVEF (%) | 52 – 72 | 41 – 51 | 30 – 40 | < 30 |
Women
| Parameter | Normal | Mildly abnormal | Moderately abnormal | Severely abnormal |
|---|---|---|---|---|
| LVEDVi (mL/m²) | 29 – 61 | 62 – 70 | 71 – 80 | > 80 |
| LVESVi (mL/m²) | 8 – 24 | 25 – 32 | 33 – 40 | > 40 |
| LVEF (%) | 54 – 74 | 41 – 53 | 30 – 40 | < 30 |
Measurement Technique
Frame selection
End-diastole is taken at the largest LV volume, or the first frame after mitral valve closure. End-systole is taken at the smallest LV volume, or the frame after aortic valve closure. Average approximately three cardiac cycles in sinus rhythm, and at least five representative cycles in atrial fibrillation where feasible.
Tracing convention
Trace the compacted endocardial border. Papillary muscles and trabeculae are excluded from the blood-pool cavity. Avoid apical foreshortening — use off-axis or lower intercostal windows if needed to maximise LV long-axis length, and confirm the apex is not truncated before accepting the trace.
EF Classification by Heart Failure Phenotype
LVEF contributes to heart failure classification, prognosis and treatment selection, but does not establish the diagnosis by itself. These thresholds are used across ESC, AHA/ACC/HFSA 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 |
| Previous ≤ 40%, now > 40% | Heart failure with improved ejection fraction | HFimpEF |
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 an ultrasound-enhancing agent or 3D instead |
| Inconsistent tracing convention | Papillary muscle and trabecular handling varies by operator and software → affects cavity volume and EF reproducibility |
| Limited representation of regional dysfunction | The biplane method samples only two planes — abnormal geometry or wall motion outside these planes is not captured. See 17-segment model and coronary territories |
| 2D vs 3D vs CMR discrepancy | 2D Simpson's systematically underestimates volumes compared with 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 |
| UEA-enhanced (contrast) 2D | When ≥ 2 contiguous endocardial segments are not visualised. Improves accuracy and reproducibility |
| 3D echocardiography | Preferred when available — fewer geometric assumptions, better reproducibility, closer agreement with CMR. Favoured for serial monitoring |
| CMR | Reference standard for ventricular volumes and EF. Use when echo is suboptimal or discrepant with the clinical picture, or when EF sits near a major management cut-point such as a device decision |
3D and UEA-Enhanced (Contrast) LV Volumes
3D echocardiography makes fewer geometric assumptions and is more reproducible than 2D methods, with volumes closer to CMR. Upper reference limits differ from the Simpson's biplane values above and should not be used interchangeably with them.
3D Echocardiography — ASE/EACVI 2015 Upper Reference Limits
| Parameter | Men | Women |
|---|---|---|
| 3D LVEDVi (mL/m²) | < 79 | < 71 |
| 3D LVESVi (mL/m²) | < 32 | < 28 |
Ultrasound-Enhancing Agent (Contrast) Echocardiography
| Parameter | Men | Women |
|---|---|---|
| UEA-enhanced LVEDVi (mL/m²) — proposed | < 98 | < 83 |
Global Longitudinal Strain (GLS)
GLS is measured by speckle-tracking echocardiography from apical four-chamber, two-chamber and three-chamber views. It is reported as a negative value, with more negative values indicating better longitudinal function; absolute values are conventionally used for grading.
| GLS | Normal | Borderline | Abnormal |
|---|---|---|---|
| Absolute value | > 18% | 16 – 18% | < 16% |
| Signed value | More negative than −18% | −16% to −18% | Less negative than −16% |
Serial Change in GLS
| Setting | Relative change considered meaningful |
|---|---|
| General longitudinal monitoring | Approximately 10 – 15% relative change, depending on image quality and measurement reproducibility |
| Cardio-oncology (CTRCD criterion) | ≥ 15% relative reduction from baseline |
In patients receiving potentially cardiotoxic cancer therapy, a relative GLS reduction of ≥ 15% from baseline — even when the absolute GLS remains above 16% — should prompt cardiology review. GLS decline may precede a measurable reduction in LVEF and can identify subclinical dysfunction during surveillance. See echocardiography in cardio-oncology for the full surveillance protocol.
GLS Regional Patterns — Clinical Significance
GLS is not only a global number — the regional strain distribution provides diagnostic clues, and the bull's-eye plot should be reviewed for characteristic patterns.
| Pattern | Description | Consider |
|---|---|---|
| Apical sparing | Reduced basal and mid-ventricular strain with preserved apical strain — quantitatively, mean apical longitudinal strain more than twice the mean of the remaining segments | Raises suspicion for cardiac amyloidosis, particularly when LV wall thickness is increased. Not diagnostic or specific in isolation — also reported in other hypertrophic phenotypes, aortic stenosis and advanced renal disease. See unexplained LV hypertrophy |
| 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 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 aetiological interpretation |
Frequently Asked Questions
What is a normal LV end-diastolic volume index?
By 2D Simpson's biplane in adults, normal LVEDVi is 34–74 mL/m² in men and 29–61 mL/m² in women. Upper reference limits are higher for 3D echocardiography (79 mL/m² in men, 71 mL/m² in women) and higher again for ultrasound-enhancing-agent studies, so the method used must be stated alongside the value.
What is a normal LV end-systolic volume index?
Normal LVESVi by 2D Simpson's biplane is 11–31 mL/m² in men and 8–24 mL/m² in women. The corresponding 3D upper reference limits are 32 mL/m² in men and 28 mL/m² in women.
What is a normal left ventricular ejection fraction?
Normal LVEF is 52–72% in men and 54–74% in women. LVEF is calculated as (LVEDV − LVESV) ÷ LVEDV × 100. Values of 41–51% in men and 41–53% in women are mildly abnormal, 30–40% moderately abnormal, and below 30% severely abnormal.
When should 3D or contrast echocardiography be used instead of Simpson's biplane?
Use an ultrasound-enhancing agent when two or more contiguous endocardial segments are not adequately visualised, or whenever quantitative LVEF is important to prognosis or management. Use 3D echocardiography where available, particularly for serial monitoring, because it makes fewer geometric assumptions and agrees more closely with CMR. Reference ranges differ between all three methods and are not interchangeable.
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