Severity colours: Normal Mild Moderate Severe. Values follow the current guideline named in each section heading (checked September 2026). Always combine several parameters. Open the calculators with the button at the bottom right.
Standard views & what to measure
| View | Walls / structures seen | Measure |
|---|---|---|
| PLAX | Anteroseptum (basal–mid) · inferolateral wall · MV, AV, LVOT, aortic root, LA | LVIDd/s, IVSd, LVPWd (chordal level, end-diastole) · LVOT diameter (mid-systole, ~0.5–1 cm below annulus) · aortic root/sinus/STJ/asc Ao · LA AP diameter · RVOT prox |
| RV inflow | RV, TV (anterior & posterior leaflets), RA | TR colour/CW |
| PSAX – AV level | AV cusps, RVOT, PV, PA, TV, LA, IAS | AV morphology (tri/bicuspid) · RVOT distal · PA diameter · PV PW/CW (AcT) · PR · TR |
| PSAX – MV level | Basal 6 segments · MV fish-mouth | MVA planimetry · scallop localisation |
| PSAX – papillary level | Mid 6 segments | Wall motion · septal flattening / eccentricity index |
| PSAX – apical | Apical 4 segments | Wall motion · apical thrombus |
| A4C | Inferoseptum · anterolateral wall · apex · all 4 chambers | Biplane Simpson (with A2C) · LA/RA volume/area · RV basal/mid/long dims · TAPSE · RV S' · FAC · MV inflow E/A, DT · e' septal & lateral · TR CW |
| A5C | LVOT, AV | LVOT PW VTI · AV CW (Vmax, mean gradient, VTI) · AR |
| A2C | Inferior · anterior walls · LAA | Biplane Simpson · LA volume |
| A3C / APLAX | Anteroseptum · inferolateral wall · LVOT/AV | AV CW · MR/AR · LVOT gradient (HCM) |
| RV-focused A4C | RV free wall · lateral TV annulus | RV basal (>41 dilated), mid, length · FAC · RV strain |
| Subcostal | IAS · RV free wall · IVC · pericardium · hepatic veins | RV wall thickness · IVC diameter & collapse · effusion · hepatic vein flow |
| Suprasternal | Arch, descending aorta | Coarctation · desc. aorta PW (holodiastolic reversal in AR) |
Right parasternal view is often needed to get the true AV peak velocity in AS — use the Pedoff (non-imaging) probe from apex, right parasternal and suprasternal windows.
Left ventricle ASE/EACVI 2015
Linear dimensions (PLAX, end-diastole)
| Parameter | Men | Women |
|---|---|---|
| LVIDd | 42–58 mm | 38–52 mm |
| LVIDs | 25–40 mm | 22–35 mm |
| LVIDd / BSA | 22–30 mm/m² | 23–31 mm/m² |
| IVSd / PWd | 6–10 mm | 6–9 mm |
| Fractional shortening | 25–43 % | 27–45 % |
| RWT = 2·PWd / LVIDd | 0.24–0.42 (>0.42 = concentric) | |
| LV mass index (linear) | 49–115 g/m² | 43–95 g/m² |
LV dilatation (LVIDd)
| Normal | Mild | Moderate | Severe | |
|---|---|---|---|---|
| Men | 42–58 | 59–63 | 64–68 | >68 mm |
| Women | 38–52 | 53–56 | 57–61 | >61 mm |
Wall thickness (LVH severity, IVS/PW)
| Normal | Mild | Moderate | Severe | |
|---|---|---|---|---|
| Men | 6–10 | 11–13 | 14–16 | ≥17 mm |
| Women | 6–9 | 10–12 | 13–15 | ≥16 mm |
LV geometry
| LV mass index normal | LV mass index ↑ | |
|---|---|---|
| RWT ≤ 0.42 | Normal geometry | Eccentric hypertrophy |
| RWT > 0.42 | Concentric remodelling | Concentric hypertrophy |
Volumes (biplane Simpson)
| Parameter | Men | Women |
|---|---|---|
| EDV | 62–150 mL | 46–106 mL |
| ESV | 21–61 mL | 14–42 mL |
| EDV index | ≤ 74 mL/m² | ≤ 61 mL/m² |
| ESV index | ≤ 31 mL/m² | ≤ 24 mL/m² |
Systolic function
| LVEF | Normal | Mildly ↓ | Moderately ↓ | Severely ↓ |
|---|---|---|---|---|
| Men | 52–72 % | 41–51 % | 30–40 % | <30 % |
| Women | 54–74 % | 41–53 % | 30–40 % | <30 % |
HF classification (LVEF)
HFrEF ≤ 40 % · HFmrEF 41–49 % · HFpEF ≥ 50 % · HFimpEF: baseline ≤40 % with ≥10-point rise to >40 %Global longitudinal strain
Normal ≈ −20 %. More negative than −18 % likely normal; less negative than −16 % abnormal (vendor-dependent). >15 % relative drop = cardiotoxicity flag.Other
SV index normal ≥ 35 mL/m² · LVOT VTI ~18–22 cm (<15 cm = low output) · MR dP/dt >1200 mmHg/s normal, <1000 impaired17-segment model & coronary territories
LADRCALCx
Top = anterior · left = septum · right = lateral · bottom = inferior
Tap a segment for its name, territory and the views that show it. In wall-motion scoring mode each tap cycles the score (1→2→3→4).
| Level | Segments |
|---|---|
| Basal (1–6) | 1 anterior · 2 anteroseptal · 3 inferoseptal · 4 inferior · 5 inferolateral · 6 anterolateral |
| Mid (7–12) | 7 anterior · 8 anteroseptal · 9 inferoseptal · 10 inferior · 11 inferolateral · 12 anterolateral |
| Apical (13–16) | 13 anterior · 14 septal · 15 inferior · 16 lateral |
| Apex (17) | 17 apical cap |
| Artery | Typical segments |
|---|---|
| LAD | 1, 2, 7, 8, 13, 14, 17 (± 16 in wrap-around LAD) |
| RCA | 3, 4, 9, 10, 15 (± 5, 11 if right-dominant) |
| LCx | 5, 6, 11, 12, 16 |
Which walls in which view
| View | Wall 1 | Opposite wall |
|---|---|---|
| PLAX | Anteroseptal (2, 8) | Inferolateral (5, 11) |
| A4C | Inferoseptal (3, 9, 14) | Anterolateral (6, 12, 16) + apex 17 |
| A2C | Inferior (4, 10, 15) | Anterior (1, 7, 13) + apex 17 |
| A3C / APLAX | Inferolateral (5, 11) | Anteroseptal (2, 8) + apex 17 |
| PSAX (base/mid/apex) | All 6 (or 4) segments at that level — best view to confirm territory | |
Wall-motion score
1 normal/hyperkinetic · 2 hypokinetic · 3 akinetic · 4 dyskinetic (aneurysm scored as dyskinetic in current ASE). WMSI = sum ÷ segments scored; normal = 1.0.Definitions
Hypokinetic: reduced thickening (<40 %) · Akinetic: <10 % thickening · Dyskinetic: systolic outward motion/thinning. Thin (<6 mm), bright wall = scar.Pattern clues
Regional abnormality not following one territory → think takotsubo (apical ballooning), myocarditis, sarcoid (basal septum), LBBB/pacing (septal flash).Walls by view standard display: apex at top of screen for apical views
Tap any segment: it lights up in every view where it appears (and on the bull's-eye above). Tap again to clear. Colours = LAD · RCA · LCx.
PLAX
Only basal & mid · apex usually off-screen (left)
Top: anteroseptal 2 · 8Bottom: inferolateral 5 · 11
PSAX — basal (mitral valve)
Fish-mouth MV · segments 1–6
Clockwise from 12: anterior → anterolateral → inferolateral → inferior → inferoseptal → anteroseptal
PSAX — mid (papillary muscles)
Segments 7–12 · best level for global wall motion
AL-PM: dual supply (LAD diag + LCx) · PM-PM: single (RCA or LCx) → rupture-prone
PSAX — apical
Below papillary muscles · 4 segments 13–16
Anterior 13 · lateral 16 · inferior 15 · septal 14
A4C
RV on the left of the screen, LV on the right
Left wall: inferoseptal 3 · 9 · 14Right wall: anterolateral 6 · 12 · 16
A2C
From A4C rotate ~60° counter-clockwise · RV disappears, LAA appears
Left wall: inferior 4 · 10 · 15Right wall: anterior 1 · 7 · 13
A3C / apical long axis
Rotate another ~60° · LVOT and aorta appear on the right
Left wall: inferolateral 5 · 11Right wall: anteroseptal 2 · 8
The grey apical parts in A3C fall between the four apical segments. Assign them using A4C and A2C.
Commonly confused walls
| Pair | How to tell them apart | Artery |
|---|---|---|
| Anteroseptal vs inferoseptal | Anteroseptal is the septum that runs into the aortic root / LVOT (PLAX top wall, A3C right wall). Inferoseptal is the septum next to the RV and tricuspid valve (A4C left wall). | LAD vs RCA (PDA) |
| Anterolateral vs inferolateral | Anterolateral = lateral wall in A4C. Inferolateral (old name "posterior") = PLAX bottom wall and A3C left wall, behind the mitral valve, next to the LA / descending aorta. | LCx (+ LAD diagonals) vs LCx (± RCA) |
| Anterior vs anterolateral | Anterior = right wall in A2C (on the LAA side), 12 o'clock in PSAX. Anterolateral = right wall in A4C, 2 o'clock in PSAX. | LAD vs LCx |
| Inferior vs inferolateral | Inferior = left wall in A2C, 6 o'clock in PSAX. Inferolateral = A3C / PLAX, 4 o'clock in PSAX. | RCA vs LCx |
| Inferior vs inferoseptal | Inferior = A2C left wall. Inferoseptal = A4C left wall (septum). Both are usually RCA. | RCA (both) |
Rule of thumb
The septum in A4C is inferoseptal. The septum in PLAX / A3C is anteroseptal. The lateral wall in A4C is anterolateral. The lateral wall in PLAX / A3C is inferolateral.Rotation sequence
A4C → (≈60° CCW) → A2C → (≈60° CCW) → A3C. Each apical plane slices the PSAX ring through two opposite walls. Tick apical planes on the basal PSAX drawing to see this.Clock face (PSAX)
12 anterior · 2 anterolateral · 4 inferolateral · 6 inferior · 8 inferoseptal · 10 anteroseptal. The RV sits on the septal side (screen left).Diastolic function ASE 2025 update (replaces ASE/EACVI 2016) · applies at any LVEF
Step 1: three primary variables
| Variable | Abnormal if | Meaning |
|---|---|---|
| e′ (relaxation) | Septal ≤ 6 · lateral ≤ 7 · average ≤ 6.5 cm/s | Impaired relaxation (age-specific values allowed) |
| E/e′ | Average ≥ 14 · septal ≥ 15 · lateral ≥ 13 | Filling pressure marker |
| TR velocity / PASP | TR ≥ 2.8 m/s or PASP ≥ 35 mmHg | Filling pressure marker (exclude pre-capillary PH) |
Step 2: supplemental parameters (when the primary ones are discordant)
| Parameter | Suggests ↑ LAP if |
|---|---|
| LA reservoir strain (LARS) | ≤ 18 % |
| Pulmonary vein S/D ratio | ≤ 0.67 (not in young / athletes) |
| LA volume index (biplane) | > 34 mL/m² (not in athletes, bradycardia, AF history, MR) |
| IVRT | ≤ 70 ms |
| Others | Ar − A duration > 30 ms · Valsalva ΔE/A ≥ 50 % · mitral L-wave ≥ 50 cm/s · PR end-diastolic V ≥ 2 m/s |
Measure e′, E/e′ and TR / PASP
All normal
Normal diastolic function
normal LAP
normal LAP
Only e′ reduced
E/A ≤ 0.8 → Grade 1
normal LAP
normal LAP
E/A > 0.8 → supplemental ↓
1–2 abnormal (E/e′ or TR)
Supplemental: LARS ≤ 18 % · PV S/D ≤ 0.67 · LAVI > 34 · IVRT ≤ 70
None → normal LAP
Grade 1 if e′ ↓, else normal
Grade 1 if e′ ↓, else normal
≥ 1 → ↑ LAP
All 3 abnormal
↑ LAP
↑ LAP → grade by E/A: < 2 = Grade 2 (mild–moderate ↑ LAP) · ≥ 2 = Grade 3 (marked ↑ LAP)
Atrial fibrillation
Several parameters needed; no single one is reliable. ↑ LAP supported by: septal E/e′ ≥ 11 · TR > 2.8 m/s · DT ≤ 160 ms (reduced EF) · IVRT ≤ 65 ms · PV diastolic DT ≤ 220 ms · E/Vp ≥ 1.4. Average over 5–10 beats.Special populations
MAC / MV disease: E/e′ unreliable, so use E/A and IVRT. LBBB / RV pacing: use lateral e′. Pre-capillary PH: use lateral E/e′ and LARS. Constriction: medial e′ > 7 with annulus reversus.HFpEF diagnosis
The 2025 guideline also scores HFpEF likelihood by adding echo (↑ LAP, LA size/strain, LVH) to clinical data. Diastolic stress echo is abnormal if average E/e′ ≥ 14 (or septal ≥ 15) and peak TR > 3.2 m/s.Atria LA: ASE/EACVI 2015 · RA: ASE 2025
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| LA volume index (biplane) | 16–34 | 35–41 | 42–48 | > 48 mL/m² |
| LA reservoir strain | > 18 % (normal ≈ 39 %) | ≤ 18 % suggests ↑ LAP | ||
| LA AP diameter (PLAX) | M 30–40 · F 27–38 mm | Diameter underestimates size, so use volume | ||
| RA volume index (disks) | < 30 | 30–36 | > 36–41 | > 41 mL/m² |
| RA area (A4C, end-systole) | < 19 | 19–22 | > 22–24 | > 24 cm² |
| RA major dimension | < 54 | 54–58 | > 58–63 | > 63 mm |
| RA minor dimension | < 42 | 42–47 | > 47–51 | > 51 mm |
Measure atria at end-systole (the frame before the MV/TV opens) in atrial-focused views, avoiding foreshortening. Exclude the pulmonary veins and LAA from the LA tracing. ESC 2025 counts severe LA dilatation (LAVI ≥ 60 mL/m² or diameter ≥ 55 mm) as a trigger for primary MR repair.
Right ventricle ASE 2025 right heart guideline (graded severity)
Size (RV-focused A4C, end-diastole)
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| RV basal diameter | < 41 | 41–44 | > 44–49 | > 49 mm |
| RV mid diameter | < 35 | 35–38 | > 38–42 | > 42 mm |
| RV longitudinal | < 82 | 82–89 | > 89–96 | > 96 mm |
| RVOT PLAX | < 33 | 33–35 | > 35–39 | > 39 mm |
| RVOT PSAX proximal | < 34 | 34–38 | > 38–41 | > 41 mm |
| RVOT PSAX distal | < 29 | 29–30 | > 30–33 | > 33 mm |
| RV wall thickness (subcostal) | < 5 | 5–7 | > 7–9 | > 9 mm |
| RV EDA | < 25 | 25–28 | > 28–32 | > 32 cm² |
| RV ESA | < 14 | 14–16 | > 16–19 | > 19 cm² |
| 3D RV EDV index | < 90 | 90–103 | > 103–115 | > 115 mL/m² |
| RV/LV basal ratio | < 1.0 | > 1.0 suggests PH / RV overload | ||
Systolic function
| Parameter | Normal | Mild ↓ | Moderate ↓ | Severe ↓ |
|---|---|---|---|---|
| TAPSE | > 17 | 17–13 | < 13 to > 10 | ≤ 10 mm |
| RV S′ (TDI) | > 9.5 | 9.5–7.2 | < 7.2 to > 5.0 | ≤ 5.0 cm/s |
| FAC | > 35 | 35–29 | < 29 to > 22 | ≤ 22 % |
| RV free-wall strain (absolute) | > 20 | 20–15 | < 15 to ≥ 11 | < 11 % |
| RV global strain (absolute) | > 17 | 17–13 | < 13 to > 9 | ≤ 9 % |
| 3D RVEF | > 45 | 45–39 | < 39 to ≥ 32 | < 32 % |
| RIMP (TDI) | < 0.55 | 0.55–0.61 | 0.62–0.69 | ≥ 0.70 |
| RIMP (PW) | < 0.40 | 0.40–0.48 | 0.49–0.56 | ≥ 0.57 |
RV–PA coupling
TAPSE/PASP: normal ≈ 0.5–0.7 mm/mmHg. < 0.55 is an ESC/ERS PH sign. 0.3–0.4 or lower = RV–PA uncoupling with higher mortality.Septal flattening (PSAX)
LV eccentricity index > 1.1. D-shape in systole = pressure overload. D-shape in diastole = volume overload.McConnell sign
RV free-wall akinesis with apical sparing suggests acute PE (not specific). "60/60" sign: PAAT < 60 ms plus TR gradient < 60 mmHg.RV anatomy
Free wall: basal, mid, apical (A4C) · RVOT · inferior wall (subcostal). Moderator band at the apex. Septal TV leaflet sits more apical than the mitral (offset ≤ 8 mm/m²; more suggests Ebstein).RA pressure & pulmonary hypertension
RA pressure from IVC (subcostal, 1–2 cm from RA)
| IVC | Collapse on sniff | RAP estimate |
|---|---|---|
| ≤ 21 mm | > 50 % | 3 mmHg (0–5) |
| ≤ 21 mm | < 50 % | 8 mmHg (5–10) |
| > 21 mm | > 50 % | 8 mmHg (5–10) |
| > 21 mm | < 50 % | 15 mmHg (10–20) |
Not valid in ventilated patients. Supportive of high RAP: restrictive TV inflow, tricuspid E/e′ > 6, diastolic-predominant hepatic vein flow, RA strain. Young athletes may have a dilated IVC with normal RAP.
Haemodynamic grading ASE 2025
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| RAP | 0–< 5 | 5–< 10 | 10–< 15 | ≥ 15 mmHg |
| TR velocity | < 2.8 | 2.8–3.1 | 3.2–3.5 | ≥ 3.6 m/s |
| RVSP / PASP | ≤ 34 | 35–49 | 50–69 | ≥ 70 mmHg |
| RVOT acceleration time | > 105 | 80–105 | 60–< 80 | ≤ 60 ms |
| PA diameter | < 25 | 25–30 | > 30–35 | > 35 mm |
Echo probability of PH ESC/ERS 2022 (PH = mPAP > 20 mmHg)
| Peak TR velocity | Other echo PH signs | Probability |
|---|---|---|
| ≤ 2.8 m/s or not measurable | No | Low |
| ≤ 2.8 m/s or not measurable | Yes | Intermediate |
| 2.9–3.4 m/s | No | Intermediate |
| 2.9–3.4 m/s | Yes | High |
| > 3.4 m/s | Not required | High |
A. Ventricles
RV/LV basal ratio > 1.0 · septal flattening (LVEI > 1.1) · TAPSE/PASP < 0.55 mm/mmHgB. Pulmonary artery
RVOT AcT < 105 ms and/or mid-systolic notching · early diastolic PR velocity > 2.2 m/s · PA diameter > aortic root or > 25 mmC. IVC & RA
IVC > 21 mm with ↓ inspiratory collapse · RA area (end-systole) > 18 cm²"Other signs" = signs from at least 2 categories (A/B/C).
Aortic stenosis ASE/EACVI 2017 · ACC/AHA 2020 · ESC/EACTS 2025
| Parameter | Sclerosis | Mild | Moderate | Severe |
|---|---|---|---|---|
| Peak velocity | ≤ 2.5 m/s | 2.6–2.9 | 3.0–3.9 | ≥ 4.0 m/s |
| Mean gradient | — | < 20 | 20–39 | ≥ 40 mmHg |
| AVA (continuity) | — | > 1.5 | 1.0–1.5 | < 1.0 cm² |
| AVA index | — | > 0.85 | 0.60–0.85 | < 0.6 cm²/m² |
| Velocity ratio (DVI) | — | > 0.50 | 0.25–0.50 | < 0.25 |
Very severe: Vmax ≥ 5 m/s or mean gradient ≥ 60 mmHg. Normal AVA 3–4 cm².
AVA ≤ 1.0 cm² (AVAi ≤ 0.6)
Vmax ≥ 4 or MG ≥ 40
High-gradient severe AS
MG < 40 · SVi ≤ 35
LVEF < 50 % → classical LFLG
Dobutamine stress echo: severe if Vmax ≥ 4 / MG ≥ 40 with AVA ≤ 1.0. Flow reserve = SV ↑ ≥ 20 %
Dobutamine stress echo: severe if Vmax ≥ 4 / MG ≥ 40 with AVA ≤ 1.0. Flow reserve = SV ↑ ≥ 20 %
LVEF ≥ 50 % → paradoxical LFLG
CT calcium score: likely severe ≥ 2000 AU (M) / ≥ 1200 AU (F)
CT calcium score: likely severe ≥ 2000 AU (M) / ≥ 1200 AU (F)
MG < 40 · SVi > 35
Normal-flow, low-gradient
Re-check LVOT diameter and search all windows for the peak velocity. Often moderate AS; use CT calcium if unsure
Re-check LVOT diameter and search all windows for the peak velocity. Often moderate AS; use CT calcium if unsure
Discordant grading: check flow first
AVA < 1.0 but mean gradient < 40 mmHg. Measure SVi (≤ 35 mL/m² = low flow). Re-check the LVOT diameter first, because the error is squared.Intervention triggers
ACC/AHA 2020: severe AS with symptoms · LVEF < 50 % · very severe (Vmax ≥ 5) asymptomatic · rapid progression (≥ 0.3 m/s/yr). ESC 2025: early intervention in asymptomatic severe AS with LVEF ≥ 50 % is now Class IIa; TAVI favoured from age ≥ 70.Mixed aortic valve disease
ESC 2025: intervene when mean gradient ≥ 40 mmHg or Vmax ≥ 4 m/s even if the AVA is not severe, because the AR raises flow.Aortic regurgitation ASE 2017
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Vena contracta | < 0.3 cm | 0.3–0.6 | > 0.6 cm |
| Jet width / LVOT | < 25 % | 25–64 % | ≥ 65 % |
| Pressure half-time | > 500 ms | 200–500 | < 200 ms |
| Desc. aorta diastolic reversal | Brief, early | Intermediate | Holodiastolic (EDV >20 cm/s) |
| Abdominal aorta reversal | — | — | Holodiastolic = severe |
| CW jet density | Faint | Dense | Dense |
| Regurgitant volume | < 30 mL | 30–59 | ≥ 60 mL |
| Regurgitant fraction | < 30 % | 30–49 % | ≥ 50 % |
| EROA | < 0.10 cm² | 0.10–0.29 | ≥ 0.30 cm² |
| LV size | Normal | Normal / dilated | Dilated (chronic) |
Surgery: ACC/AHA 2020 (chronic severe AR)
Symptoms · LVEF ≤ 55 % · LVESD > 50 mm or LVESDi > 25 mm/m² · progressive LVEDD > 65 mm (low risk).Surgery: ESC 2025 (asymptomatic)
Class I: LVEF ≤ 50 % · LVESD > 50 mm · LVESDi > 25 mm/m². Consider earlier (low risk, IIb): LVESDi > 22 mm/m² · LVESVi > 45 mL/m² · LVEF ≤ 55 %. Indexing matters most when BSA < 1.68 m².Mitral stenosis
| Parameter | Progressive (mild–mod) | Severe | Very severe |
|---|---|---|---|
| MVA (planimetry / PHT) | > 1.5 cm² | ≤ 1.5 cm² | ≤ 1.0 cm² |
| Pressure half-time | < 150 ms | ≥ 150 ms | ≥ 220 ms |
| Mean gradient (HR 60–80) | < 5 mmHg | > 5–10 (supportive) | > 10 |
| PASP | < 30 | > 50 mmHg |
MVA formulas
MVA = 220 / PHT (unreliable post-PMBC, ↓ LV compliance, severe AR) · planimetry in PSAX at leaflet tips = referenceWilkins score (PMBC suitability)
Mobility · thickening · calcification · subvalvular — each 1–4. Total ≤ 8 favourable. Also exclude LA thrombus and > mild MR.Rheumatic signs
Commissural fusion, "hockey-stick" AML doming, chordal thickening. Degenerative MS = MAC without commissural fusion.Mitral regurgitation ASE 2017
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Vena contracta | < 0.3 cm | 0.3–0.69 | ≥ 0.7 cm |
| EROA (PISA) | < 0.20 cm² | 0.20–0.39 | ≥ 0.40 cm² |
| Regurgitant volume | < 30 mL | 30–59 | ≥ 60 mL |
| Regurgitant fraction | < 30 % | 30–49 % | ≥ 50 % |
| PISA radius (Nyquist 30–40) | None / small | Intermediate | ≥ 0.9 cm |
| Colour jet area (central) | < 20 % LA | Variable | > 50 % LA / wall-hugging |
| Mitral inflow | A-wave dominant | Variable | E > 1.2 m/s |
| Pulmonary vein flow | S dominant | S blunted | Systolic reversal |
| CW jet | Faint / partial | Dense, parabolic | Dense, triangular (early peak) |
| Structural | Normal leaflets | — | Flail, ruptured papillary, large coaptation gap |
Flow = 2π r² × Valias · EROA = flow / Vmax MR · RVol = EROA × VTIMR. Shift the baseline toward the jet direction, zoom in, and measure r in mid-systole from the first aliasing line to the orifice.
Carpentier classification
I normal motion (annular dilation, perforation) · II excessive (prolapse, flail) · IIIa restricted in systole and diastole (rheumatic) · IIIb restricted in systole (ischaemic/functional)Scallops (PSAX, lateral → medial)
A1/P1 lateral (near LAA) · A2/P2 middle · A3/P3 medial (septal). The jet points away from the prolapsing leaflet.Secondary MR
ASE 2017 and ACC/AHA 2020 use the same thresholds (EROA ≥ 0.40). A crescent orifice makes PISA underestimate; EROA ≥ 0.20–0.30 is already prognostic. ESC 2025: TEER is Class I in selected symptomatic patients with LVEF < 50 % after optimised GDMT.Surgery: primary severe MR
ACC/AHA 2020: symptoms · LVEF ≤ 60 % · LVESD ≥ 40 mm · new AF or PASP > 50 (reasonable). ESC 2025: also LVESDi ≥ 20 mm/m², and repair if durable when ≥ 3 of: AF · PASP > 50 · LAVI ≥ 60 mL/m² or LA ≥ 55 mm · ≥ moderate TR.Tricuspid valve
Tricuspid regurgitation ASE 2017 + 5-grade extension
| Parameter | Mild | Moderate | Severe | Massive / torrential |
|---|---|---|---|---|
| Vena contracta | < 0.3 cm | 0.3–0.69 | 0.7–1.3 | 1.4–2.0 / ≥ 2.1 cm |
| EROA (PISA) | < 0.20 cm² | 0.20–0.39 | 0.40–0.59 | 0.60–0.79 / ≥ 0.80 |
| Regurgitant volume | < 30 mL | 30–44 | ≥ 45 mL | |
| PISA radius (Nyquist ~28) | ≤ 0.5 cm | 0.6–0.9 | > 0.9 cm | |
| Hepatic vein flow | S dominant | S blunted | Systolic reversal | |
| CW jet | Faint, parabolic | Dense, parabolic | Dense, triangular early peak | |
| Tricuspid inflow | A dominant | Variable | E ≥ 1.0 m/s |
TV annulus > 40 mm (or > 21 mm/m²) in A4C diastole → consider TV annuloplasty at time of left-sided surgery. Leaflets: anterior, septal, posterior.
Tricuspid stenosis — severe
Mean gradient ≥ 5 mmHg · PHT ≥ 190 ms · TVA ≤ 1.0 cm² (continuity) · inflow VTI > 60 cm.
Pulmonic valve
Pulmonic stenosis
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Peak velocity | < 3 m/s | 3–4 m/s | > 4 m/s |
| Peak gradient | < 36 mmHg | 36–64 | > 64 mmHg |
Pulmonic regurgitation
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Jet width / annulus | Small, narrow origin | Intermediate | > 70 % |
| CW jet / PHT | Faint, slow decel. | Dense, variable | Dense, steep; PHT < 100 ms |
| PR index | — | — | < 0.77 |
| Regurgitant fraction (CMR) | < 20 % | 20–40 % | > 40 % |
| Branch PA flow | — | — | Diastolic flow reversal |
PR end-diastolic velocity → PADP = 4·V² + RAP. Early PR velocity → mPAP ≈ 4·V² + RAP.
Prosthetic valves ASE 2024 prosthetic valve guideline
Aortic prosthesis
| Parameter | Normal | Possible stenosis | Significant stenosis |
|---|---|---|---|
| Peak velocity | < 3 m/s | 3–4 | > 4 m/s |
| Mean gradient | < 20 mmHg | 20–34 | ≥ 35 mmHg |
| DVI | ≥ 0.30 | 0.25–0.29 | < 0.25 |
| EOA | Within reference for model/size | < reference − 1 SD | < reference − 2 SD |
| Acceleration time | < 80 ms | 80–100 | > 100 ms |
| AT / ET | < 0.32 | 0.32–0.37 | > 0.37 |
| Jet contour | Triangular, early peak | Intermediate | Rounded, symmetric |
Patient–prosthesis mismatch (aortic, indexed EOA)
| BMI | No / insignificant | Moderate | Severe |
|---|---|---|---|
| < 30 kg/m² | > 0.85 | 0.66–0.85 | ≤ 0.65 cm²/m² |
| ≥ 30 kg/m² | > 0.70 | 0.56–0.70 | ≤ 0.55 cm²/m² |
Mitral prosthesis
| Parameter | Normal | Possible stenosis | Significant stenosis |
|---|---|---|---|
| Peak E velocity | < 1.9 m/s | 1.9–2.5 | ≥ 2.5 m/s |
| Mean gradient | ≤ 5 mmHg | 6–10 | > 10 mmHg |
| VTIPrMV / VTILVOT | < 2.2 | 2.2–2.5 | > 2.5 |
| EOA | ≥ 2.0 cm² | 1–2 | < 1 cm² |
| PHT | < 130 ms | 130–200 | > 200 ms |
Reading a high gradient
High gradient with a normal DVI / VTI ratio → high flow or PPM. High gradient with an abnormal ratio → obstruction (thrombus or pannus), or significant MR for a mitral prosthesis. High velocity with short AT (< 80 ms) → pressure recovery or small valve, not obstruction.Paravalvular regurgitation
Circumferential extent of the sewing ring: < 10 % mild · 10–29 % moderate · ≥ 30 % severe. Combine with jet-based and volumetric parameters.Baseline study
Get a TTE 6 weeks to 3 months after implantation as the patient's own reference ("fingerprint"). Compare every later study with it.Aorta measure leading-edge to leading-edge, end-diastole (annulus: mid-systole, inner-inner)
| Level | Men (mean ± SD) | Women (mean ± SD) | ≈ Upper normal |
|---|---|---|---|
| Annulus | 26 ± 3 mm | 23 ± 2 mm | 32 / 27 mm |
| Sinus of Valsalva | 34 ± 3 mm | 30 ± 3 mm | 40 / 36 mm |
| Sinotubular junction | 29 ± 3 mm | 26 ± 3 mm | 35 / 32 mm |
| Proximal ascending | 30 ± 4 mm | 27 ± 4 mm | 38 / 35 mm |
Size depends on BSA, age and sex — prefer indexed values / z-scores. Surgery (ACC/AHA 2022): root/ascending ≥ 55 mm; ≥ 50 mm in selected (e.g. bicuspid with risk factors, low surgical risk); ≥ 45 mm if undergoing other cardiac surgery; Marfan ≥ 50 mm (≥ 45 with risk factors).
Pericardium
| Effusion (end-diastole, echo-free space) | Size |
|---|---|
| Only in systole | Trivial |
| < 10 mm | Small |
| 10–20 mm | Moderate |
| > 20 mm | Large |