LV Dimensions, Volumes, and Mass

Parameter	Normal	Slightly Abnormal	Moderately Abnormal	Severely Abnormal
LVDD: Diastolic diameter (mm)	F38–52M42–58	F53–56M59–63	F57–61M64–68	F≥ 62M≥ 69
LVSD: Systolic diameter (mm)	F22–35M25–24	F36–38M41–43	F39–41M44–45	F≥ 42M≥ 46
Indexed diastolic volume (mL/m²)	F29–61M34–74	F62–70M75–89	F71–80M90–100	F≥ 81M≥ 101
Index systolic volume (mL/m²)	F8–24M6–10	F25–32M32–38	F33–40M39–45	F≥ 41M≥ 46
Interventricular septum (mm)	F6–9M6–10	F10–12M11–13	F13–15M14–16	F≥ 16M≥ 17
Posterior wall (mm)	F6–9M6–10	F10–12M11–13	F13–15M14–16	F≥ 16M≥ 17
Indexed LV mass (g/m²) by linear method	F43–95M49–115	F96–108M116–131	F109–121M132–148	F≥ 122M≥ 149

LV Mass Formula

LV Mass — Linear (Cube) Method

LV mass = 0.6 g + 0.8 × ( 1.04 × [ (LVDD + PW + Septum)³ − LVDD³ ] )

Where LVDD = left ventricular diastolic diameter, PW = posterior wall thickness, Septum = interventricular septal thickness. All linear measurements in centimetres.

RIMP (Right MPI): Global Myocardial Performance Index

Tissue Doppler: RV dysfunction if > 0.54
Pulsed Doppler: RV dysfunction if > 0.43

RIMP — Right Myocardial Performance Index

RIMP = IVCT + IVRTET (ejection time)

Tissue Doppler: tricuspid annulus — ET = duration of S′; and IVCT + IVRT + ET = interval between the end of A′ and the start of E′.
Pulsed Doppler: [Diagram indicates E, A, IVCT, ET, IVRT, Pulsed RVOT].

RV Dimensions and Wall Thickness

Parameter	Criteria / Definition
Basal RV diameter AP4C (mm)	Dilatation: > 41 mm
Mid-cavity RV diameter AP4C (mm)	Dilatation: > 35 mm
Longitudinal RV diameter AP4C (mm)	Dilatation: > 83 mm
RVOT diameter (mm)	Proximal: PLAX (dilatation if > 30 mm) or PSAX above the Ao valve (dilatation if > 35 mm) Distal: PSAX above the P valve (dilatation if > 27 mm)
RV wall thickness (mm)	RVH: > 5 mm — subcostal; end-diastole; at the extremity of T valve leaflets

Note on views for Basal, Mid-cavity, and Longitudinal RV diameters: RV-focused apical 4-chamber view; LV apex centered and not truncated, while displaying the largest basal RV diameter.

Septal Curvature

Pressure Overload

D-shaped septum in systole and diastole

Volume Overload

D-shaped septum in diastole

[Diagrams included for Sistole and Diastole for both conditions.]

RV Systolic Function Parameters

Parameter	RV systolic dysfunction cutoff	Details / Formula
FAC: RV fractional area change (%)	< 35%	FAC = end-diastolic area − end-systolic areaend-diastolic area × 100% AP4C; include the trabeculae in the cavity
RV S′ (Tissue Doppler)	< 9.5 cm/s	AP4C; velocity of longitudinal systolic excursion of basal segment of the free wall of the RV; angle dependent
TAPSE (tricuspid annular plane systolic excursion)	< 17 mm	AP4C; RV longitudinal function; tricuspid lateral annular longitudinal excursion by M-mode (mm)

RV Dilatation (Qualitative; AP4C)

Normal	Mild	Moderate	Severe
Size of RV < size of LV; apex belongs to LV	Size of RV similar to size of LV; apex belongs to LV	Size of RV similar to size of LV; apex shared between the two	RV > LV; apex belongs to RV

Parameter	Normal / Formula	Slightly Abnormal	Moderately Abnormal	Severely Abnormal
LA diameter PLAX (mm)	F27–38M30–40	F39–42M41–46	F43–46M47–52	F≥ 47M≥ 52
Indexed LA volume (mL/m²)	16–34	35–41	42–48	≥ 48
Indexed RA volume (mL/m²)	Normal: F21 ± 6M25 ± 7	—	—	—
Indexed RA length AP4C (cm/m²)	Normal: F2.5 ± 0.3M2.4 ± 0.3	—	—	—
Indexed RA diameter AP4C (cm/m²)	Normal: 1.9 ± 0.3	—	—	—

Volume Formulas

LA Volume — Biplane Area–Length

LA volume = 0.85 × A₁ × A₂L

Area and long axis on biplane views (AP4C and AP2C).

RA Volume — Single-Plane Area–Length

RA volume = RA area²L

AP4C, single-plane.

Long axis (Indexed RA length): parallel to the interatrial septum
Short axis (Indexed RA diameter): lateral wall of RA to interatrial septum

RA Pressure (CVP) Estimated by Subcostal View of Inferior Vena Cava (mmHg)

IVC Finding	Estimated RA Pressure
IVC ≤ 21 mm and collapse > 50%	RA pressure = 3 mmHg (0–5 mmHg)
IVC > 21 mm and collapse < 50%	RA pressure = 15 mmHg (10–20 mmHg)
Intermediate	RA pressure = 8 mmHg (5–10 mmHg)
Ventilated patient	IVC ≤ 12 mm associated with RA pressure < 10 mmHg

Parameter	Formula / Cutoffs
Systolic PAP (mmHg)	sPAP = 4 × (TR pressure gradient)² + RA pressure In the absence of RVOT obstruction: < 35 — Normal 35–50 — Mildly increased 50–80 — Moderately increased > 80 — Severely increased
Diastolic PAP (mmHg)	dPAP = 4 × (PR end-diastolic velocity)² + RA pressure
Mean PAP (mmHg)	mPAP = ⅓ sPAP + ⅔ dPAP mPAP = 4 × (early diastolic PR velocity)² + RA pressure Mahan: mPAP = 79 − (0.45 × PA acceleration time) If PA acceleration time < 120 ms: mPAP = 90 − (0.62 × PA acceleration time) PA acceleration time: start of QRS to peak pulmonary flow velocity; pulsed Doppler.
Pulmonary artery diameter (mm)	15–21 — Normal 22–25 — Mildly dilated 26–29 — Moderately dilated ≥ 30 — Severely dilated

Relative Wall Thickness (RWT)

RWT — Relative Wall Thickness

RWT = 2 × PWLVDD

PW = posterior wall thickness; LVDD = left ventricular diastolic diameter.

Parameter	Normal	Mildly Abnormal	Moderately Abnormal	Severely Abnormal
RWT Values	F0.22–0.42M0.24–0.42	F0.43–0.47M0.43–0.46	F0.48–0.52M0.47–0.51	F≥ 0.53M≥ 0.52

Geometry Classification Based on RWT and Indexed Mass

Geometry	Indexed Mass	RWT
Concentric remodeling	≤ 95 g/m² (F) and ≤ 115 g/m² (M)	> 0.42
Concentric LVH	> 95 g/m² (F) and > 115 g/m² (M)	> 0.42
Normal geometry	≤ 95 g/m² (F) and ≤ 115 g/m² (M)	≤ 0.42
Eccentric LVH	> 95 g/m² (F) and > 115 g/m² (M)	≤ 0.42

LV Function Parameters

Parameter	Values / Formulas
LVEF (%) — Simpson biplane	Normal: F 54–74, M 52–72 Mildly abnormal: F 41–53, M 41–51 Moderately abnormal: 30–40 Severely abnormal: < 30
LVEF (%) — Dumesnil	LVEF = Stroke volume ÷ ED volume Stroke volume = 0.785 × (LVOT diameter)² × LVOT VTI ED volume = 7 × LVDD³ ÷ (2.4 + LVDD)
Endocardial shortening fraction (%)	Normal: F 27–45, M 25–43 Mildly abnormal: F 22–26, M 20–24 Moderately abnormal: F 17–21, M 15–19 Severely abnormal: F ≤ 16, M ≤ 14 % shortening = (LVDD − LVSD) ÷ LVDD
Cardiac output (L/min)	CO = HR × (0.785 × LVOT diameter² × LVOT VTI) CO = HR × (ED volume − ES volume) Normal cardiac output: 4–6 L/min
dP/dt (isovolumic contraction)	dP/dt = 32 ÷ time for MR jet velocity to increase from 1 m/s to 3 m/s Normal dP/dt: > 1200 mmHg/sec
LIMP (Left MPI)	LIMP = IVCT + IVRTET (ejection time) Global myocardial performance index ▸▸

Parameter	Normal Pattern	Grade I: Abnormal Relaxation Pattern	Grade II: Pseudo-Normal Pattern	Grade III: Restrictive Pattern
E′ (cm/s) / E/E′	E sep ≥ 8 E′ lat ≥ 10 E/E′ ≤ 8	E sep < 8 E′ lat < 10 E/E′ ≤ 8	E sep < 8 E′ lat < 10 E/E′ 9–12	E′ sep < 8 E′ lat < 10 E/E′ > 13 E/E′ sep ≥ 15 E/E′ lat > 12
LA (mL/m²)	< 34	≥ 34	≥ 34	≥ 34
E/A, DT (ms), IVRT (ms)	E/A 0.8–1.5 DT 160–200	E/A < 0.8 DT > 200 IVRT ≥ 100	E/A 0.8–1.5 DT 160–200	E/A ≥ 2 DT < 160 IVRT ≤ 60
PV FLOW AR − A (ms)	PV S > D Ar − A < 0	PV S > D Ar − A < 0	PV D > S Ar − A ≥ 30	PV D > S Ar − A ≥ 30
VALSALVA	Reduction of E/A ratio < 0.5	Reduction of E/A ratio < 0.5	Reduction of E/A ratio ≥ 0.5	Variable
Additional Info	Normal filling pressures (generally) > 60 years: E/A < 1 and DT > 200 ms in the absence of LVH or heart disease → normal for age	↗ Filling pressures	↗↗↗ Filling pressures	DDx: severe decompensated heart failure; advanced RCM; severe CAD; severe acute AR; constrictive pericarditis IIIa: filling pattern improves in response to treatment IIIb: absence of improvement of the filling pattern in response to treatment

Abbreviations & Definitions Related to Diastolic Function

IVRT: Continuous Doppler LVOT; interval between end of Ao ejection and start of mitral filling (E wave)
FUSION OF E AND A: E wave > 20 cm/s at the beginning of the A wave

7.1 Aortic Stenosis (AS)

Severity Grading

Parameter	Mild	Moderate	Severe	Very Severe
Peak velocity (m/s)	2.6–2.9	3.0–3.9	≥ 4.0	≥ 5.0
Mean gradient (mmHg)	< 20	20–39	≥ 40	≥ 60
Valve area (cm²)	> 1.5	1.0–1.5	< 1.0	—
Velocity index (VTI ratio)	> 0.50	0.25–0.50	< 0.25	—

Note: Very severe AS is defined by peak velocity ≥ 5.0 m/s or mean gradient ≥ 60 mmHg.

Detailed Assessment Parameters

Parameter	Assessment / Formula	Severe
Maximum jet velocity	Look for parallel alignment between continuous Doppler and the jet	> 4 m/s
Mean gradient	Mean of instantaneous mean gradients during ejection	> 40 mmHg
Valve area by continuity equation	AVA = 0.785 × LVOT diameter² × LVOT VTIAortic valve VTI LVOT VTI and LVOT diameter obtained at the same distance from the valve Proximal velocity (LVOT) > 1.5 m/s: use peak velocity and maximum gradient to grade severity Maximum gradient = 4 × (maximum v² − proximal v²)	< 1 cm²
LVOT VTI / Ao valve VTI ratio	Independent of measurement of LVOT	< 0.25

Interpretation notes:

Velocity > 4 m/s and Area > 1 cm² → high output; significant AR; tall patient
Velocity < 4 m/s and Area < 1 cm² → low output; small patient; significant MR

7.2 Mitral Stenosis (MS)

Severity Grading

Parameter	Mild	Moderate	Severe
Valve area (cm²)	> 1.5	1.0–1.5	< 1.0
Mean gradient (mmHg)	< 5	5–10	> 10
Pressure half-time (ms)	< 130	130–200	> 200

Note: When valve area and gradient/PHT results are discordant, a comprehensive assessment is required.

Detailed Assessment Parameters

Parameter	Assessment / Formula	Severe
Mean gradient	Mean of instantaneous mean gradients during filling	> 10 mmHg
Valve area by planimetry	Method of choice in rheumatic MS • At the extremity of the leaflets (PSAX)	< 1 cm²
Valve area by pressure half-time	MVA = 220PHT Use the slope of the E wave at mid-diastole Method of choice in rheumatic MS Caveats: immediately after balloon valvuloplasty; severe AR (short PHT); abnormal LV relaxation (long PHT); ↑ LVEDP (short PHT); prosthetic valve (do not calculate prosthetic area but report PHT)	< 1 cm²
Valve area by continuity equation	MVA = 0.785 × LVOT diameter² × LVOT VTIMitral valve VTI	< 1 cm²
Valve area by PISA	MVA = 6.28 × PISA radius × Aliasing velocityPeak MS velocity × α180°	< 1 cm²

INDICATE HR AT THE TIME OF MEASUREMENTS; EVALUATE PAP

BVR Score — Balloon Valvuloplasty Registry (Wilkins Score)

Score	1 — Mobility of Leaflets	2 — Thickening of Leaflets	3 — Calcification of Leaflets	4 — Thickening of Subvalvular Apparatus
1 point	Very mobile valve; restriction of the extremity of the leaflets	Leaflets measure 4–5 mm	A single hyperechodense zone	Minimal thickening under the leaflets
2 points	Normal mobility of the base and middle parts of the leaflets	Localized thickening (5–8 mm)	Several localized hyperdense zones on the leaflets	Thickening of the chordae (1/3 of their length)
3 points	Mobility of the base of the valve	Thickening of all of the leaflet (5–8 mm)	Hyperechodensities as far as the middle portion of the leaflets	Thickening of the chordae as far as their distal third
4 points	Minimal or absent movement of the leaflets	Considerable thickening of the entire leaflet (8–10 mm)	Extensive hyperechodensities on the majority of the leaflets	Severe thickening as far as the papillary muscles

Score ≤ 8 associated with a favorable result of balloon valvuloplasty

7.3 Mitral Regurgitation (MR)

Primary MR (Degenerative)

Parameter	Mild	Moderate	Moderate–Severe	Severe
EROA (cm²)	< 0.20	0.20–0.29	0.30–0.39	≥ 0.40
Regurgitant volume (mL/beat)	< 30	30–44	45–59	≥ 60
Regurgitant fraction (%)	< 30	30–39	40–49	≥ 50
Vena contracta width (mm)	< 3	3–6.9	—	≥ 7

Secondary MR (Functional)

Parameter	Mild	Moderate	Severe
EROA (cm²)	< 0.20	0.20–0.29	≥ 0.30
Regurgitant volume (mL/beat)	< 30	30–44	≥ 45

Note: Secondary MR has lower severity thresholds due to its adverse prognostic impact.

Detailed Assessment Parameters

Parameter	Assessment / Formula	Severe
Vena contracta	Narrowest portion of the jet distal to the regurgitating orifice; avoid AP2C; Nyquist 50–60 cm/s	≥ 7 mm
Regurgitant volume	VOLUMETRIC METHOD: RegV = (0.785 × Mitral annulus diameter² × anterograde mitral VTI) − (0.785 × LVOT diameter² × LVOT VTI) Mitral annulus diameter: mean of PLAX and AP4C Significant AR: use pulmonic valve flow PISA: Regurgitant volume = EROA × MR VTI	≥ 60 cc
EROA (Effective Regurgitation Orifice Area)	VOLUMETRIC METHOD: EROA = Regurgitant volume ÷ MR VTI PISA: EROA = 6.28 × PISA radius² × “aliasing” velocityPeak MR velocity PISA corresponds to the time of peak MR velocity “Aliasing” velocity adjusted to the direction of regurgitation to obtain hemispheric convergence flow (Nyquist 20–40 cm/s)	≥ 0.40 cm² (≥ 0.20 cm² if functional MR)
PISA radius	Nyquist 40 cm/s	≥ 9 mm
Regurgitant fraction	Regurgitant fraction = Regurgitant volume0.785 × Mitral annulus diameter² × anterograde mitral VTI	≥ 50%
MR jet	• Nyquist 50–60 cm/s • Severe MR: Large central jet > 10 cm² (or > 40% LA area) or eccentric jet adhering to the wall of the LA (Coanda effect)	—

Additional Signs

Parameter	Finding	Threshold / Note
E wave	Dominant	E wave > 1.2 m/s
Envelope of the jet on continuous Doppler	• Severe MR: dense envelope; early peak and triangular shape • MVP: mid- or end-systolic envelope	—
Pulmonary venous flow	Severe MR: systolic reversal	—

LA dilatation and LV dilatation; Carpentier’s mechanism

7.4 Aortic Regurgitation (AR)

Severity Grading

Parameter	Mild	Moderate	Moderate–Severe	Severe
EROA (cm²)	< 0.10	0.10–0.19	0.20–0.29	≥ 0.30
Regurgitant volume (mL/beat)	< 30	30–44	45–59	≥ 60
Regurgitant fraction (%)	< 30	30–39	40–49	≥ 50
Vena contracta width (mm)	< 3	3–5.9	—	≥ 6
Pressure half-time (ms)	> 500	200–500	—	< 200

Note: A pressure half-time < 200 ms is a highly specific sign of severe AR.

Detailed Assessment Parameters

Parameter	Assessment / Formula	Severe
Vena contracta	Narrowest portion of the jet distal to the regurgitating orifice; PLAX; Nyquist 50–60 cm/s	≥ 6 mm
Regurgitant volume	VOLUMETRIC METHOD: RegV = (0.785 × LVOT diameter² × LVOT VTI) − (0.785 × Mitral annulus diameter² × anterograde mitral VTI) Mitral annulus diameter: mean of PLAX and AP4C Significant MR: use pulmonic valve flow PISA: Regurgitant volume = EROA × AR VTI	≥ 60 cc
EROA (effective regurgitation orifice area)	VOLUMETRIC METHOD: EROA = Regurgitant volume ÷ AR VTI PISA: EROA = 6.28 × PISA radius² × “aliasing” velocityPeak AR velocity	≥ 0.3 cm²
Regurgitant fraction	Regurgitant fraction = Regurgitant volume0.785 × LVOT diameter² × LVOT VTI	≥ 50%
Jet width / LVOT diameter	PLAX; 1 cm inside the Ao valve; Nyquist 50–60 cm/s	≥ 65%
Jet area / LVOT area	PSAX	≥ 60%
Pressure half-time	• Continuous Doppler • End-diastolic speed > 4 m/s • ↓ PHT: HTN; ↑ LV compliance; ↑ LVEDP	< 200 ms
Envelope of the jet on continuous Doppler	Severe AR: dense envelope (compare with density of the anterograde flow); rapid deceleration	—
Holodiastolic flow reversal in descending aorta	• Pulsed Doppler (after the origin of the L subclavian) • Also look for reversed flow in abdominal aorta • Reversal VTI ≈ anterograde flow VTI Illustration note: terminal velocity > 0.2 m/s; holodiastolic flow reversal	—

LV dilatation; Ao dilatation; look for eversion or malcoaptation of leaflets; severe acute AR → restrictive mitral filling pattern

7.5 Prosthetic Valve Dysfunction

Look For

Normal 60° opening of leaflets (normal movement of acoustic shadows); dehiscence / rocking movement; vegetation; thrombus; pannus; structural degeneration; abscess; intracardiac mass; pseudoaneurysm; fistula; periprosthetic regurgitation
Thrombus: large mass; similar density to that of myocardium; recent symptoms; recent subtherapeutic INR; more frequent on mechanical mitral valve prosthesis
Pannus: small, dense mass; not visualized in 30% of cases; more frequent in aortic valve prostheses

PROSTHETIC VALVE HEMODYNAMIC MEASUREMENTS: vary according to the model and dimensions of the prosthesis (compare with manufacturer’s data); vary according to cardiac output
RECOVERY PRESSURE PHENOMENON: A transprosthetic gradient overestimated on TTE compared to catheterization (especially if proximal aortic diameter < 30 mm and small prosthesis)
PROSTHETIC REGURGITATION: distinguish physiological regurgitation specific to the prosthesis from pathological regurgitation; metallic mitral valve can hide MR due to shadowing

Central Pathological Regurgitation

Immobility of a mechanical leaflet
Prolapse or perforation of a biological leaflet
Mass — vegetation — thrombus

Periprosthetic Pathological Regurgitation

Dehiscence
Rocking movement

Patient–Prosthesis Mismatch

Area of the effective prosthetic orifice too small for the patient’s body surface area; valve functions normally but with ↑ transvalvular gradients; normal prosthetic area (non-indexed) for the type of prosthesis.

Severity	Indexed EOA	Note
Mild	> 0.85 cm²/m²	—
Moderate	0.65–0.85 cm²/m²	—
Severe	< 0.65 cm²/m²	Associated with ↑ mortality (especially if LV dysfunction)
Mitral prosthesis	Aim for indexed EOA > 1.2 cm²/m²	—

Prosthetic Aortic Valve Dysfunction

Finding	Peak velocity	VTI ½ ratio	Acceleration time (aortic systolic flow)
Obstruction (degeneration; thrombus; pannus)	> 3 m/s	< 0.25	> 100 ms; delayed and parabolic peak
Regurgitation or ↑ cardiac output	> 3 m/s	Normal (≥ 0.25)	AT < 80 ms; early triangular peak
Patient–prosthesis mismatch	> 3 m/s	Indexed EOA < 0.85 cm²/m²	AT < 80 ms; VTI ratio ≥ 0.25

Prosthetic Mitral Valve Dysfunction

Finding	Peak velocity	Gradient	PHT	Prosthetic mitral valve VTI / LVOT VTI ratio
Obstruction (degeneration; thrombus; pannus)	≥ 1.9 m/s	> 5 mmHg	> 130 ms	> 2.2
Regurgitation	≥ 1.9 m/s	> 5 mmHg	< 130 ms	> 2.2
Hyperdynamic state / High output state	≥ 1.9 m/s	> 5 mmHg	< 130 ms	< 2.2 (normal)

Note: Prosthetic valve evaluation must be individualized by comparing with manufacturer-provided reference values for the specific model and size.

7.6 Tricuspid Regurgitation (TR)

Standard ASE 3-Tier Grading Scheme

Parameter	Mild	Moderate	Severe
Vena Contracta Width (cm)	< 0.3	0.3–0.69	≥ 0.7
EROA by PISA (cm²)	< 0.2	0.2–0.39	≥ 0.4
Regurgitant Volume (mL)	< 30	30–44	≥ 45
3D VCA (cm²)	—	—	≥ 0.75
Hepatic Vein Flow	Systolic dominance	Systolic blunting	Systolic flow reversal
Tricuspid Inflow	A-wave dominant	Variable	E-wave dominant (≥ 1.0 m/s)

Expanded 5-Grade Scheme (Hahn & Zamorano) for Severe TR

Parameter	Severe	Massive	Torrential
Vena Contracta Width (cm)	0.7–1.3	1.4–2.0	≥ 2.1
EROA by PISA (cm²)	0.40–0.59	0.60–0.79	≥ 0.8
3D VCA (cm²)	0.75–0.94	0.95–1.14	≥ 1.15
Regurgitant Volume (mL/beat)	45–59	60–74	≥ 75

Note: The PISA method has limitations in TR due to non-circular orifices; 3D VCA is increasingly preferred for quantifying massive/torrential TR.

Supporting Signs for TR

Sign	Mild	Moderate	Severe
Structural	Normal/mildly abnormal leaflets	Moderately abnormal	Severe valve lesions
RV/RA Size	Usually normal	Normal/mild dilation	Usually dilated
IVC Diameter	Normal	Normal/mildly dilated	Dilated > 2.5 cm
Color Flow Jet Area	Small, narrow, central	Moderate central	Large central or eccentric wall-impinging jet

7.7 Pulmonary Regurgitation (PR)

ASE Severity Grading

Parameter	Mild	Moderate	Severe
EROA (cm²)	< 0.20	0.20–0.29	≥ 0.30
Regurgitant Volume (mL/beat)	< 30	30–44	≥ 45
PR Pressure Half-Time (ms)	> 100	—	< 100
Jet Width / Pulmonary Ring Ratio	Small	Variable	> 50% of ring diameter
CW Doppler Signal	Weak, slow deceleration	Variable	Dense, steep deceleration

Note: A short PR pressure half-time (< 100 ms) indicates rapid equalization of pulmonary and right ventricular diastolic pressures, a specific sign of severe PR.

Supporting Signs for PR

Sign	Finding
Pulmonary Valve Morphology	Normal (mild/moderate) → abnormal (severe)
Ratio of Pulmonic to Aortic Flow	Normal (mild) → variable (moderate) → significantly increased (severe)
End-Diastolic PR Velocity	> 2.2 m/s supports elevated pulmonary artery pressure

Masses / Structures

Eustachian valve / crista terminalis bridge / Chiari network (RA); vegetation; thrombus; degenerative valve disease; calcification; pacemaker lead; central catheter; lipomatous interatrial septum; pericardial cyst; hydatid cyst; hiatal hernia; tuberculoma; Lambl’s excrescences / valvular strands (filiform structures; length 3–10 mm; atrial aspect of AV valves and ventricular aspect of semilunar valves; on the line of leaflet closure); benign or malignant cardiac tumor (or metastasis).

Thrombus

Absence of opacification with contrast
Adherent to a hypokinetic or akinetic region

Agitated Saline

10 mL of saline solution; 0.25 mL of air emulsified with 2 syringes; right heart imaging.

Condition	Finding
Intracardiac shunt	Opacification of L chambers within 3 beats (± Valsalva)
Intrapulmonary shunt (AVMs)	Opacification of L chambers after 5 beats
Persistent left SVC	Injection into left arm → opacification of coronary sinus

Microbubbles

Lipid microspheres containing gas and able to cross the pulmonary circulation allowing visualization of left cardiac structures; useful for LVEF — segmental wall motion — stress echocardiography — L chamber mass / thrombus (no enhancement in the presence of thrombus) — aneurysm / pseudoaneurysm — HCM — LV noncompaction.

Item	Detail
Complications	0.01%
Contraindications	Perflutren allergy; significant PHT; R → L shunt
Microbubbles mode	Reduction of mechanical index (0.4–0.5)

Modality	Definition
TISSUE DOPPLER IMAGING (TDI)	Evaluates the velocity of longitudinal movement of a cardiac structure (low velocities); angle dependent
STRAIN (%)	Longitudinal deformation evaluation; percentage change in length of the muscle during contraction (negative value by convention) or relaxation (positive value by convention)
STRAIN RATE	Instantaneous measurement of the deformation (contraction or relaxation)
TISSUE TRACKING	Distance covered (displacement) by a structure over a given time interval

Normal Reference Values

Tissue Doppler (S wave) (cm/s)	Systolic strain (%)	Strain rate (s⁻¹)	Tissue tracking (cm)
Normal basal septum: 5.97 ± 1.14	Normal basal septum: −17.5 ± 5.32	Normal basal septum: 0.99 ± 0.49	Normal basal septum: 1.2 ± 0.19

Speckle Tracking

Evaluation of the deformation of a structure; angle-independent, which allows measurement of longitudinal, radial or circumferential deformation (counterclockwise systolic movement of the apex and clockwise systolic movement of the base).

Global Longitudinal Strain (GLS)

GLS (%) = relative length change of the LV myocardium between end-diastole and end-systole

Normal peak GLS in the range of −20%.