Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study

Abstract

Aims: Availability of normative reference values for cardiac chamber quantitation is a prerequisite for accurate clinical application of echocardiography. In this study, we report normal reference ranges for cardiac chambers size obtained in a large group of healthy volunteers accounting for gender and age. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following chamber quantitation protocols approved by the European Association of Cardiovascular Imaging.

Methods: A total of 734 (mean age: 45.8 ± 13.3 years) healthy volunteers (320 men and 414 women) were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was performed on all subjects following pre-defined protocols. There were no gender differences in age or cholesterol levels. Compared with men, women had significantly smaller body surface areas, and lower blood pressure. Quality of echocardiographic data sets was good to excellent in the majority of patients. Upper and lower reference limits were higher in men than in women. The reference values varied with age. These age-related changes persisted for most parameters after normalization for the body surface area.

Conclusion: The NORRE study provides useful two-dimensional echocardiographic reference ranges for cardiac chamber quantification. These data highlight the need for body size normalization that should be performed together with age-and gender-specific assessment for the most echocardiographic parameters.

Keywords: Chamber size and function; Reference values; Two-dimensional echocardiography.

Figure 1

(A) Two-dimensional-guided measurement of left ventricle wall thickness in end-diastole from the left parasternal long-axis view. The interventricular septum thickness (white arrow), the left ventricle end-diastolic diameter (red arrow) and the posterior wall (PW; yellow arrow) thickness are measured just distal to the mitral leaflets tips, perpendicular to the long axis of the LV. (B) Proximal left ventricle outflow tract (LVOT) diameter was measured in mid-systole, using the trailing-edge-to-leading-edge method, 0.5–1 cm below the aortic cusps in a plane parallel to the aortic annulus (white arrow) from the zoomed parasternal long-axis view. The yellow dashed arrow represents the distal LVOT diameter measured just below the aortic annulus level.

Figure 2

Two-dimensional measurements of left ventricle (LV) volumes using the biplane method of discs (modified Simpson's rule), in the apical four-chamber (A4C) and apical two-chamber (A2C) views at end-diastole (LV EDV) and at end-systole (LVESV). LV trabeculations and the papillary muscles should be excluded from the cavity in the tracing.

Figure 3

(A) Measurement of right ventricle (RV) linear dimensions from the apical four-chamber view showing the RV basal (RVb) and mid cavity (RVm) dimensions and the RV longitudinal dimension (L). Measurements were obtained at end-diastole. (B) Measurement of the right ventricle (RV) end-diastolic area in the apical four-chamber view. The endocardial border is traced in the apical four-chamber views from the tricuspid annulus along the RV free wall to the apex, then back to the tricuspid annulus, along the interventricular septum. Care should be taken to enclose trabeculation, tricuspid leaflets, and chords in this area. (C) Measurement of the right ventricle (RV) end-systolic area in the apical four-chamber view. The endocardial border is traced in apical four-chamber views from the tricuspid annulus along the RV free wall to the apex, then back to the tricuspid annulus, along the interventricular septum. Care should be taken to enclose trabeculation, tricuspid leaflets, and chords in this area.

Figure 4

(A) Measurement of the left atrial diameter (LAD) from the parasternal long-axis view at end-systole. Measurement is done from trailing-edge-to-leading-edge from the posterior aortic wall to the posterior aspect of the left atrial wall in a plane parallel to the mitral annulus. (B and C) Measurement of left atrial volume using Simpson's biplane method from the apical four-chamber (A4C) and apical two-chamber (A2C) views at ventricular end-systole (maximum LA size). The LA length (L) is measured perpendicular from the mid-point of the segment that unifies the hinge points of the mitral leaflets, up to the ceiling of the LA. The LA minor dimension (D) is represented by the white line from the lateral wall to the interatrial septum. Care should be taken to exclude the pulmonary veins from the tracing the LA. (D) Measurement of the right atrial (RA) area end-systole from the parasternal four-chamber view. The right atrial major dimension (L) is represented by the yellow line from the tricuspid annulus plane centre to the superior RA wall, and the RA minor dimension (D) is represented by the white line from the anterolateral wall to the interatrial septum.