Left Ventricle

LV assessment includes chamber size, wall thickness, geometry, global systolic function, regional wall motion, and—when indicated—strain and LV outflow obstruction.

Acquisition¶

Linear measurements¶

Measure from the parasternal long-axis view at end diastole:

Perpendicular to the LV long axis
At or immediately below the mitral leaflet tips
Inner edge to inner edge for LV dimensions
Avoiding oblique or off-axis measurements

Measurement	Men	Women
LV end-diastolic diameter	4.2–5.8 cm	3.8–5.2 cm
LV end-systolic diameter	2.5–4.0 cm	2.2–3.5 cm
Septal thickness	0.6–1.0 cm	0.6–0.9 cm
Posterior-wall thickness	0.6–1.0 cm	0.6–0.9 cm

LV volumes¶

Use the biplane method of disks from nonforeshortened apical four- and two-chamber views.

Trace the endocardial border at end diastole and end systole.
Exclude papillary muscles and trabeculations from the cavity.
Use an ultrasound-enhancing agent when ≥2 contiguous LV segments are not adequately visualized.

Indexed volume	Men	Women
LV end-diastolic volume	34–74 mL/m²	29–61 mL/m²
LV end-systolic volume	11–31 mL/m²	8–24 mL/m²

Ejection Fraction¶

\[ \text{LVEF} = \frac{\text{LVEDV} - \text{LVESV}} {\text{LVEDV}} \times 100 \]

LVEF	Men	Women
Normal	52–72%	54–74%
Mildly reduced	41–51%	41–53%
Moderately reduced	30–40%	30–40%
Severely reduced	<30%	<30%

Visual estimation may supplement quantitative assessment but should not replace biplane measurement when adequate images are available.

Note

Echocardiographic grading ranges are not identical to the EF categories used in heart-failure treatment guidelines.

LV Mass and Geometry¶

\[ \text{Relative wall thickness} = \frac{2 \times \text{posterior-wall thickness}} {\text{LV end-diastolic diameter}} \]

Normal RWT: ≤0.42
Increased RWT: >0.42

LV mass index	Normal
Men	≤115 g/m²
Women	≤95 g/m²

LV mass	RWT	Geometry
Normal	≤0.42	Normal geometry
Normal	>0.42	Concentric remodeling
Increased	>0.42	Concentric hypertrophy
Increased	≤0.42	Eccentric hypertrophy

LV mass calculations magnify small errors in linear measurements. Do not calculate LV mass from an oblique or poorly visualized study.

Regional Wall Motion¶

Evaluate wall motion using the standard 17-segment model.

Score	Motion
1	Normal or hyperkinetic
2	Hypokinetic
3	Akinetic
4	Dyskinetic
5	Aneurysmal

A regional wall-motion abnormality should be confirmed in at least two orthogonal views.

Common mimics include:

LBBB
RV pacing
Prior cardiac surgery
RV pressure overload
Apical foreshortening
Translational motion
Poor endocardial definition

Global Longitudinal Strain¶

GLS detects longitudinal systolic dysfunction that may precede a reduction in EF.

Normal GLS is approximately −20%.
Less negative values indicate worse systolic deformation.
Values less negative than approximately −18% may be abnormal, depending on vendor and laboratory reference ranges.
Serial studies should use the same equipment and analysis software.

GLS is particularly useful in:

Cardio-oncology
Cardiac amyloidosis
Hypertrophic cardiomyopathy
Aortic stenosis
Suspected subclinical LV dysfunction

Interpret GLS with EF, blood pressure, loading conditions, rhythm, and image quality.

Dynamic LVOT Obstruction¶

Dynamic obstruction produces a late-peaking, dagger-shaped continuous-wave Doppler envelope.

\[ \Delta P = 4v^2 \]

Peak gradient ≥30 mm Hg at rest or with provocation indicates obstruction.
Peak gradient ≥50 mm Hg is hemodynamically important and may influence management in symptomatic HCM.
Use pulsed-wave Doppler to localize the site of flow acceleration.
Avoid contamination by the mitral regurgitation jet.

A fixed obstruction typically produces a more rounded, symmetric Doppler envelope.

Reporting¶

The left ventricle is normal in size with normal wall thickness.

LV geometry is consistent with [normal geometry/concentric remodeling/
concentric hypertrophy/eccentric hypertrophy].

LV systolic function is normal/mildly reduced/moderately reduced/
severely reduced. LVEF is ___% by the biplane method of disks.

There are no regional wall-motion abnormalities.

There is [regional] hypokinesis/akinesis involving the ___ segments.

Global longitudinal strain is ___%.

There is dynamic LV outflow obstruction with a peak gradient of
___ mm Hg at rest and ___ mm Hg with provocation.

Pitfalls¶

Foreshortening the LV apex
Obtaining linear measurements from an oblique plane
Including papillary muscles in the LV cavity
Reporting visual EF despite adequate quantitative images
Comparing EF values obtained by different methods
Diagnosing ischemia from septal motion alone
Interpreting GLS without vendor or loading-condition context
Mistaking an MR jet for the LVOT Doppler envelope
Using inaccurate linear measurements to calculate LV mass

Key Points¶

Prefer biplane LV volumes and EF from apical four- and two-chamber views.
Normal LVEF is ≥52% in men and ≥54% in women.
Normal LV mass index is ≤115 g/m² in men and ≤95 g/m² in women.
RWT >0.42 indicates concentric geometry.
Confirm regional abnormalities in two orthogonal views.
Dynamic LVOT obstruction produces a late-peaking, dagger-shaped envelope.