Appendix B — Normal Values and Severity Grading

Every value carries its source. Where the 2025 guideline generation changed a threshold, the previous value is shown for comparison.

Left ventricle — structure and systolic function

Source: ASE/EACVI 2015 chamber quantification (Lang et al.)

Parameter	Men	Women
LV end-diastolic diameter	4.2–5.8 cm	3.8–5.2 cm
LV end-diastolic volume index	34–74 mL/m²	29–61 mL/m²
LV end-systolic volume index	11–31 mL/m²	8–24 mL/m²
LV ejection fraction	52–72%	54–74%
Septal / posterior wall thickness	0.6–1.0 cm	0.6–0.9 cm
LV mass index	49–115 g/m²	43–95 g/m²
Relative wall thickness	≤ 0.42	≤ 0.42

LVEF severity: mildly reduced 41–51% (men) / 41–53% (women); moderately reduced 30–40%; severely reduced < 30%.

Longitudinal indices: MAPSE ≥ 10 mm; septal s′ ≥ 7 cm/s; GLS ≤ −20% (vendor-dependent); EPSS < 7 mm; dP/dt > 1200 mmHg/s.

Flow

Parameter	Normal	Low-flow threshold
LVOT diameter	1.8–2.4 cm	—
LVOT VTI	18–22 cm	< 18 cm
Stroke volume	60–100 mL	—
Stroke volume index	35–65 mL/m²	< 35 mL/m²
Cardiac index	2.5–4.0 L/min/m²	< 2.2 L/min/m²
SVR	800–1200 dyn·s·cm⁻⁵	—

Diastolic function

Source: ASE 2025 (Nagueh et al., JASE 2025;38:537–69)

Mitral annular e′ for impaired relaxation

	20–39 y	40–65 y	> 65 y
Septal e′	< 7 cm/s	< 6 cm/s	< 6 cm/s
Lateral e′	< 10 cm/s	< 8 cm/s	< 7 cm/s
Average e′	< 9 cm/s	< 7 cm/s	< 6.5 cm/s

Age-independent cut-offs used in the main algorithm: septal ≤ 6, lateral ≤ 7, average ≤ 6.5 cm/s.

Primary algorithm variables

Variable	Threshold for elevated LAP
Septal E/e′	≥ 15
Lateral E/e′	≥ 13
Average E/e′	≥ 14
Peak TR velocity	≥ 2.8 m/s
PASP	≥ 35 mmHg

Secondary variables

Variable	Threshold
Pulmonary vein S/D	≤ 0.67 (systolic filling fraction ≤ 40%)
LA reservoir strain	≤ 18%
LAVi	> 34 mL/m²
IVRT	≤ 70 ms

Age-stratified normal ranges (5th–95th percentile)

Measure	20–39 y	40–60 y	60–80 y
E wave, m/s	0.54–1.11	0.47–1.02	0.39–0.92
A wave, m/s	0.24–0.68	0.33–0.82	0.43–0.97
E/A	0.88–2.73	0.69–2.07	0.50–1.40
Septal e′, cm/s	7.2–16.4	5.7–13.5	4.1–10.6
Lateral e′, cm/s	9.9–22.1	7.5–17.5	5.2–13.0
Average E/e′	4.0–9.1	4.6–11.5	5.2–14.0
LAVi, mL/m²	12.1–39.4	12.9–38.3	13.7–37.1
TR velocity, m/s	1.3–2.7	1.5–2.7	1.7–2.8
LA reservoir strain, %	29.5–63.2	26.8–57.7	24.1–52.3

Invasive reference

τ > 48 ms; chamber stiffness constant > 0.015; rest mean PCWP > 15 mmHg; rest LVEDP > 16 mmHg; exercise mean PCWP ≥ 25 mmHg.

Right heart

Source: ASE 2025 right heart guideline

Parameter	Normal	Mild	Moderate	Severe
RV free wall thickness	< 0.5 cm	0.5–0.7 cm	> 0.7–0.9 cm	> 0.9 cm
RA volume index	< 33 mL/m²	33–38	39–44	> 44 mL/m²
TAPSE	> 1.7 cm	≤1.7–≥1.3	≤1.3–>1.0	≤ 1.0 cm
Tissue Doppler s′	> 9.5 cm/s	≤9.5–≥7.2	≤7.2–>5.0	≤ 5.0 cm/s
Fractional area change	> 35%	≤35–>29	≤29–>22	≤ 22%
3D RVEF	> 45%	≤45–<39	≤39–≥32	< 32%
RV free wall strain (3-seg)	> 20%	≤20–<15	<15–≥11	< 11%
RV global strain (6-seg)	> 17%	≤17–>13	≤13–>9	≤ 9%
Tissue Doppler RV MPI	< 0.55	≥0.55–<0.62	≥0.62–<0.70	≥ 0.70
Pulsed Doppler RV MPI	< 0.40	≥0.40–<0.49	≥0.49–<0.57	≥ 0.57

RV–PA coupling: TAPSE/PASP 0.3–0.4 mm/mmHg indicates uncoupling and increased mortality risk.

Acute cor pulmonale (ICU definition): RV/LV end-diastolic area ratio > 0.6 (severe > 1.0) plus septal dyskinesia.

RA pressure estimation from the IVC (spontaneously breathing only)

IVC diameter	Collapse	Estimated RAP
≤ 2.1 cm	> 50%	3 mmHg (0–5)
≤ 2.1 cm	< 50%	8 mmHg (5–10)
> 2.1 cm	> 50%	8 mmHg (5–10)
> 2.1 cm	< 50%	15 mmHg (10–20)

Not valid under positive-pressure ventilation.

Pulmonary haemodynamics

RVOT acceleration time < 105 ms suggests pulmonary hypertension; < 60 ms suggests markedly elevated PVR. The 60/60 sign = AcT < 60 ms with TR gradient ≤ 60 mmHg.

Valve stenosis

Source: EACVI/ASE 2017 focused update; 2025 ESC/EACTS valvular guidelines

	Mild	Moderate	Severe
Aortic stenosis
Peak velocity, m/s	2.6–2.9	3.0–3.9	≥ 4.0
Mean gradient, mmHg	< 20	20–39	≥ 40
AVA, cm²	> 1.5	1.0–1.5	≤ 1.0
AVA index, cm²/m²	> 0.85	0.60–0.85	≤ 0.6
Dimensionless index	> 0.50	0.25–0.50	< 0.25
Mitral stenosis
MVA, cm²	> 1.5	1.0–1.5	≤ 1.5 (severe), ≤ 1.0 (very severe)
Mean gradient, mmHg	< 5	5–10	> 10
Tricuspid stenosis			≥ 5 mmHg mean gradient

CT aortic valve calcium score supporting severe AS (2025 ESC/EACTS): > 2000 AU in men, > 1200 AU in women.

Valve regurgitation — severe thresholds

Source: ASE 2017 native valvular regurgitation

	Vena contracta	EROA	Reg volume	Reg fraction	Supporting
Aortic	> 0.6 cm	≥ 0.3 cm²	≥ 60 mL	≥ 50%	PHT < 200 ms; holodiastolic aortic flow reversal (end-diastolic velocity ≥ 20 cm/s); jet/LVOT width > 65%
Mitral (primary)	≥ 0.7 cm	≥ 0.4 cm²	≥ 60 mL	≥ 50%	Systolic pulmonary vein flow reversal; dense triangular CW jet
Mitral (secondary)	≥ 0.7 cm	≥ 0.2 cm²	≥ 30 mL	≥ 50%
Tricuspid	≥ 0.7 cm	≥ 0.4 cm²	≥ 45 mL	—	Hepatic vein systolic flow reversal

Tricuspid regurgitation — extended grading

Parameter	Mild	Moderate	Severe	Massive	Torrential
Vena contracta, cm	< 0.3	0.3–0.69	≥ 0.7	1.4–2.0	≥ 2.1
EROA, cm²	< 0.20	0.20–0.39	≥ 0.40	0.60–0.79	≥ 0.80
Regurgitant volume, mL	< 30	30–44	≥ 45	—	—

Pulmonic stenosis: mild < 3 m/s (< 36 mmHg); moderate 3–4 m/s (36–64 mmHg); severe > 4 m/s (> 64 mmHg).

Prosthetic valves

Source: Zoghbi WA, et al. ASE 2024 (JASE 2024;37:2–63) — replaces the 2009 document

Prosthetic aortic valve — all types

Parameter	Normal	Possible stenosis	Suggests significant stenosis
Jet velocity contour	Triangular, early-peaking	Triangular to intermediate	Rounded, symmetric
Acceleration time, ms	< 80	80–100	> 100
AT / LV ejection time	< 0.32	0.32–0.37	> 0.37
Peak velocity, m/s	< 3	3–4	≥ 4

Prosthetic aortic valve — SAVR specific

Parameter	Normal	Possible stenosis	Significant stenosis
Mean gradient, mmHg	< 20	20–34	≥ 35
Doppler velocity index	> 0.35	0.25–0.35	< 0.25
EOA	Reference ± 1 SD	1 SD below reference	2 SD below reference

Significant stenosis requires at least one flow-dependent (peak velocity, mean gradient) and one flow-independent (EOA, DVI) parameter.

TAVI (change from post-procedural baseline)

Parameter	Normal	Possible	Significant
Mean gradient	Change < 10 mmHg	Increase 10–19 mmHg	Increase ≥ 20 mmHg
DVI	Change < 0.1 or < 20%	Decrease 0.1–0.19 or 20–39%	Decrease ≥ 0.2 or ≥ 40%
EOA	Change < 0.3 cm² or < 25%	Decrease 0.3–0.59 cm² or 25–49%	Decrease ≥ 0.6 cm² or ≥ 50%

Prosthetic mitral valve — significant stenosis

Mean gradient > 10 mmHg at a normal heart rate; PHT > 200 ms; DVI (VTI_PrMV/VTI_LVOT) > 2.5; EOA < 1 cm².

Normal mechanical mitral: EOA 2–3 cm², mean gradient 2–3 mmHg (up to 5–6 in small valves). Normal bioprosthetic mitral: EOA 2.2–3.5 cm², mean gradient 3–5 mmHg.

Do not use PHT to calculate prosthetic mitral EOA — it overestimates, particularly in normal valves.

Patient–prosthesis mismatch (indexed EOA, cm²/m²)

Position	Normal	Moderate	Severe
Aortic, BMI < 30	> 0.85	0.85–0.66	≤ 0.65
Aortic, BMI ≥ 30	> 0.70	0.70–0.56	≤ 0.55
Mitral, BMI < 30	> 1.2	1.2–0.91	≤ 0.90
Mitral, BMI ≥ 30	> 1.0	1.0–0.76	≤ 0.75

Mechanical occluder opening angles and CT attenuation

Bileaflet 73–90°; monoleaflet 60–80°. Thrombus < 200 HU (lysis most likely < 90 HU); pannus > 200 HU. A 145 HU cutoff separates them with 87.5% sensitivity and 96% specificity.

Fluid responsiveness thresholds

Test	Threshold
Passive leg raise, ΔVTI	≥ 10%
Respiratory ΔV_peak LVOT	≥ 12%
End-expiratory occlusion, ΔVTI	≥ 5%
Mini fluid challenge (100 mL), ΔVTI	≥ 6%
Fluid challenge, ΔSV	≥ 10–15%
IVC distensibility (ventilated)	≥ 18%
IVC collapsibility (spontaneous)	> 40–50%
SVC collapsibility (TEE)	≥ 36%

Ventriculo-arterial coupling

Parameter	Normal	Decoupling
Ea	2–2.5 mmHg/mL	—
Ees	2–3 mmHg/mL	—
Ea/Ees	0.6–1.0	> 1.5 (marked > 2.0)

Tamponade

RA systolic collapse (sensitive; more specific if > ⅓ of the cardiac cycle); RV diastolic collapse (specific); mitral inflow respiratory variation ≥ 25%; tricuspid inflow variation ≥ 40%; plethoric IVC with < 50% collapse; hepatic vein expiratory diastolic flow reversal.

Respiratory variation thresholds are unreliable under positive-pressure ventilation.

Wilkins score for balloon mitral valvuloplasty

Four components (leaflet mobility, leaflet thickening, subvalvular thickening, calcification), each 1–4; total 4–16. Total ≤ 8 predicts a favourable result. Absolute contraindications regardless of score: left atrial thrombus, more than mild mitral regurgitation.