Normal Reference Intervals for Cardiac Dimensions and Function for Use in Echocardiographic Practice: A Guideline from the British Society of Echocardiography

This guideline presents reference limits for use in echocardiographic practice, updating previous guidance from the British Society of Echocardiography. The rationale for change is discussed, in addition to how the reference intervals were defined and the current limitations to their use. The importance of interpretation of echocardiographic parameters within the clinical context is explored, as is grading of abnormality. Each of the following echo parameters are discussed and updated in turn: left ventricular linear dimensions and LV mass; left ventricular volumes; left ventricular ejection fraction; left atrial size; right heart parameters; aortic dimensions; and tissue Doppler imaging. There are several important conceptual changes to the assessment of the heart’s structure and function within this guideline. New terminology for left ventricular function and left atrial size are introduced. The British Society of Echocardiography has advocated a new approach to the assessment of the aortic root, the right heart, and clarified the optimal methodology for assessment of LA size. The British Society of Echocardiography has emphasized a preference to use, where feasible, indexed measures over absolute values for any chamber size.

Change history

References

  1. British Society of Echocardiography. EchoCalc for iPhone. London, UK: British Society of Echocardiography, 2015. (available at: https://apps.apple.com/us/app/echocalc/id468166426)
  2. British Society of Echocardiography. EchoCalc for android. London, UK: British Society of Echocardiography, 2014. (available at: https://play.google.com/store/apps/details?id=bse.echocalc)
  3. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, et al.. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. Journal of the American Society of Echocardiography 2005 18 1440–1463. (https://doi.org/10.1016/j.echo.2005.10.005) ArticlePubMedGoogle Scholar
  4. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. Journal of the American Society of Echocardiography 2010 23 685–713; quiz 786. (https://doi.org/10.1016/j.echo.2010.05.010) ArticlePubMedGoogle Scholar
  5. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al.. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 2015 28 1.e14–39.e14. (https://doi.org/10.1016/j.echo.2014.10.003) ArticleGoogle Scholar
  6. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al.. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European Heart Journal: Cardiovascular Imaging 2015 16 233–270. (https://doi.org/10.1093/ehjci/jev014) PubMedGoogle Scholar
  7. Lancellotti P, Badano LP, Lang RM, Akhaladze N, Athanassopoulos GD, Barone D, Baroni M, Cardim N, Gomez De Diego JJ, Derumeaux G, et al.. Normal reference ranges for echocardiography: rationale, study design, and methodology (NORRE study). European Heart Journal: Cardiovascular Imaging 2013 14 303–308. (https://doi.org/10.1093/ehjci/jet008) PubMedGoogle Scholar
  8. Kou S, Caballero L, Dulgheru R, Voilliot D, De Sousa C, Kacharava G, Athanassopoulos GD, Barone D, Baroni M, Cardim N, et al.. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study. European Heart Journal: Cardiovascular Imaging 2014 15 680–690. (https://doi.org/10.1093/ehjci/jet284) PubMedPubMed CentralGoogle Scholar
  9. Caballero L, Kou S, Dulgheru R, Gonjilashvili N, Athanassopoulos GD, Barone D, Baroni M, Cardim N, Gomez De Diego JJ, Oliva MJ, et al.. Echocardiographic reference ranges for normal cardiac Doppler data: results from the NORRE study. European Heart Journal: Cardiovascular Imaging 2015 16 1031–1041. (https://doi.org/10.1093/ehjci/jev083) PubMedGoogle Scholar
  10. Saura D, Dulgheru R, Caballero L, Bernard A, Kou S, Gonjilashvili N, Athanassopoulos GD, Barone D, Baroni M, Cardim N, et al.. Two-dimensional transthoracic echocardiographic normal reference ranges for proximal aorta dimensions: results from the EACVI NORRE study. European Heart Journal Cardiovascular Imaging 2017 18 167–179. (https://doi.org/10.1093/ehjci/jew053) ArticlePubMedGoogle Scholar
  11. Poppe KK, Doughty RN, Gardin JM, Hobbs FDR, McMurray JJV, Nagueh SF, Senior R, Thomas L, Whalley GA, Aune E, et al.. Ethnic-specific normative reference values for echocardiographic LA and LV size, LV mass, and systolic function: the EchoNoRMAL study. JACC: Cardiovascular Imaging 2015 8 656–665. (https://doi.org/10.1016/j.jcmg.2015.02.014) Google Scholar
  12. Fisher RA. Statistical methods for research workers. 4th edn. Edinburgh, UK: Oliver & Boyd, 1932. Google Scholar
  13. Solomon SD, Anavekar N, Skali H, McMurray JJV, Swedberg K, Yusuf S, Granger CB, Michelson EL, Wang D, Pocock S, et al.. Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation 2005 112 3738–3744. (https://doi.org/10.1161/CIRCULATIONAHA.105.561423) ArticlePubMedGoogle Scholar
  14. Chubb H, Simpson JM. The use of Z-scores in paediatric cardiology. Annals of Pediatric Cardiology 2012 5 179–184. (https://doi.org/10.4103/0974-2069.99622) ArticlePubMedPubMed CentralGoogle Scholar
  15. Tsang TSM, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. American Journal of Cardiology 2002 90 1284–1289. (https://doi.org/10.1016/s0002-9149(02)02864-3) ArticlePubMedGoogle Scholar
  16. Tsang TSM, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR, Cha SS, Seward JB. Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter? Journal of the American College of Cardiology 2006 47 1018–1023. (https://doi.org/10.1016/j.jacc.2005.08.077) ArticlePubMedGoogle Scholar
  17. Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE. Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation. Circulation 1988 78 1108–1120. (https://doi.org/10.1161/01.cir.78.5.1108) ArticleCASPubMedGoogle Scholar
  18. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, Frye RL. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. Journal of the American College of Cardiology 1994 24 1536–1543. (https://doi.org/10.1016/0735-1097(94)90151-1) ArticleCASPubMedGoogle Scholar
  19. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, et al.. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines. Circulation 2017 135 e1159–e1195. (https://doi.org/10.1161/CIR.0000000000000503) ArticlePubMedGoogle Scholar
  20. Dewey FE, Rosenthal D, Murphy DJ Jr, Froelicher VF, Ashley EA. Does size matter? Clinical applications of scaling cardiac size and function for body size. Circulation 2008 117 2279–2287. (https://doi.org/10.1161/CIRCULATIONAHA.107.736785) ArticlePubMedGoogle Scholar
  21. Paterick TE, Gordon T, Spiegel D. Echocardiography: profiling of the athlete’s heart. Journal of the American Society of Echocardiography 2014 27 940–948. (https://doi.org/10.1016/j.echo.2014.06.008) ArticlePubMedGoogle Scholar
  22. D’Ascenzi F, Pelliccia A, Solari M, Piu P, Loiacono F, Anselmi F, Caselli S, Focardi M, Bonifazi M, Mondillo S. Normative reference values of right heart in competitive athletes: a systematic review and meta-analysis. Journal of the American Society of Echocardiography 2017 30 845.e2–858.e2. (https://doi.org/10.1016/j.echo.2017.06.013) Google Scholar
  23. Oxborough D, Augustine D, Gati S, George K, Harkness A, Mathew T, Papadakis M, Ring L, Robinson S, Sandoval J, et al.. A guideline update for the practice of echocardiography in the cardiac screening of sports participants: a joint policy statement from the British Society of Echocardiography and Cardiac Risk in the Young. Echo Research and Practice 2018 5 G1–G10. (https://doi.org/10.1530/ERP-17-0075) ArticlePubMedPubMed CentralGoogle Scholar
  24. McClean G, George K, Lord R, Utomi V, Jones N, Somauroo J, Fletcher S, Oxborough D. Chronic adaptation of atrial structure and function in elite male athletes. European Heart Journal Cardiovascular Imaging 2015 16 417–422. (https://doi.org/10.1093/ehjci/jeu215) ArticlePubMedGoogle Scholar
  25. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, et al.. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. European Heart Journal 2018 39 3165–3241. (https://doi.org/10.1093/eurheartj/ehy340) ArticlePubMedGoogle Scholar
  26. Mada RO, Lysyansky P, Daraban AM, Duchenne J, Voigt JU. How to define end-diastole and end-systole? Impact of timing on strain measurements. JACC: Cardiovascular Imaging 2015 8 148–157. (https://doi.org/10.1016/j.jcmg.2014.10.010) PubMedGoogle Scholar
  27. Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, Pedri S, Ito Y, Abe Y, Metz S, et al.. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. European Heart Journal: Cardiovascular Imaging 2015 16 1–11. (https://doi.org/10.1093/ehjci/jeu184) CASPubMedGoogle Scholar
  28. Wharton G, Steeds R, Allen J, Phillips H, Jones R, Kanagala P, Lloyd G, Masani N, Mathew T, Oxborough D, et al.. A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Research and Practice 2015 2 G9–G24. (https://doi.org/10.1530/ERP-14-0079) ArticlePubMedPubMed CentralGoogle Scholar
  29. SOLVD Investigators, Yusuf S, Pitt B, Davis CE, Hood WB, Cohn JN. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. New England Journal of Medicine 1991 325 293–302. (https://doi.org/10.1056/NEJM199108013250501) ArticleGoogle Scholar
  30. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995 273 1450–1456. (https://doi.org/10.1001/jama.273.18.1450) ArticleCASPubMedGoogle Scholar
  31. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. New England Journal of Medicine 1999 341 709–717. (https://doi.org/10.1056/NEJM199909023411001) ArticleCASPubMedGoogle Scholar
  32. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999 353 9–13. (https://doi.org/10.1016/S0140-6736(98)11181-9)
  33. Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A, Roecker EB, et al.. Effect of carvedilol on survival in severe chronic heart failure. New England Journal of Medicine 2001 344 1651–1658. (https://doi.org/10.1056/NEJM200105313442201) ArticleCASPubMedGoogle Scholar
  34. Granger CB, McMurray JJV, Yusuf S, Held P, Michelson EL, Olofsson B, Ostergren J, Pfeffer MA, Swedberg K & CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003 362 772–776. (https://doi.org/10.1016/S0140-6736(03)14284-5) ArticleCASPubMedGoogle Scholar
  35. Swedberg K, Komajda M, Böhm M, Borer JS, Ford I, Dubost-Brama A, Lerebours G, Tavazzi L & SHIFT Investigators. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010 376 875–885. (https://doi.org/10.1016/S0140-6736(10)61198-1) ArticleCASPubMedGoogle Scholar
  36. Swedberg K, Komajda M, Böhm M, Borer J, Robertson M, Tavazzi L, Ford I & SHIFT Investigators. Effects on outcomes of heart rate reduction by ivabradine in patients with congestive heart failure: is there an influence of beta-blocker dose? Findings from the SHIFT (Systolic Heart failure treatment with the I(f) inhibitor ivabradine Trial) study. Journal of the American College of Cardiology 2012 59 1938–1945. (https://doi.org/10.1016/j.jacc.2012.01.020) ArticleCASPubMedGoogle Scholar
  37. McMurray JJV, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, et al.. Angiotensin-neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine 2014 371 993–1004. (https://doi.org/10.1056/NEJMoa1409077) ArticlePubMedCASGoogle Scholar
  38. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, et al.. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal 2016 37 2129–2200. (https://doi.org/10.1093/eurheartj/ehw128) ArticlePubMedGoogle Scholar
  39. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, et al.. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. New England Journal of Medicine 2004 350 2140–2150. (https://doi.org/10.1056/NEJMoa032423) ArticleCASPubMedGoogle Scholar
  40. Cleland JGF, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L & Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. New England Journal of Medicine 2005 352 1539–1549. (https://doi.org/10.1056/NEJMoa050496) ArticleCASPubMedGoogle Scholar
  41. National Institute for Health and Care Excellence. Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure. Technology appraisal guidance [TA314]. London, UK: NICE, 2014. (available at: https://www.nice.org.uk/guidance/ta314) Google Scholar
  42. Tsao CW, Lyass A, Larson MG, Cheng S, Lam CSP, Aragam JR, Benjamin EJ, Vasan RS. Prognosis of adults with borderline left ventricular ejection fraction. JACC: Heart Failure 2016 4 502–510. (https://doi.org/10.1016/j.jchf.2016.03.003) PubMedGoogle Scholar
  43. Petersen SE, Aung N, Sanghvi MM, Zemrak F, Fung K, Paiva JM, Francis JM, Khanji MY, Lukaschuk E, Lee AM, et al.. Reference ranges for cardiac structure and function using cardiovascular magnetic resonance (CMR) in Caucasians from the UK Biobank population cohort. Journal of Cardiovascular Magnetic Resonance 2017 19 18. (https://doi.org/10.1186/s12968-017-0327-9) ArticlePubMedPubMed CentralGoogle Scholar
  44. Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE, Dunkman WB, Jacobs W, Francis GS, Flohr KH. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative study. New England Journal of Medicine 1986 314 1547–1552. (https://doi.org/10.1056/NEJM198606123142404) ArticleCASPubMedGoogle Scholar
  45. Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, et al.. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. New England Journal of Medicine 2004 351 2049–2057. (https://doi.org/10.1056/NEJMoa042934) ArticleCASPubMedGoogle Scholar
  46. Flather MD, Shibata MC, Coats AJS, Van Veldhuisen DJ, Parkhomenko A, Borbola J, Cohen-Solal A, Dumitrascu D, Ferrari R, Lechat P, et al.. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). European Heart Journal 2005 26 215–225. (https://doi.org/10.1093/eurheartj/ehi115) ArticleCASPubMedGoogle Scholar
  47. Lam CSP, Solomon SD. The middle child in heart failure: heart failure with mid-range ejection fraction (40–50%). European Journal of Heart Failure 2014 16 1049–1055. (https://doi.org/10.1002/ejhf.159) ArticlePubMedGoogle Scholar
  48. Rossi A, Cicoira M, Zanolla L, Sandrini R, Golia G, Zardini P, Enriquez-Sarano M. Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. Journal of the American College of Cardiology 2002 40 1425. (https://doi.org/10.1016/s0735-1097(02)02305-7) ArticlePubMedGoogle Scholar
  49. Beinart R, Boyko V, Schwammenthal E, Kuperstein R, Sagie A, Hod H, Matetzky S, Behar S, Eldar M, Feinberg MS. Long-term prognostic significance of left atrial volume in acute myocardial infarction. Journal of the American College of Cardiology 2004 44 327–334. (https://doi.org/10.1016/j.jacc.2004.03.062) ArticlePubMedGoogle Scholar
  50. Sabharwal N, Cemin R, Rajan K, Hickman M, Lahiri A, Senior R. Usefulness of left atrial volume as a predictor of mortality in patients with ischemic cardiomyopathy. American Journal of Cardiology 2004 94 760–763. (https://doi.org/10.1016/j.amjcard.2004.05.060) ArticlePubMedGoogle Scholar
  51. Osranek M, Bursi F, Bailey KR, Grossardt BR, Brown RD Jr, Kopecky SL, Tsang TS, Seward JB. Left atrial volume predicts cardiovascular events in patients originally diagnosed with lone atrial fibrillation: three-decade follow-up. European Heart Journal 2005 26 2556–2561. (https://doi.org/10.1093/eurheartj/ehi483) ArticlePubMedGoogle Scholar
  52. Le Tourneau T, Messika-Zeitoun D, Russo A, Detaint D, Topilsky Y, Mahoney DW, Suri R, Enriquez-Sarano M. Impact of left atrial volume on clinical outcome in organic mitral regurgitation. Journal of the American College of Cardiology 2010 56 570–578. (https://doi.org/10.1016/j.jacc.2010.02.059) ArticlePubMedGoogle Scholar
  53. Ujino K, Barnes ME, Cha SS, Langins AP, Bailey KR, Seward JB, Tsang TSM. Two-dimensional echocardiographic methods for assessment of left atrial volume. American Journal of Cardiology 2006 98 1185–1188. (https://doi.org/10.1016/j.amjcard.2006.05.040) ArticlePubMedGoogle Scholar
  54. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF III, Dokainish H, Edvardsen T, Flachskampf FA, Gillebert TC, Klein AL, Lancellotti P, et al.. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 2016 29 277–314. (https://doi.org/10.1016/j.echo.2016.01.011) ArticlePubMedGoogle Scholar
  55. Iskandar A, Mujtaba MT, Thompson PD. Left atrium size in elite athletes. JACC: Cardiovascular Imaging 2015 8 753–762. (https://doi.org/10.1016/j.jcmg.2014.12.032) PubMedGoogle Scholar
  56. Authors/Task Force members, Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, et al.. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). European Heart Journal 2014 35 2733–2779. (https://doi.org/10.1093/eurheartj/ehu284) ArticleCASGoogle Scholar
  57. Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA, Calkins H, Corrado D, Cox MGPJ, Daubert JP, et al.. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation 2010 121 1533–1541. (https://doi.org/10.1161/CIRCULATIONAHA.108.840827) ArticlePubMedPubMed CentralGoogle Scholar
  58. Augustine DX, Coates-Bradshaw LD, Willis J, Harkness A, Ring L, Grapsa J, Coghlan G, Kaye N, Oxborough D, Robinson S, et al.. Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Research and Practice 2018 5 G11–G24. (https://doi.org/10.1530/ERP-17-0071) ArticlePubMedPubMed CentralGoogle Scholar
  59. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, et al.. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Revista Espanola de Cardiologia 2016 69 177. (https://doi.org/10.1016/j.rec.2016.01.002) ArticlePubMedGoogle Scholar
  60. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, et al.. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal 2014 35 2873–2926. (https://doi.org/10.1093/eurheartj/ehu281) ArticlePubMedGoogle Scholar
  61. Oxborough D, Ghani S, Harkness A, Lloyd G, Moody W, Ring L, Sandoval J, Senior R, Sheikh N, Stout M, et al.. Impact of methodology and the use of allometric scaling on the echocardiographic assessment of the aortic root and arch: a study by the Research and Audit Sub-Committee of the British Society of Echocardiography. Echo Research and Practice 2014 1 1–9. (https://doi.org/10.1530/ERP-14-0004) ArticlePubMedPubMed CentralGoogle Scholar
  62. Roman MJ, Devereux RB, Kramer-Fox R, O’Loughlin J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. American Journal of Cardiology 1989 64 507–512. (https://doi.org/10.1016/0002-9149(89)90430-x) ArticleCASPubMedGoogle Scholar
  63. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, et al.. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Anesthesia and Analgesia 2010 111 279–315. (https://doi.org/10.1213/ANE.0b013e3181dd869b) ArticlePubMedGoogle Scholar
  64. Goldstein SA, Evangelista A, Abbara S, Arai A, Asch FM, Badano LP, Bolen MA, Connolly HM, Cuéllar-Calàbria H, Czerny M, et al.. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. Journal of the American Society of Echocardiography 2015 28 119–182. (https://doi.org/10.1016/j.echo.2014.11.015) ArticlePubMedGoogle Scholar
  65. Cantinotti M, Giordano R, Clemente A, Assanta N, Murzi M, Murzi B, Crocetti M, Marotta M, Scalese M, Kutty S, et al.. Strengths and limitations of current adult nomograms for the aorta obtained by noninvasive cardiovascular imaging. Echocardiography 2016 33 1046–1068. (https://doi.org/10.1111/echo.13232) ArticlePubMedGoogle Scholar
  66. Devereux RB, de Simone G, Arnett DK, Best LG, Boerwinkle E, Howard BV, Kitzman D, Lee ET, Mosley TH, Weder A, et al.. Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons ≥15 years of age. American Journal of Cardiology 2012 110 1189–1194. (https://doi.org/10.1016/j.amjcard.2012.05.063) ArticlePubMedGoogle Scholar
  67. Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, et al.. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 2014 27 911–939. (https://doi.org/10.1016/j.echo.2014.07.012) ArticlePubMedGoogle Scholar

Acknowledgments

The authors’ would like to thank Dr Mark Belham for his thoughts and assistance, and the Education Committee of the British Society for Echocardiography for their support. They also acknowledge the authors of NORRE who provided clarification of their published data in order for us to finalise the BSE reference limits.