Echocardiography (TTE)

Normative and Pathological Values for Severity Classifications

Normative Values Across the Lifespan from Neonates to Adults

This section presents a peer-reviewed compilation of normative values for echocardiographic measurements, spanning neonates, pediatric patients, and adults. It serves as a critical reference for clinicians, ensuring accurate interpretation of echocardiographic data across different age groups and enhancing diagnostic precision in various clinical scenarios.

High-yield adult echocardiography criteria for ASCeXAM preparation, with source anchors (Written July 8, 2026)

This adult-focused document is organized so that the major echocardiographic criteria can be read together with their nearby literature source anchors. The source anchors are intentionally written as plain text rather than hyperlinks, so that the document can be copied and shared without disrupting the layout.

The most important examination principle is integrated interpretation. Valve morphology, chamber response, Doppler contour, quantitative values, blood pressure, rhythm, flow state, and prior studies should agree. Discordant findings should trigger reassessment of image quality, Doppler alignment, low-flow state, high-flow state, pressure recovery, prosthesis-patient mismatch, eccentric jets, and loading conditions.

I. How to use the source anchors

II. Core equations commonly tested

Source anchor: Baumgartner 2017, Doppler acquisition and mean-gradient sections for the modified Bernoulli equation and AS continuity equation; Baumgartner 2009, mitral stenosis section for pressure half-time; Zoghbi 2017, general regurgitation quantitation sections and valve-specific tables for PISA, EROA, regurgitant volume, and regurgitant fraction; Mukherjee 2025, Hemodynamics section and Table 4 for RVSP; Lang 2015, Table 6 and Figure 6 for LV mass and relative wall thickness.

III. Chamber quantification and ventricular function

1. Left ventricle, left atrium, and LV geometry

   Source anchor: Lang 2015, Table 2 for LV size and volume reference ranges; Lang 2015, Table 4 for LVEF and LA volume index severity cutoffs; Lang 2015, Table 6 and Figure 6 for LV mass index, RWT, and LV geometry.

   Parameter	Normal or key cutoff	Severity or interpretation	Nearby source anchor
   LVEF, men	52–72%	Mildly abnormal 41–51%, moderately abnormal 30–40%, severely abnormal < 30%.	Lang 2015, Table 4.
   LVEF, women	54–74%	Mildly abnormal 41–53%, moderately abnormal 30–40%, severely abnormal < 30%.	Lang 2015, Table 4.
   LV end-diastolic internal dimension, men	42.0–58.4 mm	Values above this range support LV dilation, but body size and athletic remodeling matter.	Lang 2015, Table 2.
   LV end-diastolic internal dimension, women	37.8–52.2 mm	Values above this range support LV dilation, but body size and pregnancy history may matter.	Lang 2015, Table 2.
   LV end-diastolic volume index, men	34–74 mL/m2	Elevated values support LV enlargement and are preferred over linear size when image quality permits.	Lang 2015, Table 2.
   LV end-diastolic volume index, women	29–61 mL/m2	Elevated values support LV enlargement and are preferred over linear size when image quality permits.	Lang 2015, Table 2.
   LA volume index	16–34 mL/m2	Mild 35–41, moderate 42–48, severe > 48 mL/m2. LAVI reflects chronic loading, not acute filling pressure alone.	Lang 2015, Table 4; Nagueh 2016, Figure 8A and Figure 8B.
   LV mass index, men	≤ 115 g/m2	> 115 g/m2 supports LV hypertrophy.	Lang 2015, Table 6.
   LV mass index, women	≤ 95 g/m2	> 95 g/m2 supports LV hypertrophy.	Lang 2015, Table 6.
   Relative wall thickness	≤ 0.42	> 0.42 supports concentric remodeling pattern when LV mass is normal, or concentric hypertrophy when LV mass is increased.	Lang 2015, Table 6 and Figure 6.
   Global longitudinal strain	Approximately −20% in many adult reference datasets	Less negative strain suggests impaired longitudinal systolic function, but vendor, software, age, blood pressure, and loading conditions matter.	Lang 2015, myocardial deformation discussion.

   LV geometry source anchor: Lang 2015, Figure 6.

   LV mass index	RWT ≤ 0.42	RWT > 0.42	Interpretive point
   Normal LV mass index	Normal geometry	Concentric remodeling	Concentric remodeling is increased relative wall thickness without increased LV mass.
   Increased LV mass index	Eccentric hypertrophy	Concentric hypertrophy	Concentric hypertrophy combines increased LV mass with increased relative wall thickness.

2. Right heart structure and systolic function

   Source anchor: Mukherjee 2025, Table 1 for contemporary adult right-heart reference limits and severity bands; Lang 2015, RV size and function sections for the older chamber-quantification framework.

   Parameter	Normal or key cutoff	Severity or interpretation	Nearby source anchor
   RV basal diameter	< 4.1 cm	Mild 4.1–4.4 cm, moderate > 4.4–4.9 cm, severe > 4.9 cm.	Mukherjee 2025, Table 1.
   RV mid diameter	< 3.5 cm	Mild 3.5–3.8 cm, moderate > 3.8–4.2 cm, severe > 4.2 cm.	Mukherjee 2025, Table 1.
   RV longitudinal dimension	< 8.2 cm	Mild 8.2–8.9 cm, moderate > 8.9–9.6 cm, severe > 9.6 cm.	Mukherjee 2025, Table 1.
   RV free-wall thickness	< 0.5 cm	≥ 0.5 cm supports RV hypertrophy; use subcostal view at end-diastole when possible.	Mukherjee 2025, Table 1 and measurement section.
   TAPSE	> 1.7 cm	≤ 1.7 cm is abnormal; severe reduction is typically ≤ 1.0 cm. TAPSE is angle- and load-dependent.	Mukherjee 2025, Table 1.
   RV S′	> 9.5 cm/s	≤ 9.5 cm/s is abnormal. It reflects longitudinal basal motion and may be misleading after cardiac surgery.	Mukherjee 2025, Table 1.
   RV FAC	> 35%	≤ 35% is abnormal; severe reduction is typically ≤ 22%.	Mukherjee 2025, Table 1.
   3D RVEF	> 45%	≤ 45% is abnormal. 3D RVEF is preferred when image quality and software allow reliable tracing.	Mukherjee 2025, Table 1.
   RV free-wall strain	Absolute value > 20%	Absolute value ≤ 20% is abnormal. Severe reduction is typically absolute value < 11%.	Mukherjee 2025, Table 1.
   RA area	< 19 cm2	Mild 19–22, moderate > 22–24, severe > 24 cm2.	Mukherjee 2025, Table 1.
   RA volume index by single-plane disk method	< 30 mL/m2	Mild 30–36, moderate > 36–41, severe > 41 mL/m2.	Mukherjee 2025, Table 1.

IV. Diastolic function and filling pressure

1. Classic 2016 ASE/EACVI algorithm for patients with normal LVEF

   Source anchor: Nagueh 2016, Key Points section and Figure 8A. This remains a common examination framework because it is simple and heavily taught.

   Variable	Positive cutoff	Meaning	Nearby source anchor
   Septal e′	< 7 cm/s	Reduced annular relaxation velocity.	Nagueh 2016, Figure 8A.
   Lateral e′	< 10 cm/s	Reduced annular relaxation velocity.	Nagueh 2016, Figure 8A.
   Average E/e′	> 14	Suggests elevated LV filling pressure, particularly when supported by LA enlargement and TR velocity.	Nagueh 2016, Figure 8A.
   TR peak velocity	> 2.8 m/s	Supports elevated pulmonary pressure in the setting of increased left-sided filling pressure, after excluding other causes.	Nagueh 2016, Figure 8A.
   LA volume index	> 34 mL/m2	Reflects chronic elevation of filling pressure unless another cause of LA enlargement is present.	Nagueh 2016, Figure 8A; Lang 2015, Table 4.

   Number of positive variables	2016 interpretation	Exam point	Nearby source anchor
   More than half positive	Diastolic dysfunction is present.	For 4 variables, 3 or 4 positive variables support diastolic dysfunction.	Nagueh 2016, Figure 8A.
   Less than half positive	Diastolic function is normal.	For 4 variables, 0 or 1 positive variable supports normal diastolic function.	Nagueh 2016, Figure 8A.
   Exactly half positive	Indeterminate.	For 4 variables, 2 positive variables are indeterminate.	Nagueh 2016, Figure 8A.

2. Classic 2016 grading when myocardial disease or reduced LVEF is present

   Source anchor: Nagueh 2016, Figure 8B and Key Points section. This algorithm begins with mitral inflow and then adjudicates intermediate patterns with E/e′, TR velocity, and LAVI.

   Transmitral inflow	Next step	Grade and filling pressure	Nearby source anchor
   E/A ≤ 0.8 and E velocity ≤ 50 cm/s	No additional variables are required if the pattern fits the clinical setting.	Grade I diastolic dysfunction; normal or low LA pressure.	Nagueh 2016, Figure 8B.
   E/A ≥ 2.0	No additional variables are required if the pattern fits the clinical setting.	Grade III diastolic dysfunction; elevated LA pressure.	Nagueh 2016, Figure 8B.
   E/A ≤ 0.8 with E velocity > 50 cm/s, or E/A > 0.8 to < 2.0	Use average E/e′ > 14, TR velocity > 2.8 m/s, and LAVI > 34 mL/m2.	Two or more positive variables indicate elevated LA pressure and Grade II. Two or more negative variables indicate Grade I. Discordance is indeterminate.	Nagueh 2016, Figure 8B.

3. Key 2025 update points to recognize

   Source anchor: Nagueh 2025, Figure 2, Figure 3, Table 6, and Table 7. The 2025 update adds more structured use of age-adjusted e′, left atrial reservoir strain, pulmonary pressure markers, and special-population logic.

   Update item	Criteria or threshold	Practical meaning	Nearby source anchor
   Age-adjusted reduced e′	Approximate abnormal cutoffs: age 20–39 years septal < 7, lateral < 10, average < 9 cm/s; age 40–65 years septal < 6, lateral < 8, average < 7 cm/s; age > 65 years septal < 6, lateral < 7, average < 6.5 cm/s.	Older patients normally have lower e′, so age context matters.	Nagueh 2025, Table 6.
   Left atrial reservoir strain	LARS ≤ 18%	Supports chronic elevation of LV filling pressure when LA strain is technically reliable and atrial rhythm allows interpretation.	Nagueh 2025, Figure 2 and Figure 3.
   Mean LAP at rest	Reduced e′, increased E/e′, TR velocity ≥ 2.8 m/s or PASP ≥ 35 mmHg, LAVI > 34 mL/m2, LARS ≤ 18%, short IVRT, and pulmonary venous indices are integrated.	The updated approach emphasizes multiple corroborating markers rather than one isolated Doppler value.	Nagueh 2025, Figure 3.

4. Diastolic stress echocardiography

   Source anchor: Nagueh 2016, Section VI on diastolic stress testing; Nagueh 2025, diastolic exercise testing update and Figure 7.

   Finding	Classic threshold	Interpretation	Nearby source anchor
   Exercise average E/e′	> 14	Supports abnormal exercise-induced rise in LV filling pressure.	Nagueh 2016, Section VI.
   Exercise septal E/e′	> 15	Used when only septal annular velocity is available.	Nagueh 2016, Section VI.
   Exercise TR velocity	> 2.8 m/s in the classic 2016 algorithm; newer material often emphasizes ≥ 3.2 m/s during exercise.	Supports abnormal pulmonary pressure response, especially when paired with abnormal exercise E/e′.	Nagueh 2016, Section VI; Nagueh 2025, Figure 7.
   Normal exercise response	Exercise E/e′ < 10 and peak TR velocity < 2.8 m/s in classic teaching.	Argues against exercise-induced elevation of LV filling pressure.	Nagueh 2016, Section VI.

V. Native valve stenosis

1. Aortic stenosis

   Source anchor: Baumgartner 2017, AS grading tables, continuity-equation section, low-flow low-gradient AS section, dobutamine stress echo section, and Figure 8.

   Severity	Peak velocity	Mean gradient	AVA	Indexed AVA	Dimensionless index	Nearby source anchor
   Aortic sclerosis	≤ 2.5 m/s	Not stenotic by gradient criteria	Usually not reduced	Not applicable	Not applicable	Baumgartner 2017, AS severity tables.
   Mild AS	2.6–2.9 m/s	< 20 mmHg	> 1.5 cm2	> 0.85 cm2/m2	> 0.50	Baumgartner 2017, AS severity tables.
   Moderate AS	3.0–4.0 m/s	20–40 mmHg	1.0–1.5 cm2	0.60–0.85 cm2/m2	0.25–0.50	Baumgartner 2017, AS severity tables.
   Severe AS	≥ 4.0 m/s	≥ 40 mmHg	< 1.0 cm2	< 0.60 cm2/m2	< 0.25	Baumgartner 2017, AS severity tables and Figure 8.
   Very severe AS	≥ 5.0 m/s is commonly used clinically	≥ 60 mmHg is commonly used clinically	Usually markedly reduced	Usually markedly reduced	Usually markedly reduced	Baumgartner 2017, high-gradient severe AS discussion; valve guideline staging frameworks.

   Discordant AS scenario	Criteria	How to interpret	Nearby source anchor
   Low flow	Stroke volume index < 35 mL/m2	Low flow can make a truly severe valve appear to have a low gradient.	Baumgartner 2017, low-flow AS section.
   Classical low-flow low-gradient severe AS	AVA < 1.0 cm2, mean gradient < 40 mmHg, LVEF < 50%, SVI < 35 mL/m2	Dobutamine stress echo can distinguish true severe AS from pseudo-severe AS when feasible.	Baumgartner 2017, low-flow low-gradient AS section and Figure 8.
   Paradoxical low-flow low-gradient severe AS	AVA < 1.0 cm2, mean gradient < 40 mmHg, LVEF ≥ 50%, SVI < 35 mL/m2	Often associated with small hypertrophied LV, impaired filling, and low forward stroke volume despite preserved EF.	Baumgartner 2017, low-flow low-gradient AS section and Figure 8.
   Dobutamine stress echo contractile reserve	Stroke volume increase > 20%	Presence of flow reserve improves interpretability of dobutamine stress AS assessment.	Baumgartner 2017, dobutamine stress echo section.
   CT calcium support for severe AS	Severe AS likely at approximately ≥ 2,000 AU in men and ≥ 1,200 AU in women; very likely at approximately ≥ 3,000 AU in men and ≥ 1,600 AU in women.	Useful when echo criteria are discordant and valve calcification is the main mechanism.	Baumgartner 2017, discordant AS and CT calcium section.

2. Mitral stenosis

   Source anchor: Baumgartner 2009, mitral stenosis section and mitral stenosis severity tables.

   Severity	Mitral valve area	Mean gradient	Pulmonary artery systolic pressure	Exam interpretation	Nearby source anchor
   Mild MS	> 1.5 cm2	< 5 mmHg	< 30 mmHg	Planimetry is preferred when feasible, especially in rheumatic MS.	Baumgartner 2009, MS severity table.
   Moderate MS	1.0–1.5 cm2	5–10 mmHg	30–50 mmHg	Mean gradient is strongly dependent on heart rate, rhythm, and transmitral flow.	Baumgartner 2009, MS severity table.
   Severe MS	< 1.0 cm2	> 10 mmHg	> 50 mmHg	Clinically significant MS is often considered at MVA < 1.5 cm2, especially when symptomatic or pulmonary pressure is elevated.	Baumgartner 2009, MS severity table and MS intervention discussion.

   Important ASCeXAM trap: A mean gradient of 12 mmHg during tachycardia or high-output state does not necessarily mean the anatomic stenosis is severe. Conversely, low flow can reduce the gradient despite important stenosis.

3. Tricuspid and pulmonic stenosis

   Source anchor: Baumgartner 2009, tricuspid stenosis and pulmonic stenosis sections, including stenosis severity tables.

   Valve	Key criteria	Interpretive note	Nearby source anchor
   Significant tricuspid stenosis	Mean gradient ≥ 5 mmHg, inflow VTI > 60 cm, pressure half-time ≥ 190 ms, or valve area by continuity ≤ 1.0 cm2.	RA enlargement and a dilated IVC provide important supportive evidence. Gradients vary with respiration and heart rate.	Baumgartner 2009, tricuspid stenosis section.
   Mild pulmonic stenosis	Peak velocity < 3.0 m/s or peak gradient < 36 mmHg.	Use the highest well-aligned velocity across the pulmonary valve.	Baumgartner 2009, pulmonic stenosis section.
   Moderate pulmonic stenosis	Peak velocity 3.0–4.0 m/s or peak gradient 36–64 mmHg.	Assess RV hypertrophy, RV pressure, and post-stenotic PA dilation.	Baumgartner 2009, pulmonic stenosis section.
   Severe pulmonic stenosis	Peak velocity > 4.0 m/s or peak gradient > 64 mmHg.	RV pressure overload is expected unless advanced RV failure reduces forward velocity.	Baumgartner 2009, pulmonic stenosis section.

VI. Native valve regurgitation

1. Mitral regurgitation

   Source anchor: Zoghbi 2017, Table 8 and Figure 18 for integrated MR severity; Zoghbi 2017, MR mechanism and quantitative assessment sections for PISA, vena contracta, pulmonary venous flow, and secondary MR caveats.

   Severity	Vena contracta width	EROA	Regurgitant volume	Regurgitant fraction	Supportive signs	Nearby source anchor
   Mild MR	< 0.3 cm	< 0.20 cm2	< 30 mL	< 30%	Small central jet, weak CW density, normal LV and LA size when chronic.	Zoghbi 2017, Table 8.
   Moderate MR, Grade II	Intermediate	0.20–0.29 cm2	30–44 mL	30–39%	Requires integration because intermediate color jet measures alone are not reliable.	Zoghbi 2017, Table 8 and Figure 18.
   Moderate MR, Grade III	Intermediate	0.30–0.39 cm2	45–59 mL	40–49%	May be clinically important, especially in secondary MR with a crescentic orifice.	Zoghbi 2017, Table 8 and secondary MR discussion.
   Severe MR	≥ 0.7 cm; biplane threshold often ≥ 0.8 cm	≥ 0.40 cm2	≥ 60 mL	≥ 50%	Flail leaflet, large coaptation defect, PISA radius about ≥ 1.0 cm at Nyquist 30–40 cm/s, pulmonary vein systolic reversal, dense triangular CW jet, E-wave dominant mitral inflow > 1.2 m/s, and enlarged LV/LA in chronic MR.	Zoghbi 2017, Table 8 and Figure 18.

   Interpretive note: In acute severe MR, the LA and LV may not yet be enlarged. In secondary MR, the regurgitant orifice is often dynamic and crescentic, so a two-dimensional PISA-derived EROA may underestimate severity.

2. Aortic regurgitation

   Source anchor: Zoghbi 2017, Table 11 and Figure 25 for AR severity; Zoghbi 2017, AR Doppler section for pressure half-time and holodiastolic flow reversal limitations.

   Severity	Jet width/LVOT width	Vena contracta width	Pressure half-time	EROA	Regurgitant volume and fraction	Nearby source anchor
   Mild AR	< 25%	< 0.3 cm	> 500 ms	< 0.10 cm2	RVol < 30 mL; RF < 30%.	Zoghbi 2017, Table 11.
   Moderate AR	25–64%	0.3–0.6 cm	200–500 ms	0.10–0.29 cm2	RVol 30–59 mL; RF 30–49%.	Zoghbi 2017, Table 11 and Figure 25.
   Severe AR	≥ 65%	> 0.6 cm	< 200 ms	≥ 0.30 cm2	RVol ≥ 60 mL; RF ≥ 50%.	Zoghbi 2017, Table 11 and Figure 25.

   • Highly specific severe sign: prominent holodiastolic flow reversal in the descending thoracic aorta.
   • Chronic severe AR response: LV dilation with initially hyperdynamic and later impaired systolic function.
   • Acute severe AR caveat: the LV may be normal-sized, and pressure half-time is load-dependent.

3. Tricuspid regurgitation

   Source anchor: Zoghbi 2017, Table 14 and Figure 31 for TR severity; Mukherjee 2025, right-heart chamber and pulmonary pressure sections for associated right-heart findings.

   Severity	Vena contracta width	EROA	Regurgitant volume	Supportive signs	Nearby source anchor
   Mild TR	< 0.3 cm	< 0.20 cm2	< 30 mL	Small central jet and usually normal right-sided chamber size.	Zoghbi 2017, Table 14.
   Moderate TR	0.3–0.69 cm	0.20–0.39 cm2	30–44 mL	Intermediate findings require integration with RV/RA size and hepatic vein flow.	Zoghbi 2017, Table 14 and Figure 31.
   Severe TR	≥ 0.7 cm	≥ 0.40 cm2	≥ 45 mL	Flail leaflet or large coaptation gap, triangular dense CW signal, PISA radius > 0.9 cm at Nyquist 30–40 cm/s, hepatic vein systolic reversal, RA/RV dilation, and plethoric IVC.	Zoghbi 2017, Table 14 and Figure 31.

4. Pulmonic regurgitation

   Source anchor: Zoghbi 2017, Table 16 and Figure 35 for PR severity, including jet width, pressure half-time, deceleration time, regurgitant fraction, and pulmonary artery flow reversal.

   Severity	Regurgitant fraction	Doppler and structural clues	Nearby source anchor
   Mild PR	< 20%	Thin jet, normal RV size, faint or incomplete CW signal.	Zoghbi 2017, Table 16.
   Moderate PR	20–40%	Intermediate jet size and Doppler density; RV size helps determine chronic impact.	Zoghbi 2017, Table 16 and Figure 35.
   Severe PR	> 40%	Broad jet origin, jet width/pulmonary annulus often ≥ 70%, pressure half-time < 100 ms, deceleration time < 260 ms, PR index < 0.77, diastolic reversal in main or branch pulmonary arteries, and RV dilation in chronic PR.	Zoghbi 2017, Table 16 and Figure 35.

VII. Right heart hemodynamics and pulmonary hypertension probability

1. Right atrial pressure from IVC

   Source anchor: Rudski 2010, right-heart guideline section on estimating right atrial pressure; Mukherjee 2025, Hemodynamics section and Table 4 for contemporary right-heart pressure reporting.

   IVC diameter	Inspiratory collapse	Estimated RAP	Practical interpretation	Nearby source anchor
   ≤ 21 mm	≥ 50%	3 mmHg	Normal right atrial pressure estimate.	Rudski 2010, RAP estimation section.
   ≤ 21 mm	< 50%	8 mmHg	Intermediate estimate.	Rudski 2010, RAP estimation section.
   > 21 mm	≥ 50%	8 mmHg	Intermediate estimate.	Rudski 2010, RAP estimation section.
   > 21 mm	< 50%	15 mmHg	Elevated right atrial pressure estimate.	Rudski 2010, RAP estimation section.
   > 25 mm with markedly abnormal systemic venous findings	< 50%	Consider 20 mmHg	Especially when hepatic veins are dilated with reflux or spontaneous contrast.	Rudski 2010, RAP estimation section; Mukherjee 2025, Hemodynamics section.

2. Pulmonary pressure and pulmonary hypertension probability

   Source anchor: Mukherjee 2025, Table 1 for RVSP and TR velocity severity bands; Mukherjee 2025, Hemodynamics section and Table 4 for RVSP calculation and reporting cautions.

   Parameter	Cutoff or severity band	Interpretation	Nearby source anchor
   RVSP or PASP	\(4(TRV)^2 + RAP\)	Assumes no pulmonic stenosis or RV outflow obstruction. Use the best dense TR envelope and avoid post-extrasystolic beats.	Mukherjee 2025, Table 4 and Hemodynamics section.
   RVSP	Normal ≤ 34 mmHg; mild 35–49; moderate 50–69; severe ≥ 70 mmHg	RVSP ≥ 35 mmHg is generally abnormal, but echo-estimated pressure does not replace right-heart catheterization when definitive PH diagnosis is required.	Mukherjee 2025, Table 1.
   TR peak velocity	Normal < 2.8 m/s; mild 2.8–3.1; moderate 3.2–3.5; severe ≥ 3.6 m/s	TR velocity is a probability marker, not a complete pulmonary hypertension diagnosis.	Mukherjee 2025, Table 1.
   Echo-derived PVR	\(PVR = 10 \times \dfrac{TRV}{RVOT\ VTI} + 0.16\)	PVR > 2 Wood units is abnormal, but echocardiographic PVR is supportive rather than definitive.	Mukherjee 2025, Hemodynamics section.
   Adjunctive PH signs	RV enlargement, septal flattening/eccentricity index abnormality, short RVOT acceleration time, RA enlargement, PA dilation, and abnormal IVC.	Resting TRV ≥ 2.9 m/s, or TRV ≥ 2.8 m/s with at least two supportive echo signs, increases suspicion for PH.	Mukherjee 2025, PH probability and right-heart hemodynamics sections.

VIII. Prosthetic valves

1. Prosthetic aortic valve stenosis

   Source anchor: Zoghbi 2024, Table 5 and Figure 13. The exam logic is to pair flow-dependent findings, such as velocity and gradient, with less flow-dependent findings, such as DVI, acceleration time, and EOA.

   Finding	Normal	Possible stenosis	Significant stenosis	Nearby source anchor
   Doppler contour	Triangular, early peaking	Intermediate	Rounded, symmetric, delayed peaking	Zoghbi 2024, Table 5 and Figure 13.
   Acceleration time	< 80 ms	80–100 ms	> 100 ms	Zoghbi 2024, Table 5.
   Acceleration time/ejection time	< 0.32	0.32–0.37	> 0.37	Zoghbi 2024, Table 5.
   Peak velocity	< 3.0 m/s	3.0–4.0 m/s	≥ 4.0 m/s	Zoghbi 2024, Table 5.
   Mean gradient, surgical AVR	< 20 mmHg	20–34 mmHg	≥ 35 mmHg	Zoghbi 2024, Table 5.
   DVI	> 0.35	0.25–0.35	< 0.25	Zoghbi 2024, Table 5.
   Effective orifice area	Near reference for valve type and size	Approximately 1 SD smaller than reference	Approximately 2 SD smaller than reference	Zoghbi 2024, Table 5.

2. Prosthetic mitral valve stenosis

   Source anchor: Zoghbi 2024, Table 10 for prosthetic mitral parameters and Table 11 for Doppler findings suggestive of prosthetic mitral stenosis.

   Finding	Normal	Possible stenosis	Significant stenosis	Nearby source anchor
   Peak velocity	< 1.9 m/s	1.9–2.5 m/s	≥ 2.5 m/s	Zoghbi 2024, Table 11.
   Mean gradient	≤ 5 mmHg	6–10 mmHg	> 10 mmHg	Zoghbi 2024, Table 11.
   VTIprosthetic mitral/VTILVOT	< 2.2	2.2–2.5	> 2.5	Zoghbi 2024, Table 11.
   Effective orifice area	≥ 2.0 cm2	1.0–2.0 cm2	< 1.0 cm2	Zoghbi 2024, Table 11.
   Pressure half-time	< 130 ms	130–200 ms	> 200 ms	Zoghbi 2024, Table 11.

3. Prosthesis-patient mismatch and structural valve deterioration

   Source anchor: Zoghbi 2024, Table 7 for prosthesis-patient mismatch; Zoghbi 2024, structural valve deterioration table for serial hemodynamic deterioration.

   Valve position	BMI	No or mild PPM	Moderate PPM	Severe PPM	Nearby source anchor
   Aortic prosthesis indexed EOA	< 30 kg/m2	> 0.85 cm2/m2	0.66–0.85 cm2/m2	≤ 0.65 cm2/m2	Zoghbi 2024, Table 7.
   Aortic prosthesis indexed EOA	≥ 30 kg/m2	> 0.70 cm2/m2	0.56–0.70 cm2/m2	≤ 0.55 cm2/m2	Zoghbi 2024, Table 7.
   Mitral prosthesis indexed EOA	< 30 kg/m2	> 1.20 cm2/m2	0.91–1.20 cm2/m2	≤ 0.90 cm2/m2	Zoghbi 2024, Table 7.
   Mitral prosthesis indexed EOA	≥ 30 kg/m2	> 1.00 cm2/m2	0.76–1.00 cm2/m2	≤ 0.75 cm2/m2	Zoghbi 2024, Table 7.

   Serial finding	Possible hemodynamic structural valve deterioration	Significant hemodynamic structural valve deterioration	Nearby source anchor
   Mean gradient rise with EOA or DVI worsening	Increase in mean gradient ≥ 10 mmHg resulting in mean gradient ≥ 20 mmHg, with EOA decrease ≥ 0.3 cm2 or ≥ 25%, and/or DVI decrease ≥ 0.1 or ≥ 20% from baseline.	Increase in mean gradient ≥ 20 mmHg resulting in mean gradient ≥ 30 mmHg, with EOA decrease ≥ 0.6 cm2 or ≥ 50%, and/or DVI decrease ≥ 0.2 or ≥ 40% from baseline.	Zoghbi 2024, structural valve deterioration table.
   New or worsening intraprosthetic regurgitation	New or increased intraprosthetic regurgitation may support structural valve deterioration when consistent with morphology and serial change.	Marked worsening of intraprosthetic regurgitation with supportive structural abnormality suggests significant deterioration.	Zoghbi 2024, structural valve deterioration table.

IX. Pericardial disease and hypertrophic cardiomyopathy

1. Cardiac tamponade

   Source anchor: Klein 2013, cardiac tamponade section and Doppler respiratory variation discussion.

   Echo finding	High-yield criterion	Meaning and caveat	Nearby source anchor
   Right atrial collapse	Collapse lasting more than one third of the cardiac cycle is highly suggestive.	Sensitive but not perfectly specific; correlate with clinical tamponade physiology.	Klein 2013, tamponade section.
   Right ventricular collapse	Early diastolic RV free-wall collapse.	More specific than brief RA collapse in the appropriate setting.	Klein 2013, tamponade section.
   IVC plethora	Dilated IVC with reduced inspiratory collapse.	Very common, but may be absent with hypovolemia or early regional tamponade.	Klein 2013, tamponade section.
   Mitral inflow respiratory variation	Inspiratory decrease in E velocity usually > 25% to 30%.	Use caution with positive-pressure ventilation, severe lung disease, and arrhythmia.	Klein 2013, Doppler respiratory variation discussion.
   Tricuspid inflow respiratory variation	Inspiratory increase in E velocity usually > 40%.	Reflects exaggerated ventricular interdependence.	Klein 2013, Doppler respiratory variation discussion.
   Hepatic vein Doppler	Prominent expiratory diastolic flow reversal can support tamponade physiology.	Interpret with rhythm, respiration, and right-sided pressures.	Klein 2013, tamponade section.

2. Constrictive pericarditis versus restrictive cardiomyopathy

   Source anchor: Klein 2013, constrictive pericarditis section; Nagueh 2025, constriction and special-population diastolic sections for contemporary integration of annular velocities and hepatic vein Doppler.

   Finding	Constrictive pericarditis	Restrictive cardiomyopathy	Nearby source anchor
   Septal motion	Respiratory septal shift or septal bounce.	Usually absent or less prominent.	Klein 2013, constriction section.
   Mitral inflow variation	> 25% respiratory variation.	Usually less respiratory variation.	Klein 2013, constriction Doppler section.
   Tricuspid inflow variation	> 40% respiratory variation.	Usually less respiratory variation.	Klein 2013, constriction Doppler section.
   Medial e′	Preserved or increased, often > 7–8 cm/s.	Reduced, often < 6 cm/s.	Klein 2013, annular velocity discussion; Nagueh 2025, constriction section.
   Annulus reversus	Medial e′ > lateral e′.	Usually absent.	Klein 2013, constriction section.
   Hepatic vein Doppler	Expiratory diastolic reversal ratio around ≥ 0.8 supports constriction.	Less typical; high RA pressure may cause blunted patterns.	Klein 2013, constriction hepatic vein Doppler section.

3. Hypertrophic cardiomyopathy

   Source anchor: Ommen 2024, HCM diagnostic criteria and obstructive HCM management sections; major HCM imaging documents for morphology and Doppler characterization.

   Criterion	Threshold	Clinical meaning	Nearby source anchor
   Adult HCM wall thickness	Unexplained maximal LV wall thickness ≥ 15 mm	Diagnostic threshold in adults when not explained by loading conditions such as hypertension or aortic stenosis.	Ommen 2024, diagnostic criteria section.
   Borderline wall thickness	13–14 mm	Can support HCM when family history, genotype, ECG, morphology, or other phenotype markers are present.	Ommen 2024, diagnostic criteria section.
   LVOT obstruction	Peak instantaneous gradient ≥ 30 mmHg at rest or with provocation	Defines obstructive physiology.	Ommen 2024, obstructive HCM section.
   Intervention-relevant LVOT gradient	≥ 50 mmHg with refractory symptoms	Common threshold for considering septal reduction therapy in otherwise appropriate candidates.	Ommen 2024, septal reduction therapy section.
   Massive LVH risk marker	≥ 30 mm	Important sudden cardiac death risk marker.	Ommen 2024, sudden cardiac death risk marker section.
   Doppler clue	Late-peaking, dagger-shaped CW Doppler profile	Differentiate from MR contamination; MR jet is usually higher velocity, more holosystolic, and directed into the LA.	HCM imaging guidance and obstructive HCM Doppler sections.

X. Stress echocardiography, ischemia, shunts, and aorta

1. Stress echocardiography wall-motion scoring

   Source anchor: Pellikka 2020, Grading of Regional Function section, Figure 9, Table 3, and Table 4. The key point is that wall-motion scoring is based on both endocardial inward motion and systolic wall thickening. Passive translation or tethering should not be mistaken for active contraction.

   Score	Label	What should be seen	How to assign the score	Common exam trap	Nearby source anchor
   1	Normal or hyperkinetic	Clear systolic inward endocardial motion with visible systolic wall thickening. With stress, normal segments usually become more hyperdynamic and the LV cavity becomes smaller.	Use score 1 when thickening is normal or augmented. The ASE stress guideline describes normal systolic thickening as generally > 50%.	Do not call a segment abnormal simply because the entire heart translates; judge thickening and endocardial motion relative to adjacent segments.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   2	Hypokinetic	Reduced but still present systolic inward motion and reduced wall thickening.	Use score 2 when contraction is present but clearly reduced. The ASE stress guideline describes hypokinesis as systolic thickening generally < 40%.	Foreshortening may make the apex appear falsely abnormal. Confirm the true apex and compare multiple views.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   3	Severely hypokinetic or akinetic	Nearly absent or absent systolic wall thickening. In true akinesis, there is no meaningful active inward systolic endocardial excursion. The segment may still move passively because of tethering by adjacent segments or whole-heart translation.	Use score 3 when systolic thickening is absent or almost absent. The ASE stress guideline describes severe hypokinesis or akinesis as systolic thickening generally < 10%.	Do not score passive motion as contraction. A scarred akinetic segment can be pulled inward by neighboring normal segments, but it does not thicken.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   4	Dyskinetic	Paradoxical systolic outward motion away from the center of the LV cavity.	Use score 4 when the segment moves outward during systole rather than inward.	Akinetic-to-dyskinetic change during stress may reflect mechanical behavior of an infarcted segment and is not automatically equivalent to inducible ischemia.	Pellikka 2020, Grading of Regional Function section and Table 3.
   5	Aneurysmal	Diastolic deformation or outpouching, often with thin scarred myocardium and abnormal systolic motion.	Use score 5 for aneurysmal deformation rather than simple akinesis alone.	An aneurysmal segment should be reported anatomically and clinically, not merely averaged into the WMSI.	Pellikka 2020, Grading of Regional Function section and reporting Table 4.

   \(WMSI = \dfrac{sum\ of\ segment\ scores}{number\ of\ scored\ segments}\). A 16-segment model is commonly used for stress echo wall-motion analysis. A 17-segment model may be used when comparison with perfusion imaging or CMR is relevant.

   Stress response pattern	Definition	Interpretation	Nearby source anchor
   Normal response	Normal global and regional wall motion at rest and stress; stress produces smaller LV end-systolic cavity and more vigorous contraction.	No echocardiographic evidence of inducible ischemia at the achieved workload and heart rate.	Pellikka 2020, Table 3.
   Ischemic response	New wall-motion abnormality during stress or worsening of a resting wall-motion abnormality.	Suggests inducible ischemia in the involved coronary territory.	Pellikka 2020, Table 3 and reporting Table 4.
   Fixed abnormality	Severe resting wall-motion abnormality that does not improve or worsen significantly with stress.	Often indicates infarcted or nonviable scar, depending on clinical context.	Pellikka 2020, Table 3.
   Viability or contractile reserve	Resting hypokinetic or akinetic segment improves at low-dose dobutamine.	Suggests viable myocardium.	Pellikka 2020, dobutamine stress and viability discussion.
   Biphasic response	Improvement at low-dose dobutamine followed by worsening at higher dose.	Suggests viable but jeopardized myocardium supplied by a significantly stenotic artery.	Pellikka 2020, dobutamine stress and viability discussion.
   High-risk stress echo features	Extensive inducible abnormalities, ischemia at low workload or low heart rate, stress-induced LV dilation, fall in EF, or multivessel-territory involvement.	Supports higher-risk ischemic burden.	Pellikka 2020, interpretation and reporting sections.

2. Shunts and aortic measurement clues

   Source anchor: Lang 2015, aortic measurement section for adult TTE measurement conventions; ASE contrast and shunt guidance for agitated saline timing; contemporary valve and congenital frameworks for Qp/Qs interpretation.

   Topic	High-yield criterion	Interpretive note	Nearby source anchor
   Qp/Qs	\(Qp/Qs = \dfrac{pulmonary\ flow}{systemic\ flow}\)	Qp/Qs ≥ 1.5 is commonly considered hemodynamically significant when pulmonary vascular resistance is acceptable.	Adult congenital and shunt quantification guidance; continuity-flow method sections.
   Agitated saline study	Left-sided bubbles within approximately 3 cardiac cycles suggest intracardiac shunt; later appearance suggests intrapulmonary shunt.	Timing depends on shunt size, Valsalva quality, injection site, cardiac output, and pulmonary transit time.	ASE contrast and shunt imaging guidance.
   Aortic root measurement	Adult TTE convention commonly uses leading-edge to leading-edge at end-diastole for the sinus of Valsalva and ascending aorta.	Aortic annulus is generally measured inner-edge to inner-edge in mid-systole.	Lang 2015, aortic measurement section.
   Ascending aorta dilation	≥ 4.0 cm is commonly considered dilated in adults.	Clinical thresholds depend on body size, sex, etiology, growth rate, bicuspid aortic valve, and genetic syndrome.	Contemporary aortic disease guideline measurement and intervention sections.

XI. Illustrative charts

The following charts are intentionally limited to high-yield thresholds that are commonly memorized. They do not replace multiparametric interpretation.

XII. Reference map

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ASCeXAM 대비 성인 심초음파 고빈도 기준, 근접 reference anchor 포함

이 문서는 성인 ASCeXAM 대비에 필요한 주요 심초음파 기준을, 해당 기준과 가까운 위치에서 문헌상 근거 위치를 바로 확인할 수 있도록 구성한 것입니다. 공유와 복사를 쉽게 하기 위해 reference anchor는 링크가 아닌 일반 텍스트로 제시하였습니다.

시험에서 가장 중요한 원칙은 통합 판정입니다. 판막 형태, 심방·심실 반응, 도플러 파형, 정량 수치, 혈압, 리듬, 유량 상태, 이전 검사와의 비교가 서로 맞아야 합니다. 서로 맞지 않으면 영상 품질, 도플러 정렬, 저유량, 고유량, pressure recovery, prosthesis-patient mismatch, 편심성 제트, 부하 조건을 다시 검토하는 것이 타당합니다.

I. Source anchor 사용법

II. 자주 출제되는 핵심 공식

Source anchor: Modified Bernoulli equation 및 AS continuity equation은 Baumgartner 2017, Doppler acquisition 및 mean-gradient sections; pressure half-time은 Baumgartner 2009, mitral stenosis section; PISA, EROA, regurgitant volume, regurgitant fraction은 Zoghbi 2017, general regurgitation quantitation sections 및 valve-specific tables; RVSP는 Mukherjee 2025, Hemodynamics section and Table 4; LV mass 및 RWT는 Lang 2015, Table 6 and Figure 6.

III. 심방·심실 정량 및 심실 기능

1. 좌심실, 좌심방, 좌심실 기하학

   Source anchor: LV size 및 volume reference range는 Lang 2015, Table 2; LVEF 및 LA volume index severity cutoff는 Lang 2015, Table 4; LV mass index, RWT, LV geometry는 Lang 2015, Table 6 and Figure 6.

   항목	정상 또는 핵심 기준	중증도 또는 해석	근접 source anchor
   남성 LVEF	52–72%	경도 이상 41–51%, 중등도 이상 30–40%, 중증 이상 < 30%.	Lang 2015, Table 4.
   여성 LVEF	54–74%	경도 이상 41–53%, 중등도 이상 30–40%, 중증 이상 < 30%.	Lang 2015, Table 4.
   남성 LV end-diastolic internal dimension	42.0–58.4 mm	상한 초과 시 LV dilation을 지지하지만, 체격과 운동선수 remodeling을 고려해야 합니다.	Lang 2015, Table 2.
   여성 LV end-diastolic internal dimension	37.8–52.2 mm	상한 초과 시 LV dilation을 지지하지만, 체격과 임신력 등도 고려해야 합니다.	Lang 2015, Table 2.
   남성 LV end-diastolic volume index	34–74 mL/m2	상승 시 LV enlargement를 지지하며, 영상이 가능하면 선형 직경보다 용적 평가가 선호됩니다.	Lang 2015, Table 2.
   여성 LV end-diastolic volume index	29–61 mL/m2	상승 시 LV enlargement를 지지하며, 영상이 가능하면 선형 직경보다 용적 평가가 선호됩니다.	Lang 2015, Table 2.
   LA volume index	16–34 mL/m2	경도 35–41, 중등도 42–48, 중증 > 48 mL/m2. LAVI는 급성 충만압보다는 만성 부하를 반영합니다.	Lang 2015, Table 4; Nagueh 2016, Figure 8A and Figure 8B.
   남성 LV mass index	≤ 115 g/m2	> 115 g/m2이면 LV hypertrophy를 지지합니다.	Lang 2015, Table 6.
   여성 LV mass index	≤ 95 g/m2	> 95 g/m2이면 LV hypertrophy를 지지합니다.	Lang 2015, Table 6.
   Relative wall thickness	≤ 0.42	> 0.42이면 LV mass가 정상일 때 concentric remodeling, LV mass가 증가했을 때 concentric hypertrophy를 지지합니다.	Lang 2015, Table 6 and Figure 6.
   Global longitudinal strain	많은 성인 reference dataset에서 대략 −20%	덜 음성인 값은 longitudinal systolic function 저하를 시사하지만, vendor, software, 연령, 혈압, 부하 조건이 중요합니다.	Lang 2015, myocardial deformation discussion.

   LV geometry source anchor: Lang 2015, Figure 6.

   LV mass index	RWT ≤ 0.42	RWT > 0.42	해석 포인트
   정상 LV mass index	Normal geometry	Concentric remodeling	Concentric remodeling은 LV mass 증가 없이 relative wall thickness가 증가한 상태입니다.
   증가한 LV mass index	Eccentric hypertrophy	Concentric hypertrophy	Concentric hypertrophy는 LV mass 증가와 relative wall thickness 증가가 함께 있는 상태입니다.

2. 우심장 구조와 우심실 수축기능

   Source anchor: 현대적 성인 우심장 reference limit 및 severity band는 Mukherjee 2025, Table 1; 기존 chamber quantification framework는 Lang 2015, RV size and function sections.

   항목	정상 또는 핵심 기준	중증도 또는 해석	근접 source anchor
   RV basal diameter	< 4.1 cm	경도 4.1–4.4 cm, 중등도 > 4.4–4.9 cm, 중증 > 4.9 cm.	Mukherjee 2025, Table 1.
   RV mid diameter	< 3.5 cm	경도 3.5–3.8 cm, 중등도 > 3.8–4.2 cm, 중증 > 4.2 cm.	Mukherjee 2025, Table 1.
   RV longitudinal dimension	< 8.2 cm	경도 8.2–8.9 cm, 중등도 > 8.9–9.6 cm, 중증 > 9.6 cm.	Mukherjee 2025, Table 1.
   RV free-wall thickness	< 0.5 cm	≥ 0.5 cm이면 RV hypertrophy를 지지합니다. 가능하면 end-diastole의 subcostal view에서 측정합니다.	Mukherjee 2025, Table 1 and measurement section.
   TAPSE	> 1.7 cm	≤ 1.7 cm이면 비정상이며, 중증 감소는 대개 ≤ 1.0 cm입니다. TAPSE는 angle 및 load dependent입니다.	Mukherjee 2025, Table 1.
   RV S′	> 9.5 cm/s	≤ 9.5 cm/s이면 비정상입니다. Longitudinal basal motion을 반영하므로 심장수술 후에는 오해될 수 있습니다.	Mukherjee 2025, Table 1.
   RV FAC	> 35%	≤ 35%이면 비정상이며, 중증 감소는 대개 ≤ 22%입니다.	Mukherjee 2025, Table 1.
   3D RVEF	> 45%	≤ 45%이면 비정상입니다. 영상 품질과 software가 허용되면 3D RVEF가 선호됩니다.	Mukherjee 2025, Table 1.
   RV free-wall strain	절대값 > 20%	절대값 ≤ 20%이면 비정상입니다. 중증 감소는 대개 절대값 < 11%입니다.	Mukherjee 2025, Table 1.
   RA area	< 19 cm2	경도 19–22, 중등도 > 22–24, 중증 > 24 cm2.	Mukherjee 2025, Table 1.
   Single-plane disk method 기준 RA volume index	< 30 mL/m2	경도 30–36, 중등도 > 36–41, 중증 > 41 mL/m2.	Mukherjee 2025, Table 1.

IV. 이완기능과 충만압

1. LVEF 정상 환자에서의 고전적 2016 ASE/EACVI 알고리즘

   Source anchor: Nagueh 2016, Key Points section and Figure 8A. 단순하고 교육적으로 널리 쓰이기 때문에 시험 대비에서 매우 중요합니다.

   변수	양성 기준	의미	근접 source anchor
   Septal e′	< 7 cm/s	승모판륜 이완 속도 감소입니다.	Nagueh 2016, Figure 8A.
   Lateral e′	< 10 cm/s	승모판륜 이완 속도 감소입니다.	Nagueh 2016, Figure 8A.
   Average E/e′	> 14	특히 LA enlargement 및 TR velocity 상승과 함께 있으면 LV filling pressure 상승을 시사합니다.	Nagueh 2016, Figure 8A.
   TR peak velocity	> 2.8 m/s	다른 원인을 제외한 후, 좌심장 충만압 상승에 따른 폐동맥압 상승 맥락을 지지합니다.	Nagueh 2016, Figure 8A.
   LA volume index	> 34 mL/m2	다른 LA enlargement 원인이 없다면 만성 충만압 상승을 반영합니다.	Nagueh 2016, Figure 8A; Lang 2015, Table 4.

   양성 변수 수	2016 해석	시험 포인트	근접 source anchor
   절반 초과 양성	Diastolic dysfunction이 있습니다.	4개 변수 중 3개 또는 4개 양성이면 diastolic dysfunction을 지지합니다.	Nagueh 2016, Figure 8A.
   절반 미만 양성	Diastolic function은 정상입니다.	4개 변수 중 0개 또는 1개 양성이면 정상 diastolic function을 지지합니다.	Nagueh 2016, Figure 8A.
   정확히 절반 양성	Indeterminate입니다.	4개 변수 중 2개 양성이면 판정 보류입니다.	Nagueh 2016, Figure 8A.

2. 심근질환 또는 LVEF 감소가 있을 때의 고전적 2016 등급화

   Source anchor: Nagueh 2016, Figure 8B and Key Points section. 이 알고리즘은 승모판 유입 혈류에서 시작하고, 중간 패턴은 E/e′, TR velocity, LAVI로 판정합니다.

   승모판 유입 혈류	다음 단계	등급 및 충만압	근접 source anchor
   E/A ≤ 0.8 그리고 E velocity ≤ 50 cm/s	임상 상황과 맞으면 추가 변수 없이 판단 가능합니다.	Grade I diastolic dysfunction; LA pressure 정상 또는 낮음.	Nagueh 2016, Figure 8B.
   E/A ≥ 2.0	임상 상황과 맞으면 추가 변수 없이 판단 가능합니다.	Grade III diastolic dysfunction; LA pressure 상승.	Nagueh 2016, Figure 8B.
   E/A ≤ 0.8이지만 E velocity > 50 cm/s, 또는 E/A > 0.8에서 < 2.0	Average E/e′ > 14, TR velocity > 2.8 m/s, LAVI > 34 mL/m2를 사용합니다.	두 개 이상 양성이면 LA pressure 상승 및 Grade II. 두 개 이상 음성이면 Grade I. 불일치하면 indeterminate입니다.	Nagueh 2016, Figure 8B.

3. 알아두면 좋은 2025 업데이트 포인트

   Source anchor: Nagueh 2025, Figure 2, Figure 3, Table 6, and Table 7. 2025 update에서는 age-adjusted e′, left atrial reservoir strain, pulmonary pressure marker, special-population logic이 더 구조화되었습니다.

   업데이트 항목	기준 또는 역치	실제 의미	근접 source anchor
   연령 보정 reduced e′	대략적 이상 기준: 20–39세 septal < 7, lateral < 10, average < 9 cm/s; 40–65세 septal < 6, lateral < 8, average < 7 cm/s; > 65세 septal < 6, lateral < 7, average < 6.5 cm/s.	고령에서는 e′가 정상적으로 낮아질 수 있으므로 연령 맥락이 중요합니다.	Nagueh 2025, Table 6.
   Left atrial reservoir strain	LARS ≤ 18%	LA strain이 기술적으로 신뢰 가능하고 atrial rhythm 해석이 가능할 때, 만성 LV filling pressure 상승을 지지합니다.	Nagueh 2025, Figure 2 and Figure 3.
   Mean LAP at rest	Reduced e′, increased E/e′, TR velocity ≥ 2.8 m/s 또는 PASP ≥ 35 mmHg, LAVI > 34 mL/m2, LARS ≤ 18%, short IVRT, pulmonary venous indices를 통합합니다.	업데이트 접근은 단일 Doppler 값보다 여러 marker의 일치를 강조합니다.	Nagueh 2025, Figure 3.

4. 이완기 스트레스 심초음파

   Source anchor: Nagueh 2016, Section VI on diastolic stress testing; Nagueh 2025, diastolic exercise testing update and Figure 7.

   소견	고전적 기준	해석	근접 source anchor
   운동 중 average E/e′	> 14	운동 유발 LV filling pressure 상승을 지지합니다.	Nagueh 2016, Section VI.
   운동 중 septal E/e′	> 15	Septal annular velocity만 이용 가능할 때 사용됩니다.	Nagueh 2016, Section VI.
   운동 중 TR velocity	고전적 2016 알고리즘에서는 > 2.8 m/s; 최근 자료에서는 운동 중 ≥ 3.2 m/s가 자주 강조됩니다.	특히 exercise E/e′ 이상과 함께 있으면 비정상 폐동맥압 반응을 지지합니다.	Nagueh 2016, Section VI; Nagueh 2025, Figure 7.
   정상 운동 반응	고전적 교육에서는 exercise E/e′ < 10 및 peak TR velocity < 2.8 m/s.	운동 유발 LV filling pressure 상승 가능성을 낮춥니다.	Nagueh 2016, Section VI.

V. 자연판막 협착

1. 대동맥판 협착

   Source anchor: Baumgartner 2017, AS grading tables, continuity-equation section, low-flow low-gradient AS section, dobutamine stress echo section, and Figure 8.

   중증도	최고 속도	평균 압력차	AVA	Indexed AVA	Dimensionless index	근접 source anchor
   Aortic sclerosis	≤ 2.5 m/s	압력차 기준상 협착 아님	대개 감소하지 않음	해당 없음	해당 없음	Baumgartner 2017, AS severity tables.
   경도 AS	2.6–2.9 m/s	< 20 mmHg	> 1.5 cm2	> 0.85 cm2/m2	> 0.50	Baumgartner 2017, AS severity tables.
   중등도 AS	3.0–4.0 m/s	20–40 mmHg	1.0–1.5 cm2	0.60–0.85 cm2/m2	0.25–0.50	Baumgartner 2017, AS severity tables.
   중증 AS	≥ 4.0 m/s	≥ 40 mmHg	< 1.0 cm2	< 0.60 cm2/m2	< 0.25	Baumgartner 2017, AS severity tables and Figure 8.
   Very severe AS	임상적으로 ≥ 5.0 m/s가 자주 사용됨	임상적으로 ≥ 60 mmHg가 자주 사용됨	대개 현저히 감소	대개 현저히 감소	대개 현저히 감소	Baumgartner 2017, high-gradient severe AS discussion; valve guideline staging frameworks.

   Discordant AS 상황	기준	해석	근접 source anchor
   저유량	Stroke volume index < 35 mL/m2	저유량에서는 실제 중증 판막도 낮은 gradient로 보일 수 있습니다.	Baumgartner 2017, low-flow AS section.
   Classical low-flow low-gradient severe AS	AVA < 1.0 cm2, 평균 압력차 < 40 mmHg, LVEF < 50%, SVI < 35 mL/m2	가능하면 dobutamine stress echo로 true severe AS와 pseudo-severe AS를 감별합니다.	Baumgartner 2017, low-flow low-gradient AS section and Figure 8.
   Paradoxical low-flow low-gradient severe AS	AVA < 1.0 cm2, 평균 압력차 < 40 mmHg, LVEF ≥ 50%, SVI < 35 mL/m2	작고 비후된 LV, impaired filling, preserved EF에도 낮은 forward stroke volume과 관련될 수 있습니다.	Baumgartner 2017, low-flow low-gradient AS section and Figure 8.
   Dobutamine stress echo contractile reserve	Stroke volume 증가 > 20%	Flow reserve가 있으면 dobutamine stress AS 평가 해석 가능성이 좋아집니다.	Baumgartner 2017, dobutamine stress echo section.
   CT calcium으로 중증 AS 지지	대략 남성 ≥ 2,000 AU, 여성 ≥ 1,200 AU에서 severe AS 가능성이 높고, 남성 ≥ 3,000 AU, 여성 ≥ 1,600 AU에서 매우 높습니다.	Echo 기준이 discordant하고 석회화가 주 기전일 때 유용합니다.	Baumgartner 2017, discordant AS and CT calcium section.

2. 승모판 협착

   Source anchor: Baumgartner 2009, mitral stenosis section and mitral stenosis severity tables.

   중증도	승모판 면적	평균 압력차	폐동맥 수축기압	시험 해석	근접 source anchor
   경도 MS	> 1.5 cm2	< 5 mmHg	< 30 mmHg	가능하면 특히 류마티스성 MS에서 planimetry가 선호됩니다.	Baumgartner 2009, MS severity table.
   중등도 MS	1.0–1.5 cm2	5–10 mmHg	30–50 mmHg	Mean gradient는 심박수, 리듬, transmitral flow에 크게 좌우됩니다.	Baumgartner 2009, MS severity table.
   중증 MS	< 1.0 cm2	> 10 mmHg	> 50 mmHg	임상적으로 유의한 MS는 증상 또는 폐동맥압 상승이 있으면 흔히 MVA < 1.5 cm2부터 고려됩니다.	Baumgartner 2009, MS severity table and MS intervention discussion.

   중요한 ASCeXAM 함정: 빈맥 또는 high-output state에서 mean gradient 12 mmHg라고 해서 해부학적 협착이 반드시 severe라는 뜻은 아닙니다. 반대로 저유량에서는 중요한 협착이 있어도 gradient가 낮을 수 있습니다.

3. 삼첨판 및 폐동맥판 협착

   Source anchor: Baumgartner 2009, tricuspid stenosis and pulmonic stenosis sections, including stenosis severity tables.

   판막	핵심 기준	해석상 주의점	근접 source anchor
   유의한 삼첨판 협착	평균 압력차 ≥ 5 mmHg, inflow VTI > 60 cm, pressure half-time ≥ 190 ms, 또는 연속방정식상 판막면적 ≤ 1.0 cm2.	RA enlargement 및 dilated IVC가 중요한 보조 소견입니다. Gradient는 호흡과 심박수에 따라 변합니다.	Baumgartner 2009, tricuspid stenosis section.
   경도 폐동맥판 협착	최고 속도 < 3.0 m/s 또는 최고 압력차 < 36 mmHg.	폐동맥판을 지나는 가장 잘 정렬된 최고 속도를 사용합니다.	Baumgartner 2009, pulmonic stenosis section.
   중등도 폐동맥판 협착	최고 속도 3.0–4.0 m/s 또는 최고 압력차 36–64 mmHg.	RV hypertrophy, RV pressure, post-stenotic PA dilation을 함께 봅니다.	Baumgartner 2009, pulmonic stenosis section.
   중증 폐동맥판 협착	최고 속도 > 4.0 m/s 또는 최고 압력차 > 64 mmHg.	진행된 RV failure로 forward velocity가 낮아진 상황이 아니라면 RV pressure overload가 예상됩니다.	Baumgartner 2009, pulmonic stenosis section.

VI. 자연판막 역류

1. 승모판 역류

   Source anchor: 통합 MR severity는 Zoghbi 2017, Table 8 and Figure 18; PISA, vena contracta, pulmonary venous flow, secondary MR caveat는 Zoghbi 2017, MR mechanism and quantitative assessment sections.

   중증도	Vena contracta width	EROA	역류량	역류분획	보조 소견	근접 source anchor
   경도 MR	< 0.3 cm	< 0.20 cm2	< 30 mL	< 30%	작은 중심성 제트, 약한 CW density, 만성 MR에서 정상 LV 및 LA 크기.	Zoghbi 2017, Table 8.
   중등도 MR, Grade II	중간 범위	0.20–0.29 cm2	30–44 mL	30–39%	중간 범위 color jet만으로는 신뢰도가 낮아 통합 판정이 필요합니다.	Zoghbi 2017, Table 8 and Figure 18.
   중등도 MR, Grade III	중간 범위	0.30–0.39 cm2	45–59 mL	40–49%	특히 crescentic orifice를 가진 secondary MR에서는 임상적으로 중요할 수 있습니다.	Zoghbi 2017, Table 8 and secondary MR discussion.
   중증 MR	≥ 0.7 cm; biplane 기준은 흔히 ≥ 0.8 cm	≥ 0.40 cm2	≥ 60 mL	≥ 50%	Flail leaflet, 큰 coaptation defect, Nyquist 30–40 cm/s에서 PISA radius 약 ≥ 1.0 cm, pulmonary vein systolic reversal, dense triangular CW jet, E-wave dominant mitral inflow > 1.2 m/s, 만성 MR에서 LV/LA 확장.	Zoghbi 2017, Table 8 and Figure 18.

   해석상 주의점: 급성 중증 MR에서는 LA와 LV가 아직 확장되지 않았을 수 있습니다. Secondary MR에서는 regurgitant orifice가 동적이고 초승달형인 경우가 많아 2D PISA-derived EROA가 중증도를 과소평가할 수 있습니다.

2. 대동맥판 역류

   Source anchor: AR severity는 Zoghbi 2017, Table 11 and Figure 25; pressure half-time 및 holodiastolic flow reversal의 한계는 Zoghbi 2017, AR Doppler section.

   중증도	Jet width/LVOT width	Vena contracta width	Pressure half-time	EROA	역류량 및 역류분획	근접 source anchor
   경도 AR	< 25%	< 0.3 cm	> 500 ms	< 0.10 cm2	RVol < 30 mL; RF < 30%.	Zoghbi 2017, Table 11.
   중등도 AR	25–64%	0.3–0.6 cm	200–500 ms	0.10–0.29 cm2	RVol 30–59 mL; RF 30–49%.	Zoghbi 2017, Table 11 and Figure 25.
   중증 AR	≥ 65%	> 0.6 cm	< 200 ms	≥ 0.30 cm2	RVol ≥ 60 mL; RF ≥ 50%.	Zoghbi 2017, Table 11 and Figure 25.

   • 중증에 특이적인 소견: descending thoracic aorta에서 prominent holodiastolic flow reversal.
   • 만성 중증 AR의 반응: LV dilation, 초기 hyperdynamic systolic function, 이후 systolic dysfunction.
   • 급성 중증 AR caveat: LV가 정상 크기일 수 있고 pressure half-time은 load-dependent입니다.

3. 삼첨판 역류

   Source anchor: TR severity는 Zoghbi 2017, Table 14 and Figure 31; 동반 우심장 소견은 Mukherjee 2025, right-heart chamber and pulmonary pressure sections.

   중증도	Vena contracta width	EROA	역류량	보조 소견	근접 source anchor
   경도 TR	< 0.3 cm	< 0.20 cm2	< 30 mL	작은 중심성 제트 및 대개 정상 우심방·우심실 크기.	Zoghbi 2017, Table 14.
   중등도 TR	0.3–0.69 cm	0.20–0.39 cm2	30–44 mL	중간 범위 소견은 RV/RA 크기 및 hepatic vein flow와 통합해야 합니다.	Zoghbi 2017, Table 14 and Figure 31.
   중증 TR	≥ 0.7 cm	≥ 0.40 cm2	≥ 45 mL	Flail leaflet 또는 큰 coaptation gap, triangular dense CW signal, Nyquist 30–40 cm/s에서 PISA radius > 0.9 cm, hepatic vein systolic reversal, RA/RV dilation, plethoric IVC.	Zoghbi 2017, Table 14 and Figure 31.

4. 폐동맥판 역류

   Source anchor: PR severity는 Zoghbi 2017, Table 16 and Figure 35. Jet width, pressure half-time, deceleration time, regurgitant fraction, pulmonary artery flow reversal가 포함됩니다.

   중증도	역류분획	도플러 및 구조적 단서	근접 source anchor
   경도 PR	< 20%	얇은 제트, 정상 RV 크기, 약하거나 불완전한 CW signal.	Zoghbi 2017, Table 16.
   중등도 PR	20–40%	중간 정도의 제트 크기와 Doppler density; RV 크기가 만성 영향을 판단하는 데 도움이 됩니다.	Zoghbi 2017, Table 16 and Figure 35.
   중증 PR	> 40%	넓은 jet origin, jet width/pulmonary annulus 흔히 ≥ 70%, pressure half-time < 100 ms, deceleration time < 260 ms, PR index < 0.77, main 또는 branch pulmonary artery diastolic reversal, 만성 PR에서 RV dilation.	Zoghbi 2017, Table 16 and Figure 35.

VII. 우심장 혈역학과 폐고혈압 가능성

1. IVC를 이용한 우심방압 추정

   Source anchor: IVC 기반 RAP 추정은 Rudski 2010, right-heart guideline section on estimating right atrial pressure; 현대적 right-heart pressure reporting은 Mukherjee 2025, Hemodynamics section and Table 4.

   IVC 직경	흡기 collapse	추정 RAP	실제 해석	근접 source anchor
   ≤ 21 mm	≥ 50%	3 mmHg	정상 우심방압 추정입니다.	Rudski 2010, RAP estimation section.
   ≤ 21 mm	< 50%	8 mmHg	중간 추정값입니다.	Rudski 2010, RAP estimation section.
   > 21 mm	≥ 50%	8 mmHg	중간 추정값입니다.	Rudski 2010, RAP estimation section.
   > 21 mm	< 50%	15 mmHg	상승한 우심방압 추정입니다.	Rudski 2010, RAP estimation section.
   현저한 전신정맥 이상을 동반한 > 25 mm	< 50%	20 mmHg 고려	간정맥 확장, reflux 또는 spontaneous contrast가 있으면 고려합니다.	Rudski 2010, RAP estimation section; Mukherjee 2025, Hemodynamics section.

2. 폐동맥압과 폐고혈압 가능성

   Source anchor: RVSP 및 TR velocity severity bands는 Mukherjee 2025, Table 1; RVSP calculation 및 reporting cautions는 Mukherjee 2025, Hemodynamics section and Table 4.

   항목	기준 또는 중증도 범위	해석	근접 source anchor
   RVSP 또는 PASP	\(4(TRV)^2 + RAP\)	폐동맥판 협착 또는 RV outflow obstruction이 없어야 합니다. 가장 선명하고 dense한 TR envelope를 사용하고 post-extrasystolic beat는 피합니다.	Mukherjee 2025, Table 4 and Hemodynamics section.
   RVSP	정상 ≤ 34 mmHg; 경도 35–49; 중등도 50–69; 중증 ≥ 70 mmHg	RVSP ≥ 35 mmHg는 대체로 비정상입니다. 그러나 echo-estimated pressure는 definitive PH diagnosis가 필요할 때 right-heart catheterization을 대체하지 않습니다.	Mukherjee 2025, Table 1.
   TR peak velocity	정상 < 2.8 m/s; 경도 2.8–3.1; 중등도 3.2–3.5; 중증 ≥ 3.6 m/s	TR velocity는 probability marker이며, 폐고혈압 진단 전체를 대체하지 않습니다.	Mukherjee 2025, Table 1.
   Echo-derived PVR	\(PVR = 10 \times \dfrac{TRV}{RVOT\ VTI} + 0.16\)	PVR > 2 Wood units이면 비정상이지만, 심초음파 PVR은 definitive value보다 supportive marker입니다.	Mukherjee 2025, Hemodynamics section.
   폐고혈압 보조 소견	RV enlargement, septal flattening/eccentricity index abnormality, 짧은 RVOT acceleration time, RA enlargement, PA dilation, abnormal IVC.	Resting TRV ≥ 2.9 m/s, 또는 TRV ≥ 2.8 m/s와 두 개 이상의 supportive echo signs가 있으면 PH 가능성이 증가합니다.	Mukherjee 2025, PH probability and right-heart hemodynamics sections.

VIII. 보철판막

1. 대동맥 보철판막 협착

   Source anchor: Zoghbi 2024, Table 5 and Figure 13. 시험상 핵심은 velocity와 gradient 같은 flow-dependent finding을 DVI, acceleration time, EOA 같은 상대적으로 less flow-dependent finding과 함께 보는 것입니다.

   소견	정상	협착 가능	유의한 협착	근접 source anchor
   Doppler contour	Triangular, early peaking	중간 양상	Rounded, symmetric, delayed peaking	Zoghbi 2024, Table 5 and Figure 13.
   Acceleration time	< 80 ms	80–100 ms	> 100 ms	Zoghbi 2024, Table 5.
   Acceleration time/ejection time	< 0.32	0.32–0.37	> 0.37	Zoghbi 2024, Table 5.
   최고 속도	< 3.0 m/s	3.0–4.0 m/s	≥ 4.0 m/s	Zoghbi 2024, Table 5.
   평균 압력차, surgical AVR	< 20 mmHg	20–34 mmHg	≥ 35 mmHg	Zoghbi 2024, Table 5.
   DVI	> 0.35	0.25–0.35	< 0.25	Zoghbi 2024, Table 5.
   유효구면적	판막 종류와 크기에 따른 reference에 근접	Reference보다 약 1 SD 작음	Reference보다 약 2 SD 작음	Zoghbi 2024, Table 5.

2. 승모 보철판막 협착

   Source anchor: Prosthetic mitral parameters는 Zoghbi 2024, Table 10; prosthetic mitral stenosis를 시사하는 Doppler finding은 Zoghbi 2024, Table 11.

   소견	정상	협착 가능	유의한 협착	근접 source anchor
   최고 속도	< 1.9 m/s	1.9–2.5 m/s	≥ 2.5 m/s	Zoghbi 2024, Table 11.
   평균 압력차	≤ 5 mmHg	6–10 mmHg	> 10 mmHg	Zoghbi 2024, Table 11.
   VTIprosthetic mitral/VTILVOT	< 2.2	2.2–2.5	> 2.5	Zoghbi 2024, Table 11.
   유효구면적	≥ 2.0 cm2	1.0–2.0 cm2	< 1.0 cm2	Zoghbi 2024, Table 11.
   Pressure half-time	< 130 ms	130–200 ms	> 200 ms	Zoghbi 2024, Table 11.

3. Prosthesis-patient mismatch 및 structural valve deterioration

   Source anchor: Prosthesis-patient mismatch는 Zoghbi 2024, Table 7; serial hemodynamic deterioration은 Zoghbi 2024, structural valve deterioration table.

   판막 위치	BMI	없음 또는 경도 PPM	중등도 PPM	중증 PPM	근접 source anchor
   대동맥 보철판막 indexed EOA	< 30 kg/m2	> 0.85 cm2/m2	0.66–0.85 cm2/m2	≤ 0.65 cm2/m2	Zoghbi 2024, Table 7.
   대동맥 보철판막 indexed EOA	≥ 30 kg/m2	> 0.70 cm2/m2	0.56–0.70 cm2/m2	≤ 0.55 cm2/m2	Zoghbi 2024, Table 7.
   승모 보철판막 indexed EOA	< 30 kg/m2	> 1.20 cm2/m2	0.91–1.20 cm2/m2	≤ 0.90 cm2/m2	Zoghbi 2024, Table 7.
   승모 보철판막 indexed EOA	≥ 30 kg/m2	> 1.00 cm2/m2	0.76–1.00 cm2/m2	≤ 0.75 cm2/m2	Zoghbi 2024, Table 7.

   Serial finding	Possible hemodynamic structural valve deterioration	Significant hemodynamic structural valve deterioration	근접 source anchor
   Mean gradient 상승과 EOA 또는 DVI 악화	Mean gradient가 ≥ 10 mmHg 증가하여 mean gradient ≥ 20 mmHg가 되고, EOA가 ≥ 0.3 cm2 또는 ≥ 25% 감소하거나 DVI가 ≥ 0.1 또는 ≥ 20% 감소.	Mean gradient가 ≥ 20 mmHg 증가하여 mean gradient ≥ 30 mmHg가 되고, EOA가 ≥ 0.6 cm2 또는 ≥ 50% 감소하거나 DVI가 ≥ 0.2 또는 ≥ 40% 감소.	Zoghbi 2024, structural valve deterioration table.
   새로운 또는 악화된 intraprosthetic regurgitation	형태학 및 serial change와 맞으면 새로운 또는 증가한 intraprosthetic regurgitation이 structural valve deterioration을 지지할 수 있습니다.	구조적 이상과 함께 현저한 intraprosthetic regurgitation 악화가 있으면 significant deterioration을 시사합니다.	Zoghbi 2024, structural valve deterioration table.

IX. 심낭질환과 비후성 심근병증

1. 심장눌림증

   Source anchor: Klein 2013, cardiac tamponade section and Doppler respiratory variation discussion.

   심초음파 소견	고빈도 기준	의미 및 caveat	근접 source anchor
   우심방 collapse	심주기의 1/3 이상 지속되는 collapse는 매우 시사적입니다.	민감하지만 완전히 특이적이지는 않습니다. 임상적 tamponade physiology와 맞아야 합니다.	Klein 2013, tamponade section.
   우심실 collapse	초기 이완기 RV free-wall collapse.	적절한 상황에서는 짧은 RA collapse보다 특이도가 높습니다.	Klein 2013, tamponade section.
   IVC plethora	확장된 IVC와 감소한 흡기 collapse.	흔한 소견이지만 저혈량 또는 초기 regional tamponade에서는 없을 수 있습니다.	Klein 2013, tamponade section.
   승모판 유입 혈류 호흡성 변화	흡기 시 E velocity 감소가 대개 > 25–30%.	양압환기, 중증 폐질환, 부정맥에서는 주의가 필요합니다.	Klein 2013, Doppler respiratory variation discussion.
   삼첨판 유입 혈류 호흡성 변화	흡기 시 E velocity 증가가 대개 > 40%.	Exaggerated ventricular interdependence를 반영합니다.	Klein 2013, Doppler respiratory variation discussion.
   간정맥 도플러	뚜렷한 expiratory diastolic flow reversal이 tamponade physiology를 지지할 수 있습니다.	리듬, 호흡, 우심장 압력과 함께 해석합니다.	Klein 2013, tamponade section.

2. 협착성 심낭염과 제한성 심근병증 감별

   Source anchor: Klein 2013, constrictive pericarditis section; annular velocity 및 hepatic vein Doppler의 현대적 통합은 Nagueh 2025, constriction and special-population diastolic sections.

   소견	협착성 심낭염	제한성 심근병증	근접 source anchor
   Septal motion	Respiratory septal shift 또는 septal bounce.	대개 없거나 덜 뚜렷합니다.	Klein 2013, constriction section.
   승모판 유입 혈류 변화	> 25% respiratory variation.	대개 respiratory variation이 작습니다.	Klein 2013, constriction Doppler section.
   삼첨판 유입 혈류 변화	> 40% respiratory variation.	대개 respiratory variation이 작습니다.	Klein 2013, constriction Doppler section.
   Medial e′	보존 또는 증가, 흔히 > 7–8 cm/s.	감소, 흔히 < 6 cm/s.	Klein 2013, annular velocity discussion; Nagueh 2025, constriction section.
   Annulus reversus	Medial e′ > lateral e′.	대개 없습니다.	Klein 2013, constriction section.
   간정맥 도플러	Expiratory diastolic reversal ratio 약 ≥ 0.8이면 constriction을 지지합니다.	덜 전형적이며, 높은 RA pressure로 인해 blunted pattern이 보일 수 있습니다.	Klein 2013, constriction hepatic vein Doppler section.

3. 비후성 심근병증

   Source anchor: Ommen 2024, HCM diagnostic criteria and obstructive HCM management sections; morphology 및 Doppler characterization은 major HCM imaging documents.

   기준	역치	임상적 의미	근접 source anchor
   성인 HCM wall thickness	고혈압 또는 AS 같은 부하 조건으로 설명되지 않는 maximal LV wall thickness ≥ 15 mm	성인 진단 기준입니다.	Ommen 2024, diagnostic criteria section.
   경계성 wall thickness	13–14 mm	가족력, genotype, ECG, morphology, 기타 phenotype marker가 있으면 HCM을 지지할 수 있습니다.	Ommen 2024, diagnostic criteria section.
   LVOT obstruction	안정 시 또는 유발 시 peak instantaneous gradient ≥ 30 mmHg	Obstructive physiology를 정의합니다.	Ommen 2024, obstructive HCM section.
   치료 결정에 중요한 LVOT gradient	난치성 증상이 있을 때 ≥ 50 mmHg	적절한 후보에서 septal reduction therapy를 고려하는 흔한 기준입니다.	Ommen 2024, septal reduction therapy section.
   Massive LVH risk marker	≥ 30 mm	Sudden cardiac death risk marker로 중요합니다.	Ommen 2024, sudden cardiac death risk marker section.
   Doppler clue	Late-peaking, dagger-shaped CW Doppler profile	MR contamination과 감별해야 합니다. MR jet은 대개 더 빠르고 holosystolic에 가까우며 LA 방향입니다.	HCM imaging guidance and obstructive HCM Doppler sections.

X. 스트레스 심초음파, 허혈, 단락, 대동맥

1. 스트레스 심초음파 벽운동 점수

   Source anchor: Pellikka 2020, Grading of Regional Function section, Figure 9, Table 3, and Table 4. 핵심은 wall-motion scoring이 endocardial inward motion과 systolic wall thickening을 함께 보고 매긴다는 점입니다. Passive translation 또는 tethering을 active contraction으로 오해하지 않아야 합니다.

   점수	명칭	보여야 하는 소견	점수 부여 방법	흔한 시험 함정	근접 source anchor
   1	Normal 또는 hyperkinetic	분명한 systolic inward endocardial motion과 눈에 보이는 systolic wall thickening이 있습니다. Stress 시 정상 segment는 대개 더 hyperdynamic해지고 LV cavity가 작아집니다.	Thickening이 정상 또는 증가하면 score 1입니다. ASE stress guideline에서는 정상 systolic thickening을 대체로 > 50%로 설명합니다.	심장 전체가 움직이는 translation만 보고 이상이라고 판단하지 않습니다. Thickening과 endocardial motion을 인접 segment와 비교합니다.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   2	Hypokinetic	감소했지만 남아 있는 systolic inward motion과 감소한 wall thickening이 있습니다.	수축은 존재하지만 명확히 감소했을 때 score 2입니다. ASE stress guideline에서는 hypokinesis를 systolic thickening 대체로 < 40%로 설명합니다.	Foreshortening은 apex를 거짓으로 비정상처럼 보이게 할 수 있습니다. True apex를 확인하고 여러 view에서 비교합니다.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   3	Severely hypokinetic 또는 akinetic	Systolic wall thickening이 거의 없거나 없습니다. 진정한 akinesis에서는 의미 있는 active inward systolic endocardial excursion이 없습니다. 다만 인접 segment에 끌리거나 심장 전체가 움직여서 segment가 수동적으로 움직이는 것처럼 보일 수 있습니다.	Systolic thickening이 없거나 거의 없으면 score 3입니다. ASE stress guideline에서는 severe hypokinesis 또는 akinesis를 systolic thickening 대체로 < 10%로 설명합니다.	Passive motion을 contraction으로 점수화하지 않습니다. Scarred akinetic segment는 주변 정상 segment에 의해 안쪽으로 끌려갈 수 있지만 두꺼워지지 않습니다.	Pellikka 2020, Grading of Regional Function section and Figure 9.
   4	Dyskinetic	수축기 때 LV cavity 중심에서 멀어지는 paradoxical outward motion이 있습니다.	Segment가 수축기에 안쪽이 아니라 바깥쪽으로 움직이면 score 4입니다.	Stress 중 akinetic segment가 dyskinetic해지는 것은 infarcted segment의 기계적 반응일 수 있으며, 자동으로 inducible ischemia와 동일하지 않습니다.	Pellikka 2020, Grading of Regional Function section and Table 3.
   5	Aneurysmal	Diastolic deformation 또는 outpouching이 있으며, 흔히 얇은 scarred myocardium과 abnormal systolic motion이 동반됩니다.	단순 akinesis가 아니라 aneurysmal deformation이 있으면 score 5입니다.	Aneurysmal segment는 WMSI 평균값에만 넣고 끝내지 말고, 해부학적 위치와 임상적 의미를 보고해야 합니다.	Pellikka 2020, Grading of Regional Function section and reporting Table 4.

   \(WMSI = \dfrac{sum\ of\ segment\ scores}{number\ of\ scored\ segments}\). Stress echo wall-motion analysis에서는 16-segment model이 흔히 사용됩니다. Perfusion imaging 또는 CMR과 비교할 때는 17-segment model이 사용될 수 있습니다.

   Stress response pattern	정의	해석	근접 source anchor
   Normal response	Rest와 stress에서 global 및 regional wall motion이 정상입니다. Stress 시 LV end-systolic cavity가 작아지고 수축이 더 강해집니다.	달성한 workload와 heart rate에서 inducible ischemia의 echo 증거가 없습니다.	Pellikka 2020, Table 3.
   Ischemic response	Stress 중 새로운 wall-motion abnormality가 생기거나 기존 resting wall-motion abnormality가 악화됩니다.	해당 coronary territory의 inducible ischemia를 시사합니다.	Pellikka 2020, Table 3 and reporting Table 4.
   Fixed abnormality	중증 resting wall-motion abnormality가 stress에서 의미 있게 좋아지거나 나빠지지 않습니다.	임상 맥락에 따라 infarcted 또는 nonviable scar를 시사합니다.	Pellikka 2020, Table 3.
   Viability 또는 contractile reserve	Resting hypokinetic 또는 akinetic segment가 low-dose dobutamine에서 호전됩니다.	Viable myocardium을 시사합니다.	Pellikka 2020, dobutamine stress and viability discussion.
   Biphasic response	Low-dose dobutamine에서 호전된 뒤 high dose에서 다시 악화됩니다.	유의한 협착 혈관이 공급하는 viable but jeopardized myocardium을 시사합니다.	Pellikka 2020, dobutamine stress and viability discussion.
   High-risk stress echo features	광범위한 inducible abnormality, 낮은 workload 또는 낮은 heart rate에서 ischemia 발생, stress-induced LV dilation, EF 감소, multivessel-territory involvement.	더 높은 ischemic burden을 지지합니다.	Pellikka 2020, interpretation and reporting sections.

2. 단락 및 대동맥 측정 단서

   Source anchor: 성인 TTE 대동맥 측정 관례는 Lang 2015, aortic measurement section; agitated saline timing은 ASE contrast and shunt guidance; Qp/Qs 해석은 contemporary valve and congenital frameworks.

   주제	고빈도 기준	해석상 주의점	근접 source anchor
   Qp/Qs	\(Qp/Qs = \dfrac{pulmonary\ flow}{systemic\ flow}\)	폐혈관저항이 허용 범위라면 Qp/Qs ≥ 1.5는 흔히 혈역학적으로 유의한 단락으로 간주됩니다.	Adult congenital and shunt quantification guidance; continuity-flow method sections.
   Agitated saline study	좌심장 기포가 대략 3 cardiac cycles 이내 나타나면 intracardiac shunt, 더 늦게 나타나면 intrapulmonary shunt를 시사합니다.	Timing은 shunt size, Valsalva quality, injection site, cardiac output, pulmonary transit time에 따라 달라집니다.	ASE contrast and shunt imaging guidance.
   Aortic root measurement	성인 TTE에서는 sinus of Valsalva와 ascending aorta를 흔히 end-diastole에 leading-edge to leading-edge로 측정합니다.	Aortic annulus는 대개 mid-systole에 inner-edge to inner-edge로 측정합니다.	Lang 2015, aortic measurement section.
   Ascending aorta dilation	성인에서 ≥ 4.0 cm는 흔히 dilated로 간주됩니다.	임상 threshold는 체격, 성별, 원인, 성장 속도, bicuspid aortic valve, genetic syndrome에 따라 달라집니다.	Contemporary aortic disease guideline measurement and intervention sections.

XI. 이해를 돕는 차트

아래 차트는 자주 암기되는 대표 threshold만 시각적으로 압축한 것입니다. Multiparametric interpretation을 대체하지 않습니다.

XII. Reference map

Written on July 8, 2026

Echocardiography Study Notes for Quick Reminder

This quick reference guide provides a synthesized overview of key echocardiography concepts, focusing on the relationship between echocardiographic findings and underlying pathophysiological mechanisms. Designed to aid in the comprehensive assessment and management of cardiovascular conditions, it highlights how specific echocardiographic results correlate with various cardiac pathologies. Drawn from my personal study notes, this summary serves as a helpful reminder of essential materials, though I cannot guarantee the absolute accuracy of these notes.

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(A) Right Ventricle

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(B) Right Atrium

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(C) Diastolic Dysfunction and Left Atrium

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(E) Surgical Indications

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(F) Other Diseases