Ref 1

1. Ages 6-23 y/o 2. Significant LVM differences by gender – 3. For males 95th percentiles:

a. LVM/BSA = 103 b. LVM/height = 100

4. For females 95th percentiles: a. LVM/BSA = 84 b. LVM/height = 81

Ref 2

1. Ages 6-17 y/o 2. Significant LVM differences by gender – males avg 99 g, females avg 80 g 3. Across races and genders - Indexing by LV mass /height **3 provided the best correlation with

LV mass/lean body mass compared to indexing with a. BSA b. Height c. Height **2 d. Height ** 2.7

4. For entire group (all races and genders) 95th percentiles: a. LVM/BSA = 89 b. LVM/height = 85 c. LVM/height **2 = 52 d. LVM/height **2.7 =39 e. LVM/height**3 = 34

Ref 3

1. The method of correcting LVM for body size and the criteria used to define LVH have varied between studies

2. Because of the rise in the prevalence of obesity, indexing of LVM to weight or body surface area may allow an increased LVM to be interpreted erroneously as normal. Height2.7 (in meters) has been validated as an indicator of lean body mass and has been recommended for indexing LVM. Use of height2.7 to index LVM also minimizes the effect of age, gender, and race.10,11

3. LVH by adult criteria was defined as LVMI > 51 g/m2.7 and by pediatric criteria as LVMI > 38.6 g/m2.7.

Ref 4

See graph

Ref 5

Adult values See Table

1. Women LVM/BSA < 95 2. Men LVM/BSA < 115

Ref 6

ASE Peds Quantification paper – Not much help.

Ref 7 (agrees with Ref 3)

1. 241 adults and 444 infants to young adults 2. Normalizations of left ventricular mass for height or body surface area introduce artifactual

relations of indexed ventricular mass to body size and errors in estimating the impact of overweight. These problems are avoided and variability among normal subjects is reduced by using left ventricular mass/height**2.7

Ref 8

1. Scaling LV mass to BSA in children results in less misclassification with respect to LVH than does scaling to height.

2. Ours is not the first study to conclude that height based LV mass normalization results in overestimation of the prevalence of LVH among the obese.

Ref 9

A number of controversies surround the measurement of LV mass. There are significant problems in standardizing echocardiographic measurement of LV mass across echocardiography laboratories. Historically, one method for overcoming this variability in adults is to index the LV mass to body size, most commonly BSA, height in meters squared, or to the 2.7th power [10]. Dividing LV mass by height to the power of 2.7 accounts for LV mass and scaling myocardial mass to body size. This useful application has been adapted in children to compensate for normal growth [11]. However, this indexing method is also limited in the pediatric population because LVMI2.7 increases with decreasing height [7]. Numerous studies have shown that LVMI2.7 overestimates LV mass in adults [5]. Foster et al. [9] showed that expressing LV mass relative to BSA or height has limitations in the pediatric population because LV mass

varies in proportion to lean body mass; however scaling LV mass to BSA in children appears to be better than scaling to height.

Ref 10

The children and adolescents who have elevated BMI (overweight and obese) with NWC (normal waist circumference) had LVM and LBM similar to normal controls with NWC despite having an elevated BMI and elevated non-LBMI (as an estimation of adipose tissue). Additionally, similar to normal controls, those subjects with elevated BMI and NWC had a stronger correlation between LVM and LBM than subjects with elevated BMI with IWC (increased waist circumference).

Ref 11

LVM scaled by height **2.7

> 9 y/o > 40 in girls and > 45 in boys is abnormal

Under 9 y/o must use curves

References

1. S. Daniels, et al. Echocardiographically Determined Left Ventricular Mass Index in Normal Children, Adolescents, and Young Adults J Am Coll Cardiol 1988;12:703-8

2. S. Daniels, et al. Indexing Left Ventricular Mass to Account for Differences in Body size… Am J Cardiol 1995;76:699-701.

3. Hanevold C, The Effects of Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children: A Collaborative Study of the International Pediatric Hypertension Association. Pediatrics 2004;113:328 –333.

4. Cain PA. et al. Age and gender specific normal values of left ventricular mass, volume and function for gradient echo magnetic resonance imaging: a cross sectional study. BMC Medical Imaging. www.biomedcentral.com/1471-2342/9/2.

5. ASE 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. JASE 2005 Vol 14;12:1440-1463.

6. ASE Recommendations for Quantification Methods During the Performance of a Pediatric Echocardiogram: A Report From the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. JASE 2010;23:465-95.

7. De Simone G, et al. Left Ventricular Mass and Body Size in Normotensive Children and Adults: Assessment of Allometric Relations and Impact of Overweight. J Am Coli CardioI1992;20:1251-60

8. Foster et, al Limitations of expressing LV mass relative to height and to BSA in children. JASE 2013;26:410-8.

9. Mirchandani D, et al. Concordance of measures of left-ventricular hypertrophy in pediatric hypertension Pediatric Cardiology, Pediatr Cardiol. 2014 Apr;35(4):622-6. doi: 10.1007/s00246-013-0829-7. Epub 2013 Nov 20.

10. Am J Cardiol. 2014 Mar 15;113(6):1054-7. doi: 10.1016/j.amjcard.2013.11.068. Epub 2013 Dec 25. Left ventricular mass in children and adolescents with elevated body mass index and normal waist circumference. Mehta SK.

11. Khoury et al JASE 2009;22:709-14 Age specific reference intervals for indexed left ventricular mass in children

Ref 11

Colan, et al. JACC 1984;4:715-24

(J Am Soc Echocardiogr 2007;20:1276-1284.

Figure 7. Centile chart of the quotient of early to atrial filling phase peak flow velocity (E/A Vmax). Numerical values are displayed in the table. The asterisk in the table labels median, P5 and P95 of infants aged 2 to 5 months (n = 42). The dashed line represents P90 in the subpopulation with high heart rates and signal superimposition (EA). Decreasing heart rate (HR↓) influences parameter expression in age groups 2 through 5. P = percentile.

JACC Volume 32, Issue 5, 1 November 1998, Pages 1441-1448

Ggg

Journal of the American College of Cardiology

Volume 32, Issue 5, November 1998

Journal of the American Society of Echocardiography 2016 29, 277-314DO

1. Report Left Atrial Filling Pressures

Depressed EF

E/A below normal (adult < 1)

normal LAP

E/A normal but suspect pseudo normal

E/e’ ≤8

normal LAP

E/e’ ≥15

LAP

E/e’ 9-14

Indeterminate

E/A above normal (adult > 2)

LAP

Intact EF

E/e’ ≤8

normal LAP

E/e’ ≥15

LAP

E/e’ 9-14

LA vol ≥ 34 ml/m2

LAP

LA vol < 34 ml/m2

Normal LAP

2. Grade Diastolic (Dx) Function (Fx)

e’ normal (adult Sept e’ ≥ 8Lat e’ ≥ 10)

LA vol < 34 ml/m2

Normal DxFx

LA vol ≥34 ml/m2

Normal DxFxor Athlete orConstriction

e’ abnorml (adult Sept e’ < 8Lat e’ < 10)

E/e’ ≤8

Grade 1

E/e’ ≥15

Grade 3

E/e’ 9-14

Grade 2

J Am Soc Echocardiogr 2009;22:108-133J Am Soc Echocardiogr 2007;20:1276-1284JACC 1998;32:1441-1448

Journal of the American Society of Echocardiography 2009 22, 715-719DOI: (10.1016/j.echo.2009.03.026ggggggg

Copyright © 2009 American Society of Echocardiography Terms and Conditions Journal of the American Society of Echocardiography 2009 22, 715-719DOI: (10.1016/j.echo.2009.03.026)

Valve Stenosis Normal Mild SevereAortic Stenosis- Mean Gradient < 25 mm Hg > 50 mm Hg- Peak Gradient < 30 mm Hg > 70 mm Hg- Peak velocity < 1.8 m/secVTI Ratio (VTI-LVOT/VTI-AoV) > 1 0.5-1.0 < 0.25 =CSA-LVOT/CSA-AoV ( Pulmonary Stenosis- Mean Gradient < 20 mm Hg > 40 mm Hg- Peak Gradient < 30 mm Hg > 60 mm Hg- velocity < 1.5 m/secPeripheral Pulmonary stenosis <1.5 m/sec >= 2 m/sec, < ? > 60 mm Hg ?Mitral Stenosis- Mean Gradient < 6 mm Hg > 12 mm Hg- Peak velocity < 1.3 m/secTricuspid Stenosis- Mean Gradient < 5 mm Hg > 10 mm Hg- Peak velocity < 1.0 m/secValve Regurgitation Mild SevereAortic regurgitation- decay slope < 2 m/sec-sec > 3 m/sec-sec- pressure half time < 300-400 msSystolic Function Hyperdynamic Mildly Decreased Severely DecreasedLV Fractional Shortening > 45% 20%-25% < 15%LV Ejection Fraction > 75% 45%-54% < 30%RV Ejection Fraction ? 35%-45%? ?Systolic and Diastolic Function Normal Indeterminate AbnormalMitral Valve E/Ea < 8 8-15 > 15RV dP/dT ? ? ?LV dP/dT > 1200 Hg/s 1000-1200 Hg/s < 1000 Hg/sSystolic and Diastolic Function Normal Range Alternative - AbnormalIVRT_corrected 63 +/- 7 msecMPI (Tei Index) LV ?0.35 +/- 0.05? < 0.40MPI (Tei index) RV ?0.32 +/- 0.05?Color M Mode Prop Vel Slope > 50 > 45PHTN Mild PHTN Severe PHTN AlternativeTR Gradient 25-35 mm Hg >65 mm Hg report % of systemic

Z Scores Mildly Abnormal Moderately Abn Severely AbnormalZ Scores (negative) -3.0 < z < -2.0 -5.0 < z < -3.0 z < -5.0Z scores (positive) 2.0 < z < 3.0 3.0 < z < 5.0 z > 5.0

Assessment of Tamponade Physiology, Respiratory Variability Normal OtherMV inflow (peak or VTI) < 25 % any degree of RV diastolic collapse TV inflow (peak or VTI) < 40% prolonged (>1/3 card cycle) RA collapse

Echocardiographic Parameter Severity Guidelines*

* these are simply guidelines. Of course one has to take into account co-existing conditions such as cardiac function, valve regurgitation, heart rate, age, etc. when making such determination of severity