Table 3.

Echocardiographic parameters characterizing patients with heart failure (HF) symptoms and normal or preserved left ventricular ejection fraction (LVEF) in left atrial (LA) phenotype

Echocardiographic parameter	Normal ranges—cut offs	Methodological aspects	Mandatory to determine (methods)	Why worth to do in routine
LA parameters and parameters of diastolic function
LAD—left atruial diameter (mm)	♂ 31–39 Cut off < 39 ♀ 28–37 Cut off < 37 [85]	“Old” parameter, which can only be used in normal LA geometry	No—only if LA dimensions are documented as normal	To document LA dimension—if LA geometry is normal
LAD/BSA (mm/m2)	♂ 13–23 Cut off < 23 ♀ 14–24 Cut off < 24 [85]	“Old” parameter, which can only be used in normal LA geometry	No—only if LA dimensions are documented as normal	To document LA dimension—if LA geometry is normal
LAVImax—maximum LA volume indexed to BSA (ml/m2)	♂ 18–35 Cut off < 39 ♀ 18–36 Cut off < 38 (Cut off < 34) [84, 85, 112]	Avoid foreshortening, prefer triplane analysis or 3D volumetry. Increased LA volume predicts increased LV filling pressure	Yes	To document chronic diseases due to impaired LV filling
LAVImin—minimum LA volume indexed to BSA (ml/m2)	♂ 8–18 Cut off < 18 ♀ 18–18 Cut off < 18 [6]	Avoid foreshortening, prefer triplane analysis or 3D volumetry. Increased LAVImin predicts impaired active LA contractility	Yes—under certain conditions	To document impact on active LA contraction on global LA function
Total LA emptying fraction (LAEF) (%)	51–61 Cut off > 38 [112]	Avoid foreshortening, prefer triplane analysis or 3D volumetry. Reduced LA emptying fraction indicates LA dysfunction	Yes-—under certain conditions	To characterize LA function
Average LA reservoir strain—reservoir LAS (%): LA reservoir function	31–42 Cut off > 23 [89]	LA strain analysis is only possible if image quality is adequate. 4ChV is usually used for LA strain analysis	Yes—especially in normal or LV phenotype—helpful to detect subclinical states of cardiac diseases	To characterize global LA function
Passive LA conduit strain—passive LAS (%): LA conduit function	15–23 Cut off > 11 [89]	LA strain analysis is only possible if image quality is adequate. 4ChV is usually used for LA strain analysis	Yes—especially in normal or LV phenotype—helpful to detect subclinical states of cardiac diseases	To characterize passive LA filling properties
Active LAS contraction strain—active LAS (%): LA contraction function	14–21 Cut off > 8 [89]	LA strain analysis is only possible if image quality is adequate. 4ChV is usually used for LA strain analysis	Yes—especially in normal or LV phenotype—helpful to detect subclinical states of cardiac diseases	To characterize active LA contractility
LA stiffness—E/E´ devided by LAEF (%−1)	0.13–0.17 Cut off < 0.27 [89]	Standardize the Doppler assessment with respect to breathing to ensure comparability in follow-ups	No—especially in normal or LV phenotype—helpful in suspected infiltrative/storage diseases	To detect causes of LA stiffness by conventional parameters
LA stiffness—E/E´ devided by LAS (%−1)	0.18–0.29 Cut off < 0.55 [89]	Standardize the Doppler assessment with respect to breathing to ensure comparability in follow-ups	No—especially in normal or LV phenotype—helpful in suspected infiltrative/storage diseases	To detect causes of LA stiffness using speckle tracking
E-peak E-wave velocity (cm/sec)	♂ 42–116 Cut off > 42 ♀ 43–115 Cut off > 43 [110]	Acquire the pw Doppler spectra using Duplex mode to control correct positioning of the sample volume at the level of mitral valve (MV) coaptation	Yes—to differentiate between normal, abnormal relaxation, pseudo-normal, and restrictive	E reflects LA-LV gradient during early diastole
Peak A-wave velocity (cm/sec)	♂ 25–93 Cut off > 25 ♀ 29–93 Cut off > 29 [110]	Acquire the pw Doppler spectra using Duplex mode to control correct positioning of the sample volume	Yes—to differentiate between normal, abnormal relaxation, pseudo-normal, and restrictive	A reflects LA-LV gradient during late diastole
Transmitral A-duration (msec)	100–176 Cut off > 100 [102, 103]	Acquire an additional pw Doppler spectrum of blood LV inflow at the level of mitral anulus (MA). Time speed must be100mm/sec to ensure sufficient temporal resolution	Yes—especially in normal or LV phenotype	To be able to compare forward and retrograde LA blood flow during LA contraction
Transmitral E/A ratio	♂ 0.62–2.34 cut off > 0.62 ♀ 0.32–2.44 cut off > 0.32 [110]	Acquire the pw Doppler spectrum with sharp contours (possibly highest Doppler frequencies) with a sample volume in the central blood stream of LV inflow	Yes—- to differentiate between normal, abnormal relaxation, pseudo-normal, and restrictive	To distinguish between impaired LV relaxation, pseudonormal conditions, and LV restriction
Edt—E-wave deceleration time (msec)	♂ 78–302 cut off > 78 ♀ 99–275 cut off > 99 [110]	Acquire the pw Doppler spectrum with sharp contours (possibly highest Doppler frequencies) with a sample volume in the central blood stream of LV inflow	Yes- especially in normal or LV phenotype	To detect impaired LV relaxation and LV stiffness
IVRT—isovolumetric relaxation time (msec)	73–101 cut off ≤ 70 [102, 103]	Acquire an additional pw Doppler spectrum with the sample volume positioned at the anterior mitral leaflet. IVRT estimates relaxation (τ)	Yes—especially in normal or LV phenotype	Prolonged in impaires relaxation; shortened if LAP increases
L-wave (transmitral velocity spectrum and tissue doppler spectra)	Qualitative sign of diastolic dysfunction [102, 103]	The L-wave is documented in the transmitral pw Doppler spectrum and in the LV tissue Doppler spectra	Yes	If present, indicates increased LVEDP
Peak E´-velocity basal septal (cm(sec)	♂ 6–11 Cut off > 6 ♀ 5–10 Cut off > 5 [110]	Acquire the pw tissue Doppler spectra using Duplex mode to control proper sample volume positioning of. Try to center the LV septum for optimal image quality	Yes	E´ includes LV relaxation, restoring forces and LV filling pressure
Peak E´-velocity basal lateral [cm (sec)]	♂ 5–16 Cut off > 5 ♀ 5–14 Cut off > 5 [110]	Acquire the pw tissue Doppler spectra using Duplex mode to control proper sample volume positioning. Try to center the later LV segment for optimal image quality	Yes	E´ includes LV relaxation, restoring forces and LV filling pressure
Average E/E´ratio	< 8 normal 8–14 borderline  > 14 pathological [102, 103]	Check the respective positions of the sample volumes and standardize both documentation to comparable breathing periods	Yes	To estimate LVEDP. E/E’reflects normal or pathological relaxation
TE´-E—time interval between E´- and E-onset (msec)	0–8 Cut off > 8 [113]	The estimation is within the limit of detection. Significant differences of time intervals in Doppler spectra can be detected by intervals > 20 ms	Optional—it can be used as a qualitative sign of diastolic dysfunction	TE´-E can distinguish between restriction (prolonged) and constriction (normal)
IVRT/TE´-E ratio	> 2 [113]	The estimation should only be performed if TE´-E is > 20	Optional—but helpful to detect increased LVEDP	If ratio is < 2, PCWP and LAP are increased
ArD—retrograde pulmonary vein Ar-duration (msec)	53–173 Cut off Ar < A [102, 103]	Acquire pw Doppler spectrum using low pulse repetition frequency (LPRF). Prefer time speed of the spectrum at 100 mm/sec or more to ensure sufficient temporal resolution	Yes—especially in normal or LV phenotype	Prolonged ArD indicates diastolic dysfunction an increased VEDP
Peak Ar velocity (cm/s)	− 11to − 39 Cut off < 35 [102, 103]	Acquire pw Doppler spectrum using LPRF. Try to increase contour sharpness by increasing Doppler frequencies in the range of LPRF	Yes—especially in normal or LV phenotype	Increased Ar velocity indicates increased VEDP
Transmitral A duration–Ar duration	0–20 cut Off < 30 [102, 103]	For optimal documentation of sample volume position at the levels of MV coaptation and MA acquire both spectra using Duplex mode	Yes—especially in normal or LV phenotype	Prolonged A—Ar indicates increased LVEDP
Vp—left ventricular diastolic flow propagation (cm/sec)	Cut off ≥ 50 [102, 103]	Vp correlates with LV relaxation and the invasive parameter (τ. Adjust color Doppler setting and prefer time speed of the spectrum at 100 mm/sec or more	Yes—especially in normal or LV phenotype	Decreased Vp indicates LVEDP increase
E/Vp ratio (sec)	Cut off ≤ 2.5 [102, 103]	Perform Measure E and Vp in transmitral pw spectra and mitral flow color M-modes at standardized comparable breathing intervals	Yes—especially in normal or LV phenotype	E/Vp correlates with LAP and PCWP. Decreased E/Vp indicates increases of LAP and PCWP

For each echocardiographic parameter the normal ranges (and cut offs), methodological aspects, the importance of its determination, and the value to determine it in routine are listed. Mandatory parameters to be determined in clinical practice are labeled in bold print

LAD left atrial diameter, BSA body surface area, LAVI_max maximum LA volume indexed to BSA, LA left atrial, LAVI_min minimum LA volume indexed to BSA, LAEF total LA emptying fraction, LAS left atrial strain, E maximum early mitral flow velocity, E´ maximum early tissue Doppler lengthening velocity of the myocardium near to the mitral anulus, A maximum forward transmitral atrial flow velocity, Edt E-wave deceleration time, IVRT isovolumetric relaxation time, L flow velocity peak of transmitral flow during diastasis, T_E´-E Time interval between E´ and E-onset, ArD retrograde pulmonary vein flow duration, Vp left ventricular diastolic flow propagation