Clinical Investigations
Normal Values of Left Ventricular Mass by Echocardiography
Normal Values of Left Ventricular Mass by Two-Dimensional and Three-Dimensional Echocardiography: Results from the World Alliance Societies of Echocardiography Normal Values Study

https://doi.org/10.1016/j.echo.2022.12.016Get rights and content

Highlights

  • Normal values of LV mass were derived from 1,854 subjects.

  • The upper limits of normal were established for linear, 2D, and 3D techniques.

  • Normal values differ by age, sex, race, and technique used.

Background

Although increased left ventricular (LV) mass is associated with adverse outcomes, measured values vary widely depending on the specific technique used. Moreover, the impact of sex, age, and race on LV mass remains controversial, further limiting the clinical use of this parameter. Accordingly, the authors studied LV mass using a variety of two-dimensional and three-dimensional echocardiographic techniques in a large population of normal subjects encompassing a wide range of ages.

Methods

Transthoracic echocardiograms obtained from 1,854 healthy adult subjects (52% men) enrolled in the World Alliance Societies of Echocardiography (WASE) Normal Values Study, were divided into three age groups (young, 18-35 years; middle aged, 36-55 years; and old, >55 years). LV mass was obtained using five conventional techniques, including linear and two-dimensional methods, as well as direct three-dimensional measurement. All LV mass values were indexed to body surface area, and differences according to sex, age, and race were analyzed for each technique.

Results

LV mass values differed significantly among the five techniques. Three-dimensional measurements were considerably smaller than those obtained using the other techniques and were closer to magnetic resonance imaging normal values reported in the literature. For all techniques, LV mass in men was significantly larger than in women, with and without body surface area indexing. These technique- and sex-related differences were larger than measurement variability. In women, age differences in LV mass were more pronounced and depicted significantly larger values in older age groups for all techniques, except three-dimensional echocardiography, which showed essentially no differences. LV mass was overall larger in black subjects than in white or Asian subjects.

Conclusions

Significant differences in LV mass values exist across echocardiographic techniques, which are therefore not interchangeable. Sex-, race-, and age-related differences underscore the need for separate population specific normal values.

Section snippets

Study Design and Population

The rationale and design of the WASE study have been previously described in detail.7,12 In the WASE study, a “normal” subject was defined as an adult ≥18 years of age without a history or clinical evidence of heart, lung, or kidney disease; no history of hypertension, dyslipidemia, or diabetes; blood pressure < 140/90 mm Hg; body mass index 20 to 30 kg/m2; and mild or less valvular disease.7 Pregnant women, competitive athletes, and subjects with significant renal insufficiency were excluded.7

Results

Of the 2,008 total subjects, 154 subjects were excluded because of image quality that was deemed unsuitable for LV mass analysis. In total, 1,854 subjects were included in the final analysis. LV mass measurements were feasible by the linear method in 1,685 subjects, the truncated ellipsoid method in 1,423 subjects, the area-length method in 1,423 subjects, and volumetric analysis of 3DE data sets in 992 subjects.

Baseline demographic characteristics are listed in Table 1. Both sexes were equally

Discussion

It is well known that LV mass is an important risk factor and a predictor of cardiovascular morbidity and mortality.1,3, 4, 5,17 To the best of our knowledge, this is the first study to define normative values for LV mass in a large, global cohort of healthy adults using linear, 2DE, and 3DE techniques and to determine how sex, age, and race influence these measurements. We found that (1) there were significant and large intertechnique differences in normal reference values, suggesting that

Conclusion

Our results from the WASE Normal Values Study provide normal reference values for all different methods to calculate LV mass, which differ by age, sex, and race. Importantly, we found that there were significant intertechnique differences in LV mass calculation, suggesting that the various echocardiographic techniques are not interchangeable. Moreover, sex-, age-, and race-related differences underscore the need for separate age-specific normal values for men and women of different ages and

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  • The WASE study was supported by the American Society of Echocardiography.

    Conflicts of Interest: None.

    William A. Zoghbi, MD, FASE, served as guest editor for this report.

    The WASE Study Investigators are listed in the Appendix.

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