Diastolic Function

What to measure in neonates and children, reference values, and why the adult ASE algorithm does not apply

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Neonates

Group	Values	Source
What to Measure
Neonate	LA:Ao normal <1.5 (M-mode, parasternal long axis); a poor PDA marker on its own.	ASE 2024 TNE, Table 3

Stable Preterm Infants (<30 Weeks): Reference Centiles · 10th / 50th / 90th centile (de Waal 2025, Table 2)
Measure	Early NICU (day 3–21)	Late NICU (34–37 wk)
Mitral E (cm/s)	33 / 41 / 55	57 / 80 / 97
Mitral A (cm/s)	43 / 56 / 70	76 / 91 / 116
E/A	0.61 / 0.73 / 0.90	0.67 / 0.91 / 1.05
Deceleration time (ms)	57 / 83 / 108	57 / 92 / 130
Septal e′ (cm/s)	2.8 / 3.4 / 4.6	4.0 / 5.6 / 6.7
Septal a′ (cm/s)	4.8 / 5.9 / 7.5	6.6 / 8.4 / 10.9
Septal E/e′	9.2 / 11.9 / 15.4	10.5 / 14.0 / 21.0
IVRT, septal TDI (ms)	35 / 45 / 58	38 / 44 / 55
LA reservoir strain (%)	26 / 34 / 43	26 / 36 / 44
LA volume (mL/kg)	0.58 / 0.86 / 1.24	0.72 / 1.00 / 1.33

Neonatal Tissue Doppler e′ by Gestation and Day of Life · Pooled mean e′, cm/s (Ciarcià 2025 meta-analysis; pulsed TDI). Study means, not normal limits.
Site	Term, day ≤7	Term, day >7	32–36 wk, day ≤7	<32 wk, day ≤7	<32 wk, day >7
LV lateral e′	6.79	8.58	6.07	3.78	4.94
Septal e′	5.27	8.56	3.51	3.23	5.97
RV e′	7.41	12.49	5.98	4.75	7.92
LV lateral a′	6.54	7.55	6.15	4.30	6.61
LV IVRT, TDI (ms)	46.9	41.8	44.8	54.3	48.0

Cohort and caveats

35 studies, 3,747 neonates. Heterogeneity was high, and some cells rest on one or two studies.

RV a′ exceeds e′ throughout the neonatal period. In preterm infants 23–33 weeks, mitral E/e′ medians were about 8–12 at day 7 and 36 weeks (Di Maria 2015, a cohort that included PDA and BPD).

Infants and children

Group	Values	Source
Reference Values
Child	Use z-scores (age, size, heart rate; tables not on this page). Nomograms disagree: mitral A at 3 years, 42 to 61 cm/s by source.	ASE 2024 pediatric (Table 16); Cantinotti 2025 review
Child	Healthy (median 12 y, n = 80): lateral mitral e′ 19.3, septal 13.5, lateral tricuspid 16.3 cm/s. HCM: 13.2, 9.4, 13.3.	McMahon 2004 abstract
Child	LA volume: index allometrically, not per BSA. BSA ≤1 m²: LAV/BSA^1.48, mean 31.5 ± 5.5; BSA >1 m²: LAV/BSA^1.08, 26.0 ± 4.2 (n = 300). Adult LAVi >34 mL/m² does not transfer to small children.	Bhatla 2012 abstract; cited by ASE 2024
Filling Pressure: What Studies Found · study results, not guideline cut-offs
Child	Raised end-diastolic pressure: Ar / A duration ≥1.2 (sensitivity 88%, specificity 86%) or Ar − A ≥29 ms (90%, 86%).	O'Leary 1998 abstract
Child	Adult (2009) criteria failed: delayed relaxation in 14% of HCM, never in DCM or RCM; grade agreement 36%.	Dragulescu 2013 abstract; cited by ASE 2024
Child	E/e′ >16.4: LVEDP above the 90th centile (AUC 0.81, sensitivity 71%, specificity 93%). Septal e′ <6.2 cm/s: prolonged relaxation (AUC 0.86).	Masutani 2014 abstract
Child	Cardiomyopathy (38 children): E/e′ did not correlate with filling pressure; mitral E/A did (r 0.59).	Ezon 2015 abstract
Child	After cardiac surgery: lateral E/e′ ≥13 matched LA pressure ≥13 mmHg in 13 of 15 studies (PPV 87%); poor agreement in the first 72 hours.	Figueras-Coll 2015 abstract
Child	Heart transplant: E/e′ weakly associated with wedge pressure (C-statistic 0.66–0.70); studies disagree.	Lunze 2019; Alfares 2024; Wisotzkey 2022 abstract
Child	HCM: E/septal e′ predicted death, cardiac arrest or VT (cited by adult ASE 2016).	McMahon 2004 abstract

Adolescents and adult ASE

Adult ASE Normal Values · Mean ± SD (ASE 2009, Table 1, adult document)
Measure	16–20 y	21–40 y
IVRT (ms)	50 ± 9	67 ± 8
E/A	1.88 ± 0.45	1.53 ± 0.40
Deceleration time (ms)	142 ± 19	166 ± 14
A duration (ms)	113 ± 17	127 ± 13
Pulmonary vein S/D	0.82 ± 0.18	0.98 ± 0.32
Pulmonary vein Ar (cm/s)	16 ± 10	21 ± 8
Septal e′ (cm/s)	14.9 ± 2.4	15.5 ± 2.7
Lateral e′ (cm/s)	20.6 ± 3.8	19.8 ± 2.9

E/A >2 and pulmonary-vein S/D <1 can be normal when young (ASE 2016).

Sinus rhythm; not for children. First-line: e′, E/e′, TR velocity. Full algorithm (ASE 2025).

The Adult ASE 2025 Algorithm, for Comparison Adult · e′ values indicating impaired relaxation by age (ASE 2025, Table 6)
Site	20–39 y	40–65 y	>65 y
Septal e′ (cm/s)	<7	<6	<6
Lateral e′ (cm/s)	<10	<8	<7
Average e′ (cm/s)	<9	<7	<6.5

Algorithm and cut-offs

First-line variables: reduced e′ (septal ≤6, lateral ≤7 or average ≤6.5 cm/s, or age-specific values); raised E/e′ (septal ≥15, lateral ≥13, average ≥14); TR velocity ≥2.8 m/s or PA systolic pressure ≥35 mmHg.
All normal: normal LA pressure. All three abnormal: raised. Reduced e′ only with E/A ≤0.8: grade 1, normal pressure.
Otherwise use second-line markers: pulmonary-vein S/D ≤0.67, LA reservoir strain ≤18%, LA volume index >34 mL/m² (or IVRT ≤70 ms). Any one present means raised LA pressure.
Grade when pressure is raised: E/A <2 is grade 2; E/A ≥2 is grade 3.
New since 2016: the algorithm starts with e′; LA strain added; pulmonary-vein cut-off changed from <1 to ≤0.67; LA volume moved to a tie-breaker; exercise echo is positive only with TR ≥3.2 m/s.

Right ventricle

Group	Values	Source
RV Diastolic Function
Child	Tricuspid E/e′ does not reliably reflect RV filling pressure in children (repaired tetralogy).

ASE 2024 pediatric guideline

Not routinely evaluated. Tricuspid E and A should be recorded; tricuspid annular e′, a′ and s′ may be. Lateral tricuspid e′ may predict outcome.
Other markers: RA size, hepatic-vein A-wave reversal (reduced RV compliance), and end-diastolic forward flow in the pulmonary artery (restrictive RV physiology; significance not fully defined).
Healthy infants: mean tricuspid E/A about 1.1 in the first month and up to 2 years, with wide variation; E was below A on all three beats in about half of healthy infants (Cantinotti 2025, RV diastolic markers).

Key points

No validated pediatric algorithm. Adult ASE documents exclude children; ASE 2024 pediatric calls diastolic assessment not routine in children.
E/e′ has not reliably tracked LV filling pressure in children (ASE 2024 pediatric); pulmonary-vein Ar is validated only in adults. Read patterns together against age-specific normals.
Record: mitral E, A, E/A; lateral and septal e′, a′, s′; E/e′ (ASE 2024). LA:Ao correlates poorly with LA volume.
Neonates: E/A <1 is normal, term or preterm. E > A in a preterm infant suggests a loaded LA (e.g. PDA). Do not measure fused E and A.
Adult cut-offs misclassify the young. Stable preterm born before 30 weeks, at 34–37 weeks corrected: septal E/e′ median 14, 90th centile 21. Per-BSA LA indexing is invalid in small children.

Sources and how this page was checked

ASE guidelines (full text read)

Lopez L, Saurers DL, Barker PCA, et al. Guidelines for performing a comprehensive pediatric transthoracic echocardiogram: recommendations from the ASE. J Am Soc Echocardiogr 2024;37:119-170. doi:10.1016/j.echo.2023.11.015.
McNamara PJ, Jain A, El-Khuffash A, et al. Guidelines and recommendations for targeted neonatal echocardiography and cardiac point-of-care ultrasound in the NICU. J Am Soc Echocardiogr 2024;37:171-215. doi:10.1016/j.echo.2023.11.016.
Nagueh SF, Sanborn DY, Oh JK, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography and for heart failure with preserved ejection fraction diagnosis: an update from the ASE. J Am Soc Echocardiogr 2025;38:537-569. doi:10.1016/j.echo.2025.03.011. Supersedes 2016.
Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the ASE and EACVI. J Am Soc Echocardiogr 2016;29:277-314. doi:10.1016/j.echo.2016.01.011.
Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009;22:107-133. doi:10.1016/j.echo.2008.11.023 (Table 1, age-group normals).
Lopez L, Colan SD, Frommelt PC, et al. Recommendations for quantification methods during the performance of a pediatric echocardiogram. J Am Soc Echocardiogr 2010;23:465-495. doi:10.1016/j.echo.2010.03.019.
Mertens L, Seri I, Marek J, et al. Targeted neonatal echocardiography in the neonatal intensive care unit. J Am Soc Echocardiogr 2011;24:1057-1078. doi:10.1016/j.echo.2011.07.014.

Reference-value studies

de Waal K, Petoello E, Crendal E, Phad N. Reference ranges of left ventricular diastolic multimodal ultrasound parameters in stable preterm infants in the early and late NICU admission period. J Perinatol 2025;45:920. doi:10.1038/s41372-025-02278-1 (full text).
Ciarcià M, Malanima MA, Ficial B, et al. Normal ranges of TDI echocardiographic parameters in healthy term and preterm newborns: a systematic review and meta-analysis. Eur J Pediatr 2025;184:551. doi:10.1007/s00431-025-06323-1 (full text).
Di Maria MV, Younoszai AK, Sontag MK, et al. Maturational changes in diastolic longitudinal myocardial velocity in preterm infants. J Am Soc Echocardiogr 2015;28:1045-1052. doi:10.1016/j.echo.2015.04.016 (full text).
Cantinotti M, Marchese P, Capponi G, et al. Pediatric echocardiographic nomograms: an up-to-date review. J Clin Med 2025;14:5215. doi:10.3390/jcm14155215 (full text; review).
Cantinotti M, Capponi G, Scalese M, et al. Echocardiographic markers of RV diastolic dysfunction in neonates and infants with congenital heart disease. J Clin Med 2025;15:98. doi:10.3390/jcm15010098 (full text).
Bhatla P, Nielsen JC, Ko HH, et al. Normal values of left atrial volume in pediatric age group using a validated allometric model. Circ Cardiovasc Imaging 2012;5:791-796. doi:10.1161/CIRCIMAGING.112.974428 (abstract).
McMahon CJ, et al. Circulation 2004;109:1756-1762 (children with HCM; tissue Doppler). doi:10.1161/01.CIR.0000124723.16433.31 (abstract).
O'Leary PW, Durongpisitkul K, Cordes TM, et al. Diastolic ventricular function in children. Mayo Clin Proc 1998;73:616-628. doi:10.4065/73.7.616 (abstract).
Dragulescu A, Mertens L, Friedberg MK. Interpretation of left ventricular diastolic dysfunction in children with cardiomyopathy by echocardiography: problems and limitations. Circ Cardiovasc Imaging 2013;6:254-261. doi:10.1161/CIRCIMAGING.112.000175 (abstract).
Masutani S, et al. Heart Vessels 2014;29:825-833. doi:10.1007/s00380-013-0422-2 (abstract).
Ezon DS, et al. Congenit Heart Dis 2015;10:E203-E209. doi:10.1111/chd.12267 (abstract).
Figueras-Coll M, et al. World J Pediatr Congenit Heart Surg 2015;6:438-442. doi:10.1177/2150135115589999 (abstract).
Lunze FI, et al. Pediatr Transplant 2019;23:e13543. doi:10.1111/petr.13543 (abstract).
Alfares FA, et al. Cardiol Young 2024;34:1799-1804. doi:10.1017/S1047951124000908 (abstract).
Wisotzkey BL, et al. Cardiol Young 2022;32:531-538. doi:10.1017/S104795112100247X (abstract).
Dallaire F, Slorach C, Hui W, et al. Reference values for pulse wave Doppler and tissue Doppler imaging in pediatric echocardiography. Circ Cardiovasc Imaging 2015;8:e002167. doi:10.1161/CIRCIMAGING.114.002167 (abstract).
Roberson DA, Cui W, Chen Z, et al. Annular and septal Doppler tissue imaging in children: normal z-score tables and effects of age, heart rate, and body surface area. J Am Soc Echocardiogr 2007;20:1276-1284. doi:10.1016/j.echo.2007.02.023 (abstract).
Eidem BW, et al. Impact of cardiac growth on Doppler tissue imaging velocities: a study in healthy children. J Am Soc Echocardiogr 2004;17:212-221. doi:10.1016/j.echo.2003.12.005 (abstract).
Cantinotti M, et al. Nomograms for mitral inflow Doppler and tissue Doppler velocities in Caucasian children. J Cardiol 2016;68:288-299. doi:10.1016/j.jjcc.2015.10.004 (abstract).

How it was checked

ASE guidelines and the studies marked full text were read in full (October 2026); numbers are copied from the named tables. Studies marked abstract could not be opened in full; their numbers come from the authors' abstracts.
Not yet reproduced (full text needed): the age-banded pediatric tables and z-score equations of Dallaire 2015, Roberson 2007, Eidem 2004, O'Leary 1998 and Cantinotti 2016, and the Bhatla 2012 z-score tables.
The ASE 2025 key points print e′ thresholds with "<" while its figures use "≤"; the page follows the figures.