LV and RV Systolic Function

Name: Echo: Systolic Function · HeartCalc
Creator: Piyawat Arichai, MD, FAAP

How to measure, and reference values for neonates and children (ASE), with adult ASE cut-offs for adolescents

Show values for

Left ventricle

Group	Values	Source
LV Ejection Fraction (LVEF)
Neonate	Normal 55–70% (area-length or biplane Simpson)	ASE 2024 TNE, Table 3
Child	Abnormal <50% (5/6 area-length)	ASE 2024 pediatric; Frommelt 2019 (PHN)
Adult	Normal: men 52–72%, women 54–74%. Mild: men 41–51, women 41–53. Moderate: 30–40. Severe: <30 (2D biplane).	ASE/EACVI 2015, Table 4
Fractional Shortening (FS)
Neonate	Normal 30–45%, only with normal septal motion	ASE 2024 TNE, Table 3
Child	Abnormal <25% (PHN threshold)	Frommelt 2019 (PHN)
Adult	No FS range; EF is the standard.	ASE/EACVI 2015
LV Global Longitudinal Strain (GLS) · %, more negative = better
Preterm	<29 weeks (GE): day 1 −18.4 ± 3.5; day 2 −20.3 ± 3.2; day 5–7 −20.7 ± 3.0; stable to 1 year corrected (−19.7 to −21.4).	Levy 2017 (Tables 3 and 5)
Child	Lower limit of normal about −17% to −18% (endocardial)	ASE 2024 pediatric
Child	Pooled mean −20.2% (study means −16.7 to −23.6). 0–1 y −18.7; 2–9 y −21.7; 10–13 y −20.0; 14–21 y −19.9.	Levy 2016 meta-analysis
Adult	Normal more negative than −18%; borderline −16 to −18%; abnormal less negative than −16%.	ASE/EACVI 2025 strain consensus
Other LV Indices (s′, MPI, mVCFc)
Neonate	MPI 0.25–0.38 in healthy neonates (ventricle not stated)	ASE 2011 neonatal
Child	LV MPI, 1 day–18 y (n = 289): TDI 0.38 ± 0.06; PW 0.36 ± 0.07; M-mode 0.29 ± 0.08	Cui 2006 abstract

Right ventricle

Group	Values	Source
Tricuspid Annular Plane Systolic Excursion (TAPSE)
Preterm–term	26th week of gestation 0.44 cm (±2 z 0.30–0.59), rising linearly to the 41st week 1.03 cm (0.85–1.21); first 48 h; n = 258	Koestenberger 2011, Table 1
Newborn–18 y	Term newborn 0.91 cm (±3 z 0.56–1.26), rising with age and BSA to 2.47 cm at 18 y (1.84–3.10); n = 640	Koestenberger 2009, Table 1
Adult	Normal >1.7 cm. Mild 1.3–1.7; moderate 1.0–1.3; severe ≤1.0 cm.	ASE 2025 right heart, Table 1
RV Fractional Area Change (FAC)
Neonate	Normal ≥35% (RV 3- or 4-chamber view); fits after the first weeks, means are lower at birth (next row)	ASE 2024 TNE, Table 3
Neonate	Preterm 23–28 weeks: birth 26 ± 4%, 4 weeks 35 ± 5%. Term: birth 33 ± 5%, 1 month 39 ± 4%. Term at 15–35 h: 3-chamber 36 ± 5% vs 4-chamber 24 ± 7%.	Levy 2015 (Tables 2–4); Jain 2014 abstract
Child	No ASE pediatric reference values.	ASE 2010, 2024 pediatric
Adult	Normal >35%. Mild 29–35; moderate 22–29; severe ≤22%.	ASE 2025 right heart, Table 1
Tissue Doppler S′ Velocity
Newborn–18 y	Newborn 7.2 cm/s (±2 z 4.8–9.5), rising non-linearly to 14.3 cm/s at 18 y (10.6–18.6); n = 860	Koestenberger 2012 abstract
Adult	Normal >9.5 cm/s. Mild 7.2–9.5; moderate 5.0–7.2; severe ≤5.0.	ASE 2025 right heart, Table 1
RV Free Wall and Global Longitudinal Strain (RVFWS, RVGLS) · %
Preterm	Free wall, <29 weeks (GE), postnatal age: day 1 −18.1 ± 4.0; day 5–7 −20.5 ± 3.2; 4–6 weeks −21.0 ± 2.5; 60–79 weeks −27.5 ± 2.4; 80–99 weeks −28.7 ± 2.5.	Levy 2017 (Tables 3 and 5)
Child	Pooled mean global −29.0% (study means −20.8 to −34.1); free wall −30.1%; all GE; adolescents (14–21 y) trend lower (about −26%).	Levy 2014 meta-analysis
Adult	Free wall (magnitude): normal >20; mild 15–20; moderate 11–15; severe <11. Global, 6-segment: normal >17; mild 13–17; moderate 9–13; severe ≤9.	ASE 2025 right heart, Table 1
RV Index of Myocardial Performance (RIMP, Tei Index)
Child	1 day–18 y (n = 308): TDI 0.37 ± 0.05; PW 0.34 ± 0.06 (methods differ)	Roberson & Cui 2007 (RV Tei) abstract
Adult	TDI: normal <0.55; mild 0.55–0.62; moderate 0.62–0.70; severe ≥0.70. PW: normal <0.40; mild 0.40–0.49; moderate 0.49–0.57; severe ≥0.57.	ASE 2025 right heart, Table 1

Key points

Child: EF <50% (cited by ASE 2024), FS <25% (PHN study cut-off); no ASE table by age. 17% of healthy PHN children fell below one or both: confirm by eye and a second method.
Prefer volumetric EF. Avoid FS with abnormal septal motion, RV loading or a non-circular LV.
RV: combine indices (TAPSE, FAC, s′, strain). RIMP is not useful in a normal RV.
Neonates: TAPSE more than doubles from 26 weeks to term; use gestational-age, weight- or age-specific references.
Strain: serial studies on the same vendor and software.

Why

There is no ASE table of pediatric EF or FS by age. The 2024 ASE pediatric guideline cites EF <50% as an accepted abnormal threshold; the Pediatric Heart Network (PHN) used EF <50% and FS <25%. In its normal database, 17% of healthy children fell below one or both, most often the youngest and smallest.
Volumetric EF: 5/6 area-length or biplane Simpson; 3D when feasible. FS is acceptable by M-mode or 2D, but the PHN z-scores are 2D-derived: do not apply them to M-mode.
Read RV indices with the visual impression and the loading conditions; apical indices miss the RV outflow tract.
Neonates: use gestational-age-, weight- or age-specific references; RV FAC rises over the first month. Strain is vendor-specific.

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 American Society of Echocardiography. J Am Soc Echocardiogr 2024;37:119-170. doi:10.1016/j.echo.2023.11.015. Supersedes the 2006 and 2010 pediatric documents.
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: an update from the ASE. J Am Soc Echocardiogr 2024;37:171-215. doi:10.1016/j.echo.2023.11.016, with its published correction (tracing rules for papillary muscles and trabeculations).
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 (superseded; methods still cited).
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 (superseded by 2024).
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults. J Am Soc Echocardiogr 2015;28:1-39. doi:10.1016/j.echo.2014.10.003.
Mukherjee M, Rudski LG, Addetia K, et al. Guidelines for the echocardiographic assessment of the right heart in adults and special considerations in pulmonary hypertension. J Am Soc Echocardiogr 2025;38:141-186. doi:10.1016/j.echo.2025.01.006.
Thomas JD, Edvardsen T, Abraham T, et al. Clinical applications of strain echocardiography: a clinical consensus statement from the ASE developed with the EACVI. J Am Soc Echocardiogr 2025;38:985-1020. doi:10.1016/j.echo.2025.07.007. Leaves pediatric strain normals to future pediatric guidance.

Normative studies

Frommelt PC, Minich LL, Trachtenberg FL, et al. Challenges with left ventricular functional parameters: the Pediatric Heart Network normal echocardiogram database. J Am Soc Echocardiogr 2019;32:1331-1338. doi:10.1016/j.echo.2019.05.025 (full text).
Levy PT, Machefsky A, Sanchez AA, et al. Reference ranges of left ventricular strain measures by 2D speckle-tracking echocardiography in children: a systematic review and meta-analysis. J Am Soc Echocardiogr 2016;29:209-225. doi:10.1016/j.echo.2015.11.016 (full text).
Levy PT, Sanchez Mejia AA, Machefsky A, et al. Normal ranges of right ventricular systolic and diastolic strain measures in children: a systematic review and meta-analysis. J Am Soc Echocardiogr 2014;27:549-560. doi:10.1016/j.echo.2014.01.015 (full text).
Levy PT, Dioneda B, Holland MR, et al. Right ventricular function in preterm and term neonates: reference values for right ventricle areas and fractional area of change. J Am Soc Echocardiogr 2015;28:559-569. doi:10.1016/j.echo.2015.01.024 (full text).
Levy PT, El-Khuffash A, Patel MD, et al. Maturational patterns of systolic ventricular deformation mechanics by 2D speckle-tracking echocardiography in preterm infants over the first year of age. J Am Soc Echocardiogr 2017;30:685-698. doi:10.1016/j.echo.2017.03.003 (full text).
Koestenberger M, Ravekes W, Everett AD, et al. Right ventricular function in infants, children and adolescents: reference values of TAPSE in 640 healthy patients and calculation of z score values. J Am Soc Echocardiogr 2009;22:715-719. doi:10.1016/j.echo.2009.03.026 (full text).
Koestenberger M, Nagel B, Ravekes W, et al. Systolic right ventricular function in preterm and term neonates: reference values of TAPSE in 258 patients and calculation of z-score values. Neonatology 2011;100:85-92. doi:10.1159/000322006 (full text).
Koestenberger M, Nagel B, Ravekes W, et al. Reference values of tricuspid annular peak systolic velocity in healthy pediatric patients, calculation of z score, and comparison to TAPSE. Am J Cardiol 2012;109:116-121. doi:10.1016/j.amjcard.2011.08.013 (abstract).
Jain A, Mohamed A, El-Khuffash A, et al. A comprehensive echocardiographic protocol for assessing neonatal right ventricular dimensions and function in the transitional period. J Am Soc Echocardiogr 2014;27:1293-1304. doi:10.1016/j.echo.2014.08.018 (abstract).
Dallaire F, Slorach C, Bradley T, et al. Pediatric reference values and z score equations for left ventricular systolic strain measured by two-dimensional speckle-tracking echocardiography. J Am Soc Echocardiogr 2016;29:786-793. doi:10.1016/j.echo.2016.03.018 (full text).
Romanowicz J, Ferraro AM, Harrington JK, et al. Pediatric normal values and z score equations for left and right ventricular strain by two-dimensional speckle-tracking echocardiography derived from a large cohort of healthy children. J Am Soc Echocardiogr 2023;36:310-323. doi:10.1016/j.echo.2022.11.006 (full text).
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).
Roberson DA, Cui W. Right ventricular Tei index in children: effect of method, age, body surface area, and heart rate. J Am Soc Echocardiogr 2007;20:764-770. doi:10.1016/j.echo.2006.11.002 (abstract).
Cui W, Roberson DA. Left ventricular Tei index in children: comparison of tissue Doppler imaging, pulsed wave Doppler, and M-mode echocardiography normal values. J Am Soc Echocardiogr 2006;19:1438-1445. doi:10.1016/j.echo.2006.06.006 (abstract).

How it was checked

The ASE guidelines and the studies marked "full text" were read in full (October 2026). Studies marked abstract could not be opened in full; their numbers come from the authors' published abstracts, and their age-band tables and z-score equations are not reproduced here.
Parameter names and abbreviations follow ASE usage: LVEF and FS (ASE 2024 neonatal, Figure 3 and text); GLS and RIMP (ASE/EACVI 2015); TAPSE, FAC, tissue Doppler S′, RVFWS and RVGLS (ASE 2025 right heart, Table 1 and text).
Wording is condensed; numbers are as printed in the source table named in each row. Adult cut-offs are labelled Adult and apply to adolescents only as a guide.
Strain values from meta-analyses are pooled means (with confidence intervals of the mean in the source), not normal limits.
Not reproduced here: s′ z-score tables, Dallaire 2015 tissue Doppler z-scores, pediatric 3D EF normals and the stress–velocity regression. TAPSE by age is on Pulmonary Hypertension; strain by age on Strain Normal Values.