How do I measure left ventricular function using transthoracic echocardiography?

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Last updated: October 29, 2026 • View editorial policy

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Measuring Left Ventricular Function Using Transthoracic Echocardiography

Measure LV volumes using the biplane method of disks summation (modified Simpson's rule) from apical 4-chamber and 2-chamber views to calculate ejection fraction, and add global longitudinal strain (GLS) by speckle tracking for comprehensive assessment of LV systolic function 1.

Primary Method: Volumetric Assessment with Modified Simpson's Rule

The gold standard approach for measuring LV function by TTE involves:

Image Acquisition

  • Obtain apical 4-chamber and 2-chamber views with careful attention to maximize LV areas while avoiding foreshortening 1
  • Position the transducer to ensure the entire LV cavity is visible from apex to base
  • Foreshortening causes significant volume underestimation, so adjust probe position until LV length is maximized

Volume Calculation

  • Use the biplane method of disks summation (modified Simpson's rule) as the recommended 2D technique 1
  • Trace the endocardial border at end-diastole and end-systole in both apical views
  • The software automatically calculates end-diastolic volume (EDV) and end-systolic volume (ESV)
  • Calculate ejection fraction: EF = (EDV - ESV) / EDV × 100%
  • Index volumes to body surface area (BSA) for comparison across different body sizes 1

Critical Technical Points

  • Use contrast enhancement when two or more contiguous LV segments are poorly visualized in apical views 1
  • Contrast-enhanced images provide volumes closer to cardiac MRI reference standards
  • Position calipers at the interface between myocardium and cavity, not including trabeculations or papillary muscles

Avoid Outdated Linear Methods

Do not use the Teichholz or Quinones methods that calculate volumes from linear dimensions 1. These methods assume the LV is a prolate ellipsoid, which is inaccurate in most cardiac pathologies including regional wall motion abnormalities, dilated cardiomyopathy, or hypertrophic hearts.

Linear measurements from parasternal long-axis views (LV internal dimensions, wall thickness) remain useful for chamber size assessment but should not be used to calculate volumes or EF.

Advanced Techniques: 3D Echocardiography

When available, 3D echocardiography is superior to 2D methods for volume and EF measurements 2:

  • No geometric assumptions required
  • Unaffected by foreshortening
  • More accurate and reproducible compared to 2D methods
  • Ensure the entire LV is captured within the pyramidal data set
  • Maximize temporal resolution without compromising spatial resolution

Essential Complementary Measure: Global Longitudinal Strain

Always add GLS measurement by speckle tracking echocardiography to your assessment 3, 4:

  • GLS detects LV dysfunction earlier than EF, particularly in pathologically remodeled hearts
  • More sensitive and reproducible than EF for serial monitoring
  • Provides additional prognostic information beyond EF alone
  • Normal GLS is approximately -20% (more negative is better)
  • Abnormal GLS with preserved EF indicates subclinical LV dysfunction

GLS is particularly valuable in:

  • Chemotherapy cardiotoxicity monitoring (guideline-recommended) 4
  • Valvular heart disease assessment
  • Heart failure across the entire EF spectrum
  • Detecting early dysfunction in hypertrophic cardiomyopathy, amyloidosis, and other infiltrative diseases 2

Additional Functional Parameters

For comprehensive assessment, measure:

  • Mitral annular plane systolic excursion (MAPSE) by M-mode: reflects longitudinal function
  • S' velocity by tissue Doppler at the mitral annulus: another measure of longitudinal systolic function 5
  • These serve as useful surrogates when strain imaging is unavailable

Common Pitfalls to Avoid

  • Foreshortening of apical views: The most common error leading to volume underestimation. Always maximize LV length in both apical views
  • Poor endocardial definition: Use contrast when needed rather than guessing border position
  • Relying solely on visual estimation: This has unacceptable interobserver variability
  • Using M-mode or linear dimension formulas: These are obsolete for volume/EF calculation
  • Ignoring GLS when EF appears normal: Subclinical dysfunction is missed without strain imaging

References

2
Research

ECHOCARDIOGRAPHIC METHODS FOR ASSESSING LEFT VENTRICULAR SYSTOLIC FUNCTION.

Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego, 2023

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.