Evaluation of Left Ventricular Size

and Function by Echocardiography

Results in Normal Children
HOWARD P. GUTGESELL, M.D., MARC PAQUET, M.D.
DESMOND F. DUFF, M.D., AND DAN G. MCNAMARA, M.D.
With the Technical Assistance of Linda Kaufman

SUMMARY Left ventricular (LV) size and function were studied

by echocardiography in 145 normal children. The LV end-diastolic
diameter (EDD) and its percentage change with systole (%ALVD)
were measured and mean velocity of circumferential fiber shortening
(Vcf) calculated. The LV pre-ejection period (PEP) and ejection
time (LVET) were determined from recordings of aortic valve motion.
The EDD increased by approximately threefold during childhood
and was best correlated with the log of body weight (r = 0.95) and

the log of body surface area (r = 0.96). The mean %lALVD was
36 4 (SD), and this index of LV function was independent of age
and heart rate. Mean Vcf was higher, and the absolute values of
PEP and LVET shorter, in younger children with a faster heart rate.
The mean ratio of PEP/LVET was 0.31 0.003, and was relatively
independent of age (r = -0.41) and heart rate (r = 0.37). The
%ZALVD and PEP/LVET appear to be particularly useful indices of
LV function because they remain constant during the course of
childhood.

ONE OF THE MOST PROMISING APPLICATIONS of

echocardiography is the noninvasive evaluation of left ventricular (LV) function. A variety of echographic indices of
LV performance have been described,' 8 based largely on
studies of adults. The demonstration that systolic time intervals can be measured by echocardiography9g12 adds another
index of LV function to the conventional echocardiographic
measurements.
In this study, we have used echocardiography to study left
ventricular size and function in a group of normal children
with a wide range of age and heart rate. We have attempted
to determine which of the indices of LV function change during the course of childhood and where changes occur, to
determine if they are related to age, heart rate, or a combination of these variables.

casionally a shallow left lateral decubitus position was required to record the ventricular septum clearly.
Left ventricular dimensions were measured in the standard
manner (fig. 1). End-diastolic diameter (EDD) was measured
at the start of the QRS complex. End-systolic diameter
(ESD) was measured at the point in late systole where the
septum and LV posterior wall were in closest apposition.
These measurements were made with the transducer angled
slightly inferiorly and laterally from the point of maximal
excursion of the mitral valve in subjects over one year of age.
In younger children, as previously noted by Sahn et al.,7 the
mitral leaflets appear to extend farther toward the apex, and
the LV diameter decreases rapidly as the transducer is
directed below the mitral valve. Therefore, in infants under
one year of age the LV dimensions were measured at the
point of maximal excursion of the mitral valve, from a position from which both leaflets could be visualized. Recordings
satisfactory for determination of LV dimensions were obtained in 143 of the 145 subjects (99%).
Left ventricular systolic time intervals were determined
from recordings of the aortic valve at 100 mm/sec paper
speed (fig. 2). The pre-ejection period (PEP) was measured
from the onset of ventricular depolarization in lead II of the
electrocardiogram to the onset of opening of the aortic valve.
The left ventricular ejection time (LVET) was measured
from aortic valve opening to closing. An average was obtained from three cardiac cycles and the value was rounded
off to the nearest five milliseconds. Recordings satisfactory
for measuring systolic time intervals were obtained in 118 of
the 145 subjects (81%).
During the first half of this study, 0.5 sec time lines
generated by the echograph were employed. For the
remainder of the study, 0.02 sec time lines from a quartz
crystal oscillator were available. The time lines of the echograph differed from those produced by the oscillator by less
than 3%. We considered this error insignificant and the data
from the two phases of the study were combined.
From these measurements, the following calculations were
made.

Materials and Methods

Echocardiograms were obtained from 145 normal
children, 80 boys and 65 girls. The ages of the subjects
ranged from one day to 19 years. None had heart disease as
judged by history and physical examination. Their age distribution was as follows: 1 day to 30 days, N = 30; 1 month
to 24 months, N = 27; 2 to 6 years, N = 37; 7 to 11 years,
N = 26; 12 to 19 years, N = 25.
The echocardiograms were obtained with a Hoffrel Model
101 Ultrasonoscope interfaced to a Honeywell Model 1856
strip chart recorder. Transducers of 2.25, 3.5 or 5.0 MHz
were used, depending on the subject's size. Studies were obtained from the third or fourth intercostal space at the left
parasternal edge with the subject in the supine position. Oc-

From the Section of Cardiology, Department of Pediatrics, Baylor

College of Medicine, and Texas Children's Hospital, Houston, Texas.
Supported in part by Grant HL-5756 from the USPHS, Grant RR-00188
from the General Clinical Research Branch, NIH, and by a grant from the
Texas Affiliate, American Heart Association.
Address for reprints: Howard P. Gutgesell, M.D., Section of Pediatric
Cardiology, Texas Children's Hospital, 6621 Fannin, Houston, Texas 77030.
Received February 3, 1977; revision accepted April 29, 1977.

457
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458

4't-

CI RCULATION

VOL 56, No 3, SEPTEMBER 1977

...

r- st9

t-o

t '+ s t*_ X _ F0 _~~~~~~~~~~~~~~~4

..E

I). I

12

EC

it

IA-

..

...-

FIGURE 2. Echocardiogram of aortic valve showing method by

which left ventricular systolic time intervals were determined.
Paper speed 100 mm/sec. time lines 0.5 sec.

Results
E _G

t,f

Left Ventricular Diameter

FIGURE 1. Echocardiogram demonstrating method by which left

ventricular dimensions were determined. End-diastolic diameter
(EDD) was measured between the endocardial surfaces of the ventricular septum (IVS) and the left ventricular posterior wall
(L VPW) at the start of the QRS complex of the electrocardiogram (ECG). End-systolic diameter (ESD) was defined as
the shortest distance between the septum and the posterior wall.
Portions of mitral valve (MV) are recorded.

1) The percentage change in left ventricular diameter with

systole (%zALVD):
EDD - ESD
A
EDD

Left ventricular EDD increased by approximately threefold as body weight increased from 3 to 60 kg. The correlation coefficients and regression equations relating EDD to
body size are shown in table 1. The EDD was best correlated
with the log of BSA (r - 0.96, SEE = 2.78) although the correlations with the log of body weight and height as well as
with the root functions of height and BSA, were nearly as
strong. The linear relationship between EDD and the log of
body weight is shown in figure 3.
%ALVD

Left ventricular diameter decreased by slightly over onethird with systole. The mean %ALVD was 36 4%. The
100

2) The ratio of the pre-ejection period to ejection time:

PEP
LVET
3) Mean velocity of circumferential fiber shortening
(Vcf):
EDD -ESD
EDD X LVET
In the latter calculation, the value for LVET was that obtained from the recording of aortic valve motion.
The LV diameter was compared to body size by linear
regression analysis. Correlation coefficients were determined
for the relationship of EDD to body weight, height, and surface area (BSA), as well as the square root, cube root, and
log of each of these variables.
To relate %ALVD, systolic time intervals, and Vcf to age
and heart rate, the following types of linear regression
analysis were performed: 1) simple, 2) multiple, two variable,
and 3) partial, with one variable constant.

60

40

EDD

320

20

u0

....

7 8 g

15

20

J3

1,
I..
40 50 60 J90
m0

BODY WEIGHT (Vg)

FIG&URE 3. Relationship of left ventricular end-diastolic diameter

(EDD) to body weight in kilograms. The horizontal axis is
logarithmic. In this and the subsequent graphs, the solid diagonal
line represents the regression line and the dashed lines estimate the
upper and lower limits of 95% of the normal population.

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ECHO OF LV SIZE AND FUNCTION/Gutgesell et al.

459

TABLE 1. Relationship of Left Ventricular End-diastolic Diameter to Body Size in Normal Children
Independent
variable

Correlation

cooefficient

Wt (kg)

EDD
EDD
EDD
EDD
EDD
EDD
EDD
EDD
EDD
EDD
EDD
EDD

0.85
0.92

V--IR

a+ii
VW-0.93
Log wt*
Ht (cm)

0.95
0.92
0.93
0.93
0.94
0.92
0.95
0.95
0.96

'TWR

3it
Log ht*

BSA(m2)

-VBSA
a

NBSTA

Log BSA*

=
=
=
=
=

=
=
=
=

Standard

Regression equation
21.73 + 0.44 (wt)
12.14 + 4.53 ( Vw-t
2.83 + 11.17 (3 vWt)
6.94 + 9.22 (log wt)
8.56 + 0.22 (Ht)
-13.26 + 4.44 ( VrU
-35.10 + 14.35 (3 ffTl)
-68.55 + 21.86 (log Ht)
17.41 + 17.92 (BSA)
4.49 + 32.26 (JBA)
-8.36 + 45.51 (3VBT-)
37.75 + 12.88 (log BSA)

(mm)
5.2
3.9
3.5
3.2
3.95
3.60
3.52
3.42
3.98
3.15
2.96
2.78

error

*Natural log.

Abbreviations: Wt = weight; Ht = height; BSA = body surface area.

%zALVD was greater than 44% in only seven subjects and

was less than 28% in two.
There was no correlation between %ALVD and age or
heart rate (table 2). The constancy of %ALVD despite wide
variations in heart rate is illustrated in figure 4.

In contrast to PEP and LVET, the ratio PEP/LVET was

relatively independent of age and heart rate. The mean
PEP/LVET was 0.31 0.03. Since the slope of the regression line of heart rate versus LVET was steeper than that for
PEP, the ratio PEP/LVET was slightly higher for subjects
with faster heart rates (fig. SC). The correlation coefficients
between PEP/LVET and heart rate (r = 0.37) and age
(r = -0.41) were weak and in practice can probably be disregarded.

Systolic Time Intervals

As expected, there was an inverse correlation between age
and heart rate (r = -0.80). The correlation coefficients and
regression equations relating the systolic time intervals to
age and heart rate are shown in tables 2 and 3. As illustrated
in figures 5A and SB, both PEP and LVET were inversely
related to heart rate (r = -0.70 and -0.88, respectively).
However, the correlations of PEP and LVET with age were
nearly as strong (r = 0.61 and 0.81). Thus, although we have
only illustrated the relationship of the systolic time intervals
to heart rate, similar graphs with the opposite slope could be
constructed with age as the independent variable. Very little
increase in correlation was achieved by use of multiple
regression analysis, simultaneously taking both age and
heart rate into consideration (table 2). For example, the correlation coefficient between LVET and heart rate was -0.88;
that relating LVET to heart rate and age was -0.89.
Partial regression analysis with age or heart rate held constant showed that both PEP and LVET had a positive correlation with age and a negative correlation with heart rate
(table 2). However, with the exception of the partial correlation coefficient relating LVET to heart rate with age held
constant (r = -0.67), the partial correlation coefficients
were all less than 0.50; those relating heart rate to PEP and
LVET were higher than those for age.

Mean Vcf

Mean Vcf, normalized for EDD, was higher in the

younger children, who also had faster heart rate (tables 2 and
3). As in the case of PEP and LVET, there was an association between Vcf and both heart rate (r = 0.67) and age

(r = -0.65).
The relationship of Vcf to heart rate and age simply
reflects the formula from which Vcf is calculated:

Vcf=

DDX LVET
The enclosed measurements represent the %ALVD which
was independent of heart rate and age (table 2 and figure 4).
Since LVET is directly related to age and inversely related to
heart rate, younger subjects, with a faster heart rate, had a
shorter ejection time and thus a higher value of Vcf.
Discussion
We have combined two commonly used noninvasive techniques to obtain a profile of left ventricular function in nor-

TABLE 2. Correlation Coefficients Relating Echocardiographic Indices of Left Ventricular Function to Heart
Rate and Age
analysis
Type of regression
-e,-

Index of
left ventricular
function
-

.7 Jt'-

---

Simple linear

Simple linear

Multiple linear
HR and age

Partial
HR

(Age constant)

Partial
age
(HR constant)

+0.04
-0.70*
-0.88*
+0.37*
+0.67*

+0.02
+0.61*
+0.81*
-0.41*
-0.65*

+0.09
-0.72*

+0.09
-0.43*

+0.08

-0.89*

-0.67*

+0.36*
+0.70*

+0.16

+0.35*
+0.08

%ALVD
PEP
LVET
PEP/LVET
VCf

HR

age

+0.16

+0.37*
-0.27*
= pre-ejection period; LVET

Abbreviations: HR = heart rate; %ALVD = percent change in left ventricular diameter; PEP
left ventricular ejection time; Vcf = mean velocity of circumferential fiber shortening.
*Correlation coefficient statistically significant, P <0.05.

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CIRCULATION

460

VOL 56. No 3, SEPTEMBER 1977

TABLE 3. Regression Equations Relating Selected Indices* of Left Ventricular Function to Age and Heart Rate
Heart rate (beats/min)

PEP

Age (yr)

y = 0.104 - 0.0003 (HR)

Heart rate and age

0.066 + 0.001 (age) y = 0.094 - 0.0002 (HR) + 0.0004 (age)

SEE = 0.01 sec
SEE = 0.01 sec
y = 0.206 + 0.007 (age) y = 0.342 - 0.001 (HR) - 0.002 (age)
SEE = 0.03 sec
SEE = 0.02 sec
y = 1.740 - 0.042 (age) y = 1.075 + 0.005 (HR) - 0.020 (age)
SEE = 0.28 circ/sec
SEE = 0.26 cire/sec
y

SEE = 0.008 sec

LVET y = 0.389 - 0.001 (HR)
SEE = 0.02
Vef
y = 0.648 + 0.008 (HR)
SEE = 0.27 circ/sec

*Includes those relationships with a correlation coefficient greater than 0.5 (table 2).

mal children. Echocardiographic recording of septal and left

ventricular posterior wall motion has been shown to be a
reproducible method' of evaluating left ventricular function.
It likewise has been shown to have a good correlation with
angiographic techniques.6" 6
Systolic time intervals, particularly the ratio of
PEP/LVET, have been used to assess left ventricular function under a variety of conditions.'3-l8 However, the conventional method employing simultaneous recording of the electrocardiogram, phonocardiogram, and carotid or axillary
pulse tracing is difficult to use in small children. Several recent studies have shown a good correlation between systolic
time intervals obtained by echocardiography and those obtained by conventional external methods10-12 or by intracardiac recording.'0 12 Since satisfactory aortic valve
tracings can be obtained in most children, we have adopted
this technique.
The left ventricular EDD is perhaps the most elementary
index of LV function. Our results are in accord with previous
studies of cardiac growth in childhood. Lundstrom'7 found a
strong correlation between EDD and the cube root of body
weight, while Epstein et al.'8 found EDD linearly related to
BSA. Our slightly larger EDD compared to that of
Lundstrom may result from our measuring LV diameter
higher in the ventricle in children under one year of age. It
appears to make little difference whether EDD is predicted
from weight, height, or BSA; we prefer weight (fig. 3)
because it is easily and more accurately determined in small
infants.
The EDD is proportionally greater (per unit of body size)
in the newborn than in adolescents or adults. For example,
the average EDD in a 3 kg newborn with a BSA of 0.2 m2 is
70[
60
5C
o

4C

ALVD
30

20
% ALVD - 0.369 -0-00007(HR)
r = 005
SEE - 004

50

60

70

80

90

100

110 0
HEART RATE

00

140

B-

60

TB

FIGURE 4. Plot of percent change in left ventricular diameter

(%AL VD) against heart rate. The %AL VD remains constant
within a wide range of heart rates.

16 mm, or 80 mm/M2n. Feigenbaum'9 and Popp20 propose

19-32 mm/M2 as the normal range for adults. In the present
study, an average EDD as low as 32 mm/Mi was not obtained until BSA reached 1.2 M2n. Thus, it does not appear
possible to use a simple mm/M2 index to predict EDD in
childhood.
The percent change in the left ventricular minor axis
(%ALVD) was one of the first echocardiographic indices of
LV function described3 but has been somewhat overlooked
since. Most investigators have chosen to convert the LV
dimensions to volumes, either by the cube method' or by
regression equations derived from angiocardiographic comparisons8. 21, 22 and have thus expressed %ALVD as ejection
fraction. Conversion of the LV dimensions to volumes has
the advantage that terms such as end-diastolic volume or
ejection fraction have more general familiarity. The conversion has the disadvantage that it magnifies any errors in the
original measurement.
The %ALVD appears to be of particular value in the
assessment of LV function in children because it remains
constant throughout childhood. The average value of
36 4% obtained in the present study, is essentially the
same as reported values for normal adults.3' 20 28 This confirms the observation that the LV ejection fraction measured
by angiocardiography is virtually the same in normal
children 2 6 and adults.'6' 27
In the present study, the %ALVD was the same for
younger subjects with a fast heart rate as for older subjects
with a slower heart rate, suggesting that %zALVD is independent of heart rate. Hirshleifer et al.'8 obtained essentially the
same results by acutely increasing the heart rate of adults by
the administration of atropine: %ALVD (which they expressed as ejection fraction) remained constant, while Vcf increased as heart rate increased. The %,ALVD did fall,
although not as much as Vcf, when afterload was acutely increased by the administration of phenylephrine.
There is disagreement regarding the relative contributions
of age and heart rate to the changes in systolic time intervals
which occur during the course of childhood.'93' In the present study, PEP and LVET were slightly better correlated
with heart rate than age, and LVET varied inversely with
heart rate if age was held constant. In general, however, the
strong correlation (r = -0.80) between age and heart rate
makes it impossible, and perhaps unrealistic, to attribute
changes of systolic intervals in childhood to either one or the
other of these variables.
The mean PEP/LVET for children in this study was
0.31 0.03, which is the same as that obtained in 76 normal
children studied by Spitaels et al." with external pulse and
phonocardiographic methods. Since PEP tends to lengthen
while LVET shortens in the presence of left ventricular

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*,. _-.:

ECHO OF LV SIZE AND FUNCTION/Gutgesell et al.

012
0.11

0.101.
009

PEP
(sec) 008
007

006
OD5

PEP= 010 -000028((HR)

r Q70
SEE 0008

*..

U.94
0

60

70

80

loo

90

110

HEART F

035

130

STE0

~~~~~~~F3

11,

60

150

140

LVE

10

000134(HR)

461

settle the issue it does emphasize the fact that Vcf, unlike
%ALVD, is directly related to heart rate and inversely
related to age. Caution is therefore required in using Vcf to
compare subjects of different ages or heart rates, or the same
subjects before and after interventions which may alter heart
rate.
The use of the echocardiogram to determine both ventric~ - .ular dimensions and LV systolic time intervals has several
advantages. Both determinations can be made fairly rapidly
by one person with the same piece of equipment. If one of the
measurements cannot be made reliably (for example,
%ALVD in a subject with paradoxical septal motion), it still
may be possible to make some estimation of left ventricular
function from the other parameter. The %ALVD and the
ratio of PEP/LVET appear to be particularly useful indices
of LV function in children because they remain relatively
constant during childhood.

SEE= 0022

0.30

Acknowledgment

1,

We are indebted to Dr. Howard Thompson for assistance in the statistical

analysis of the data. We would like to thank Sue Lambert for editing and
typing the manuscript.

1- I

LVET
(sec)

025

II

020

I,

References

I
I

1,

1,

""V

1.1

_~

70

60

530

90

80

1p3

120

HEART RATE

130

150

140

170

160

050
045

_ _

0.40
035

PE&-

030

..

0LVET025
015

o0io

..

020

_ _

..

PEL/ET 0.2265000007(HR)

SEE

005

c0D

m0

90

10

no

12

13

=0.37

=006
150

e6

mi

HEART RATE

FIGURE 5. Graph illustrating relationship of A) pre-ejection

period (PEP), B) left ventricular ejection time (L VET), and C) the
ratio PEP/L VET to heart rate in normal subjects. PEP and L VET
are inversely related to heart rate. PEP/L VET tends to be slightly
higher at faster heart rates.

failure,14 an elevated ratio has been used widely as an indicator of myocardial dysfunction.15,
Mean Vcf has been advocated as a valuable index of LV
function in both children7 25, 32 and adults.2 5 26 By adding an
element of time to the measurement of change in left ventricular dimensions, Vcf has been reported to offer better
separation of normals from patients with abnormal left ventricular function than ejection fraction alone.55,1 25 However, in two recent studies38 "4 the percent of minor axis
shortening (%ALVD) was as sensitive as Vcf in detecting
depressed LV function. Although the present study does not

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VOL 56, No 3, SEPTEMBER 1977

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Human Ventricular Refractoriness

LI.

Effects of Procainamide

JOHN A. KASTOR, M.D., MARK E. JOSEPHSON, M.D.,

STEPHEN B. Guss, M.D., AND LEONARD N. HOROWITZ, M.D.
SUMMARY The effects of procainamide (PA) on the ventricular
effective refractory period (ERP-V) and on the relationship of refractoriness to recovery of excitability were evaluated in eight patients
during ventricular pacing. Measurements of ERP-V and plasma
levels of PA were taken before and after intravenous administration
of 500 mg of PA. The ERP-V was prolonged from a group mean
value of 237 7 msec (SE) to 279 16 msec (P < 0.05). Peak increase occurred at maximal drug levels five minutes after administration of PA. The QT intervals increased from a group mean value of

421 8 msec to 461 9 msec after PA (P < 0.01). The ratio ERPV/QT increased in seven of eight patients from 0.56 0.01 to 0.62
0.04 after infusion of PA (0.1 < P < 0.2). The ratio remained unchanged in one patient.
This study reveals that PA increases ERP-V in man and usually increases the ratio ERP-V/QT. Thus a longer portion of the ventricular recovery period is refractory after administration of the drug.
The data, which correlate with animal studies, help to explain how
PA may suppress human re-entrant ventricular arrhythmias.

PROCAINAMIDE is one of the most effective and frequently employed drugs for the treatment of ventricular
arrhythmias. It appears to work by several mechanisms: 1)
decreasing the slope of spontaneous phase 4 depolarization
in ventricular Purkinje cells; 2) slowing and equalizing conduction and refractoriness in regions of unidirectional block
or converting unidirectional to bidirectional block; 3) affecting the relationship of refractoriness to the recovery of the
threshold of excitability.1`4 None of these mechanisms has
been conclusively demonstrated in man.
The development of the ventricular extrastimulus method
permits evaluation of ventricular refractoriness to be per-

formed with safety and reproducibility in man.5 Total ventricular recovery can be estimated from the familiar QT interval of the electrocardiogram. In this study, we have
evaluated the effects of procainamide on these two electrophysiological characteristics of the human ventricle in eight
patients and have correlated the data with blood levels of the
drug.

From the Cardiac Clinical Electrophysiology Laboratory, Hospital of the

University of Pennsylvania and the Cardiovascular Section, Department of
Medicine, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania.
Supported in part by grants from the National Institutes of Health (HL
14807) and the American Heart Association, Southeastern Pennsylvania and
Berks County Affiliates.
Dr. Guss' present address is Morristown Memorial Hospital, Department
of Cardiology, Morristown, New Jersey 07960.
Address for reprints: John A. Kastor, M.D., 942 Gates Building, Hospital
of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.
Received September 30, 1976; revision accepted April 22, 1977.

were described and each patient gave informed consent. The

investigative evaluations were performed after completion of
electrophysiological diagnostic studies for which the patient
had been referred to the laboratory. In each patient, all cardiac medicines had been discontinued at least 48 hours
before study.
Electrode catheters were inserted as follows: a tripolar
catheter from the femoral vein across the tricuspid valve to
record the bundle of His potential, a quadripolar catheter
via a femoral or antecubital vein to the high right atrium for

Patients and Methods

The effects of procainamide on human ventricular electrophysiologic function were evaluated in eight patients
referred to the Clinical Cardiac Electrophysiology
Laboratory (table 1). The purpose and nature of the studies

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Evaluation of left ventricular size and function by echocardiography. Results in normal

children.
H P Gutgesell, M Paquet, D F Duff and D G McNamara
Circulation. 1977;56:457-462
doi: 10.1161/01.CIR.56.3.457
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1977 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

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