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Frontiers of Medicine

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Front. Med.    2024, Vol. 18 Issue (4) : 649-663    https://doi.org/10.1007/s11684-023-1045-3
Echocardiographic Measurements in Normal Chinese Adults (EMINCA) II focusing on left ventricular and left atrial size and function by three-dimensional echocardiography
Yingbin Wang1, Yu Zhang1, Guihua Yao1,2, Hong Tang3, Lixin Chen4, Lixue Yin5, Tiangang Zhu6, Jianjun Yuan7, Wei Han8, Jun Yang9, Xianhong Shu10, Ya Yang11, Yulin Wei12, Yanli Guo13, Weidong Ren14, Dongmei Gao15, Guilin Lu16, Ji Wu17, Hongning Yin18, Yuming Mu19, Jiawei Tian20, Lijun Yuan21, Xiaojing Ma22, Hongyan Dai23, Yunchuan Ding24, Mingyan Ding25, Qing Zhou26, Hao Wang27, Di Xu28, Mei Zhang1(), Yun Zhang1()
1. State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan 250012, China
2. Department of Cardiology, Qilu Hospital of Shandong University (Qingdao), Qingdao 266000, China
3. Department of Ultrasonography, West China Hospital, Sichuan University, Chengdu 610041, China
4. Department of Ultrasonography, Shenzhen People’s Hospital/The Second Clinical Medical College of Jinan University, Shenzhen 518020, China
5. Department of Ultrasonography, Electronic Science and Technology University of China, The Affiliated Sichuan Provincial People’s Hospital, Chengdu 610072, China
6. Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
7. Department of Ultrasonography, Henan Provincial People’s Hospital, Zhengzhou 463599, China
8. Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin 150007, China
9. Department of Echocardiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
10. Department of Echocardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
11. Department of Echocardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
12. Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
13. Department of Ultrasonography, The Southwest Hospital of AMU, Chongqing 400038, China
14. Department of Ultrasonography, Shengjing Hospital of China Medical University, Shenyang 110136, China
15. Department of Ultrasonography, China-Japan Union hospital of Jilin University, Changchun 130033, China
16. Department of Ultrasonography, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi 832000, China
17. Department of Ultrasonography, The First Affiliated Hospital of Guangxi Medical University, Nanning 537406, China
18. Department of Echocardiology, The Second Hospital of Hebei Medical University, Shijiazhuang 050061, China
19. Department of Ultrasonography, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
20. Department of Ultrasonography, The Second Affiliated Hospital of Harbin Medical University, Harbin 150088, China
21. Department of Ultrasonography, Tangdu Hospital of Air Force Medical University of PLA, Xi’an 710038, China
22. Department of Ultrasonography, Wuhan Asia Heart Hospital, Wuhan 430022, China
23. Department of Cardiology, Qingdao Municipal Hospital, Qingdao 266071, China
24. Department of Ultrasonography, Yan’an Hospital Affiliated to Kunming Medical University, Kunming 650051, China
25. Department of Ultrasonography, The People’s Hospital of Liaoning Province, Shenyang 110067, China
26. Department of Ultrasonography, Renmin Hospital of Wuhan University/ Hubei General Hospital, Wuhan 430060, China
27. Department of Ultrasonography, Fuwai Hospital/Chinese Academy of Medical Sciences, Beijing 100037, China
28. Department of Ultrasonography, Jiangsu Province Hospital, Nanjing 210029, China
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Abstract

Current guidelines encourage large studies in a diverse population to establish normal reference ranges for three-dimensional (3D) echocardiography for different ethnic groups. This study was designed to establish the normal values of 3D-left ventricular (LV) and left atrial (LA) volume and function in a nationwide, population-based cohort of healthy Han Chinese adults. A total of 1117 healthy volunteers aged 18–89 years were enrolled from 28 collaborating laboratories in China. Two sets of 3D echocardiographic instruments were used, and full-volume echocardiographic images were recorded and transmitted to a core laboratory for image analysis with a vendor-independent off-line workstation. Finally, 866 volunteers (mean age of 48.4 years, 402 men) were qualified for final analysis. Most parameters exhibited substantial differences between different sex and age groups, even after indexation by body surface area. The normal ranges of 3D-LV and 3D-LA volume and function differed from those recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, presented by the World Alliance Societies of Echocardiography (WASE) study, and from the 2D values in the EMINCA study. The normal reference values of 3D echocardiography-derived LV and LA volume and function were established for the first time in healthy Han Chinese adults. Normal ranges of 3D-LV and 3D-LA echocardiographic measurements stratified with sex, age, and race should be recommended for clinical applications.
Keywords three-dimensional echocardiography      left ventricle      left atrium      normal reference values      Chinese adults     
Corresponding Author(s): Mei Zhang,Yun Zhang   
Just Accepted Date: 10 April 2024   Online First Date: 22 May 2024    Issue Date: 30 August 2024
 Cite this article:   
Yingbin Wang,Yu Zhang,Guihua Yao, et al. Echocardiographic Measurements in Normal Chinese Adults (EMINCA) II focusing on left ventricular and left atrial size and function by three-dimensional echocardiography[J]. Front. Med., 2024, 18(4): 649-663.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-023-1045-3
https://academic.hep.com.cn/fmd/EN/Y2024/V18/I4/649
Inclusion criteria
Han nationality
≥ 18 years of age
No history of hypertensiona, dyslipidemiaa, diabetes, and more than mild valvular disease
Blood pressure < 140/90 mmHg
Body mass index 18–28 kg/m2
Exclusion criteria
Pregnant or lactating women
Competitive athletes
History of alcoholism
Abnormal renal function (blood creatinine > 2 mg/dL or 177 mmol/L)
Abnormal liver function (serum alanine aminotransferase or aspartate aminotransferase > 2.0 times the upper limit of normal)
Hyperlipidemia (serum total cholesterol ≥ 5.72 mmol/L or triglyceride ≥ 1.70 mmol/L)
diabetes mellitus (fasting blood glucose > 7 0.0 mmol/L)
Any other major diseases (cardiovascular diseases, endocrine diseases, respiratory diseases, severe anemia, and connective tissue disease)
Tab.1  Inclusion and exclusion criteria of enrolled volunteers
Fig.1  Representative left ventricular three-dimensional echocardiograms. 4CH, four-chamber view; 2CH, two-chamber view; 3CH, three-chamber view; ED, end-diastole; ES, end-systole.
Fig.2  Representative left atrial three-dimensional echocardiograms. 4CH, four-chamber view; 2CH, two-chamber view; SAX, short-axis view; ED, end-diastole; ES, end-systole.
Variables Values (percentage)
Age (year) 48 (18–88)
Age group (year)
18–29 185 (21.3%)
30–39 153(17.7%)
40–49 141 (16.3%)
50–59 139 (16.1%)
60–69 136 (15.7%)
≥ 70 112 (12.9%)
Sex
Men 402 (46.4%)
Women 464 (53.6%)
Height (cm) 165 (146–188)
Weight (kg) 61 (45–91)
BSA (m2) 1.76 (1.48–2.25)
Hear rate (beats/min) 72 (50–90)
SBP (mmHg) 120 (80–145)
DBP (mmHg) 76 (50–90)
Tab.2  Demographic characteristics of enrolled volunteers
Men Women
Parameters Total (n = 365) 18−40 (n = 151) 41−65 (n = 148) > 65 (n = 66) Total (n = 425) 18−40 (n = 178) 41−65 (n = 173) > 65 (n = 74)
3D-LVEDV (mL) 87.7 ± 21.6 95.6 ± 20.7 84.9 ± 20.9* 75.2 ± 17.8*& 74.2 ± 16.3# 76.8 ± 16.1# 73.1 ± 15.6# 70.3 ± 17.2
3D-LVEDVI (mL/m2) 49.5 ± 12.5 53.9 ± 12.0 47.5 ± 12.5* 43.8 ± 10.2* 46.8 ± 12.8# 48.1 ± 13.6# 45.9 ± 12.1 45.3 ± 12.1
3D-LVESV (mL) 33.6 ± 10.4 37.6 ± 9.9 31.9 ± 10.1* 28.2 ± 8.8* 27.6 ± 8.2# 28.0 ± 7.9# 27.5 ± 8.0# 26.6 ± 9.0
3D-LVESVI (mL/m2) 19.1 ± 5.9 21.2 ± 5.6 18.0 ± 5.8* 16.4 ± 4.9* 17.7 ± 5.4# 18.1 ± 5.3# 17.6 ± 5.2# 17.1 ± 6.1
3D-LVSV (mL) 54.0 ± 13.3 58.0 ± 13.3 53.0 ± 13.1* 47.0 ± 10.4*& 46.7 ± 9.9# 48.8 ± 10.2# 45.6 ± 9.1*# 43.7 ± 9.9
3D-LVSVI (mL/m2) 30.6 ± 7.6 32.7 ± 7.7 29.8 ± 7.4* 27.4 ± 6.1*& 30.0 ± 6.8 31.4 ± 6.9 29.2 ± 6.2* 28.2 ± 7.2
3D-LVEF (%) 61.9 ± 5.3 60.8 ± 5.3 62.6 ± 5.5* 62.8 ± 4.6* 63.2 ± 5.3# 63.9 ± 5.0# 62.7 ± 5.1 62.7 ± 6.2
3D-LVGLS (%) −22.2 ± 4.0 −21.9 ± 3.9 −22.3 ± 4.1 −22.4 ± 4.0 −23.0 ± 4.9# −23.0 ± 5.6# −22.9 ± 4.0 −23.2 ± 4.8
3D-LVGCS (%) −30.1 ± 5.2 −29.6 ± 5.0 −30.4 ± 5.4 −30.5 ± 4.8 −30.9 ± 5.3 −30.7 ± 5.4 −30.9 ± 5.1 −30.6 ± 5.9
Tab.3  Measurements of 3D left ventricular volume and function stratified by sex and age
Fig.3  Comparison of 3D LV and LA volume and function between men and women. (A,B) Values of LV and LA, respectively. LVEDVI, left ventricular end-diastolic volume index; LVESVI, left ventricular end-systolic volume index; LVSVI, left ventricular stroke volume index; LVEF, left ventricular ejection fraction; 3D-LVGLS, three-dimensional left ventricular global longitudinal strain; 3D-LVGCS, three-dimensional left ventricular global circumferential strain; LAVmaxI, left atrial maximum volume index; LAVminI, left atrial minimum volume index; LAEVI, left atrial end-diastolic volume index; LAEF, left atrial emptying fraction. *, P < 0.05 versus men.
EMINCA II (mean ± SD) WASE (mean ± SD) Guidelines (mean ± SD)
Parameters Men Women P Men Women Men Women
3D-LVEDVI (mL/m2) 50 ± 13* 47 ± 13* 0.001 70 ± 15 65 ± 12 50 ± 12 46 ± 9
3D-LVESVI (mL/m2) 19 ± 5.9* 18 ± 5.4* <0.001 28 ± 7 25 ± 6 19 ± 5 17 ± 4
3D-LVEF (%) 62 ± 5.3^ 63 ± 5.3 0.005 60 ± 5 62 ± 5 61 ± 4 63 ± 4
3D-LVGLS (%) −22 ± 4.0* −23 ± 4.9* 0.022 −21 ± 3 −22 ± 3 NA NA
3D-LVGCS (%) −30 ± 5.2 −31 ± 5.3* 0.868 −31 ± 4 −32 ± 4 NA NA
Tab.4  Comparison of 3D LV measurements in EMINCA II, WASE, and ASE/EACVI guideline
Fig.4  Comparison between the normal ranges of 3D LV measurements in EMINCA II stratified by sex and age with those in ASE/EACVI guidelines of 2015 and the 3D WASE study of 2021. The means and normal ranges of 3D LV measurements in EMINCA II for each age group were presented as dots and vertical lines, respectively. The relationship to the normal ranges of the ASE/EACVI guidelines and the 3D WASE study were presented as horizontal blue lines and yellow horizontal bars, respectively. LVEDVI, left ventricular end-diastolic volume index; LVESVI, left ventricular end-systolic volume index; LVEF, left ventricular ejection fraction; LVGLS, left ventricular global longitudinal strain; LVGCS, left ventricular global circumferential strain; LNLs, lower normal limits; UNLs, upper normal limits.
Men Women
Parameters Total (n = 358) 18–40 (n =144) 41–65 (n = 148) > 65 (n = 66) Total (n = 425) 18–40 (n = 180) 41–65 (n = 172) > 65 (n = 73)
3D-LAVmax (mL) 34.5 ± 10.7 32.3 ± 10.2 35.8 ± 9.9* 36.0 ± 12.8* 32.1 ± 10.2# 29.4 ± 9.2# 33.3 ± 10.1*# 35.7 ± 11.1*
3D-LAVmaxI (mL/m2) 19.4 ± 5.9 17.8 ± 5.5 20.2 ± 5.5* 20.9 ± 7.1* 20.7 ± 6.5 19.0 ± 5.9 21.3 ± 6.4* 23.2 ± 7.1*&#
3D-LAVmin (mL) 13.9 ± 4.5 12.9 ± 4.3 14.6 ± 4.3* 14.4 ± 5.2* 12.7 ± 4.4# 11.2 ± 3.5# 13.6 ± 4.5*# 14.4 ± 4.7*
3D-LAVminI (mL/m2) 7.8 ± 2.5 7.1 ± 2.3 8.2 ± 2.3* 8.4 ± 2.9* 8.2 ± 2.8 7.2 ± 2.3 8.7 ± 2.9* 9.4 ± 3.0*
3D-LAEV (mL) 20.6 ± 7.1 19.5 ± 6.9 21.2 ± 6.6* 21.5 ± 8.4* 19.5 ± 7.0# 18.4 ± 7.0 19.8 ± 6.7*# 21.3 ± 7.2*
3D-LAEVI (mL/m2) 11.6 ± 4.0 10.7 ± 3.7 12.0 ± 3.7 12.5 ± 4.7 12.5 ± 4.4# 11.8 ± 4.4 12.6 ± 4.2 13.9 ± 4.6*
3D-LAEF (%) 57.3 ± 5.7 58.8 ± 5.5 56.7 ± 6.2 56.4 ± 5.0 57.5 ± 6.4 58.9 ± 6.1 57.6 ± 5.9 55.8 ± 7.3*
Tab.5  Measurements of 3D LA volume and function stratified by sex and age
EMINCA II (mean ± SD) WASE (mean ± SD)
Men Women Men Women
Parameters 18–40 y 41–65 y > 65 y 18–40 y 41–65 y > 65 y 18–40 y 41–65 y > 65 y 18–40 y 41–65 y > 65 y
3D-LAVmax (mL) 32 ± 10* 36 ± 10* 36 ± 13* 29 ± 9* 33 ± 10* 36 ± 11* 51 ± 14 55 ± 16 56 ± 15 44 ± 11 47 ± 12 49 ± 13
3D-LAVmaxI (mL/m2) 18 ± 6* 20 ± 6* 21 ± 7* 19 ± 6* 21 ± 6* 23 ± 7* 27 ± 6 29 ± 8 31 ± 8 27 ± 6 28 ± 7 30 ± 7
3D-LAVmin (mL) 13 ± 4* 15 ± 4* 14 ± 5* 11 ± 4* 14 ± 5* 14 ± 5* 19 ± 7 21 ± 8 22 ± 8 16 ± 5 18 ± 6 20 ± 7
3D-LAVminI (mL/m2) 7.1 ± 2* 8 ± 2* 8.4 ± 32.9* 7.2 ± 2* 8.7 ± 3* 9.4 ± 3* 10 ± 3 11 ± 4 12 ± 4 10 ± 3 11 ± 4 12 ± 4
3D-LAEV (mL) 20 ± 7* 21 ± 7* 22 ± 8* 18 ± 7* 20 ± 7* 21 ± 7* 30 ± 10 36 ± 12 39 ± 12 25 ± 7 30 ± 9 34 ± 10
3D-LAEVI (ml/m2) 11 ± 4* 12 ± 4* 13 ± 5* 11 ± 4* 13 ± 4* 14 ± 5* 16 ± 4 19 ± 6 21 ± 6 15 ± 4 18 ± 5 21 ± 6
3D-LAEF (%) 59 ± 6* 57 ± 6 56 ± 5* 59 ± 6* 58 ± 6* 56 ± 7 63 ± 8 62 ± 7 60 ± 8 65 ± 7 62 ± 8 60 ± 7
Tab.6  Comparison of 3D LA measurements in EMINCA II and WASE
Fig.5  Comparison of the proportion of abnormal 3D LV volume and function in men and women as defined by the normal range limits of the current study (EMINCA), the 3D WASE study, and the latest ASE/EACVI guideline. LVEDVI, left ventricular end-diastolic volume index; LVESVI, left ventricular end-systolic volume index; LVEF, left ventricular ejection fraction; LVGLS, left ventricular global longitudinal strain.
Fig.6  Comparison of the proportion of abnormal 3D LA volume in men and women as defined by the normal range limits of the current study (EMINCA) and the 3D WASE study in different age groups. LAVmaxI, left atrial maximum volume index; LAVminI, left atrial minimum volume index; LAEVI, left atrial end-diastolic volume index.
Men (LNL to UNL) Women (LNL to UNL)
Parameters Total men 18–40 y 41–65 y > 65 y Total women 18–40 y 41–65 y > 65 y
3D-LVEDV (mL) 50.4–138.0 59.3–144.7 49.6–132.7 43.3–133.1 43.1–108.2 47.8–107.4 42.1–108.8 42.2–109.4
3D-LVEDVI (mL/m2) 27.6–76.0 33.5–76.6 21.6–74.2 19.7–73.9 29.2–70.2 30.0–73.0 29.3–68.2 24.5–66.1
3D-LVESV (mL) 17.7–56.3 21.6–58.1 16.6–55.5 17.1–58.8 14.5–46.8 17.4–46.4 13.8–45.2 12.4–48.8
3D-LVESVI (mL/m2) 10.0–32.0 12.0–32.7 8.8–32.0 6.7–32.4 9.1–29.5 9.1–31.0 8.3–29.0 8.0–29.1
3D-LVSV (mL) 32.2–82.7 35.9–89.1 31.8–81.4 26.9–79.3 26.1–68.9 28.8–70.5 25.5–67.7 25.4–63.9
3D-LVSVI (ml/m2) 17.8–48.1 20.1–49.6 16.3–46.7 17.6–44.5 17.5–45.0 16.3–47.0 17.2–42.2 13.5–41.1
3D-LVEF (%) 51.5–72.3 51.1–70.6 50.0–72.7 49.8–71.9 52.8–73.6 53.3–73.3 52.3–72.4 49.7–77.0
3D-LVGLS (%) −15.4 to −29.7 −15.6 to −30.4 −14.4 to −30.0 −14.6 to −30.0 −15.7 to −32.7 −16.1 to −33.0 −15.7 to −31.6 −15.2 to −33.8
3D-LVGCS (%) −20.5 to −40.9 −20.9 to −39.3 −20.0 to −41.9 −19.3 to −41.1 −20.5 to −41.3 −19.9 to −41.0 −19.7 to −41.6 −20.5 to −45.5
3D-LAVmax (mL) 16.1–57.0 16–57 19–54 17–70 15–56 16–53 17–56 15–61
3D-LAVmaxI (mL/m2) 10–32 9–31 11–31 10–40 10–36 10–36 11–35 10–39
3D-LAVmin (mL) 7–26 7–25 8–25 7–31 6–23 6–20 7–23 7–25
3D-LAVminI (mL/m2) 4–14 4–13 4–13 4–17 4–15 4–13 5–16 4–16
3D-LAEV (mL) 9–37 9–36 10–36 10–40 9–35 8–35 9–34 9–38
3D-LAEVI (mL/m2) 5–21 5–18 6–21 5–23 6–23 5–23 6–21 6 –24
3D-LAEF (%) 46–70 45–71 46–70 45–65 44–69 44–69 43–67 44–63
Tab.7  Normal ranges of 3D LV and 3D LA stratified by sex and age
Fig.7  Bland–Altman plots of intra- and inter-observer variabilities of left ventricular end-diastolic volume (LVEDV), (A and B), left ventricular end-systolic volume (LVESV) (C and D), left ventricular ejection fraction (LVEF) (E and F), left ventricular global longitudinal strain (LVGLS) (G and H), and left atrial emptying fraction (LAEF) (I and J).
EMINCA II EMINCA
Parameters Men Women P Men (n = 678) Women (n = 716) P
3D-LVEDV (mL) 87.7 ± 21.6 74.2 ± 16.3 < 0.001
2D-LVEDV (mL) 86.7 ± 20.8 72.2 ± 17.6 < 0.001
3D-LVESV (mL) 33.6 ± 10.4* 27.6 ± 8.2* < 0.001
2D-LVESV (mL) 31.2 ± 9.6 26.0 ± 9.0 < 0.001
3D-LVEF (%) 61.9 ± 5.3* 63.2 ± 5.3* 0.005
2D-LVEF (%) 64.4 ± 6.0 65.0 ± 6.2 0.34
3D-LAVmax (mL) 34.5 ± 10.7* 32.1 ± 10.2* 0.002
2D-LAV (mL) 38.0 ± 11.6 34.8 ± 10.7 < 0.001
Tab.8  Comparison of 3D measurements in EMINCA II and 2D measurements in EMINCA
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