Systolic Function: Ejection Fraction Methods, Fractional Shortening & Strain

RDCS Adult Echocardiography AE

Track your progress as you read

Finished sections get a check mark.

1 Introduction & Exam Overview

The RDCS AE Exam, SPI Requirement & Logistics Content Outline, Domain Weights & How to Study

2 Cardiac Anatomy

Chambers, Walls, Myocardial Layers & the 17-Segment Model Cardiac Valves & Subvalvular Apparatus Great Vessels, Pericardium, Coronary & Venous Anatomy

3 Cardiac Physiology & Hemodynamics

Cardiac Cycle, Phases & Pressure-Volume Relationships Normal Systolic & Diastolic Function Hemodynamic Principles & Response to Stress

4 Echo Modalities, Instrumentation & Contrast

2D (B-Mode) and M-Mode Imaging Spectral, Color, and Tissue Doppler Modalities Image Optimization, Artifacts, and Contrast Echocardiography

5 Standard Views, Windows & Protocol

Parasternal Long- & Short-Axis Views Apical Views Subcostal & Suprasternal-Notch Views Exam Protocol, Patient Positioning & Provocative Maneuvers

6 Quantification & Doppler Hemodynamic Calculations

Chamber Quantification: LV, LA, RA, and RV Size, Mass, and Volumes Systolic Function: Ejection Fraction Methods, Fractional Shortening & Strain Diastolic Function Grading (ASE/EACVI 2016) Core Doppler Math: Modified Bernoulli, VTI, Stroke Volume & the Continuity Equation Advanced Hemodynamics: PISA/EROA, Pressure Half-Time, dP/dt, Qp/Qs & RVSP

7 Aortic & Mitral Valve Disease

Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation

8 Right-Sided, Prosthetic & Infective Valve Disease

Tricuspid & Pulmonic Valve Disease and Pulmonary Hypertension Assessment Infective Endocarditis and Vegetations Prosthetic Valves and Postoperative Evaluation

9 Ischemic Disease & Cardiomyopathies

Coronary Anatomy, Ischemic Heart Disease & Wall-Motion Abnormalities Stress Echocardiography & Myocardial Viability Mechanical Complications of Myocardial Infarction Dilated & Restrictive Cardiomyopathy Hypertrophic Cardiomyopathy, SAM & LVOT Obstruction

10 Pericardial Disease, Masses & Aorta

Pericardial Effusion & Cardiac Tamponade Constrictive Pericarditis vs. Restrictive Physiology Cardiac Masses, Tumors & Thrombi Aortic Disease: Aneurysm, Dissection & Atheroma

11 Congenital Heart Disease & Shunts

Septal Defects & Shunt Quantification Common Adult Congenital Lesions

12 Clinical Care & Safety

Patient Care, Clinical-Data Integration & Exam Protocols Bioeffects, ALARA, Infection Control & Ergonomics

Systolic Function: Ejection Fraction Methods, Fractional Shortening & Strain

Key Takeaways Explain This Topic AI

Ejection fraction = (EDV − ESV) ÷ EDV × 100; the ASE-recommended 2D method is the biplane method of discs (modified Simpson's rule).

Normal LVEF by 2D biplane is 52–72% in men and 54–74% in women.

Fractional shortening = (LVIDd − LVIDs) ÷ LVIDd × 100, with a widely used normal range of approximately 25–45%.

The Teichholz formula, V = [7.0 ÷ (2.4 + D)] × D³, is a single-dimension M-mode volume estimate that current ASE guidance no longer recommends for clinical LV volume or EF measurement.

Normal global longitudinal strain (GLS) is approximately −18% to −20% or more negative; values less negative than −16% are considered abnormal.

Last updated: July 2026

Ejection Fraction: The Core Formula

Ejection fraction (EF) describes the fraction of end-diastolic volume ejected with each systole:

EF (%) = (EDV − ESV) ÷ EDV × 100

EDV and ESV can come from 2D biplane volumes, 3D volumes, or (historically) single-dimension linear estimates. The method used to obtain EDV and ESV determines the formula's accuracy and its current guideline status.

Simpson Biplane Method (Modified Simpson's Rule)

The biplane method of discs , also called modified Simpson's rule, is the ASE-recommended 2D method for calculating LV volumes and EF. The endocardial border is traced at end-diastole and end-systole in both the apical 4-chamber and apical 2-chamber views. The software divides the traced LV cavity into a stack of parallel discs of equal height between the mitral annular plane and the apex, sums the disc volumes, and averages the two biplane estimates. Because it does not assume a fixed LV shape (unlike single-dimension formulas), it remains reliable in dilated, foreshortened, or asymmetrically remodeled ventricles, which is why it is the current standard of care.

• Parameter Men — normal Women — normal
• LVEF (2D biplane) 52–72% 54–74%

Severity partitions for LVEF are also sex-specific:

• Severity Men Women
• Normal 52–72% 54–74%
• Mildly abnormal 41–51% 41–53%
• Moderately abnormal 30–40% 30–40%
• Severely abnormal <30% <30%
• Teichholz Method

Before biplane discs became standard, LV volume was often estimated from a single M-mode LVID measurement using a geometric formula assuming a prolate-ellipsoid shape:

LV volume (mL) = [7.0 ÷ (2.4 + D)] × D³

where D is the LV internal diameter in centimeters, applied separately at end-diastole (using LVIDd) and end-systole (using LVIDs) to obtain EDV and ESV, from which EF is then derived using the standard EF formula. Because this method depends entirely on one linear dimension and a fixed geometric assumption, it becomes inaccurate whenever the ventricle is not uniformly shaped — regional wall motion abnormalities, aneurysms, or asymmetric hypertrophy all invalidate the assumption. Current ASE guidance explicitly states that the Teichholz (and Quinones) method is no longer recommended for clinical LV volume or EF measurement , though the formula still appears on the AE exam blueprint and candidates must be able to calculate it correctly and recognize its limitations.

Fractional Shortening

Fractional shortening (FS) is a simpler, single-dimension linear index of systolic function derived directly from the LV internal diameters:

FS (%) = (LVIDd − LVIDs) ÷ LVIDd × 100

A widely used normal range for FS is approximately 25–45% , which broadly corresponds to a normal EF range. Like the Teichholz method, FS relies on a single M-mode dimension measured at the LV base and is therefore only representative of global function in a symmetrically contracting ventricle ; it should not be relied upon when regional wall motion abnormalities are present, since the base may contract normally while a distal segment does not.

Global Longitudinal Strain (GLS)

Strain quantifies the percentage deformation (shortening or lengthening) of myocardium relative to its baseline length, most commonly assessed by 2D speckle-tracking echocardiography (STE) :

Strain (%) = (Lₜ − L₀) ÷ L₀

Global longitudinal strain ( GLS ) averages this deformation across all myocardial segments in the standard apical views as the LV shortens along its long axis during systole. Because the myocardium shortens, GLS is reported as a negative number — a more negative value indicates better systolic function.

• GLS Value Interpretation
• ≤ −18% (e.g., around −20%) Normal
• Less negative than −16% Abnormal

GLS by speckle tracking is angle-independent , unlike tissue Doppler-derived indices, and has demonstrated incremental prognostic value over LVEF in a wide range of cardiac conditions, including valve disease, cardiomyopathy, and cancer-therapy cardiotoxicity surveillance. Because GLS values vary meaningfully between vendors and software versions, serial comparisons in an individual patient should use the same equipment and software each time. Acquisition begins with the apical long-axis view (to visualize aortic valve opening and closing clicks for accurate timing), followed by the 4- and 2-chamber views; results are commonly displayed as a color-coded 17-segment "bull's-eye" map alongside the numeric peak GLS value.

Technique Pitfalls That Affect Accuracy

All apical-view volumetric and strain measurements share the same acquisition pitfalls, and the AE exam frequently tests recognition of these errors rather than the formulas alone. Apical foreshortening — failing to capture the true long axis and apex — systematically underestimates LV length and therefore underestimates EDV, ESV, and can spuriously alter EF. Endocardial dropout , common in patients with poor acoustic windows, can be corrected with contrast enhancement (LV opacification) when two or more contiguous endocardial segments are not well visualized, per ASE indications for contrast use. For GLS specifically, when regional tracking quality is suboptimal in more than two myocardial segments in a single view, the calculation of that view's contribution to global strain should be avoided altogether rather than reported with reduced confidence.

Choosing the Right Method

On the AE exam, expect scenario-based questions that require recognizing which EF method is appropriate: biplane discs for routine and serial clinical assessment (the current ASE-recommended 2D standard), 3D echocardiography when available and image quality permits (more accurate and reproducible than 2D, without geometric assumptions), GLS as a complementary, more sensitive marker of subclinical systolic dysfunction that can be abnormal even when EF is still preserved, and Teichholz/FS recognized primarily as legacy single-dimension techniques with well-defined geometric limitations rather than current first-line tools.