2D echo report: what every line means

A 2D echo is an ultrasound film of your heart. A probe is moved over your chest with some gel, and sound waves — the same kind used to scan a pregnancy — bounce back to build a moving picture of the heart working, beat by beat. Nothing enters your body, there is no radiation, and it usually takes fifteen to thirty minutes.

If you have read how your heart works, the echo is the inspection of the rooms and the doors. It looks at how big each room is, how well the walls move, and whether each one-way door opens fully and shuts properly.

This page goes through the lines you will actually find on your report, in roughly the order they appear. Most of them will be normal. You do not need to understand all of them — but you should be able to find the two or three your doctor is talking about.

What an echo can and cannot see

It sees the muscle, the four rooms, the four doors, the sac around the heart, and the direction and speed of blood moving through all of it. That is a great deal.

It cannot see your coronary arteries. The pipes that supply the heart wall run on the outside surface and are two to three millimetres wide — far too small for this scan. So a completely normal echo does not tell you your arteries are clear, and an abnormal one does not by itself prove they are blocked. That question is answered by a different test: a TMT, a CT coronary angiogram, or a conventional angiogram.

It is also operator-dependent, and honest reports say so. Image quality depends on your build, your lungs and the person holding the probe. A report may note “suboptimal windows”, which means the pictures were harder to obtain than usual — not that something was hidden.

Ejection fraction — the pumping number

EF, or ejection fraction, is the pumping capacity of the heart, and it is the number almost everyone is handed and worries about.

Think of the left lower room as a tank with a motor sitting inside it. Between beats the tank fills. Then the motor switches on and pushes some of that blood out to the body. The ejection fraction is simply what share of the tankful leaves with each squeeze.

A tank never empties completely, and it is not supposed to. A strong motor pushes out a little over half of what is in the room — which is why “normal” is around 55 to 70 per cent and not 100.

Now weaken the motor. Less goes out with each beat, and what does not go out stays behind. The room is fuller than it should be when the next lot of blood arrives, so there is less space for it. That blood is coming from the lungs, and if it cannot get in, it backs up into the lungs. That is when you feel breathlessness — first on climbing stairs or hurrying, later on lying flat, because lying down sends even more blood back to the chest.

If the pressure keeps building backwards, it eventually reaches the right side of the heart and then the veins beyond it. That is where swelling of the ankles and legs comes from, and the fullness some people feel in the upper abdomen. The swelling is not a leg problem. It is the far end of a queue that starts at a weak motor.

What is normal

The reference ranges from the American Society of Echocardiography are 52–72% for men and 54–74% for women. Most Indian labs print a single simpler range, usually 55–70%, on the template. An EF below 50% is unlikely to be normal at any age, in either sex.

Reading your number

The confusion worth clearing up

An EF of 60% does not mean 40% blockage. This is the single commonest misreading we see in clinic. Ejection fraction is a share of the blood in a room, not a percentage of anything in your arteries. The two numbers have nothing to do with each other, and the echo cannot see your arteries at all.

One change worth knowing about

For years, reports and guidelines used three fixed bands: reduced (≤40%), mildly reduced (41–49%) and preserved (≥50%). In May 2026 the major cardiology societies published a new joint definition that steps back from fixed cut-offs and uses three clinically useful groups instead — reduced, preserved and improved ejection fraction. “Mildly reduced” was retired.

Both will be in circulation for a while: report templates and current treatment guidelines still print the old bands. Neither changes your number or what your doctor does about it.

The good news is in that third category. Improved ejection fraction is a recognised outcome — an EF that started at 40% or below, rose by at least 10 points, and is now above 40%. Cardiologists gave it a name because it happens often enough to need one.

Expect some variation between scans

Repeated measurements by the same experienced operator typically vary by 3 to 4 percentage points, and different observers can differ more. This is a real property of the test, not carelessness. So a fall from 55% to 50% between two scans may be measurement variation rather than deterioration — which is why the trend across scans, read alongside your symptoms, matters more than any single value.

The size of the rooms

You will see measurements in millimetres, usually labelled LVIDd and LVIDs — the width of the left lower room when it is full (d, diastole) and after it squeezes (s, systole). Normal LVIDd is roughly 42–58 mm in men and 38–52 mm in women.

A room stretches when it has been handling more than it should for a long time — too much volume coming back through a leaking door, or a muscle that has weakened and dilated to compensate. A bigger room is a sign of struggle, not of strength. This is the opposite of a biceps, and it surprises people.

LA or left atrial size gets its own line. The left upper room enlarges when pressure upstream of it has been raised for years, so it is often the first quiet evidence that something has been going on for a long time — even when everything else still reads normal.

It has one consequence worth knowing, because it explains a symptom people often have and have not connected to their heart. The wiring’s timer sits in the upper part of the heart, and a room that has been stretched for years disturbs the wiring running through its wall. That is why an enlarged left atrium so often arrives alongside atrial fibrillation — the fluttering, irregular heartbeat, sometimes felt as a thumping in the chest or unexplained tiredness.

The thickness of the walls

IVSd and LVPWd are the thickness of the dividing wall and of the back wall, in millimetres. Above roughly 11 mm is usually reported as hypertrophy — thickened muscle.

A wall thickens for the same reason any wall gets reinforced: it has been pushing against resistance for years. The commonest resistance is long-standing high blood pressure; a narrowed aortic door does it too.

This is the opposite of a biceps, and the word on the report misleads people. A thickened heart wall is not a stronger one. Thickened muscle is stiffer muscle, and a stiff room cannot relax and fill properly between beats — so what it cannot accept stays behind, and behind it are the lungs. That is why a thickened wall so often arrives with breathlessness on exertion in someone whose pumping number is perfectly normal, and why hypertrophy and the next section usually appear on the same report.

Wall motion — RWMA

“No RWMA” is a reassuring line. It means every segment of muscle moved normally.

RWMA stands for regional wall motion abnormality, and the report may name a region — “hypokinesia of the anterior wall”, or “akinetic inferior segment”. It means one stretch of wall is moving less than the rest, while the rest moves normally.

That pattern is the clue. Because each region of muscle is fed by a particular pipe, a segment that moves poorly points straight at the pipe that feeds it — the whole wall would be affected if the problem were the muscle itself, and only one territory is affected if the problem is its supply.

For some people this is the first they learn of a heart attack they did not know they had, which happens more often than most patients expect, particularly with long-standing diabetes. A quiet region does not prove a blockage on its own, but it raises the question sharply, and it is one of the findings most likely to lead to a stress test or an angiogram.

Diastolic function — the filling half

This is where most of the confusion on an echo report lives, and it is worth reading even if your EF is normal.

Squeezing is only half the job. Between beats the room has to relax and let itself be filled. A young heart is pliable — it opens out easily and accepts its share of blood in the fraction of a second available. Over the years, and much faster under high blood pressure or with a thickened wall, the muscle becomes stiff.

A stiff room cannot accept its full share in the time it has. Even when the motor is strong, what the room cannot take stays behind in the chamber before it — and behind that are the lungs. So the pressure builds backwards exactly as it does with a weak motor, and you feel the same breathlessness, for the opposite reason.

That is why you can be genuinely breathless with a perfectly normal ejection fraction, and why a doctor may take your symptoms seriously even after telling you the pumping is fine.

Reports grade it, usually:

You will also see E/A and E/e′ — ratios from the speed of blood crossing the mitral door and the speed of the muscle itself. They are the raw material for the grade. You do not need to interpret them; the grade is the summary.

The doors — when they leak

Every echo report gives each of the four doors two comments: whether it leaks, and whether it opens fully.

A leak is called regurgitation. A door that does not shut completely lets some blood slip back the way it came. The volume that should have gone forward now goes backward — so the room has to handle the same blood twice, and the pressure builds upstream.

Where the backward blood goes depends on which door leaks:

• Mitral or aortic — the left-side doors. Backward means towards the lungs, so a significant leak here shows up as breathlessness.
• Tricuspid or pulmonary — the right-side doors. Backward means into the body’s veins, so a significant leak here shows up as swollen ankles, distended neck veins, and fullness in the abdomen from a congested liver.

Grades run trivial · mild · moderate · severe.

The doors — when they will not open

A door that has stiffened and no longer opens fully is called stenosis, and every valve can develop it. Aortic stenosis is the one most often found in older adults.

Picture a crowded room emptying through a doorway. Wide open, everybody leaves easily. Now open that door only a quarter of the way. The people behind can push as hard as they like — only so many get through, and the crowd behind builds up. The room has to work harder and harder for the same result, and over time, as with any overworked muscle, the walls thicken.

That is exactly what a narrowed valve does to the room behind it. It is why aortic stenosis and left ventricular hypertrophy so often appear on the same report, and why the classic symptoms are breathlessness, chest tightness or light-headedness on exertion — when the crowd trying to get through is at its largest.

Because “moderate” and “severe” here decide whether a valve needs treating, stenosis is graded on numbers rather than words. You will see a gradient in mmHg — the pressure difference across the door, higher when the opening is tighter — and a valve area in cm². Your report may also give a peak velocity in m/s. These are the numbers a cardiologist uses to decide whether and when anything needs to be done.

The doors — what the report says the valve is

The two sections above describe what a door does — whether it leaks, whether it opens. A report also describes what a door is: how it was built, and what age or an old illness has done to it. These are the words that worry people most, because they sound like the name of a disease. Most of them are descriptions.

Sclerosis, and calcium in the ring — the ageing ones

Aortic valve sclerosis — your report may say the aortic door is sclerosed, thickened or calcified, and will usually add no stenosis or no significant gradient.

This is the valve ageing. It is the same kind of change as a cataract — a tissue that was once smooth and supple slowly stiffening with the years, in a body part that is used constantly and never rests. Nobody causes a cataract and nobody causes this. It is one of the commonest findings on the reports of people over sixty.

What does it mean for you day to day? Almost always nothing, and you will feel nothing — the door has stiffened a little but still opens properly, which is exactly what no stenosis on your report is saying. It needs no treatment and no medicine.

Two honest additions. It is watched, because in a small minority it slowly tightens over many years into true narrowing — but here the cataract stops being a good guide. A cataract nearly always ends in an operation; a sclerosed aortic valve usually does not. Most people who have this line on their report have it on the next report too, and nothing more happens. And it is a quiet sign that arteries elsewhere are ageing in the same way, which is a reason to keep blood pressure, cholesterol and sugar in hand — not a heart problem in itself.

Mitral annular calcification (MAC) is the same story in a different place: calcium in the ring the mitral door hangs from, rather than in the door itself. Common with age, commoner with diabetes and with kidney trouble. Usually it needs nothing at all, though a heavy deposit can stiffen or leak the valve a little, and your report will say so if it has.

Bicuspid aortic valve — how the door was built

A bicuspid aortic valve (BAV) is a door built with two leaves instead of the usual three, from the day the flat was built. It is not damage and nothing caused it. It is the commonest variation people are born with in the heart, roughly one in fifty to a hundred, and it often works perfectly well for decades.

What follows from it is simple arithmetic: two leaves share the work three normally do, so they take more wear each. A bicuspid door therefore tends to stiffen or start leaking earlier in life than a three-leaved one — often in the fifties or sixties rather than the eighties. That is why it is scanned from time to time rather than treated.

Two things travel with it. The aorta just beyond the door is measured on the same scan, because a bicuspid valve often comes with a slightly wider aortic wall that is worth keeping an eye on. And because it runs in families, a parent, brother, sister or child is usually offered a simple echo of their own.

Most people with a bicuspid valve need nothing but periodic scans — the scans exist so that if the door ever does tighten, it is found early rather than late.

Mitral valve prolapse — a door that billows

Myxomatous mitral valve, or mitral valve prolapse (MVP): the mitral leaflets have gone a little soft, thick and generous, so instead of meeting flush they billow back into the upper room as the heart squeezes.

It is a common description and in many people the door still seals, so there is little or no leak, and you feel nothing. What matters is not the word — it is whether the billowing is letting blood back, and whether the rooms have changed size because of it. If the leak is trivial or mild and the rooms are normal, this is a valve to watch, not to treat.

Rheumatic heart disease — the one that matters

Rheumatic heart disease (RHD) is damage left behind by rheumatic fever — the body’s reaction to a throat infection, usually in childhood, often years or decades before the scan.

Here is what the inflammation actually does. The door has leaves that must separate cleanly each time it opens. Long inflammation makes the edges where those leaves meet stick to one another, as though glued — and once stuck, they never fully part again. The door has not been broken or bent. Its leaves simply no longer open away from each other, so what should be a wide doorway becomes a slit.

Follow that downstream and the symptoms explain themselves. Most often it is the mitral door, so blood cannot get out of the left upper room fast enough. It banks up behind the narrowing, and behind that room are the lungs — so the first thing people notice is breathlessness, on stairs or hurrying at first, later on lying flat. The stretched upper room also disturbs the wiring running through it, which is why an irregular, fluttering heartbeat so often comes with it. And because the same inflammation thickens and shortens the cords holding the leaves, a rheumatic door commonly leaks as well as narrows — your report may describe both.

The confusion worth killing: you do not still have the infection. The throat infection was over decades ago and there is nothing active to cure. What remains is the mark it left. The penicillin many patients stay on for years is not treating that damage — it is preventing another attack from adding to it.

This is the finding on this page most likely to appear in a younger person, it is common in India, and it is followed closely. When the door becomes tight enough it can be opened with a balloon or, if needed, replaced — but whether and when is a decision for your cardiologist, made with you and your family.

Pressure in the lungs — PASP

Often reported as an estimate in mmHg, sometimes with the phrase “no evidence of pulmonary hypertension”. PASP is the pressure in the vessels carrying blood from the heart to the lungs.

It is usually a consequence rather than a cause. When the left side of the heart cannot accept blood easily — a weak motor, a stiff room, a leaking or narrowed door — the pressure backs up along the route it came from, and that route ends at the lungs. So a raised PASP is often the same story as the rest of the report, read one step further back, and it is part of why breathlessness is the symptom that ties so many echo findings together.

Two cautions. It is worked out indirectly, from the speed of the small backward jet across the tricuspid door, so it is an estimate rather than a measurement. And a mildly raised value on a single scan is read alongside everything else on the report — not on its own.

IVC, pericardium, and the other lines

• IVC — the large vein returning blood to the heart. The report notes its width and whether it collapses when you breathe in. A wide vein that does not collapse suggests the system is running full; a normal, collapsing one is reassuring.
• Pericardial effusion — fluid in the thin sac around the heart. Small effusions are common and often mean nothing; larger ones are followed, because a big enough collection can press on the heart.
• TAPSE — a millimetre measurement of how well the right lower room moves. Around 17 mm or more is generally normal.
• “No clot”, “no vegetation”, “aortic root normal” — these are things specifically looked for and not found. A report lists them so the absence is on record.

The impression

The last few lines are the impression, or conclusion: the sonographer’s or cardiologist’s summary of what mattered. Read it first, then use the lines above it as the evidence behind it.

Two honest cautions. It is written for the doctor who ordered the scan, in their shorthand. And it summarises this scan alone — not your history, your examination, your blood tests or your last echo, all of which change what it means.

What happens after an abnormal echo

The pattern is usually: find the cause, treat it, then re-scan after a few months to see how the heart has responded.

Finding the cause is where other tests appear — blood tests, an ECG, often a stress test, and sometimes an angiogram if the pipes look like the likely culprit. A repeat echo is usually done months later, not weeks, because the heart responds to treatment slowly and because two scans done close together mostly measure the variation described above.

If your report has raised the possibility of a procedure, ask your cardiologist to walk you through what it involves and why they are suggesting it now — and take a family member with you. That conversation is part of the treatment, not an extra to it.

Common questions

Is EF 45% dangerous?

EF 45% is below normal but it is not an emergency, and it is one of the more treatable findings in cardiology. It means the motor is pushing out less than it should, so your doctor will look for the cause — most often blocked arteries, long-standing high blood pressure, or a problem in the heart muscle itself. Modern heart-failure medicines improve the ejection fraction in a substantial proportion of people, sometimes back into the normal range.

Does EF 60% mean 40% blockage?

No, and this is the most common misreading of an echo report. Ejection fraction is the share of blood in the room that leaves with each squeeze, not a measure of how blocked your arteries are. EF 60% is normal pumping. A 2D echo cannot see the coronary arteries at all — blockages are assessed with a TMT, a CT angiogram or a conventional angiogram.

My EF is normal, so why am I breathless?

Because the squeeze is only half the job. The room also has to relax and fill between beats, and a stiff room cannot accept its full share in the time available. What it cannot accept stays behind, and behind it are the lungs. That is diastolic dysfunction, and it causes breathlessness with a perfectly normal ejection fraction. A leaking or narrowed valve, anaemia, thyroid disease and lung disease can each do the same.

My report says trivial or mild mitral regurgitation. Is my valve damaged?

Usually not. Modern machines are sensitive enough to pick up a trace of backflow at one or two doors in a great many completely normal hearts. At trivial or mild grade, on its own, it is generally a description of a normal valve rather than a diagnosis. What matters is the grade, whether the heart chambers have changed size because of it, and whether it changes over the years.

My EF was 55% last year and 50% now. Has my heart got worse?

Not necessarily. Ejection fraction is measured, not weighed: repeated measurements by the same experienced person typically vary by around 3 to 4 percentage points, and different observers can differ more. A 5-point change between two scans may be measurement variation rather than a real decline, which is why cardiologists read the trend across several scans alongside your symptoms rather than reacting to one number.

What is a normal ejection fraction?

The reference range from the American Society of Echocardiography is 52 to 72 per cent for men and 54 to 74 per cent for women. Most Indian labs print a simpler 55 to 70 per cent on the report template. An ejection fraction below 50 per cent is unlikely to be normal at any age or in either sex, and deserves a conversation with your doctor.

Do I need to stop working or exercising because of my echo report?

Do not make that decision from a report alone. Advice about exertion depends on why the finding is there, what your symptoms are, and what else the scan showed — and for many people supervised exercise is part of the treatment rather than something to avoid. Ask your cardiologist specifically what level of activity is safe for you.

Why does my report have so many numbers I cannot find explained anywhere?

An echo report is written for the doctor who ordered it, not for you, and it lists every measurement taken whether or not it turned out to matter. Most of the lines will be normal and will never be discussed. The impression at the end is the part your doctor is summarising for, and the lines above it are the evidence behind it.