Strain: Normal Values

Name: Echo: Strain Normal Values · HeartCalc
Creator: Piyawat Arichai, MD, FAAP

LV, RV and LA speckle-tracking strain from preterm birth to 21 years, by platform, with adult ASE/EACVI limits

Show values for

Birth to 21 years, by platform

Peak systolic strain, %, mean ± SD; 1,032 healthy children, Philips EPIQ images (Romanowicz 2023, Table 2).
Parameter	Neonate	Infant	1–5 y	>5–10	>10–14	>14–18	>18–21
LV apical 4-ch LSQLAB 10.8	−21 ± 3	−23 ± 3	−24 ± 3	−24 ± 3	−22 ± 3	−21 ± 3	−21 ± 3
LV apical 4-ch LSAutoSTRAIN	−20 ± 3	−22 ± 3	−25 ± 3	−24 ± 3	−23 ± 3	−22 ± 3	−22 ± 3
LV mid circumferentialQLAB 10.8, papillary level	−27 ± 4	−29 ± 4	−32 ± 4	−31 ± 3	−30 ± 4	−30 ± 4	−29 ± 4
RV free wallAutoSTRAIN, RV-focused	−25 ± 2	−29 ± 5	−32 ± 5	−30 ± 4	−29 ± 5	−27 ± 4	−27 ± 4
RV 4-chamber, septum includedAutoSTRAIN	−22 ± 2	−24 ± 4	−28 ± 3	−26 ± 3	−25 ± 4	−23 ± 3	−23 ± 4

Z-scores, numbers and caveats

Printed as decimal fractions (−0.21 = −21%). Neonate ≤28 days; infant to 1 year. LV rows: 40–266 children per band; RV rows: 7 neonates and 10 infants.
Z-scores: Romanowicz 2023 Table 3 gives equations by age for each row above (authors' online calculator: zscore.chboston.org). With the printed equations a less negative strain gives a positive Z; check the sign convention of any online calculator. Dallaire 2016 gives GE EchoPAC equations by BSA, 1–18 y (apical 4-chamber LS; basal, mid and apical circumferential), on absolute values: reduced LS gives a negative Z, but mid circumferential strain is modelled on 1/value, so a reduced value gives a positive Z. Neither paper sets an abnormal Z.
No equation exists for 3-view GLS, for QLAB 10.8 RV strain (LV algorithm applied to the RV; the authors advise against it) or for GE RV strain.
Pooled means across studies (mostly GE): LV GLS −20.2%, study means −16.7 to −23.6 (Levy 2016); RV free wall −30.1% (Levy 2014). Pooled means are not normal limits.

Neonates

Group	Values (%)	Source
Preterm <29 wk	Mean ± SD. LV GLS day 1 −18.4 ± 3.5, day 5–7 −20.7 ± 3.0, then stable to 1 year corrected age. RV free wall day 1 −18.1 ± 4.0, day 5–7 −20.5 ± 3.2, 4–6 weeks −21.0 ± 2.5, 60–79 weeks −27.5 ± 2.4 (GE)	Levy 2017, Tables 3, 5
Term, days 1–23	95% reference interval: LV apical 4-ch −24.65 to −14.62; RV free wall −28.69 to −10.68; RV 4-chamber −22.30 to −11.37 (Philips QLAB 15 AutoSTRAIN, n = 103)	Toma 2022, Tables 3–4
Neonates, pooled	LV GLS pooled mean 21.0% (magnitude; 4-chamber only 19.5%, 3 views 22.5%); 10 studies	Khan 2020

Left atrial strain

Group	Values (%)	Source
Neonate, first 48 h	Reservoir at 24 h / 48 h: ≤32 wk 32.3 / 36.8; 32–37 wk 33.3 / 36.9; ≥37 wk 33.3 / 36.7 (TomTec, R-R, 4-chamber; n = 30 per group)	Ficial 2022, Table 5
31 days–18 y	Reservoir, R-R, mean ± SD: 31 d–24 mo 49.3 ± 15.0; 2–5 y 54.2 ± 16.4; 5–11 y 53.2 ± 15.7; 11–18 y 50.5 ± 16.5. Conduit means 31.5–40.0 and contraction means 13.2–18.2 across age bands (QLAB 10 atrial package, 4-chamber; n = 580)	Marchese 2021, Table 2A
31 days–17 y	Reservoir 5th centile 40.0–42.2 across age bands; means 52.8–58.1 (QLAB 9 LV software adapted, R-R, 4-chamber; n = 836)	Cantinotti 2019, Table 2, Suppl. Table 6
Adult	Reservoir normal about 30–60%, lower limit 23%, borderline 23–30%. <18% goes with raised LV filling pressure.	ASE/EACVI 2025

Adult limits (not validated in children)

Group	Values (%)	Source
Adult	LV GLS: normal more negative than −18; borderline −16 to −18; abnormal less negative than −16. A relative fall of 10–15% on serial studies is likely meaningful.	ASE/EACVI 2025
Adult	RV free wall: lower limit −20 in men, −21 in women; less negative is abnormal. Grading bands: Systolic Function.	ASE/EACVI 2025

How to measure

Sign, timing, views and frame rate

Sign: LV and RV longitudinal and circumferential strain are negative; print the sign. Less negative = worse. LA reservoir is positive; the Task Force signs conduit and contraction negative, but many pediatric papers print magnitudes.
Timing: zero at end-diastole; the default report is end-systolic strain at aortic valve closure (ASE/EACVI 2025). Romanowicz, Dallaire and Toma used peak systolic strain, Levy 2017 end-systolic; the Task Force asks for peak systolic RV strain.
LV: 3-view GLS averages the apical 4-, 2- and 3-chamber views; both pediatric z-score sets are apical 4-chamber only. Reject badly tracked segments. Radial and segmental strain are not for clinical use.
RV: RV-focused apical 4-chamber; free-wall strain is the default report, 4-chamber (with septum) an option. Use dedicated RV software when available.
LA: LA-focused apical 4-chamber, R-R gating (zero at QRS onset), dedicated atrial software, tracing across the pulmonary-vein and appendage orifices. P-P gating gives lower values.
Frame rate: for longitudinal strain, neonates need a frame-rate to heart-rate ratio of at least 0.7–0.9 (about 110–130 frames/s preterm, 90–110 term), and above 1 for circumferential strain (El-Khuffash 2018).
Layer: often unreported in pediatric papers. Endocardial GLS runs about 1% larger in magnitude than mid-wall.

Key points

No pediatric abnormal threshold exists. Compare with age- and platform-matched values, and follow a child on the same vendor and software version.
Every value depends on platform, view and timing: apical 4-chamber LS is not 3-view GLS; RV free wall is not RV 4-chamber.
LV and RV strain peak at about 4–5 years, then fall through adolescence (QLAB 10.8 and AutoSTRAIN).
Neonates and young infants: least reliable (fast heart rates, small hearts, rapid maturation).
Beyond the newborn period, LA reservoir strain runs near 50%: adult cut-offs (23%, 18%) do not apply to children.

Why

The AEPC 2026 consensus notes the absence of accepted thresholds and advises reading serial change within multimodality follow-up. ASE/EACVI 2025 leaves pediatric ranges to pediatric guidance. Neither z-score paper sets a lower limit.
GE and Philips agree poorly (ICC as low as 0.34 for LV GLS and 0.12 for circumferential strain, AEPC 2026). Older QLAB 10.5 gave larger LV longitudinal strain than QLAB 10.8 and AutoSTRAIN, most in neonates and infants (Romanowicz 2023).
Strain is load-dependent: preterm infants with a significant PDA on day 5–7 had a more negative LV GLS (−23.9 vs −20.6%, Levy 2017).

Sources and how this page was checked

Guidance (full text read)

Cantinotti M, Ramcharan T, Dorobantu DM, McMahon C, et al. Applications of speckle tracking echocardiography in paediatric and congenital heart disease: an expert consensus paper from AEPC Imaging Working Group. Eur Heart J Imaging Methods Pract 2026;4(3):qyag132. doi:10.1093/ehjimp/qyag132.
Thomas JD, Edvardsen T, Abraham T, et al. Clinical applications of strain echocardiography: a clinical consensus statement from the ASE developed in collaboration with the EACVI. J Am Soc Echocardiogr 2025;38:985-1020. doi:10.1016/j.echo.2025.07.007. Adult values.
Badano LP, Kolias TJ, Muraru D, et al. Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force. Eur Heart J Cardiovasc Imaging 2018;19:591-600. doi:10.1093/ehjci/jey042.
El-Khuffash A, Schubert U, Levy PT, et al. Deformation imaging and rotational mechanics in neonates: a guide to image acquisition, measurement, interpretation, and reference values. Pediatr Res 2018;84(Suppl 1):30-45. doi:10.1038/s41390-018-0080-2 (text; its reference table was not used).

Normative studies (full text read)

Romanowicz J, Ferraro AM, Harrington JK, et al. Pediatric normal values and Z score equations for left and right ventricular strain by two-dimensional speckle-tracking echocardiography derived from a large cohort of healthy children. J Am Soc Echocardiogr 2023;36:310-323. doi:10.1016/j.echo.2022.11.006.
Dallaire F, Slorach C, Bradley T, et al. Pediatric reference values and Z score equations for left ventricular systolic strain measured by two-dimensional speckle-tracking echocardiography. J Am Soc Echocardiogr 2016;29:786-793. doi:10.1016/j.echo.2016.03.018.
Levy PT, El-Khuffash A, Patel MD, et al. Maturational patterns of systolic ventricular deformation mechanics by two-dimensional speckle tracking echocardiography in preterm infants over the first year of age. J Am Soc Echocardiogr 2017;30:685-698. doi:10.1016/j.echo.2017.03.003.
Toma D, Toganel R, Fagarasan A, et al. Interobserver agreement and reference intervals for biventricular myocardial deformation in full-term, healthy newborns: a 2D speckle-tracking echocardiography-based strain analysis. Int J Environ Res Public Health 2022;19:8620. doi:10.3390/ijerph19148620.
Khan U, Omdal TR, Matre K, Greve G. What is left ventricular strain in healthy neonates? A systematic review and meta-analysis. Pediatr Cardiol 2020;41:1-11. doi:10.1007/s00246-019-02219-8.
Levy PT, Machefsky A, Sanchez AA, et al. Reference ranges of left ventricular strain measures by two-dimensional speckle-tracking echocardiography in children: a systematic review and meta-analysis. J Am Soc Echocardiogr 2016;29:209-225. doi:10.1016/j.echo.2015.11.016.
Levy PT, Sanchez Mejia AA, Machefsky A, et al. Normal ranges of right ventricular systolic and diastolic strain measures in children: a systematic review and meta-analysis. J Am Soc Echocardiogr 2014;27:549-560. doi:10.1016/j.echo.2014.01.015.
Ficial B, Corsini I, Clemente M, et al. Feasibility, reproducibility and reference ranges of left atrial strain in preterm and term neonates in the first 48 h of life. Diagnostics 2022;12:350. doi:10.3390/diagnostics12020350.
Marchese P, Scalese M, Giordano R, et al. Pediatric ranges of normality for 2D speckle-tracking echocardiography atrial strain: differences between p- and r-gating and among new (atrial designed) and conventional (ventricular specific) software's. Echocardiography 2021;38:2025-2031. doi:10.1111/echo.15244.
Cantinotti M, Scalese M, Giordano R, et al. Left and right atrial strain in healthy Caucasian children by two-dimensional speckle-tracking echocardiography. J Am Soc Echocardiogr 2019;32:165-168.e3. doi:10.1016/j.echo.2018.10.002.

How it was checked

Sources were read in full text (October 2026), except the El-Khuffash 2018 reference table and the online supplements of Romanowicz and Marchese. Numbers are as printed in the table named in each row; Romanowicz fractions are shown as percentages.
Pooled means from meta-analyses are not normal limits. Adult values are labelled Adult.
Where sources disagree, the page follows the primary study: the AEPC consensus says QLAB 10.5 differs most in older children, but Romanowicz found the largest differences in neonates and infants; atrial software lowered LA reservoir strain only at 5–18 y (Marchese).
Not shown: Romanowicz centile curves and sex-specific tables (online supplement), 3-view GLS by age (5–54 children per band), and right atrial strain (not advised clinically).