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OBJECTIVE: To assess prospectively the intra- and interobserver variability, accuracy, and prognostic value of right and left ventricular short-axis diameter (RVd and LVd) measurements for risk stratification in patients with pulmonary embolism (PE) using ECG-gated compared to non-gated CT. MATERIALS AND METHODS: Sixty consecutive patients (33 women; mean age 58.7±10.3 years) with suspicion of PE underwent both non-gated and ECG-gated chest CT. RVd and LVd on four-chamber views and intra- and interobserver agreements were calculated for both protocols. RVd/LVd ratios were calculated and were related to 30-days adverse clinical events using receiver operating characteristics with area-under-the-curve (AUC) analyses. RESULTS: Both inter- and intraobserver variability showed narrower limits of agreement for all measurements with ECG-gated as compared to non-gated CT. Diameter measurements were significantly lower using non-ECG-gated CT as compared to ECG-gated CT for RVd and LVd (both p<.05). The AUC for the RVd/LVd ratio from ECG-gated CT was significantly larger than that from non-gated CT (0.956, 95% CI: 0.768-0.999 versus 0.675, 95% CI: 0.439-0.860; p=.048). CONCLUSION: RVd and LVd measurements from ECG-gated chest CT show less intra- and interobserver variability and more accurately reflect ventricular function. In our patient cohort ECG-gated chest CT allows better prediction of short-term outcome of patients with acute PE that needs to be validated in a larger outcome study.