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2.1 BASIC ELEMENTS
Echotech Reporting Guidelines
Version 12
Authors: Dr R Sharma and K Elton
Next Review: January 2013
Echotech © 2012
Rationale
These guidelines have been devised to:
•promote both the quality and consistency of all Echotech reports
•encourage a systematic approach to reporting and
•facilitate the accurate comparison of echocardiograms performed by different Echotech
Cardiac Physiologists at different sites
In terms of the echocardiographic views (see section 1) and measurements, the BSE guidelines for ‘A
Minimum Dataset for a Standard Adult Transthoracic Echocardiogram’1 are followed.
In terms of reference values, this document reflects the BSE Guidelines for Chamber and Valve
Quantification2.
1. Recommended Views (for recording)
1.1 Parasternal long axis (with and without colour)
1.2 Parasternal long axis M mode of LV and aorta / LA
1.3 Parasternal long axis inflow (TV) and outflow (PV) views (with and without colour)
1.4 Parasternal short axis: LV level (from papillary muscle level to apex), MV level and AV level
(including colour flow and Doppler of PV)
1.5 Apical 4 chamber (with and without colour)
• MV Doppler assessment
• PW for inflow pattern
• CW for MR / PHT
• CW Doppler assessment of TV
• Colour Doppler assessment of MV and TV
• Pulmonary vein flow assessment (PW and colour)
1.6 Apical 5 chamber
• Colour Doppler assessment of AV
• CW assessment of AV
• PW assessment of LVOT
1.7 Apical 2 chamber
• Colour Doppler assessment of MV
• CW assessment of MV
1.8 Apical long axis
• Colour Doppler assessment of MV and AV
• CW assessment of MV and AV
1.9 Subcostal
• Assessment of IAS / IVS, IVC, pericardial effusion and abdominal aorta
• Assessment of chambers and valves, with and without colour (when other views
unobtainable)
1.10 Suprasternal notch
• Assessment of distal ascending aorta, aortic arch, proximal descending aorta and right
pulmonary artery
• Assessment of left pulmonary artery (modified suprasternal view)
NB. Regional wall motion abnormalities assessed from all views where the LV is visualised.
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Echotech Reporting Guidelines
2. Core Measurements (normal ranges)
Male
Female
2.2 – 3.6 cm
Aortic Root
3.0 – 4.0 cm
Left Atrium
2.7 – 3.8 cm
0.6 – 1.2 cm
Septum
4.2 – 5.9 cm
LV End Diastolic Diameter
3.9 – 5.3 cm
Posterior LV Wall
0.6 – 1.2 cm
LV End Systolic Diameter
2.5 – 4.0 cm
3. 3.1 Reporting LV Systolic Function
LV Systolic Ranges
Normal LVSF
≥ 55%
Mild LVSD
45 to 54%
Moderate LVSD
36 to 44%
Severe LVSD
≤ 35 %
3.2 Ejection Fraction
•Where possible, an EF will be calculated (Biplane Simpson’s Method, M Mode or 2D). If not
possible, a visual assessment will be stated, with a range of no greater than 10%
•Any regional wall motion abnormality will be detailed in the technical report section
•It is critical that the visual and calculated LVEF are consistent with the report comments
3.3 Long Axis Function
• Perform PW TDI at lateral wall, septum or both of MV annulus
Normal LV systolic function
> 7.5 cm/sec
Abnormal LV systolic function
< 7.5 cm/sec
• Normal Mitral Annular Peak Systolic Excursion (MAPSE)
Men
>13mm
Women
>11mm
3.4 Wall Motion Assessment
• The left ventricle should be assessed according to a 17 segment model
• The thickening and endocardial motion of each segment should be described as normal,
hypokinetic, akinetic or dyskinetic
Basal Segments
Mid-cavity Segments
Apical Segments
1. basal anterior
7. mid anterior
13. apical anterior
2. basal anteroseptal
8. mid anteroseptal
14. apical septal
3. basal inferoseptal
9. mid inferoseptal
15. apical inferior
4. basal inferior
10. mid inferior
16. apical lateral
5. basal inferolateral
11. mid inferolateral
17. apex
6. basal anterolateral
12. mid anterolateral
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Echotech Reporting Guidelines
Recommended 17 LV Segment Model recognises LV apical segment
anterior
anteroseptal
1
anterolateral
2
6
3
5
Basal
4
inferoseptal
inferolateral
inferior
apex
17
anterior
14
anteroseptal
7
anterolateral
8
12
Mid-cavity
11
9
10
inferoseptal
16
9
12
3
6
inferolateral
inferior
Horizontal Long Axis (HLA)
(4 chamber)
anterior
septal
Apical
apex
13
14
16
17
15
15
13
lateral
inferior
7
10
Short Axis (SA)
1
4
Vertical Long Axis (VLA)
(2 chamber)
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4. Reporting LV Diastolic Function
4.1 Normal Ranges
Measurement
Ages 35 and above
E:A ratio
0.8 to 1.4
E deceleration time (ms)
141 to 239
E:Ea ratio
< 8.0
4.2 [Grade 1] Slow Relaxation or Mild LVDD
E:A ratio
≤ 0.7
E deceleration time (ms)
≥ 240
4.3 (Any one of these)
[Grade 2] Pseudo normalisation or Moderate LVDD
E:A ratio
0.8 to 1.4
E deceleration time (ms)
141 to 239
E:Ea ratio
> 15
Characterised by:
• Normal filling pattern at rest
• With valsalva manoeuvre, slow filling pattern shown, or,
• E:Ea ratio >15
4.4 [Grade 3] Restrictive or Severe LVDD
E:A ratio
≥ 2.0
E deceleration time
≤ 140
4.5 [Grade 4] Irreversible LVDD
• Restrictive pattern that does not reverse with valsalva manoeuvre
4.6 Key Notes
• For Ea value place sample volume at septal mitral annulus
• If E:Ea ratio <8, the patient will have normal diastolic function
• If the E:Ea ratio 8-15 and LA size is normal then there is no significant diastolic dysfunction
• If E:Ea ratio 8-15 and LA size is increased (>4.00cm), significant LV diastolic dysfunction can
not be excluded
• When Diastology assessment is not appropriate, do not mention in the conclusion of the report
4.7 Patients under 35 years
• All parameters are relevant for patients with cardiomyopathy so should be recorded in patients with known cardiomyopathy
4.8 Atrial Fibrillation
• Diastology assessment not appropriate
4.9 Pacing
• Standard diastology measurements are inaccurate when the patient is being paced
• Measurements should only be taken if the pacing is inhibited and the patient is in intrinsic
rhythm
4.10 Mitral Valve Disease
• Diastolic parameters are not relevant in patients with mitral stenosis
• In patients with mitral regurgitation, parameters are not relevant in those with organic/
structural mitral valve disease or moderate/severe mitral regurgitation
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Echotech Reporting Guidelines
LEFT VENTRICULAR DIASTOLIC DYSFUNCTION (LVDD)
ASSESSMENT ALGORITHM
Ages 35 and above
TRANSMITRAL FLOW
E:A Ra o 0.7
Or
E Decel 240ms
E:A Ra o 2.0
Or
E Decel 140ms
Measurements
(E:A Ra o & E Decel)
Within Normal Ranges
E:Ea > 15
E:Ea = 8 - 15
E:Ea < 8
Normal
LA Size
LA Size
> 4.0cm
Pulmonary
Vein Flow
A Vel < 0.35m/s
A Dur < 30ms
A Vel > 0.35m/s
A Dur > 30ms
Unable to Obtain
PV Flow
SLOW FILLING
(Grade 1)
LVDD
NORMAL
LVDD
NO
SIGNIFICANT
LVDD
UNABLE TO
EXCLUDE
SIGNIFICANT
LVDD
PSEUDONORMAL
(Grade 2)
LVDD
RESTRICTIVE
(Grade 3-4)
LVDD
Last revised August 2011
PVa dur - MVa dur = a rev dur(ms)
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Echotech Reporting Guidelines
5. Valve Assessment
5.1 Mitral Stenosis
Severity
PHT (ms)
MV area (cm2)
Mean MV gradient (VTI) (mmHg)
Mild
60 to 120
> 1.5
<5
Moderate
120 to 220
1.0 to 1.5
5 to 10
Severe
> 220
< 1.0
> 10
5.2 Mitral Regurgitation
This is made from several parameters. Visual analysis of the regurgitant jet with colour flow mapping
may underestimate the regurgitation severity with eccentric jets and overestimate severity with
central jets.
Indirect indicators of severe mitral regurgitation include:
• Peak mitral valve PW velocity > 1.2 m/sec
• Pulmonary venous flow reversal
• Mitral jet area/atrial jet area ratio > 40%
• Dense CW mitral regurgitant signal
Direct indicators of severe mitral regurgitation include:
• Vena Contracta > 5 mm
• Effective regurgitant orifice area > 0.4 cm2 (or > 0.2 cm2 for ischemic mitral regurgitation)
Comment on mitral valve morphology, annular size and leaflet tethering. Classify mitral valve as:
• Excess leaflet motion (usually due to mitral valve prolapse)
• Restricted leaflet motion (usually due to ischaemic heart disease or rheumatic heart
disease)
• Normal leaflet morphology and motion with annular disease and possible leaflet tethering
• If valve and annulus are completely normal and there is no obvious LV dysfunction state
‘mechanism for MR unknown’
5.3 Aortic Stenosis
Severity
Velocity (m/s)
Peak AV gradient (mmHg)
AV area (cm2)
Mild
1.7 - 2.9
< 36
1.5 - 2.0
Moderate
3-4
36 - 64
1.0 - 1.4
Severe
>4
> 64
< 1.0
•Ensure CW Doppler tracings recorded from 5 and 3 chamber views and right parasternal
view with stand alone probe
•Aortic valve area is mandatory in patients with moderate and severe aortic stenosis
•Aortic valve area should always be calculated when aortic flow rate is affected by conditions
such as LV dysfunction, AR, MR, pregnancy
•Comment on whether aortic valve is bi or tricuspid, site and extent of calcification and if
calcification extends into mitral valve apparatus. With rheumatic aortic stenosis, comment on
the degree of commissural fusion
•The pattern and extent of left ventricular hypertrophy, LVEF, coexistent valve disease and
any dilatation of aorta should always be mentioned in the conclusion
•Aortic dimensions should be given at level of aortic annulus, sinus of valsalva, sinotubular
junction
•Aortic sclerosis is calcified and thickend aortic valve with peak CW velocity < 1.7 m/s and
valve area > 2 cm2
•If aortic valve peak CW velocity is between 1.7 and 1.9 m/s and valve looks entirely normal
with normal excursion, valve area should be calculated (if >2 cm² then no AS)
•In atrial fibrillation, obtain CW tracings of 5 consecutive beats and quote the maximal value
obtained
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Echotech Reporting Guidelines
5.4 Aortic Regurgitation
• Visually assess by use of colour flow and CW Doppler
• Detailed evaluation of aortic valve, aortic root, LV size and LVEF essential
• Comment on whether aortic valve bicuspid or tricuspid, rheumatic or degenerative
• Measure aortic root at aortic annulus, sinus of valsalva and sinotubular junction
• All quantification techniques have limitations and severity grade should be based on a
combination of parameters
• Reliance on colour flow mapping and PHT alone will underestimate eccentric jets,
underestimated due to poor Doppler alignment
Quantification of Aortic Regurgitation
Mild
Moderate
Severe
Jet density
Incomplete
Dense
Dense
Jet decel rate (PHT) ms
> 500
-
< 250
Diastolic flow in descending
aorta
Brief, early diastolic
Intermediate
Prominent, holodiastolic
reversal
Vena contracta (cm)
< 0.3
-
> 0.6
Jet width / LVOT Diameter (%)
< 25
-
> 65
Regurgitant volume (ml/beat)
< 30
31 - 59
> 60
Regurgitant Fraction
< 30
30 - 50
> 50
EROA (CM2)
< 0.1
0.11 - 0.29
> 0.3
5.5 Tricuspid Stenosis
Normal
Severe
Mean gradient (mmHg)
Valve Area (cm²)
5.6 >5
.> 7.0
<1.0
Tricuspid Regurgitation
Severity
Jet Area (cm²)
VC Width (cm) PISA radius (cm)
CW Density
Hepatic Vein Flow
Mild
<5
?
< 0.5
Faint
Normal systolic
predominance
Moderate
5 -10
< 0.7
0.6 – 0.9
Dense
Systolic blunting
Severe
> 10
> 0.7
> 0.9
Dense with
early peaking
Systolic
Reversal
5.7 Pulmonary Stenosis
Severity
Peak PV gradient (mmHg)
Mild
< 40
Moderate
40 to 75
Severe
> 75
5.8 Pulmonary Regurgitation
Mild
Moderate
Severe
Jet size (CFM) (cm)
Narrow, <1.0
Intermediate
Wide, Large
Regurgitant Fraction (%)
<40
40 - 60
>60
CW jet density/deceleration rate
Soft/Slow
Dense/Variable
Dense/Steep
RVOTVTI /LVOTVTI
↑
↑↑
↑↑↑
• Visually assess by use of colour flow and CW Doppler
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Echotech Reporting Guidelines
5.9 Assessment of Prosthetic Valves
• Key measurements are (i) peak velocity and (ii) calculated mean gradient (CW) [See
reference book for valve size and type]
• Visual assessment of regurgitation by use of colour flow and CW Doppler
• Assess whether regurgitant jet is within (closure jet) or outside (paravalvular) the sewing
ring
• Visually assess stability of valve
6. Reporting Right Heart Function and Size
6.1 RV Systolic Function
•This should be based on a combination of visual assessment, quantitative and
semiquantitative techniques
•The quantitative technique is fractional area change but should only be used when there is
good endocardial border definition
•Semiquantitative techniques include tricuspid annular peak systolic excursion via m-mode
and tricuspid annular peak systolic velocity via tissue Doppler imaging. The semiquantitative
techniques cannot reliably distinguish between mild and moderate disease
RV function
Abnormal
RV Fractional Area Change (%)
<35
Tricuspid annular peak systolic excursion
<16
Tricuspid annular peak systolic velocity
<11.5
6.2 RV Size
RV dimension (apical 4 chamber)
Abnormal
PA diameter (parasternal SAX)
Abnormal
Basal RV diameter (RVD1) (cm)
>4.2
Main PA (PA1) (cm)
>2.2
Mid RV diameter (RVD2) (cm)
>3.5
Base to apex length (RVD3) (cm)
>8.6
RVOT diameters (parasternal SAX)
Abnormal
RV area
Abnormal
RVOT at AV level (RVOT1) (cm)
>3.5
RV diastolic area (cm2)
>25
RVOT at PV annulus (RVOT2) (cm)
>2.7
RV systolic area (cm2)
>14
6.3 RA size
• Apical 4 chamber view and sub costal view best reflects RA size
• RA size ≤ 3.5 cm
6.4 PA pressure estimation
• Where possible, the PA pressure should always be estimated from the tricuspid regurgitation
peak velocity (4v²) and the inferior vena cava size and motion with respiration (an estimate
of RA pressure)
Severity
0-5mmHg
5-10
10-15
15-20
>20
IVC
size (cm)
Respiratory/sniff variation
< 1.5
collapse
1.5-2.5
↓>50%
1.5-2.5
↓<50%
>2.5
↓<50%
>25
No Change
normal
normal
↑
↑↑
↑
↑↑
↑↑
Other
RA size
Hepatic vein size
An example of reporting PA pressure (PAP) is:
Pressure difference (4v2) = 30mmHg from TR jet
RA pressure = 10 – 15 from IVC
PAP = 4v2 + RA = 40 – 45 mmHg
• If PAP measures between 35 and 60 mmHg, state elevated PAP
• If PAP > 60 mmHg, state severe pulmonary hypertension
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Echotech Reporting Guidelines
7. Reporting the Aorta
A detailed assessment is required for the following referrals:
• Hypertension
• Aortic valve disease
• Marfan’s Syndrome
Site
Normal Range Diameter (cm) Best views
Annulus *
1.7 to 2.5
PLAX, PSAX (AV level)
Sinus of Valsalva *
2.2 to 3.6
PLAX
Sinotubular Junction *
1.8 to 2.6
PLAX
Ascending
< 3.7
PLAX, PSAX, Suprasternal, Apical 5 Chamber
Arch
1.4 to 2.9
Suprasternal
Descending
1.1 to 2.3
PLAX, Subcostal
Abdominal
1.0 to 2.2
* Mandatory measurements for all patients
• All measured at maximum points
Subcostal
8. Pericardial Disease
• Visually assess for pericardial effusion on all patients
8.1 Pericardial Effusion
Pericardial Effusion Size
Normal amount of fluid
< 0.8cm (anterior space only)
Small effusion
0.8-1.0 cm
Moderate effusion
1 - 2 cm
Large effusion
> 2 cm
* Should be measured in end diastole
• State whether global or loculated - If loculated, state area
• State measurement of fluid
• State if any wall compromise
• Look at the IVC and measure size and amount of respiratory collapse
• Any sized global pericardial effusion should be considered pathological
8.2 8.3 Signs of Pericardial Tamponade
• Abrupt flattening of posterior wall in mid diastole
• Double septal motion in diastole
• > 25% drop in mitral inflow E wave with inspiration
• > 25% rise in tricuspid inflow E wave with inspiration
• > 25% drop in subaortic outflow with inspiration
• Preserved mitral annular peak systolic velocity
• The rate of accumulation of fluid is as important as the size of the pericardial effusion
• RV diastolic collapse > 35%
• > 25% drop in mitral inflow E wave with inspiration
• > 25% rise in tricuspid inflow E wave with inspiration
Pericardial Constriction
No single sign can exclude or diagnose pericardial constriction and the diagnosis should be made based
on a combination of parameters.
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Echotech Reporting Guidelines
9. Technical Report Comments
•The technical report section is divided into 5 areas: LV assessment, Right Heart Assessment,
Valves, Other and Conclusion
For each cardiac structure both morphology and function is described
•The Echotech report is primary care focussed and is therefore written in clear, descriptive terms, stating all key findings, whether normal or abnormal
•Abbreviations are not used in the conclusion
•All measurements that are not detailed elsewhere on the report but are relevant to
the findings (e.g. aortic valve gradient) are stated within the technical report section (LV
Assessment, Right Heart Assessment, Valves and Other)
• Measurements are not detailed in the Conclusion
• When a finding requires clarification / peer review then the term ‘suspicion of /query of…’ is used within the technical report and the ‘peer review required’ box is ticked
• The report states a conclusion / summary which
1) Details the LV systolic function and the LV diastolic function (where appropriate)
2) Emphasises the abnormal findings and
3) Answers the question(s) posed by the referring clinician
10. Report Tick Boxes
• The use of tick boxes is used extensively to further enhance the clarity of the report
LV Systolic Function
Tick relevant box as detailed in Section 3.1
Mitral Valve / Aortic Valve
Tick severity of stenosis and / or regurgitation as
either mild, moderate or severe
Atrial Fibrillation
Tick if patient is in AF
Diastolic Dysfunction
Tick if patient [ages 35 and above] has any degree
of LVDD [grades 1 to 4] as detailed in Section 4
RV Systolic Dysfunction
Tick if patient has any degree of RVSD [mild to
severe]
Significant Valve Disease
Tick if patient has valve disease of moderate
severity or above
Technical Quality
Tick the technical quality of the study as either
good, fair or poor
Peer Review
Tick if a second opinion is required [study images
will be reviewed]
Urgent Findings
Tick if urgent action is required and dealt with
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Echotech Reporting Guidelines
11. Grade
1
2
3
4
Onward Cardiology Referral Recommendations
Recommendation
Criteria
Actions
Referral not
suggested based
on Echo criteria
alone
• Normal and Mild pathologies
1. No Action Required from Echotech (GP
may still wish to refer on clinical grounds)
Suggest Cardiology
Referral
• LV / RV systolic dysfunction of moderate or above
• Grade 2 and above diastolic dysfunction with LA
size > 4.0cm
• Any unexplained left ventricular hypertrophy and/
or significant left ventricular hypertrophy (> 1.6cm)
• Moderate or above valve disease
• Any global pericardial effusion or anterior space
effusion > 0.8cm
• Suspected intra cardiac shunt (except PFO)
• Ascending aorta measurement ≥ 4.5cm [or
ascending aorta measurement ≥ 4.0cm for patients
with suspected Marfan’s syndrome]
• Aneurysmal LV wall
1. Write: ‘Suggest Cardiology Referral’
in the Cardiac Referral Comments box
on the Access Report
• Severe pathologies
1. Write: ‘Suggest Urgent Cardiology
Referral’ in the Cardiac Referral Comments
box on the Access Report
2. Send a copy of the report (via FAX) to
the referring practice on the same day of
the scan and confirm the report has been
received (via Phone)
3. Tick the ‘Urgent Findings Processed On
Day of Scan’ box on the Access Report
Suggest Urgent
Cardiology Referral
Urgent Clinical
Advice Required
prior to patient
discharge
•Post MI
- ventricular septal rupture
- severe MR
- pseudo aneurysm
• Aortic dissection
• Large pericardial effusion
• Cardiac mass (myxoma, thrombus, vegetation)
1. MUST be discussed with referring GP
or duty Dr prior to patient discharge with
a view to strong consideration of hospital
admission
2. Write: ‘Suggest Urgent Cardiology
Referral’ in the Cardiac Referral Comments
box on the Access Report
3. Email the UltraLinq ‘refer exam’ link to
Dr Raj Sharma (for Cardiology review) and
Line Clinical Operations Manager and/or
Keli Elton (where possible)
4. Send a copy of the report (via FAX) to
the referring practice on the same day of
the scan and confirm the report has been
received (via Phone)
5. Tick the ‘Urgent Findings Processed On
Day of Scan’ box on the Access Report
12. Patients in Atrial Fibrillation (AF)
• If AF is noted, state this in the conclusion, as well as ticking ‘Atrial Fibrillation’ box
• In the conclusion, state a mean heart rate
• An average of three Doppler and Ejection Fraction measurements should be taken
• At least three beat loops should be recorded
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Echotech Reporting Guidelines
Appendices
Appendix 1
Herceptin
•BSE Guidelines state that patients should not be commenced on Herceptin (Trastuzumab)³
if their baseline EF is ≤ 55%
•If the EF falls by more than 10% or to < 50%, referral to a Cardiologist should be suggested on
the echo report
•Accurate measurement of EF is required as a 10% change in EF should reflect a ‘true’ change
•To assist the accurate measurement of EF, the use of (biplane) Simpson’s Rule Method is
required [if this is not possible, then referral to the Secondary Care Cardiology Dept is
appropriate]
•To track the EF for serial echocardiograms, a folder for the Herceptin patients will be kept
within the echo file
Appendix 2
Left ventricular hypertrophy due to hypertensive heart disease
• Wall thickness rarely exceeds 2cm
• Pattern LVH usually concentric but may be ASH
• SAM and LVOTO less common but may occur
• LVEF rarely > 65%
• Often distinguishing HCM from Hypertensive heart disease very difficult and requires clinical
features, ECG, ETT, 24 hour ECG, CMR
Features of physiological left ventricular hypertrophy (athletes heart)
• LV wall thickness rarely exceeds 1.6cm
• LVH pattern concentric with < 2mm difference between LV segments
• LVEDD often 5.5 – 6.5cm (HCM LVEDD rarely > 4.5cm)
• LVOTO and SAM rare
• Ea usually > 9 cm/sec
Appendix 3
Echo Exclusion Criteria
• Age less than 16
• Known congenital heart disease
• A congenital disorder in which cardiac disease may be suspected
E.g. Down’s syndrome, Noonan’s syndrome, William’s disease
Appendix 4
Congenital Assessment
ASD
Check atrial septum visually & with colour from all possible views i.e. SAX (AV level), 4
chamber & subcostal (4ch & SAX)
Turn colour scale down (i.e. 54) to stop low velocity signals being missed
Record subcostal views on inspiration & expiration, as PFO’s are sometimes missed on
inspiration alone
Measure right heart size, ideally from 4 chamber view, but visually assess from all views
If possible measure the shunt velocity (in m/s) & size (in mm) of the defect
VSD
Check ventricular septum visually & with colour from all possible views i.e. PLAX, SAX
(all levels), 4 chamber & subcostal
Turn colour scale down (i.e. 54) to stop low velocity signals being missed
Important to measure LV dimensions (Normally right heart is normal size)
Measure the shunt velocity (in m/s)
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Echotech Reporting Guidelines
PDA
Best views to assess for a PDA are: SAX (PA/branch level) & Suprasternal notch
Colour flow in SAX view – Look for a RED flow originating from the Left PA branch (right
side of screen) or the branch bifurcation
CW Doppler through the PA (SAX view) - look for continuous flow above the baseline
throughout systole & diastole
Suprasternal view – Angle probe with marker slightly towards the patients left ear.
Pulmonary artery will appear under the Aortic Arch. A PDA is shown as a BLUE colour jet
going from Desc Aorta – PA
AVSD
Either partial (AV cushion defect) or Complete (Common AV valve)
Associated defects with AVSD’s are: Cleft MV, Parachute MV, Bicuspid AV, Aortic coarctation, Ebsteins
Anomaly (rare), Pulmonary Stenosis (rare) and PDA (rare)
Partial
Shunt detected at valve level of Atrial or Ventricular septum or both.
Sometimes the shunt appears to be going from LV – RA (Gerbode defect)
AVSD
AV (atrio-ventricular) valves are at the same level in 4 chamber view.
Complete
Normally has a common AV valve i.e. one leaflet arising from RV free wall,
the other leaflet arising from LV wall.
Cleft MV
Often seen as MR coming through the middle of the Anterior MV leaflet
The Anterior MV leaflet normally has a thickened, elongated appearance
SAX view can sometimes show a ‘fold’ in the middle of the Anterior MV
leaflet (the ‘cleft)
Parachute MV
Elongated Anterior MV leaflet
Only one papillary muscle present
All MV chordae originate from the one papillary muscle
Ebstein’s Anomaly
Apical displacement (>1cm) & dysplasia of the septal & posterior TV leaflets
Small RV cavity & dilated RA due to atrialisation
Eccentric TR
Tricuspid stenosis can occur due to the malformation of the TV
Also check for: Pulmonary stenosis, ASD & VSD
Arrhythmias are also common i.e. WPW and SVT
Assess the TV from all views, but best seen in Apical 4 chamber view
Basic Congenital Abnormalities
What to look for
Down’s Syndrome
ASD
VSD
AVSD either partial (AV cushion defect) or Complete (Common
AV valve)
Noonan’s Syndrome
Pulmonary stenosis
Sub-pulmonary stenosis
If there are limited parasternal views, try visualising the PV from
the sub costal short-axis view
Turner’s Syndrome
Aortic stenosis
Bicuspid AV
Aortic co-arctation
VSD
Aortopathy
Remember to perform the supra-sternal view including aortic
measurements
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Echotech Reporting Guidelines
William’ Syndrome
Supra aortic stenosis
PA branch stenosis
If there are limited parasternal short axis views, try visualising
the PA branches from a sub-costal short axis view
The left PA branch can be visualised from a modified suprasternal view
IF YOU ARE UNSURE ABOUT ANY POSSIBLE CONGENITAL ABNORMALITY OR SYNDROME, RECORD
ALL THE VIEWS INCLUDING SUPRA-STERNAL AND LOOK AT ALL THE VALVES IN DETAIL.
Uncommon echo findings
Features
Amyloid
Reduced LV and RV cavity size
Reduced LV and RV systolic function
Pronounced ‘speckling’ and hypertrophy of the myocardium often
including the RV
Diffuse valve thickening
Bi-atrial dilatation
Pericardial effusions may also be present
Sarcoid
Infiltrative cardiomyopathy
LV dilatation
RWMA’s (especially of the mid and basal segments)
Carcinoid
Thickened and retracted TV and / or PV leaflets with incomplete
closure
Predominately TR / PR and less severe TS and PS
Dilated right heart
Appendix 5
Reporting errors
A significant reporting error will be recorded as per the Category 1 and Category 2 definitions detailed
below.
Review outcomes are based on the following 5 audit categories:
Category 5
No Disagreement
Category 4
Disagreement over style and / or presentation of the report
Category 3
Failure to describe clinically insignificant echo features
Category 2
Definite omission of significant echo feature but unlikely to
result in serious morbidity and mortality
Category 1
Definite omission or misinterpretation of significant echo
feature with potential for serious morbidity and mortality
Significant Reporting Error
For any Category 1 or 2, the following process will apply:
50 scans at 100% review
If a learning outcome is identified, then a supervised session will be arranged between
the Echocardiographer and the Clinical Line-Manager
References
1. 2. 3.
A minimum dataset for a standard adult transthoracic echocardiogram.
o BSE Education Committee October 2005
Guidelines for chamber and valve quantification.
o BSE Education Committee May 2008
The evaluation of left ventricular function for patients being considered or receiving
Herceptin therapy.
o The Council of the BSE June 2006
14
Echotech Reporting Guidelines