Reza Heidarpour Meymeh
► To help referring
physicians extract clinically
useful information from
► To minimize
misinterpretation of TTE
► Offering recommendation
of its use
► The most commonly performed noninvasive
► Provides comprehensive evaluation of the
cardiovascular structure, function, and
► No known side effects, even with frequent
and repeat testing.
► Real-time test , portable , low cost
Two-dimensional Echo :
► Real-time tomographic images
► Cardiac chamber size
► Wall thickness
► Global and regional systolic function
► Valvular and vascular structures
► Quantitating single dimensions of walls and
► Estimate chamber volumes
► LV mass
► uses reflections from moving RBC
► Functional information regarding intracardiac
► Systolic and diastolic flow
► Blood velocity and volumes
► Severity of valvular lesions
► Location and severity of shunts
► Assessment of diastolic function
► Before and during stress test.
► Detection of myocardial ischemia and
► Assess the efficacy of coronary
revascularization and anti-anginal
► Miniature ultrasound probe at the end of
► Two-dimensional , M-mode , Doppler
► Superior quality images
► Left atrial appendage, pulmonary valve, mitral
regurgitation in Pt. with prosthetic mitral valve.
Content of TTE reports
Date of procedure. Before studying a TTE report,
check its date
► patient’s clinical status may change as a result of
worsening disease or in response to treatment.
Reason for the test. Explaining why
echocardiography was ordered directs the
laboratory to specific techniques that can best
answer a referring physician’s question. (the type and
diameter of a prosthetic valve is prerequisite to quantifying its function).
► Images characterized as technically
difficult, fair, or poor can lead to erroneous
An error of only 1 mm in measuring wall thickness for the left ventricle
(LV) translates into a 15-g difference in the estimate of LV mass
►A statement that “no intracardiac mass or
thrombus was seen” implies no more than it states
► When image quality is unsatisfactory, the reason
should be indicated. Referring physicians can
decide whether invasive and more costly
transesophageal echocardiography would be
justified to obtain better images.
Rate and rhythm. Correct identification of common
dysrhythmias has important implications for TTE.
► Mild (grade II) LV systolic dysfunction with global
hypokinesis is often consistent with a normal
myocardium in atrial fibrillation
► In atrial fibrillation, marked bradycardia or
tachycardia (data commonly used to assess
diastolic function of the LV) are often abnormal—
not necessarily because of LV diastolic dysfunction
► consultant might recommend a full
The following cardiac and vascular structures are generally be evaluated
as part of a comprehensive adult transthoracic echocardiography
1) Left Ventricle
2) Left Atrium
3) Right Atrium
4) Right Ventricle
5) Aortic Valve
6) Mitral Valve
7) Tricuspid Valve
8) Pulmonic Valve
11) Pulmonary Artery
12) Inferior Vena Cava and Pulmonary Veins
Chamber sizes. A table
often lists the
sizes (diameters) and
compares them with
► The thicknesses of the interventricular septum and
posterior LV wall are used to determine the presence of
concentric LV hypertrophy or asymmetric septal
► Elderly patients often have a sigmoid-shaped septum that
looks abnormally thick in most views.
► the mass of a normal heart correlates with the size of the
patient, the LV mass index in g/m2 is useful.
► Record Pt.’s weight and height in the requisition
► Inaccurate self-reporting leads to inaccurate calculations.
Left ventricular systolic function
► A TTE report usually classifies LV ejection fraction (LVEF) from normal
(grade 1) through severely decreased (grade 4).
► For normal hearts, the Teicholz equation is reasonably accurate.
► When infarction has caused regional wall motion abnormalities, the
“disc method” using Simpson’s rule is preferred.
Reports should indicate which method was employed.
► LVEF in the range of 40% to 55% is abnormal,
► In moderate or severe mitral regurgitation,
even a nominally “normal” LVEF of 60% can indicate inadequate LV
► True indicator of LV function ?
► LVEF depends on preload and
afterload, both of which can change
dramatically within hours.
► Stroke volume, cardiac output, cardiac
index, and the LV index of myocardial
performance, also known as the “Tei
Index,” are increasingly reported as more
reliable quantifiers of LV systolic function
Left ventricular diastolic function.
► Diastolic dysfunction is an important factor
in clinical heart failure.
► Left ventricular DD usually precedes
development of LV systolic dysfunction.
► DD of any degree(1 through 4) is a strong
predictor of all-cause mortality.
Right ventricle. When there is no comment
on function of the right ventricle, it is
presumed normal by visual assessment.
Valvular regurgitation. Most reports of valvular
insufficiency are based on visual assessment. as
trivial (or trace), mild, moderate, or severe is
subjective, imprecise, and frequently misleading.
► Quantitative measurement is more accurate than
► Bicuspid AV is a common congenital malformation.
► Mitral and aortic stenosis are graded as
mild, moderate, or severe, based on the
maximum velocity, peak gradient across the
valve, and estimated cross-sectional area of
Intracardiac mass or thrombus
Technically difficult TTE images often cannot
differentiate between lesions and artifacts
Transesophageal echocardiography for
Right ventricular systolic pressure. When
failure on the right side of the heart is
suspected, it is helpful to estimate the right
ventricular systolic pressure or pulmonary
► obesity and hypertension,
not just by pulmonary hypertension.
Pericardium. The location of pericardial
effusion and its size
(trace, small, medium, or large) will be
reported. Small pericardial effusions are
The diameter of the aortic root is measured
► Summary of findings.
► Answer the question posed by referring physician
► Emphasize abnormal findings
► Compare important differences versus previous studies
► TTE vs TEE for cardiac embolism.
► nuclear medicine study or stress echocardiography for
► chances are high that the reason was never stated on the
requisition. Physician-to-physician discussion can answer
many queries and concerns often raised about this
► One imaging test cannot substitute for
history taking and physical examination.
► TTE is an excellent test for cardiovascular
evaluation and follow up.
► structured approach to reading TTE reports
Understanding cardiac “echo” reports
Practical guide for referring physicians
Neil H. McAlister, MD, MSC, PHD, RDCS, FRCPC
Nazlin K. McAlister, MD, CCFP, FCFP
Kenneth Buttoo, MD, FRCPC
-American Society of Echocardiography
Recommendations for Use of
Echocardiography in Clinical Trials
Writing Committee: John S. Gottdiener, MD (Chair), James Bednarz, BS, RDCS,
Richard Devereux, MD, Julius Gardin, MD, Allan Klein, MD, Warren J. Manning, MD,
Annitta Morehead, BA, RDCS, Dalane Kitzman, MD, Jae Oh, MD, Miguel Quinones, MD,
Nelson B. Schiller, MD, James H. Stein, MD, and Neil J. Weissman 2007
AMERICAN SOCIETY OF ECHOCARDIOGRAPHY
RECOMMENDATIONS FOR A STANDARDIZED REPORT FOR ADULT