Principal

brand mark
To be used in the
majority of situations.

Provider ID: 1-126775129

2.1 BASIC ELEMENTS

Echotech Reporting Guidelines

Version 15
Authors: Dr R Sharma and K Elton
Reviewed: October 2014 Echotech © 2014
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.

Echotech Reporting Guidelines

2. Core Measurements (normal ranges)
Male Female
Aortic Root 2.2 – 3.6 cm
Left Atrium 3.0 – 4.0 cm 2.7 – 3.8 cm
Septum 0.6 – 1.2 cm
LV End Diastolic Diameter 4.2 – 5.9 cm 3.9 – 5.3 cm
Posterior LV Wall 0.6 – 1.2 cm
LV End Systolic Diameter 2.5 – 4.0 cm

3. Reporting LV Systolic Function

3.1 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
3. basal inferoseptal
4. basal inferior
5. basal inferolateral
6. basal anterolateral
8. mid anteroseptal
9. mid inferoseptal
10. mid inferior
11. mid inferolateral
12. mid anterolateral
14. apical septal
15. apical inferior
16. apical lateral
17. apex

Echotech Reporting Guidelines

Recommended 17 LV Segment Model recognises LV apical segment

anterior
anteroseptal
1
anterolateral
2 6
apex
Basal
3 5 17

4 inferolateral 14 16
inferoseptal

inferior
9 12

3 6

Horizontal Long Axis (HLA)

(4 chamber)
 anterior
anteroseptal
7 anterolateral
8
12 apex
Mid-cavity
9 11 17
10 inferolateral 13
15
inferoseptal

inferior
10 7

anterior
4 1
septal
13

Apical 14 16

15
lateral
Vertical Long Axis (VLA)
(2 chamber)
inferior

Short Axis (SA)

Echotech Reporting Guidelines
4 Left Atrium
4.1 Key Points
• LA diameter is measured in PLAX, perpendicularly to the LA walls.
• In m-mode, measure the LA diameter in end-systole, from outer edge of the posterior
aortic wall to the outer edge of the posterior LA wall.
• 2-D, measure the LA diameter in end-systole, from inner edge to inner edge.
• If the anterosposterior LA diameter cannot be measured, assess the LA volume by biplane
technique from the apical 4 and 2 chamber views
• For Biplane LA volume measurement, note that the largest LA volume is measured in diastole
before mitral valve opening. The LA appendage, the pulmonary vein origins, and the funnel of
the mitral valve are excluded from the measurement.

Left Atrial Size Normal Mild Moderate Severe

LA size WOMEN
LA Diameter (cm) 2.7-3.8 3.9-4.2 4.3-4.6 ≥4.7
LA Volume (ml) 22-52 53-62 63-72 ≥73
LA size MEN
LA Diameter (cm) 3.0-4.0 4.1-4.6 4.7-5.2 ≥5.3
LA Volume (ml) 18-58 59-68 69-78 ≥79
LA size INDEX
LA Diameter (cm/m2) 1.5-2.3 2.4-2.6 2.7-2.9 ≥3.0
LA Volume (ml/m2) 16-28 29-33 34-39 ≥40

5. Reporting LV Diastolic Function

5.1 Normal Ranges

 Measurement
E:A ratio 0.8 to 1.9
E deceleration time (ms) 140 to 240
E:Ea ratio < 8.0

5.2 [Grade 1] Slow Relaxation or Mild LVDD

E:A ratio < 0.8
E deceleration time (ms) > 240

5.3 [Grade 2] Pseudo normalisation or Moderate LVDD

E:A ratio 0.8 to 1.9
E deceleration time (ms) 140 to 240
E:Ea ratio ≥ 13

5.4 [Grade 3] Restrictive or Severe LVDD
E:A ratio > 2.0
E deceleration time < 140

5.5 [Grade 4] Irreversible LVDD

• Restrictive pattern that does not reverse with valsalva manoeuvre

Echotech Reporting Guidelines

5.6 Key Notes
• Place sample volume at septal and lateral mitral annulus
• If septal Ea > 8 cm/sec and lateral Ea > 10 cm/sec then no diastolic dysfunction
• If either site has a reduced Ea then diastolic dysfunction may exist and transmitral Doppler
should be assessed
• If the transmitral Doppler is normal, take the averaged E/Ea value from the septal and lateral
mitral annulus
• If the averaged mitral E/Ea value is < 8, the patient will have normal diastolic function
• If the averaged mitral E/Ea value is ≥ 13, the patient will have diastolic dysfunction
• If the averaged mitral E/Ea value is between 8 and 12, determine whether diastolic
dysfunction exists from the pulmonary venous flow pattern
• If the averaged mitral E/Ea value is between 8 and 12 and pulmonary venous flow cannot
be obtained or indeterminate check LA size. If LA size ≥ 4.3cm, significant diastolic function
cannot be excluded; if LA size < 4.3 cm, significant diastolic dysfunction unlikely

5.7 Echo assessment of diastolic function uncertain

• Age < 40 with no history cardiomyopathy
• Prosthetic mitral valve
• Mitral Stenosis
• Severe mitral regurgitation
• Paced rhythm

Suggest recording mitral inflow and Ea from septal and lateral mitral annulus but do not make
assumptions on diastolic function

Summary: If septal Ea > 8 cm/sec and lateral Ea > 10 cm/sec then no diastolic dysfunction
 TRANSMITRAL FLOW

E:A ratio<0.8 E:A ratio & E:A ratio>2.0

Or E decel within Or
E decel>240ms normal ranges E decel<140ms

E:Ea<8 E:Ea=8-12 E:Ea≥13

LA < 4.3 LA Size ≥ 4.3

Pulmonary
Vein Flow
SL

A Vel<0.35m/s A Vel≥0.35m/s
Slow filling A Dur<30ms A Dur≥30ms Pseudonormal Restrictive
(Grade 1) (Grade 2) (Grade 3-4)
LVDD LVDD LVDD

No significant left ventricular diastolic dysfunction (LVDD)

Echotech Reporting Guidelines

6. Valve Assessment
6.1 Mitral Stenosis
• The aetiology will be rheumatic valve disease in 99% of cases.
• Comment on leaflet thickening, calcification and mobility, commissural fusion and subvalvar
thickening.
• Stenosis severity is based on several parameters.
• Planimetry of the mitral valve is limited by ‘blooming’ due to calcifications and inability to
trace the valve area at the level of the leaflet tips.
• Mean mitral valve gradient depends on flow rate so will be artificially high in high cardiac
output states (e.g. pregnancy) and low in low output states (e.g. poor LV systolic function).
• Pressure half time assumes stable left ventricular and left atrial compliance and requires
linear diastolic flow.
Severity PHT (ms) MV area (cm2) Mean MV gradient (mmHg)
Mild 60 to 120 > 1.5 <5
Moderate 121 to 220 1.0 to 1.5 6 to 9
Severe > 220 < 1.0 > 10

6.2 Mitral Regurgitation

• The aetiology is either due to intrinsic mitral valve disease (mitral valve prolapse or rheumatic
valve disease) or functional (ischaemic heart disease or heart failure)
• For mitral valve prolapse always comment on mitral leaflet size, thickening and motion as well
as annular size. Document if any ruptured chordae seen and if leaflet flail. Try to localise the
prolapsing mitral valve scallop.
• For functional mitral regurgitation always comment on mitral annular size and measure the
maximal tethering distance in the apical 4 chamber view at end systole.
• If there is mitral regurgitation with apparent normal mitral valve morphology and no evidence
of annular dilatation or leaflet tenting please state ‘mechanism of mitral regurgitation not clear’.
• Mitral regurgitation severity assessment can be difficult and is based on several measurements.
Visual analysis of the colour flow jet may underestimate regurgitation severity with eccentric jets
 and overestimate severity with central jets. Where possible, the effective regurgitant orifice area
should be calculated using the proximal isovelocity surface area (PISA) method.

Direct markers of severe mitral regurgitation:

• Vena Contracta diameter> 7mm
• Proximal Isovelocity Surface Area (PISA) radius > 1cm (when Nyquist limit is 40cm/sec)
• Regurgitant volume > 60mls
• Effective Regurgitant Orifice Area > 0.4cm2 (or 0.2cm2 with ischaemic mitral regurgitation)

Indirect markers of severe mitral regurgitation:

• Mitral jet area/atrial jet area ratio > 40%
• Peak mitral E velocity > 1.5 m/sec
• Mitral VTI/Aortic VTI ratio > 1.3
• Pulmonary venous flow reversal
• Density of the continuous wave jet
• Mitral annulus diameter should be measured in end diastole in PLAX view ideally.
• Dilatation is defined as end diastole diameter greater than 3.6cm or the ratio annulus/anterior leaflet is
greater than 1.3.
6.3 Aortic Stenosis
Severity Velocity (m/s) Peak AV gradient (mmHg) Mean AV gradient (mmHg) AV area (cm2)
Mild 2.0 - 2.9 < 36 <25 1.5 - 2.0
Moderate 3-4 36 - 64 25 - 40 1.0 - 1.4
Severe >4 > 64 > 40 < 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

Echotech Reporting Guidelines

 • 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 <2.0m/s
• If aortic valve peak CW velocity is <2.0m/s and valve looks entirely normal with normal
excursion, then report as normal Aortic Valve
• In atrial fibrillation, obtain CW tracings of 5 consecutive beats and quote the maximal value obtained
• Peak and mean gradients (using VTI) and valve area should be stated in the report for all
degrees of Aortic Stenosis

6.4 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 Brief, early diastolic Intermediate Prominent, holodiastolic
aorta 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

6.5 Tricuspid Stenosis

Normal Severe
Mean gradient (mmHg) >5
Valve Area (cm²) .> 7.0 <1.0

6.6 Tricuspid Regurgitation

Severity Jet Area (cm²) VC Width (cm) PISA radius (cm) CW Density Hepatic Vein Flow
Normal systolic
Mild <5 ? < 0.5 Faint
predominance

Moderate 5 -10 < 0.7 0.6 – 0.9 Dense Systolic blunting

Dense with
Severe > 10 > 0.7 > 0.9 Systolic Reversal
early peaking

6.7 Pulmonary Stenosis
Severity Peak PV gradient (mmHg)
Mild < 40
Moderate 40 to 75
Severe > 75

Echotech Reporting Guidelines

6.8 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
6.9 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
7. Reporting Right Heart Function and Size
7.1 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
7.2 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

7.3 RA size
• Apical 4 chamber view and sub costal view best reflects RA size
• RA size ≤ 3.5 cm
7.4 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) < 1.5 1.5-2.5 1.5-2.5 >2.5 >25
Respiratory/sniff variation collapse ↓>50% ↓<50% ↓<50% No Change
Other
RA size normal normal ↑ ↑↑ ↑↑
Hepatic vein size ↑ ↑↑

Echotech Reporting Guidelines

 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

8. Reporting the Aorta

Measurements should be made in 2D mode, from inner edge to inner edge in mid to late systole
A detailed assessment is required for the following referrals:
• Hypertension
• Aortic valve disease
• Marfan’s syndrome or other disorders with aortopathy
If any level of the Aorta is dilated then state in the conclusion, not corrected to BSA

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 Subcostal
* Mandatory measurements for all patients
• All measured at maximum points
9. Pericardial Disease
• Visually assess for pericardial effusion on all patients

9.1 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

9.2 Signs of Pericardial Tamponade

• 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

9.3 Pericardial Constriction

• Abrupt flattening of posterior wall in mid diastole

Echotech Reporting Guidelines

 • 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

No single sign can exclude or diagnose pericardial constriction and the diagnosis should be made based
on a combination of parameters.

10. 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
11. 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

Echotech Reporting Guidelines

 12. Onward Cardiology Referral Recommendations

Grade Recommendation Criteria Actions

Referral not
suggested based 1. No Action Required from Echotech (GP may still
1 • Normal and Mild pathologies
on Echo criteria wish to refer on clinical grounds)
alone

• LV / RV systolic dysfunction of moderate or

above
• Any unexplained left ventricular
hypertrophy and/or significant left ventricular
hypertrophy (> 1.6cm)
• Moderate or above valve disease 1. Write: ‘Suggest Cardiology Referral’
Suggest Cardiology
2 • Any global pericardial effusion or anterior in the Cardiac Referral Comments box
Referral
space effusion > 0.8cm on the Access Report
• Suspected intra cardiac shunt (except PFO)
• Aorta measurement ≥ 4.5cm [or aorta
measurement ≥ 4.0cm for patients with
suspected Marfan’s syndrome]
• Aneurysmal LV wall
 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
Suggest Urgent
3 • Severe pathologies practice on the same day of the scan and confirm the
Cardiology Referral
report has been received (via Phone)
3. Tick the ‘Urgent Findings Processed On Day of
Scan’ box on the Access Report

1. MUST be discussed with referring GP or duty

• Post MI
Dr prior to patient discharge with a view to strong
- ventricular septal rupture
consideration of hospital admission
- severe MR
2. Write: ‘Suggest Urgent Cardiology Referral’ in the
- pseudo aneurysm
Urgent Clinical Cardiac Referral Comments box on the Access Report
Advice Required 3. Email the UltraLinq ‘refer exam’ link to Dr Raj
• Aortic dissection
4 prior to patient Sharma (for Cardiology review) and Line Clinical
discharge Operations Manager and/or Keli Elton (where possible)
• Large pericardial effusion
4. Send a copy of the report (via FAX) to the referring
practice on the same day of the scan and confirm the
• Cardiac mass (myxoma, thrombus,
report has been received (via Phone)
vegetation)
5. Tick the ‘Urgent Findings Processed On Day of Scan’
box on the Access Report

13. 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

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)

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 co-
arctation, 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)
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
AVSD

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

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 supra-
sternal 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
Significant Reporting Error
Category 1 Definite omission or misinterpretation of significant echo
feature with potential for serious morbidity and mortality

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. Recommendations for a standard adult transthoracic echocardiogram, incorporating
requirements for a minimum dataset.
BSE Education Committee 2012
2. Guidelines for chamber and valve quantification.
BSE Education Committee May 2008
3. The evaluation of left ventricular function for patients being considered or receiving
Herceptin therapy.
The Council of the BSE June 2006

Echotech Reporting Guidelines