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HeartDemonstration data

Echocardiography (Transthoracic)

Transthoracic echocardiography is the cornerstone noninvasive test for assessing cardiac structure and function using 2D, M-mode, and Doppler techniques. It evaluates ventricular size and systolic function, valvular disease, chamber dimensions, the pericardium, and estimated intracardiac pressures. Portable and radiation-free, it is central to the diagnosis and monitoring of heart failure, valvular disease, and cardiomyopathies.

Indications

  • Heart failure and assessment of left ventricular ejection fraction
  • Evaluation of a cardiac murmur or known valvular heart disease
  • Chest pain and suspected ischemic or structural heart disease
  • Arrhythmia workup and assessment of cardiac chambers
  • Suspected cardiomyopathy, myocarditis, or infiltrative disease
  • Evaluation of pericardial effusion or tamponade physiology
  • Estimation of pulmonary artery pressure in suspected pulmonary hypertension
  • Source of embolism, endocarditis screening, and monitoring of cardiotoxic therapy

Contraindications & Cautions

  • No contraindications; noninvasive, radiation-free, and repeatable
  • Poor acoustic windows from obesity, lung disease, chest wall deformity, or mechanical ventilation limit the study
  • Consider contrast echocardiography or transesophageal echo when transthoracic images are suboptimal
  • Agitated saline or ultrasound contrast agents have their own cautions (right-to-left shunt evaluation, rare hypersensitivity)
  • Follow ALARA principles for acoustic output

Patient Preparation

  • No fasting required for a standard transthoracic study
  • Left lateral decubitus positioning to bring the heart against the chest wall; supine for subcostal views
  • ECG leads attached for gating
  • Expose the chest and explain electrode and gel placement; provide privacy and a chaperone as appropriate
  • Document blood pressure, height, and weight for indexed measurements

Technique & Parameters

  • Phased-array transducer (1-5 MHz)
  • Standard windows: parasternal long and short axis, apical (four-, two-, three-, and five-chamber), subcostal, and suprasternal notch
  • 2D imaging for chamber size, wall thickness, and regional wall motion
  • M-mode for precise timing and linear measurements
  • Color Doppler for valvular regurgitation and shunts
  • Pulsed-wave Doppler for inflow patterns and diastolic function; continuous-wave Doppler for high-velocity jets and gradients
  • LV ejection fraction by biplane Simpson method; assess diastolic function with E/A, e prime, and E/e prime
  • Estimate pulmonary artery systolic pressure from the tricuspid regurgitation jet plus right atrial pressure

Systematic Review

  • Left ventricle: size, wall thickness, global and regional systolic function, ejection fraction
  • Right ventricle: size and function (TAPSE, S prime)
  • Left and right atria: size and volume
  • Mitral, aortic, tricuspid, and pulmonary valves: morphology, stenosis, regurgitation
  • Diastolic function parameters and filling pressures
  • Pericardium: effusion, thickening, tamponade physiology
  • Great vessels: aortic root and ascending aorta, IVC size and collapsibility
  • Intracardiac masses, thrombus, or vegetations

Key Findings & Significance

  • Reduced ejection fraction with global hypokinesis indicates systolic heart failure or dilated cardiomyopathy
  • Regional wall motion abnormalities in a coronary distribution indicate prior or ongoing ischemia
  • Increased LV wall thickness suggests hypertension, hypertrophic cardiomyopathy, or infiltrative disease
  • Restricted valve opening with elevated gradients indicates stenosis; regurgitant color jets grade insufficiency
  • Elevated E/e prime indicates raised left atrial filling pressure and diastolic dysfunction
  • Pericardial effusion with right atrial and ventricular diastolic collapse indicates tamponade
  • Elevated tricuspid regurgitation velocity indicates pulmonary hypertension

Differential Considerations

  • Dilated hypokinetic LV: ischemic cardiomyopathy, dilated cardiomyopathy, myocarditis, valvular or tachycardia-induced
  • Thick-walled LV: hypertensive heart disease, hypertrophic cardiomyopathy, amyloidosis, Fabry disease
  • Aortic stenosis: calcific degenerative, bicuspid valve, rheumatic
  • Mitral regurgitation: degenerative prolapse, functional/ischemic, rheumatic, endocarditis
  • Right heart dilation: pulmonary hypertension, pulmonary embolism, RV infarct, shunt
  • Pericardial effusion: viral, uremic, malignant, post-cardiac injury, autoimmune

Pearls & Pitfalls

  • Optimize endocardial border definition; use contrast when two or more segments are poorly seen for accurate EF
  • Foreshortening of the apical views underestimates volumes and can misjudge EF and apical wall motion
  • Distinguish tamponade physiology by respiratory variation in inflow and chamber collapse, not effusion size alone
  • Assess the aortic valve in short axis to identify a bicuspid valve
  • Do not mistake a prominent Eustachian valve, Chiari network, or lipomatous septum for a mass or thrombus
  • Estimate PA pressure only with an adequate complete TR envelope
  • Integrate multiple diastolic parameters rather than relying on a single measurement

Structured Report

  • State study quality and windows obtained
  • Report LV size, wall thickness, ejection fraction, and regional wall motion
  • Report RV size and function and atrial dimensions
  • Describe each valve with severity of stenosis or regurgitation and supporting quantitation
  • Report diastolic function, estimated filling pressures, and pulmonary artery pressure
  • Describe pericardium, IVC, and any masses
  • Impression: summarize key abnormalities with severity grades and comparison to prior studies

References

  • American Society of Echocardiography Guidelines for Chamber Quantification (Lang RM et al.)
  • ASE/EACVI Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography
  • ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation and Stenosis
  • ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.