Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults
Publication Date: January 1, 2019
Last Updated: March 14, 2022
Key Points
Descriptions of transducer movements to optimize the image:
Tilt: The transducer maintains the same axis orientation to the heart but moves to a different imaging plane.
Sweep: Multiple transducer movements are used to record a long video clip to show multiple anatomic structures.
Rotate: The transducer maintains a stationary position while the index marker is moved to a new position.
Slide: The transducer moves across the patient’s skin to a new position.
Rock: Within the same imaging plane, the transducer changes orientation either toward or away from the orientation marker.
Angle: The transducer is kept at the same location on the chest, and the sound beam is directed to show a new structure.
Sweep: Multiple transducer movements are used to record a long video clip to show multiple anatomic structures.
Rotate: The transducer maintains a stationary position while the index marker is moved to a new position.
Slide: The transducer moves across the patient’s skin to a new position.
Rock: Within the same imaging plane, the transducer changes orientation either toward or away from the orientation marker.
Angle: The transducer is kept at the same location on the chest, and the sound beam is directed to show a new structure.
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Instrumentation Settings
Two-Dimensional Imaging
Grayscale maps: Select grayscale maps that best fit the laboratory’s equipment, patient population, and expected pathology. Be familiar with alternative grayscale maps for special circumstances.
Dynamic range: Select a consistent setting for the laboratory’s starting point. Adjust to a lower range for difficult studies and a higher range when more gray is necessary to display particular pathology.
Transducer frequency: Use broadband transducers with harmonics to optimize penetration and image quality. Start with high frequencies and adjust often throughout the examination to optimize image quality.
Sector size and depth: Use the entire sector to display the structure of interest at maximum frame rate and highest temporal resolution. This setting should be adjusted frequently throughout the examination and used in combination with zoomed settings to best display moving structures. Many measurements are best made in zoomed mode.
Gain: Frequently adjust and readjust the overall gain and TGC settings throughout the examination, always striving to optimize blood-tissue borders of the structure being interrogated.
Spectral Doppler
Dynamic range: Select a consistent setting for the laboratory’s starting point. Adjust to a lower range for difficult studies and a higher range when more gray is necessary to display particular pathology.
Transducer frequency: Use broadband transducers with harmonics to optimize penetration and image quality. Start with high frequencies and adjust often throughout the examination to optimize image quality.
Sector size and depth: Use the entire sector to display the structure of interest at maximum frame rate and highest temporal resolution. This setting should be adjusted frequently throughout the examination and used in combination with zoomed settings to best display moving structures. Many measurements are best made in zoomed mode.
Gain: Frequently adjust and readjust the overall gain and TGC settings throughout the examination, always striving to optimize blood-tissue borders of the structure being interrogated.
Velocity scale: Similar to sector size optimization, adjust the velocity scale display to unambiguously show flow signals. A larger signal on the display is more easily and accurately measured.
Sweep speed: Set the sweep speed to optimize measurements for the flow phenomenon being displayed. Faster speeds are best for timing flowvelocity integrals and slopes and slower sweep speeds for demonstrating respiratory-related flow changes.
Sample volume: Set the volume size to display the clearest spectrum signal depending on the structure being interrogated.
Gain: Set to show a smooth flow signal with an unambiguous modal velocity. Do not overgain. Avoid measuring weak, poorly defined signals outside of the major modal velocity.
Tissue Doppler: Use the manufacturer’s recommended presets to obtain an optimal velocity signal at the proper gain setting.
Sweep speed: Set the sweep speed to optimize measurements for the flow phenomenon being displayed. Faster speeds are best for timing flowvelocity integrals and slopes and slower sweep speeds for demonstrating respiratory-related flow changes.
Sample volume: Set the volume size to display the clearest spectrum signal depending on the structure being interrogated.
Gain: Set to show a smooth flow signal with an unambiguous modal velocity. Do not overgain. Avoid measuring weak, poorly defined signals outside of the major modal velocity.
Tissue Doppler: Use the manufacturer’s recommended presets to obtain an optimal velocity signal at the proper gain setting.
Color Doppler Imaging
Sector size: First optimize the 2D sector size, then add the color Doppler ROI sized appropriately to show the flow information being evaluated. A more narrow and shallow ROI optimizes frame rate and velocity scale.
Color gain: Set color gain just below the point of random speckle. Adjust the gains frequently throughout the examination to maximize display of flow.
Color maps: Select a standard map for the laboratory at a consistent default scale setting (50–70 cm/sec). This will enhance consistency across studies and allow better longitudinal comparisons. In low-flow settings, adjust the velocity scale downward to better display the color Doppler image.
Color gain: Set color gain just below the point of random speckle. Adjust the gains frequently throughout the examination to maximize display of flow.
Color maps: Select a standard map for the laboratory at a consistent default scale setting (50–70 cm/sec). This will enhance consistency across studies and allow better longitudinal comparisons. In low-flow settings, adjust the velocity scale downward to better display the color Doppler image.
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Measurements
- Linear measurements of the left ventricle should be made in the PLAX view with the ventricular chamber optimally centered and as perpendicular as possible to the long axis.
- Consistently make LV dimension measurements just beyond the leaflet tips of the MV. Pay careful attention to the posterior wall; avoid measuring mitral chordal and papillary muscle apparatus. Similarly, avoid including right-sided structures that insert into the septum when measuring septal thickness.
- If a basal septal bulge is present, move the dimension measurements slightly apical beyond the bulge.
- The anterior-posterior diameter of the left atrium may be measured using M-mode or 2D imaging as the diameter line extending from the SoVAo to the posterior wall of the left atrium. Two-dimensional imaging is preferred over the M-mode technique. Both measurement techniques should maintain a consistent orientation to these two structures.
- Diameters of the LVOT and aortic annulus are systolic measurements, and measurements of the aorta are diastolic measurements. The outflow tract diameter is defined by the septum and anterior mitral leaflet, and the location in the outflow tract is defined by placement of the sample volume that achieves laminar flow just proximal to the AV.
- LA volume calculated from the A4C and A2C views adjusted to optimize display of the left atrium is the preferred method of atrial size quantification. The superior-inferior long axes from the two views should be within 5 mm of each other.
- RV dimensions and areas are preferably measured in the RV-focused view.
- M-mode techniques are not recommended for routine linear dimension measurements. Specialized measurements such as TAPSE, IVC diameter during respiration, and prolonged analysis of AV leaflet motion in patients with LV assist devices are valuable specialized measurements.
- LV volume and LV ejection fraction are preferably measured using 3D techniques. The size and depth of the acquired volume should be optimized to maximize frame rate. Tracking of the entire cardiac cycle should be reviewable and correctable and displayed as part of the final images acquired.
- If 3D volumetric analysis is not available, the 2D biplane method of disks is preferred for calculation of LV volume and LV ejection fraction.
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Doppler Imaging and Measurements
- For routine CDI of valvular insufficiency and forward flow, use a consistent scale setting of 50 to 70 cm/sec. Maintain optimal gain settings.
- CDI scale velocity should be adjusted for specialized circumstances to best display color flow, particularly in low-flow states.
- Spectral PW and CW Doppler measurements should be made at the modal (densest) margin of the flow signal. Do not overgain. Do not measure weak, ill-defined signals beyond the modal velocity.
- Obtain spectral Doppler signals as parallel as possible to flow. CDI interrogation may help orientation.
- Flow signals may be acquired (e.g., tricuspid regurgitation) from multiple anatomic sites. Use the highest quality and highest velocity signals for final measurements. Edit out velocity data from poor-quality and lower velocity signals for the final reported velocity. Do not report Doppler flow signals of poor definition or marginal quality.
- Use CDI and pulsed Doppler mapping to characterize the origin of unusual signals within chambers or blood vessels.
- When recording spectral Doppler for measurements of velocity and time intervals, use a default sweep speed of 100 mm/sec. Slower sweep speeds are valuable for specialized pathology.
- For tissue Doppler, always maximize the signal display and use manufacturer-recommended presets.
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Recommendation Grading
Overview
Title
Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults
Authoring Organization
American Society of Echocardiography
Publication Month/Year
January 1, 2019
Last Updated Month/Year
June 12, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Establish the content of a comprehensive TTE examination, provide recommendations for technical performance, provide guidance for the integration of the various ultrasound-based imaging modalities into the comprehensive examination, and describe best practices for the measurement and display of the data generated by the comprehensive examination.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room, Outpatient, Radiology services
Intended Users
Radiology technologist, medical assistant, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D018570 - Risk Assessment, D004452 - Echocardiography
Keywords
Transthoracic echocardiography, Doppler echocardiography, Comprehensive examination