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190]

Expert Document

Indian Academy of Echocardiography Performance Standards

and Recommendations for a Comprehensive Transthoracic
Echocardiographic Study in Adults
Nitin Burkule1, Manish Bansal2, Rahul Mehrotra2, Ashwin Venkateshvaran3
1
Department of Cardiology, Jupiter Hospital, Thane, Maharashtra, 2Department of Cardiology, Medanta ‑ The Medicity, Sector 38, Gurgaon, Haryana,
3
Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India

Introduction research purposes. For example, measuring stroke volume at

left ventricular (LV) outflow tract (LVOT) in a case of aortic
Over the past four decades, echocardiography has evolved
stenosis (AS) with discrepant gradients to rule out low‑flow,
into an extremely useful diagnostic modality, which is
low‑gradient situation or for applying newer measurement
regularly utilized for the assessment of cardiac structure and
algorithms as they become available.
function in a wide variety of clinical settings. Its noninvasive
4. To afford medicolegal protection against potential negligence
nature, safety, easy availability, portability, and the ability
resulting from missing a pathology due to incomplete study.
to provide vast amount of diagnostic information are some
The study documentation conforming to the standards
of the reasons underlying its popularity as a diagnostic
laid down by a professional society will serve as a major
tool. However, echocardiography is an operator‑dependent
safeguard.
technique which can lead to considerable measurement
variability, misdiagnoses, and even missed diagnoses. While
adequate training is the most effective means to overcome Scope of the Document
this challenge, a standard protocol for image acquisition will
1. The present document provides a set of mandatory
improve diagnostic accuracy and maximize reproducibility
transthoracic echocardiographic views and Doppler tracings
of the technique.[1]
that are required to permit comprehensive evaluation of
each cardiac chamber, all valves, all coronary territories,
Aims and Objectives septal intactness, great arteries and veins, major cardiac
1. To ensure that no significant pathology is missed by a structures, and intracardiac hemodynamics. Any study done
beginner or a veteran in a hurry. This is especially true if in emergency or unfavorable settings, not conforming to
the study being interpreted has been performed by someone the recommended protocol, should be labeled a “focused”
else. A complete study will also guard against missing a rare echocardiographic study.
or relevant second pathology if a primary disease is very 2. All views and Doppler recordings have been devised
evident, for example, organic tricuspid valve (TV) disease for postprocessing and for routine or elaborate offline
in the presence of significant mitral stenosis (MS). measurements for clinical or research requirements. Focused
2. To enable accurate comparison, qualitative or quantitative, views are meant for drawing echocardiographer’s attention
of interval studies from the same patient performed by the to a particular region in the zoomed image.
same or different echocardiographers. Serial comparison is 3. Only minimum basic measurements are recommended to be
possible only if all the studies are complete and consist of
similar views. Address for correspondence: Dr. Nitin Burkule,
3. To permit extra, nonroutine measurements or verification Jupiter Hospital, Eastern Express Highway, Thane ‑ 400 606,
of reported measurements on stored studies for clinical or Maharashtra, India.
E‑mail: [Link]@[Link]

Videos available on: [Link]

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How to cite this article: Burkule N, Bansal M, Mehrotra R, Venkateshvaran A.

DOI: Indian academy of echocardiography performance standards and
10.4103/jiae.JIAE_27_17 recommendations for a comprehensive transthoracic echocardiographic study
in adults. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:1-17.

© 2017 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging | Published by Wolters Kluwer - Medknow 1
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Burkule, et al.: IAE guideline on adult transthoracic echo

made. Additional measurements as per the requirements of various echocardiographic windows to reduce recording
a particular pathology or institutional or research protocol time. However, the sequence can be changed as per the
can be added. clinical situation or the availability of/access to different
4. These recommendations in no way limit the study to echocardiographic windows.
conventional views only. Echocardiographers are encouraged
The following nomenclature is used in the present
to obtain additional nonconventional and creative views in
addition to (and not excluding) the protocol to improve the document for describing the transducer manipulations
diagnostic accuracy and the quality of the study. [Figure STR maneuver]:
5. These recommendations do not cover training and • Sliding: The transducer is moved in the direction parallel to
credentialing requirements for the echocardiographers. its broader side, along the imaginary line passing through
the orientation marker (X axis). This will move the image
along the ultrasound scan plane.
The Recommended Views and Measurements • Tilting or angling: The transducer is tilted parallel to its shorter
Tables 1 and 2 list the recommended views and measurements, side or perpendicular to the ultrasound scan plane (Y axis). This
respectively, required for performing a complete adult maneuver will provide radial tomographic sections.
transthoracic echocardiographic study. However, as mentioned • Rotation or twisting: This refers to turning the index marker
above, additional views and measurements may be needed clockwise or counterclockwise around a fixed pivot, i.e., the
depending on the underlying pathology and the requirements long axis of the transducer (Z axis). This maneuver will
of local institutional or research protocol. rotate the ultrasound scan plane.
When performing any echocardiographic study, it is For each view, constant fine tuning of the transducer position
recommended to: and orientation is required using a combination of sliding,
1. Store electrocardiogram (ECG) synchronized, minimum 3 tilting or angling, and rotating maneuvers to obtain the optimal
beat loops for each two‑dimensional (2D) or color Doppler
views as described below.
image and minimum 3 Doppler spectral beats for the
still images in case of pulsed-wave (PW) or continuous- Description of views
wave (CW) Doppler. For patients in atrial fibrillation or Parasternal long‑axis view
any other ongoing arrhythmia, a minimum of 5 beats are Purpose
recommended. Overview of LV inflow inflow, outflow, aortic root, and
2. For offline postprocessing and measurements, archive the LV dimensions; also helpful helpful in the assessment of
study in DICOM format. Other formats such as AVI/lossless perimembranous ventricular septal defect (VSD).
JPEG or MPEG should be used for qualitative viewing only.
Measurements
The scanning technique for obtaining each specific view • Mandatory: LV systolic and diastolic diameters;
This section describes the basic technique involved in obtaining interventricular septal and posterior wall thickness
each specific view, various cardiac structures that are seen in • Optional: LV fractional shortening.
that view, and the measurements that can be obtained. However,
it must be remembered that these are only the basic guidelines Technical description
aimed at helping relatively new echocardiographers in The transthoracic adult echocardiographic examination begins
navigating through the challenges of obtaining different views. with a parasternal long‑axis (PLAX) view that profiles the
Keeping with the individual variations in body habitus and in left heart and the proximal right ventricular (RV) outflow
cardiac size, shape, and orientation, constant modifications in tract (RVOT) in the sagittal plane [Figure 1 and Video 1].
scanning technique are required in each individual patient to The patient is placed in the left lateral decubitus position
obtain the best possible images. With increasing experience, with the left arm raised. The transducer is positioned adjacent
the echocardiographers develop the skill required to maneuver to the sternum in the left third or fourth intercostal space.
the transducer according to the imaging requirements. The orientation marker is directed toward the patient’s right
When performing an echocardiogram, it is strongly recommended shoulder, and probe angled slightly to avoid foreshortening
to first complete the recording of the entire sequence of images the LV.
for all patients with any pathology to improve the quality of Depth is adjusted to include the echogenic pericardium
the diagnostic study. The individual pathology should then be posterior to the inferolateral wall. One cine loop is acquired
delineated in greater detail, at the end of the protocol, using at a greater depth to rule out pericardial and pleural effusions.
various nonconventional imaging planes and Doppler recordings. Sector width is adjusted to include the aortic root to the right
The sequence of recording the mandatory views is designed and mid segments of the anterior septum and inferolateral wall
to minimize abrupt changes in the probe and the patient’s to the left. One ECG‑gated loop with three (normal sinus) or
positions and to maintain a seamless workflow through five (atrial fibrillation) beats is recorded.

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Table 1: Recommended views for a complete transthoracic adult echocardiographic study*,#,$

Parasternal window Apical window Other acoustic windows
PLAX 2D Apical 4‑chamber view with pericardial space Subcostal window
PLAX mitral valve zoom Focused LV 4‑chamber view Subcostal 4‑chamber view
2D Focused LV 2‑chamber view (RV focused)
Color Doppler Focused LV apical long‑axis view Interatrial septal view
PLAX aortic valve zoom Zoomed LV inflow and outflow view 2D
2D 2D Color Doppler
Color Doppler Color Doppler Aorta long axis
PLAX ascending aorta Zoomed LA 2‑chamber view 2D
2D Zoomed LA 4‑chamber view Color Doppler (PW spectral
Color Doppler Pulmonary vein flow PW spectral Doppler Doppler optional)
PLAX RV inflow view with color Doppler Focused (LA‑LV) mitral flow‑ IVC long axis
PSAX at the level of semilunar valves Color Doppler 2D
2D PW spectral Doppler (optional CW for MR and MS) IVC/hepatic veins color Doppler
Color Doppler Mitral annular tissue Doppler (PW spectral Doppler) IVC/hepatic vein PW spectral
Doppler
PSAX aortic valve zoom Medial
Suprasternal window
2D Lateral
Aortic arch long‑axis
Color Doppler Zoomed 5‑chamber LVOT
2D
PSAX main pulmonary artery and bifurcation 2D
Color Doppler
Color Doppler Color Doppler
PW/CW spectral Doppler
Pulmonary flow PW spectral Doppler (optional LVOT PW spectral Doppler
PR jet CW) Aortic valve flow CW Doppler
LV SAX at mitral valve level 2D (optional mitral Focused RA‑RV view
valve color Doppler) 2D
LV SAX at papillary muscle level 2D Color Doppler at tricuspid valve
LV SAX at apex 2D TR jet CW spectral Doppler
Tricuspid flow PW/CW spectral Doppler
*Additional views will be needed depending on the underlying pathology, #All views are 2D views, unless specifically mentioned, $All 2D and color
Doppler views refer to video clips. 2D: two‑dimensional, SAX: short‑axis, LV: left ventricle, PR: pulmonary regurgitation, CW: continuous-wave,
PSAX: parasternal short‑axis, PLAX: parasternal long‑axis, LA: left atrium, TR: tricuspid regurgitation, PW: pulsed‑wave, RA: right atrium, LVOT: left
ventricular outflow tract, MR: mitral regurgitation, MS: mitral stenosis, IVC: inferior vena cava

Table 2: Recommended gray‑scale and color measurements*

Gray‑scale measurements Doppler measurements
LV cavity systolic and diastolic diameters Peak RVOT/pulmonary flow velocity
IVS and posterior wall diastolic thickness PR end‑diastolic gradient
Aortic annulus, aortic root at sinuses, sinotubular junction, ascending aorta diameters Pulmonary vein flow S, D, A velocities
LA anteroposterior diameter, LA volume Mitral flow E, A velocities, E/A ratio, E wave deceleration time
RVOT/MPA diameter(s), RA diameter, RV basal diameter, RV free wall thickness Mitral annular E’ and S’ velocities
LV end‑diastolic and end‑systolic volumes using Simpson’s method LVOT VTI
TAPSE Aortic flow peak gradient
IVC size, along with respiratory variation TR peak gradient, estimated RVSP/PASP (mention RA pressure)
*Additional measurements will be needed depending on the underlying pathology. IVC: inferior vena cava, RVSP: right ventricular systolic pressure,
PASP: pulmonary artery systolic pressure, RA: right atrium, TAPSE: tricuspid annular plane systolic excursion, LV: left ventricle, RV: right ventricle,
RVOT: right ventricular outflow tract, MPA: main pulmonary artery, LA: left atrium, IVS: intact ventricular septum, LVOT: left ventricular outflow tract,
VTI: velocity time integral, TR: tricuspid regurgitation, PR: pulmonary regurgitation

Moving from LV inflow to outflow, the anteroposterior LVOT is visualized in long axis. Of the three aortic cusps, the
cross‑section of the left atrium (LA), mitral valve, chordae right coronary cusp (above) and noncoronary cusp (below) are
tendineae, LV cavity in long axis, LVOT, aortic valve (AoV), seen. The corresponding aortic sinuses, sino‑tubular junction,
and proximal ascending aorta can be appreciated in this view. and proximal segment of the ascending aorta are also visualized.
The longer anterior mitral leaflet (above) and short posterior The proximal RVOT is visualized in its short to oblique axis.
mitral leaflet (below) are visualized. The basal and mid segments
of the anterior septum (above) and inferolateral wall (below) Two‑dimensional left ventricle end‑diastolic and
are observed in parallel orientation. Sliding the probe one rib end‑systolic linear measurements
space inferiorly brings the distal segments into view, and it is The end‑diastolic frame is identified by the frame in which
useful when profiling the LV during stress echocardiography LV cavity is largest (the most preferred method) or the frame
studies. The apex is not visualized in this view. The tubular just after mitral valve closure. The end‑systolic frame is

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Burkule, et al.: IAE guideline on adult transthoracic echo

identified when the LV is smallest or the frame just before [Figure 2b and Video 2b]. Patients with significant jets
the mitral valve opens. Linear dimensions are to be taken demonstrate a well‑defined area of flow convergence
at the level of the mitral chordae, perpendicular to the LV proximal to the jet, a vena contracta at the point of
cavity. Measurements are made between the inner edge of the coaptation, and regurgitant jet in the LA. Sector width is to
anterior septum and inner edge of the inferolateral wall using be adjusted to cover the full extent of the regurgitant jet in
2D echocardiography (preferred) or anatomical M‑mode.[2] the posterior LA.
Parasternal long‑axis mitral valve zoom two‑dimensional Parasternal long‑axis aortic valve zoom two‑dimensional
and color Doppler and color Doppler
Purpose Purpose
2D • 2D: AoV and root pathology, LVOT size, subaortic
• Mitral leaflet motion and pathology membrane
• Color Doppler: Detection of mitral regurgitation (MR), • Color Doppler: Detection of AS or aortic regurgitation (AR),
measurement of MR jet vena contracta. measurement of AR jet vena contracta.

Measurements Measurements
2D 2D
• Mandatory: Nil • Mandatory – aortic annulus, aortic root at sinuses,
• Optional: Mitral annulus anteroposterior diameter sinotubular junction
Color Doppler Color Doppler
• Mandatory: Nil • Mandatory – Nil
• Optional: Vena contracta, proximal isovelocity surface • Optional: Jet height, vena contracta
area (PISA) • Doppler data: Qualitative.
• Doppler data: Qualitative.
Technical description
Technical description Acquiring a magnified view of the AoV provides vital
From the PLAX 2D view, a finer appreciation of the mitral valve information on the structure and pathologies of the
can be obtained by magnifying the mitral apparatus using the LVOT, annulus, aortic cusps with corresponding sinuses,
zoom function [Figure 2a and Video 2a]. In this view, the mitral the sinotubular junction, and proximal ascending aorta
annulus, anterior and posterior mitral leaflets, and the attached [Figure 3a and Video 3a]. This is of particular relevance when
chordae are well visualized. A lateral and medial angulation of measuring the LVOT diameter and cross‑sectional area to
the probe provides finer delineation of both anterolateral and calculate stroke volume, or studying structural abnormalities
posteromedial commissures and papillary muscles, respectively. associated with the LVOT. LVOT diameter is measured
This view is recommended when studying mitral leaflet motion during mid systole (with the cusp maximally opened), around
and pathology. Mitral annulus anteroposterior diameter is to be 0.5–1 cm from the aortic annulus, from inner edge to inner
measured at end-systole and end-diastole. edge. The aortic annulus itself is measured between the hinge
points of aortic cusps, during mid‑systole and from inner edge
Placing a color window over the mitral valve in this
to inner edge.[2]
view permits a qualitative evaluation of MR severity

Figure 1: Parasternal long‑axis view. LA- left atrium, LV- left ventricle,
Figure STR: Depiction of transducer manipulations RVOT- right ventricular outflow tract

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Applying color Doppler to this view provides qualitative The ostium of the inferior vena cava (IVC) including
information on the severity and extent of valvular regurgitation Eustachian valve, is seen draining into the RA. With slight
and/or valve stenosis [Figure 3b and Video 3b]. angulation, the coronary sinus is also seen. The anterior
tricuspid leaflet is seen to the right of the display and posterior
Parasternal long‑axis ascending aorta two‑dimensional
leaflet toward the left of the display. This is the only view
and color Doppler which shows the posterior tricuspid leaflet. The anterior wall
Purpose of the RV is seen toward the right of the display and the inferior
• 2D: Ascending aorta dilatation, ascending aorta aneurysm, wall toward the left. TR jet parameters can be measured in this
dissection flap, etc. view using color and CW Doppler, provided the jet is parallel
• Color Doppler: False lumen flow in case of dissection, AS to the ultrasound beam.
jets.
Parasternal short axis at the level of semilunar valves:
Measurements Two‑dimensional and color Doppler
• 2D: Mandatory ‑ Ascending aorta size Purpose
• 2D: Mandatory ‑ Nil • 2D: AoV, RVOT, and pulmonary valve pathology may also
• Doppler data: Qualitative. be helpful in the assessment of atrial septal defect (ASD).
• Color: To detect perimembranous/supracristal VSD, RVOT
Technical description stenosis, TR.
From the 2D PLAX view, the ascending aorta can be profiled by
sliding the transducer one intercostal space higher [Figure 4a and Measurements
Video 4a]. With fine angulation, the long axis of the ascending aorta • 2D: Mandatory ‑ Pulmonary valve annulus size
is profiled. Measurements made in this view include the diameter • Color: Mandatory ‑ Nil
of the aortic annulus, sinus of Valsalva, sinotubular junction, and • Doppler data: Qualitative.
ascending aorta. Measurements other than aortic annulus are
performed at end-diastole, using the leading edge to leading edge Technical description
method.[2] This view is recommended in the setting of ascending The parasternal short-axis (SAX) view is obtained from the
aorta dilatation, aneurysm, and dissection. Placing a color PLAX view by rotating the transducer orientation mark by 90°
Doppler sector over this image provides qualitative information in the clockwise direction, such that it points to the patient’s
on flow profile in the ascending aorta, localizing false lumen and left shoulder. Moving the transducer superiorly with a slight
dissections confined to this region [Figure 4b and Video 4b]. cranial angulation provides a cross‑section of the aortic root
Parasternal long‑axis right ventricle inflow view with color [Figure 6a and Video 6a]. The commonly referred to “circle
Doppler and sausage” view profiles the aortic root (circle) surrounded
by the RVOT (sausage). In addition, this view profiles the RA,
Purpose
the anterior and septal leaflets of the TV, the RV, RVOT, PV,
Tricuspid leaflet pathology, tricuspid regurgitation (TR)
and main pulmonary artery (MPA). With slight angulation,
mechanism and severity.
the bifurcation of the pulmonary artery into the right and left
Measurements branches can be visualized. Angulating the probe posteriorly
• Mandatory ‑ Nil brings the LA appendage into view. A shift in rib interspace
• Doppler data: Qualitative for TR, also CW for the estimation may occasionally be necessary to optimize the view. Applying
of TR gradient. color Doppler to this view [Figure 6b and Video 6b] provides
a qualitative assessment of stenosis or regurgitation related to
Technical description the aortic, tricuspid, or pulmonic valves. In addition, VSDs can
The PLAX RV inflow view can be obtained by angling be characterized based on location as either peri‑membranous
the transducer medially, toward the right hip [Figure 5 and (9–12 o’clock position) or outlet/supracristal/subpulmonic
Video 5]. In this view, the RA, TV, and RV can be visualized. (12–3 o’clock position).

a b a b
Figure 2: Magnified view of mitral apparatus in parasternal long‑axis view; Figure 3: Magnified parasternal long‑axis view of the left ventricular outflow tract,
(a) two‑dimensional image, (b) with color aortic valve and ascending aorta; (a) two‑dimensional image, (b) with color

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Parasternal short‑axis aortic valve zoom two‑dimensional Main pulmonary artery and bifurcation with color and
and color Doppler spectral Doppler (optional pulmonary regurgitation jet
Purpose continuous-wave)
• 2D: Aortic leaflet pathology, coronary ostia Purpose
• Color Doppler: Detection and assessment of AR jet origin and • Color Doppler: To detect pulmonic stenosis (PS), pulmonary
severity. regurgitation (PR), or ductal flow
• PW/CW: PS, high pulmonary vascular resistance (PVR)
Measurements pattern, etc.
• 2D: Mandatory – AoV planimetry in patients with AS in
patients with adequate visualization of the aortic cusps Measurements
• Color Doppler: Mandatory – Nil • Mandatory ‑ Peak pulmonary velocity, peak PS gradient
• Optional ‑ AR jet area when present, end‑diastolic PR gradient when present, peak
• Doppler data: Qualitative. and trough gradient across patent ductus arteriosus when
present
Technical description • Optional ‑ Pulmonary velocity time integral (VTI),
A magnified view of the aortic root provides a clear demonstration pulmonary acceleration time, etc.
of aortic cusp morphology and motion [Figure 7a and Video 7a]. • Doppler data ‑ Quantitative for shunt, PVR calculation.
With a slight superior angulation, the proximal right coronary
artery and left coronary artery can be visualized arising from Technical description
the anterior (right sinus) and posterior (left sinus) sinuses, A fine anterior angulation of the probe from this position
respectively. The noncoronary sinus (right and posterior) is brings the RVOT, MPA, the left pulmonary artery, and the
identified by the attachment of interatrial septum. Coronary right pulmonary artery into view. Color Doppler provides
arteries are best visualized using a higher transducer frequency a qualitative assessment of PR and localizes a region of
with careful adjustment of the focus. The left coronary artery turbulence in the setting of infundibular, valvular, or branch
arises at the 4 o’ clock position at the level of the pulmonary valve, stenosis [Figure 8a and Video 8]. In patients with congenital
and the right coronary artery is seen at the 11 o’clock position heart disease, this view is also employed to visualize a patent
coursing between the RA and the RV. Fine angulation permits ductus arteriosus flowing from the descending aorta into the
the visualization of the bifurcation of the left coronary artery
into the left anterior descending artery and the left circumflex in
selected patients. Placing a color Doppler window in this view
[Figure 7b and Video 7b] permits qualitative estimation of AR
severity by comparing AR jet area to the aortic root area. With
a reduction of the Nyquist limit, diastolic flow in the proximal
coronary arteries can be visualized in selected patients.

a b
Figure 4: Magnified view of the ascending aorta in parasternal long axis;
(a) two‑dimensional image, (b) with color Figure 5: Parasternal long‑axis right ventricle inflow view with color
Doppler. LV- left ventricle, RA- right atrium, RV- right ventricle

a b
Figure 6: Parasternal short‑axis view at the level of semilunar valves. (a) a b
two-dimensional image (b) with color LA- left atrium, LCC- left coronary Figure 7: Parasternal shor t‑axis aor tic valve zoomed view;
cusp, NCC- non-coronary cusp, RA- right atrium, RCC- right coronary (a) two‑dimensional image, (b) with color. LCC- left coronary cusp,
cusp, RVOT- right ventricular outflow tract NCC- non-coronary cusp, RCC- right coronary cusp
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left pulmonary artery. A PW Doppler sample volume placed wall, basal inferolateral wall, basal inferior wall, and basal
in the RVOT at the level of pulmonary annulus provides inferior septum are visualized.[2]
information on the peak flow velocity [Figure 8b]. Additionally,
the spectral tracing also provides the assessment of pulmonary
Left ventricle short axis at papillary muscle level
hypertension from PR and calculation of PVR. In the setting of Purpose
an increased velocity, PW can be used to map the area to locate Assessment of LV ejection fraction (LVEF), RWMA; LV mass
the specific region of flow increase, and a subsequent switch to estimation; papillary muscle geometry and morphology.
CW Doppler allows for quantification of the jet velocity and Measurements
corresponding pressure gradient. • Mandatory ‑ Nil
Left ventricle short axis at mitral valve level • Optional ‑ LV mass calculation, 2D circumferential and
radial strain.
two‑dimensional (optional mitral color Doppler)
Purpose
Technical description
Regional wall motion abnormality (RWMA), mitral valve
From the LV SAX at the base of the heart, an inferior sweep and
end‑on view for the assessment of mitral valve pathologies
slide provides an assessment at the level of the papillary muscles
such as prolapse and MS (planimetry, commissures, etc.).
[Figure 10 and Video 10]. An optimal transducer position
Measurements demonstrates a circular LV cross‑section with the anterolateral
• Mandatory: Nil; mitral valve area in those with MS. papillary muscle at the 4 o’ clock position and posteromedial
• Optional: 2D circumferential and radial strain, basal rotation. papillary muscle at 8 o’ clock position. Care needs to be taken
• Doppler data: Qualitative for regurgitant orifice. to avoid a nonperpendicular cut plane that distorts internal
dimensions and overestimates LV size and contractility.
Technical description The papillary muscle level clip provides a convenient
From the parasternal SAX at the level of the semilunar valves, eye‑balling of LV systolic function and assessment of RWMAs
an inferior sweep by sliding the probe caudal and leftward in the six segments at the mid‑LV cavity plane. Starting from
provides option for imaging the LV from base to apex in the mid‑anterior septum adjacent to the RV, moving clockwise,
SAX. A change in intercostal space is necessary to ensure the mid‑anterior wall, mid anterolateral wall, mid inferolateral
a perpendicular orientation of the short‑axis planes. The wall, mid inferior wall, and mid inferior septum are visualized.
LV SAX at the mitral valve level is characterized by a “fish Asymmetric wall thickness, if observed, can be measured using
mouth” appearance of the anterior and posterior mitral leaflets corresponding M‑mode measurements of the septal and inferior
[Figure 9 and Video 9]. Alternatively, an M‑mode performed wall. This view also provides information on papillary muscle
across the valve with a sweep speed of 100 mm/s provides morphology and geometry.
details of leaflet motion during the cardiac cycle. Pathologies
such as mitral valve prolapse can be further characterized using Left ventricle short axis at apex two‑dimensional
high temporal frame capture on M‑mode. In the setting of MS, a Purpose
careful sweep starting from the papillary muscles till the LVOT Assessment of RWMA; detection of LV apical clot; assessment
SAX permits accurate planimetry of the mitral valve area at of pathologies such as noncompaction.
the level of the leaflet edges and also allows assessment of the
Measurements
extent and morphology of commissural and chordal fusion.
• Mandatory ‑ Nil
Mitral annular and leaflet calcium can also be demonstrated
• Optional ‑ 2D circumferential and radial strain, apical rotation.
using a careful upward and downward sweep of the transducer.
The basal six segments of the LV can be identified in this view
in keeping with the current 17‑segment nomenclature. Starting
from the basal anterior septum adjacent to the RV, moving in a
clockwise direction, the basal anterior wall, basal anterolateral

a b
Figure 8: Parasternal short‑axis view showing right ventricular outflow
tract, main pulmonary artery and its bifurcation; (a) with color, (b) right
ventricular outflow tract flow spectral signal on pulsed-wave Figure 9: Left ventricle short‑axis view at the level of the mitral valve

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Technical description is 2–3 times that of the major linear axis of the LA. Once in the
From the previous view, by angling and sliding the transducer correct position, fine adjustments to transducer frequency, focus,
even more inferiorly, a uniform tapering and reduction in time gain compensation, and overall gain are made to ensure
cavity size is observed with the LV apex coming into view optimal delineation of the endocardium across all segments of
[Figure 11 and Video 11]. The apico‑anterior wall, apico‑lateral the LV. Use of tissue harmonics is recommended to improve
wall, apico‑inferior wall, and apical septum are visualized. tissue–blood pool demarcation.
The apical 4‑segment view provides information on RWMA, Focused left ventricle 4‑chamber view
pathologies such as LV noncompaction, apical aneurysms
Purpose
and thrombus.
RWMA in lateral wall and septum, LV volume estimation,
Apical 4‑chamber view with pericardial space high frame rate images for 2D strain, etc.
Purpose Measurements
Overview of chambers, pericardial or extracardiac pathology, • Mandatory ‑ LV volume and EF by Simpson’s method
ASD. • Optional ‑ 2D longitudinal strain.
Measurements
• Mandatory ‑ LA, RA, RV diameters; LA area Technical description
• Optional ‑ RA area, RV fractional shortening; LV length. A magnified view of the LV provides a more detailed
evaluation of LV volumes and function. In the focused
Technical description LV 4‑chamber view, the septum is vertically positioned
The apical 4‑chamber view is acquired with the patient in the center of the screen and divides the two ventricles
positioned in the left lateral decubitus position. A bed with a cut [Figure 13 and Video 13]. A rightward orientation of the
out section that allows convenient access to the region under septum can be corrected by moving the probe laterally and
the left breast tissue is recommended for optimal imaging. The a leftward deviation by moving the probe medially. The
apical pulse is palpated and the probe is positioned slightly focal point should be adjusted at the midcavity level. For
lateral to this position. The orientation marker is positioned at accurate assessment of LV volumes and RWMA, an optimal
the 5 o’clock position to image the four chambers of the heart. delineation of the endocardium is essential. Selective
The patient may be requested to suspend respiration at the end enhancement of the anterolateral and septal segments
of expiration during image acquisition to reduce translational is possible on certain equipment employing lateral gain
disturbances. compensation. In the eventuality of an inability to track the
endocardial surface in two or more segments, use of contrast
The apical 4‑chamber view showcases the ventricles above is recommended.[3]
and atria below [Figure 12 and Video 12]. The insertion of the
To obtain LV volumes and EF using Simpson’s method of
septal TV leaflet is seen slightly apical to the mitral valve leaflet.
discs, first ensure optimal endocardial definition in the focused
The smooth‑walled, ellipsoidal LV forms the true apex of the
LV 4‑chamber view and then trace the endocardial border in
heart, while the thin‑walled, trabeculated, wedge‑shaped RV
the end‑diastolic frame (the frame showing the largest LV
is observed to the right (left of the display). To ensure that the
cavity size, usually the frame immediately after mitral valve
LV is not foreshortened, the lowest possible apical window is
closure) and the end‑systolic frame (the frame showing the
suggested, and the apex should be seen triangular and thickening
smallest LV cavity size, usually the frame just before mitral
in systole (in a normal heart). In general, the length of the LV
valve opening). The endocardial border is traced from the

Figure 10: Left ventricle short‑axis view at the level of the papillary
muscles Figure 11: Left ventricle short‑axis view at the level of apex

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point of insertion of anterior mitral leaflet into the septum in Technical description
the clockwise direction till the insertion of the posterior leaflet A further 60° counterclockwise rotation with a slight anterior
into the lateral wall. The system then calculates a volume angulation reveals the apical long‑axis view, also called the
based on the summation of 2D‑generated discs. These steps are apical 3‑chamber view [Figure 15 and Video 15]. This view is
repeated in the end‑systolic frame. When both end‑diastolic analogous to the PLAX view, except that distal LV segments
and end‑systolic measurements are repeated in the focused and apex are also seen in this view. The inferolateral wall is
2‑chamber view, the system generates an automated biplane seen to the left of the display and anterior septum to the right
2D EF based on these volumetric measurements. of the display. The apical 3‑chamber view is recommended to
visualize systolic anterior motion (SAM) of the mitral leaflets,
Focused left ventricle 2‑chamber view LVOT dynamic obstruction, and AoV stenosis or regurgitation.
Purpose
RWMA in anterior and inferior wall, high frame rate images Zoomed left ventricle inflow and outflow view
for 2D strain, etc. two‑dimensional and color Doppler
Purpose
Measurements • 2D: LVOT dynamic narrowing, SAM of mitral leaflets/
• Mandatory ‑ LV volume and EF by Simpson’s method chordae, mitral valve pathology, etc.
• Optional ‑ 2D longitudinal strain. • Color Doppler: LVOT dynamic obstruction, MR/AR jet
delineation, etc.
Technical description
The focused LV 2‑chamber view can be obtained from the focused Measurements
4‑chamber view by rotating the transducer counterclockwise • 2D: Mandatory ‑ Nil
by approximately 60° [Figure 14 and Video 14]. This view • Color Doppler: Mandatory ‑ Nil
provides a complete visualization of the anterior wall to the • Doppler data: Qualitative, quantitative for MR effective
right of the display and the inferior wall to the left of the regurgitant orifice area by PISA method.
display. Asking the patient to take a shallow inspiration can
often help improve visualization of the anterior wall. The LA Technical description
appendage is seen to the right of the display. The RV should not A magnified view of the LV inflow and outflow can be obtained
be visible in this view. Showcasing papillary muscles should by employing the zoom function [Figure 16a and Video 16a].
be avoided. However, by tilting the transducer, one should be This view is of particular interest when assessing SAM of the
able to image both the papillary muscles from their origins to mitral valve, chordal pathology, or dynamic narrowing across
insertions into the mitral valve. Descending thoracic aorta can the LVOT. Applying a color window across this frame provides
be visualized beneath the aria. qualitative information on flow across the mitral inflow and
LV outflow [Figure 16b and Video 16b].
Focused left ventricle apical long‑axis view
Purpose Zoomed left atrium 2‑chamber and 4‑chamber views
RWMA in anterior septum, inferolateral or posterior wall; high two‑dimensional
frame rate images for 2D strain, etc. Purpose
LA intra‑cavity pathology, LA volume estimation.
Measurements
• Mandatory ‑ Nil Measurements
• Optional ‑ 2D longitudinal strain. • Mandatory ‑ LA area for volume estimation
• Optional ‑ 2D LA strain.

Figure 12: Apical 4‑chamber view. LA- left atrium, LV- left ventricle,
RA- right atrium, RV- right ventricle Figure 13: Focused left ventricle apical 4‑chamber view
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Technical description function [Figure 19 and Video 19]. Lower transmit frequencies
The LA is best assessed employing a magnified view of the are recommended and the focal point is adjusted at the plane
LA, as seen in the apical 2‑chamber [Figure 17 and Video 17] of the LA roof. To obtain an optimal spectral flow pattern, the
and 4‑chamber views [Figure 18 and Video 18]. The zoom probe is angled slightly posterior from the apical position to
function is employed after identifying the LA as the region of image the right lower pulmonary vein breaking into the LA.
interest. For optimal penetration, a lower transmit frequency A 2–3 mm sample volume is placed >0.5 cm into the vein, and
is recommended, with the focal plane adjusted at the level the velocity scale decreased to accommodate low velocity flow.
of the LA cavity. LA area and volume are measured when Certain equipment provide a low pulse repetition frequency
the LA is maximally dilated during the end‑systolic frame. function that can be activated to profile pulmonary venous flow.
The pulmonary veins and LA appendage are excluded while Wall filters may need to be adjusted to minimize noise. Sweep
tracing the LA borders. LA length is measured as the distance speed is adjusted between 50 and 100 mm/s at end expiration,
between the LA roof and the level of the mitral annulus. The and an average of three consecutive cardiac cycles are obtained.
shorter of the two lengths measured in the 4‑chamber and
2‑chamber views is employed to calculate LA volume by the Focused (left atrium‑left ventricle) mitral flow color and
area‑length method. All measurements should be indexed to pulsed‑wave spectral Doppler (optional continuous-wave
body surface area. for mitral regurgitation and mitral stenosis)
Pulmonary vein flow pulsed‑wave spectral Doppler Purpose
Purpose • Detection and evaluation of MR
Assessment of LV diastolic function. • LV diastolic function assessment, MS severity.

Measurements Measurements
• Mandatory ‑ Pulmonary vein flow systolic, diastolic, and • Mandatory ‑ Mitral inflow early and late diastolic velocities,
atrial reversal velocities deceleration time of early diastolic wave.
• Optional ‑ Duration of atrial reversal wave
• Doppler data ‑ Qualitative.

Technical description
In the apical 4‑chamber view, an assessment of pulmonary
venous flow provides complimentary information on LV diastolic

Figure 15: Focused left ventricle apical long‑axis view. LV- left ventricle

Figure 14: Focused left ventricle apical 2‑chamber view

a b
Figure 16: Magnified view of the left ventricle inflow and outflow;
(a) two‑dimensional image, (b) with color. LV- left ventricle, LVOT- left Figure 17: Magnified view of the left atrium seen in the apical 2‑chamber
ventricular outflow tract view. LA- left atrium

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Figure 18: Magnified view of the left atrium seen in the apical 4‑chamber Figure 19: Pulmonary venous flow into the left atrium seen on
view. LA- left atrium pulsed‑wave Doppler

• Optional ‑ LV inflow propagation velocity, PISA for MR, • Optional ‑ Late diastolic velocity (A’)
isovolumic relaxation time, MS severity assessment (pressure • Doppler data ‑ Quantitative for LV diastolic function.
gradients, valve area by pressure half‑time), MR dP/dt.
• Doppler data ‑ Color image: Qualitative for MR, quantitative for Technical description
PISA. PW: Quantitative for LV diastolic function, MS and MR, Mitral annular tissue Doppler is obtained from the apical
transvalvar diastolic forward flow measured at mitral annulus. 4‑chamber view by placing the PW sample volume on the medial
and lateral annular junctions [Figures 21a, b and Video 21].
Technical description All tissue Doppler presets on equipment are set to filter out
Applying color flow across the mitral valve in the focused high velocity, low amplitude signals and amplify low velocity,
LA‑LV view provides information on the hemodynamic high amplitude signals generated by the myocardium, hence
severity of MR, in addition to studying mitral inflow no gross manual adjustments may be required. By narrowing
[Figure 20a and Video 20]. Care needs to be taken to ensure the color tissue Doppler sector to cover the medial annulus and
a color window as narrow as possible that covers the mitral lateral annulus separately, an optimal frame rate of 100–120
valve to avoid a drop in frame rate and maintain a Nyquist frames/s can be acquired.
velocity of approximately 50–60 cm/s. A 5–10 mm sample volume is placed at or within 1 cm of the
A PW Doppler interrogation of mitral inflow lends significant insertion sites of the mitral leaflets on septal or lateral walls
information to the assessment of LV filling [Figure 20b]. A and adjusted to cover the longitudinal excursion of the annulus
1–3 mm sample volume is placed at the tips of the mitral in both systole and diastole. Care is to be taken to ensure an
leaflets in the LV and positioned slightly closer to the lateral angulation of <20° between the ultrasound beam and plane of
wall in keeping with flow direction across the valve. Color flow annular motion. The velocity scale is adjusted to 20 cm/s to
imaging may assist in the optimal alignment of the Doppler profile myocardial velocities above and below the baseline.
beam. Spectral mitral inflow velocities are initially obtained The tracing is recorded at a sweep speed of 100 cm/s at the
at a sweep speed of 25–50 mm/s to evaluate respiratory inflow end of expiration. 2D reference frame is frozen to improve
variation. In the setting of no respiratory variation, the sweep delineation of the spectral waveform, and an average of three
speed is adjusted to 100 cm/s, averaged over three cardiac consecutive cardiac cycles is considered. The S’, E’, and A’
cycles and captured at the end of expiration. are measured in this view. In conjunction with the early mitral
inflow velocity (E), acquired using PW Doppler, a noninvasive
Spectral gain and reject are adjusted to display a crisp diastolic
assessment of LV filling pressures (E/E’) is possible. Myocardial
profile across the valve. The resultant spectral pattern should performance index can also be measured from these images,
demonstrate a well‑defined E‑wave generated by early filling considering mitral closure to opening time and ejection time.
and A‑wave generated by atrial contraction (in normal sinus
rhythm). Zoomed 5‑chamber left ventricular outflow
tract‑two‑dimensional, color, pulsed‑wave spectral
Mitral annular tissue Doppler (medial and lateral)
Doppler
Purpose
LV systolic longitudinal function, diastolic function. Purpose
• 2D: LVOT dynamic or fixed stenosis, perimembranous VSD,
Measurements etc.
• Mandatory ‑ Mitral annular early diastolic velocity (E’), • Color: LVOT dynamic or fixed stenosis, perimembranous
mitral annular systolic velocity (S’) VSD, etc.

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a b a b

Figure 20: (a) Color flow across the mitral valve in the color left Figure 21: Mitral annular velocities on pulsed‑wave tissue Doppler
atrium ‑ left ventricle view; (b) mitral inflow pulsed‑wave spectral Doppler imaging; (a) medial annulus, (b) lateral annulus

• PW: LV stroke volume, LVOT dynamic or fixed stenosis, Focused right atrium‑right ventricle view two‑dimensional,
etc. tricuspid flow color Doppler, continuous-wave and
pulsed‑wave
Measurements Purpose
• 2D: Nil • 2D: RV size and function, interventricular septal motion,
• Color Doppler: Nil intracavity clot, mass, etc.
• PW: Quantitative for stroke volume, continuity equation.
• Color: Detection of TR
• CW: RV/PA systolic pressure
Technical description • PW: RV diastolic function, tricuspid stenosis, etc.
A more detailed evaluation of the LVOT is essential to assess
dynamic or fixed obstruction, in addition to providing a view for
Measurements
accurate PW/CW measurements [Figure 22a and Video 22a]. Color
2D
flow across the LVOT provides a qualitative assessment of AR
• Mandatory – RA, RV dimensions
and localization of the site of obstruction, if present [Figure 22b
• O p t i o n a l – Tr i c u s p i d a n n u l a r p l a n e s y s t o l i c
and Video 22b]. SAM of the mitral valve is well visualized in this
excursion (TAPSE), TV annular size
view. To assess LVOT flow or measure stroke volume using PW
Color
Doppler, a sample volume is placed just proximal to the AoV in
• Mandatory – Nil
the center of the LVOT [Figure 22c and Video 22c]. In calcified,
• Optional – TR jet PISA
degenerative AS, care should be taken to avoid placing the sample
• Doppler data: Qualitative
volume too close to the aortic cusps, as this can cause an artifactual
CW
increase in LVOT velocities. The sample volume position should
• Mandatory – TR jet peak gradient
also correspond to the location used to assess LVOT cross‑section
• Doppler data: Quantitative for PASP, RV dP/dt, etc.
in the 2D PLAX view. In the event of an aliasing spectral pattern,
PW
the sample volume can be moved toward the LV to localize the site
• Mandatory – Tricuspid inflow early diastolic velocity
of obstruction. In a normal heart, the peak velocity should rapidly
decline with this maneuver. • Optional – Tricuspid inflow late diastolic velocity,
deceleration time of early diastolic wave, pressure
Aortic valve flow continuous-wave Doppler half‑time
Purpose • Doppler data: Quantitative.
Quantification of AS severity.
Technical description
Measurements To perform a focused evaluation of the RV, one would need to
• Mandatory ‑ AS peak and mean gradients, aortic flow VTI
begin with the apical 4‑chamber view and align the RV with
• Doppler data ‑ quantitative for AoV area estimation by
the center of the screen.[4] This view is obtained by moving the
continuity equation.
transducer slightly medially and reducing the sector width to
encompass the RA and RV. In a normal heart, the RV is less
Technical description than two‑thirds the size of the LV [Figure 24a and Video 24].
Switching to CW Doppler in the previous view provides
RV size is assessed by measuring diameters at the base and
an assessment of the maximum flow across the AoV
mid‑cavity region at end‑diastole, when the chamber size is
[Figure 23 and Video 23]. A peak velocity and VTI obtained from
largest. The length of the RV is assessed from the plane of the
CW can be used in conjunction with the corresponding values
TV annulus till the RV apex in this view.
obtained in the LVOT to assess AoV area using the continuity
equation. All spectral Doppler tracings are to be recorded at 100 TAPSE is an evaluation of the systolic longitudinal excursion
mm/s, adjusting baseline and velocity scale to ensure optimal of the TV annulus and is representative of RV systolic function.
measurement. Like all Doppler evaluations, care is to be taken This is performed by placing an M‑mode cursor through the
to ensure the beam is as parallel as possible to blood flow. annulus and measuring the displacement at peak systole.

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a b

c
Figure 22: Magnified view of the left ventricular outflow tract; (a) two‑dimensional Figure 23: Flow across the aortic valve assessed by continuous-wave
image, (b) with color, (c) left ventricular outflow tract flow on pulsed‑wave Doppler
Doppler. LA- left atrium, LV- left ventricle, LVOT- left ventricular outflow tract
two ventricles are seen above the atria, with the RV visualized
Placing a color Doppler window across the TV in this view anterior to the LV. A focused view of the right ventricular free
allows one to qualitatively assess the severity of TR, or wall permits measurements of wall thickness in the setting of
turbulence across the TV [Figure 24b and Video 24]. An elevated RV afterload. Measurements are taken at end‑diastole,
approximation of RV systolic pressure can be obtained by beyond the TV leaflets at the level of the chordae.
assessing the TR jet with CW Doppler [Figure 24c] and adding Subcostal interatrial septal view two‑dimensional and
the resultant peak pressure gradient to RA mean pressure as
color Doppler
assessed by IVC size and collapsibility. The cursor is aligned
Purpose
as parallel to the flow as possible. Once the spectral Doppler
• 2D: Intactness of interatrial septum; RV free wall thickness
is obtained, the baseline and velocity scale are adjusted to
measurement (from RV‑focused view).
measure the peak velocity. Spectral gain can be adjusted to
• Color Doppler: To exclude ASD, patent foramen ovale.
provide an optimal delineation of flow pattern. An additional
measure of forward flow using PW/CW Doppler across the
Measurements
valve may be useful to study diastolic properties of the RV,
2D: Mandatory – Nil
or measure TS gradient [Figure 24d]. Tissue Doppler of the
• Optional – ASD size
lateral tricuspid annulus can also be performed, in a manner • RV free wall thickness measurement from RV‑focused
analogous to the mitral valve, to measure systolic and diastolic view
function of the RV. Color: Mandatory – Nil
Subcostal 4‑chamber view (right ventricle focused) • Optional ‑ ASD size
Purpose • Doppler data: Qualitative detection of shunt.
2D: RV free wall thickness measurement.
Technical description
Measurements From the standard subcostal 4‑chamber view, a slight posterior
2D angulation of the transducer stretches out the interatrial septum
• Mandatory – Nil and brings the two atria into focus. A magnified view of the
• Optional – RV free wall thickness measurement. interatrial septum can be obtained using the zoom function
[Figure 26a and Video 26a]. In this view, the interatrial
Technical description septum is aligned perpendicular to the ultrasound beam, and
To obtain subcostal views, the patient is rolled over to a supine hence it is the recommended view to profile a patent foramen
position and knees are bent to relieve muscle strain in the ovale or ASD. Placing a color Doppler window on this
abdominal region. The transducer is placed in the sub‑xiphoid image permits the evaluation of the intactness of the septum
region with the orientation marker pointing toward the patient’s left, [Figure 26b and Video 26b].
in the 3 o’ clock position. Angling the scan plane cephalad brings Subcostal aorta long axis two‑dimensional and color
the subcostal 4‑chamber view. Inspiration generally improves the
Doppler (pulsed‑wave spectral Doppler optional)
quality of the image by bringing the heart closer to the transducer.
Purpose
In this view, the LA, RA, interatrial septum, LV, RV, and intact • 2D: Aortic pulsations, aneurysm, dissection flap, etc.
ventricular septum are visualized [Figure 25 and Video 25]. The • Color: Phasic versus continuous flow (to diagnose

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a b

c d
Figure 24: An right ventricle focused view obtained from the apical Figure 25: Right ventricle‑focused subcostal 4‑chamber view for the
4‑chamber view; (a) two‑dimensional image, (b) with color showing measurement of right ventricle free wall thickness. LA- left atrium, LV- left
tricuspid regurgitation jet, (c) tricuspid regurgitation jet assessed by ventricle, RV- right ventricle
continuous-wave Doppler, (d) flow across the tricuspid valve assessed
by pulsed‑wave Doppler. RA- right atrium, RV- right ventricle • Doppler data: Qualitative
• PW: Mandatory – Nil.
coarctation), flow reversal, differential flow suggestive of
aortic dissection. Optional ‑ Systolic, diastolic forward and reversal velocities
and VTI Respiratory changes in flow reversal.
Measurements
2D Technical description
• Mandatory – Nil From the subcostal aorta long‑axis view, angling the probe
• Optional – Aorta size to the patient’s right will demonstrate the IVC in long axis
Color [Figure 28a and Video 28a]. The IVC is identified as a
• Mandatory – Nil thin‑walled structure that collapses on inspiration in patients
• Doppler data: Qualitative. with normal RA pressures. With fine angulations, the IVC
should be opened to a maximum diameter and clip must be
recorded during quiet inspiration. A sniff, or sudden forceful
Technical description
inspiration, demonstrates collapsibility of the IVC and provides
To obtain the long axis of the aorta, the probe is turned in the
information on central venous pressures. The maximal
counterclockwise direction till the orientation marker faces
diameter of the IVC must be measured when not collapsed,
the patient’s head, and the scan plane is tilted inferiorly, or
just proximal to the entry of the hepatic veins.[4]
toward the abdomen. A slight leftward angulation profiles
the upper abdominal aorta in long axis [Figure 27a]. The With fine angulation, the hepatic veins can be demonstrated
upper abdominal aorta can be identified as thick walled draining into the IVC [Figure 28b and Video 28b]. A color
and pulsatile. This view is useful to look for an aneurysm flow window placed over the hepatic vein provides qualitative
or dissection flap. Placing a color Doppler sector in this information on flow direction. PW Doppler can be employed for
view [Figure 27b and Video 27] provides qualitative additional information on systolic, diastolic, and flow reversal
information on flow hemodynamics such as continuous velocities [Figure 28c]. To obtain an optimal spectral waveform,
flow in the setting of coarctation and reversal in the setting a 3–5 mm PW sample volume is placed in the hepatic vein,
of significant AR. Optionally, PW Doppler can be used to taking care to align the Doppler axis parallel to the vessel flow.
assess the flow pattern.
Suprasternal long axis of aortic arch two‑dimensional,
Inferior vena cava long axis two‑dimensional, inferior color and pulsed‑wave/continuous-wave
vena cava/hepatic vein color, pulsed‑wave Purpose
Purpose • 2D: To look for aortic dissection, coarctation, etc.
• 2D: Preload status, respiratory variation in IVC size • Color: Assessment of diastolic flow reversal in AR; differential
• Color: Respiratory variation of IVC/hepatic vein flow flow in aortic dissection, turbulence in coarctation, etc.
• PW: Estimation of RA pressure. • PW/CW: Assessment of diastolic flow reversal in AR,
coarctation severity.
Measurements
• 2D: IVC size, along with respiratory variability Measurements
• Color: Mandatory – Nil • 2D: Mandatory – Nil

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Optional – Linear measurements of aortic arch and isthmus. Recommended Format for Reporting
• Color: Nil; color M‑mode for qualitative assessment of
diastolic flow reversal in case of AR a Comprehensive Adult Transthoracic
• PW/CW: Mandatory – Nil Echocardiographic Study
Optional – Descending aorta PW for diastolic flow reversal, Although as mentioned above, each institution has its own style
CW Doppler for coarctation gradient. of reporting echocardiographic findings, it is recommended that
the final report should mandatorily include the following details.
Technical description
The suprasternal long axis of the aortic arch is obtained by Patient data
placing the transducer in the suprasternal notch with the The patient name, age, gender, blood pressure, heart rate,
orientation marker pointing toward the patient’s left shoulder. rhythm, and body surface area.
With a slight anterior angulation, the aortic arch and branch
Overall study impression
vessels are seen [Figure 29a]. Moving from proximal to distal
The description should include (but not limited to) the
arch, the aortic arch first gives rise to the brachiocephalic
following points:
artery, followed by the left common carotid and the left
subclavian artery, respectively. Applying a color Doppler in this Etiological diagnosis
view provides information about blood flow characteristics, Etiological diagnosis relevant to the case should include
turbulence or reversal [Figure 29b and Video 29]. PW or CW (but not be limited to) the following as applicable: ischemic,
Doppler may be applied to measure flow reversal or high infective, degenerative, rheumatic, congenital, idiopathic, etc.
gradient forward flow, respectively [Figure 29c].
Anatomical/structural diagnosis
Pathology‑specific additional non-conventional views Anatomical or structural description relevant to the pathology
Apart from the above‑described standard views, additional should include (but not be limited to) the following as
non-conventional views may need to be obtained to better applicable: chamber enlargements, hypertrophies, myocardial
define specific cardiac pathologies. For example, off‑axis views regional wall abnormalities (thickness, scars, aneurysm),
may be required to image eccentric regurgitation jets, or for valve/annulus/outflow morphologies, septal defects, IVC size,
spatial delineation of cardiac masses or any other structure. pericardial/pleural disease, great vessel disease, prosthesis,
intracardiac masses (clot/vegetation/tumor), etc.
Functional/hemodynamic diagnosis
Functional or hemodynamic status description relevant to the
pathology should include (but not be limited to) the following as
applicable (description can be combined with anatomical details
for maintaining continuity): LV/RV systolic regional/global
function (qualitative or quantitative parameters/indices),
a b
Figure 26: Magnified view of the interatrial septum obtained from the
subcostal 4‑chamber view; (a) two‑dimensional image, (b) with color.
LA- left atrium, LV- left ventricle, RA- right atrium

a b
Figure 27: Long‑axis view of the abdominal aorta; (a) two‑dimensional
image, (b) with color
a b

c a b
Figure 28: (a) A subcostal view of the inferior vena cava in long axis, Figure 29: Suprasternal long‑axis view showing aortic arch and proximal
(b) color flow across the hepatic vein entering into the inferior vena cava, (c) segment of descending thoracic aorta; (a) two‑dimensional image,
pulsed‑wave Doppler signal across the hepatic vein. IVC-inferior vena cava (b) with color

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diastolic function grading, valve gradients, valvular regurgitation References

grades and mechanism, shunt qualitative estimates, intracardiac 1. Evangelista A, Flachskampf F, Lancellotti P, Badano L, Aguilar R,
pressure quantitative and/or qualitative estimates, prosthesis Monaghan M, et al. European Association of Echocardiography
function, dyssynchrony measurements, etc. recommendations for standardization of performance, digital storage
and reporting of echocardiographic studies. Eur J Echocardiogr
Comment about further management 2008;9:438‑48.
Therapeutic or management guidance comment relevant 2. Lang RM, Badano LP, Mor‑Avi V, Afilalo J, Armstrong A,
Ernande L, et al. Recommendations for cardiac chamber
to the pathology should include (but not be limited to) the quantification by echocardiography in adults: An update from
following as applicable: suitability for intervention, future the American Society of Echocardiography and the European
echocardiographic follow‑up, need of additional imaging, Association of Cardiovascular Imaging. J Am Soc Echocardiogr
family screening, etc. 2015;28:1‑39.e14.
3. Mulvagh SL, Rakowski H, Vannan MA, Abdelmoneim SS, Becher H,
Reporting templates can be created for common pathologies Bierig SM, et al. American Society of Echocardiography consensus
using the above principles [Appendix 1 for ischemic and statement on the clinical applications of ultrasonic contrast agents in
echocardiography. J Am Soc Echocardiogr 2008;21:1179‑201.
valvular heart disease templates]. 4. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD,
Chandrasekaran K, et al. Guidelines for the echocardiographic
Financial support and sponsorship assessment of the right heart in adults: A report from the American
Nil. Society of Echocardiography endorsed by the European Association
of Echocardiography, a registered branch of the European Society of
Conflicts of interest Cardiology, and the Canadian Society of Echocardiography. J Am Soc
There are no conflicts of interest. Echocardiogr 2010;23:685‑713.

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Appendix AVA = ....... cm2 by Doppler/planimetry at stroke volume

=… ml/m2
Appendix 1: Illustrative examples of templates for Annulus =… mm, aortic root =… mm, Asc Ao = .....mm
reporting final impressions from an echocardiographic AV gradient peak =… mean =… mmHg at heart rate
study =… blood pressure =… (imaging window: Apical/right
(Please note, these templates are only for reporting final parasternal/suprasternal)
impressions. A complete report will also include various 3. Mild/moderate/severe aortic regurgitation. Grade =…
measurements and other findings, in addition to the final Aortic regurgitation due to … (mechanism flail leaflet/
impressions) fibrosed retracted/bicuspid/annular dilatation etc.)
Aortic valve annulus =… mm, aortic root at sinuses =… mm,
A. Ischemic heart disease report template (strike out whatever
STJ = .......mm, Asc Ao = .......mm
is not relevant):
4. Mild/moderate/severe mitral stenosis.
1. Ischemic heart disease
MVA = ........ cm2 by planimetry/pressure half-time.
2. Regional wall abnormalities
Mitral valve gradient peak =… mean =… mmHg at heart
• Left ventricular basal/mid/apical segments of anteroseptum,
rate = sinus/atrial fibrillation rhythm.
apical lateral wall, apical inferior wall are hypokinetic/
Mitral valve score =…
akinetic with thinning (…mm)/scarring/preserved
Anterior mitral leaflet thickened, pliable/nonpliable,
thickness
calcification absent/present at …
• Left ventricular basal/mid segments of inferior, posterior
Posterior mitral valve leaflet thickened, pliable/nonpliable,
wall are hypokinetic/akinetic with thinning (…mm)/
calcification absent/present at …
scarring/preserved thickness Medial/lateral commissure fused/open, calcification absent/
• Left ventricular basal/mid segments of lateral wall are present at …
hypokinetic/akinetic with thinning (…mm)/scarring/ Subvalvular apparatus: chordae thickened/fused,
preserved thickness calcification present/absent at …
Graphical representation of regional wall motion abnormality 5. Mild/moderate/severe mitral regurgitation. Grade =…
may be added to textual description. Mitral regurgitation due to … (mechanism leaflet tethering,
3. Left ventricle shows normal size/dilatation/left ventricular posterior mitral valve leaflet p1/p2/p3 scallop, anterior
hypertrophy/spherical remodeling/anatomical aneurysm. mitral leaflet A1/A2/A3 segment thickened retracted/
Left ventricle clot present/absent myxomatous/prolapsing/flail, chordae shortened/
4. Left ventricular systolic function is normal/depressed elongated/ruptured/tenting, papillary muscle medial/
(left ventricular ejection fraction ==.......LVEDV........, lateral…)
LVESV......., GLS.....) Mitral annulus normal/dilated. Anteroposterior =…
5. Left ventricular diastolic function normal/dysfunction mediolateral = …mm
grade =… suggestive of normal/raised LVEDP 6. Left ventricle shows normal size/dilatation/Left ventricular
6. Left atrium size is normal/increased. Right atrium/right hypertrophy (concentric/eccentric)/spherical remodeling.
ventricle is normal in size/dilated LVIDd = .....mm, LVIDs = .....mm
7. Aortic and mitral valves: normal/sclerotic. Mitral regurgitation Left ventricular systolic function is normal/depressed. (Left
and aortic regurgitation present/absent grade… ventricular ejection fraction =… LVEDV = Left ventricular
8. Pulmonary hypertension present/absent. PASP=......, end-diastolic volume LVEDV=........, LVESV=........,
tricuspid regurgitation grade… inferior vena cava normal/ GLS=.......)
congested 7. Left atrium/right atrium size normal/dilated. Left atrium
9. Right ventricle function normal/depressed. Tricuspid appendage clot present/absent.
annular plane systolic excursion =… 8. Right ventricular size normal/dilated. Right ventricular
10. Any intracardiac clot present/absent. Pericardial effusion function normal/depressed. Tricuspid annular plane
none/present (further description ………………) systolic excursion =…
11. Additional abnormalities……………… 9. Tricuspid regurgitation present/absent, functional/organic.
Grade =… Tricuspid valve annulus size =… tricuspid
B. Valvular heart disease template (strike out nonrelevant): valve leaflets noncoaptation/thickened, retracted/fused
1. … valvular heart disease with/without evidence of infective commissures
endocarditis 10. Pulmonary hypertension present/absent. PASP = ........
2. Mild/moderate/severe aortic stenosis. mmHg, inferior vena cava normal/congested
Tricuspid/bicuspid aortic valve. Calcification: nil/mild/ 11. Aortic arch normal/dilated. Coarctation present/absent
severe. 12. Additional abnormalities ………………

Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 1 ¦ Issue 1 ¦ January-April 2017 17