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.

Echocardiography (Transthoracic)

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References