Echo reporting basics
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This document provides guidelines for reporting echocardiography exams. It recommends that reports contain three sections: 1) Demographic and identifying information about the patient and exam, 2) A detailed echocardiographic and Doppler evaluation of cardiac structures and measurements, and 3) A summary. The demographic section should include patient name, age, gender, indications for the test, and physician information. The evaluation section describes assessing structures like the ventricles, valves, and vessels and providing quantitative measurements when possible. Measurements of structures like ventricular size and function, valvular stenosis or regurgitation, and cardiac shunts are recommended.
Echo reporting basics
- 1. Reporting of Echocardiography Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI, FAPSC, FAPSIC, FAHA, FRCPG, FCCP Associate Professor of Cardiology National Institute of Cardiovascular Diseases Sher-e-Bangla Nagar, Dhaka-1207 Consultant, Medinova, Malibagh branch. Honorary Consulant, Apollo Hospital, Dhaka and Consultant STS Life Care Centre, Dhanmondi drtoufiq19711@yahoo.com
- 2. REPORT FORMAT The adult transthoracic echocardiography report should be comprised of the following sections: • 1) Demographic and other Identifying Information, • 2) Echocardiographic (Doppler, if indicated) Evaluation and • 3) Summary.
- 3. Demographic and Other Identifying Information (1) Patient’s name and/or other unique identifier, (2) Age, (3) Gender, (4) Indications for test, (5) Height, (6) Weight, (7) Blood pressure (if available), (8) Referring physician identification, (9) Interpreting physician identification, and (10) Date on which study was performed.
- 4. Demographic and Other Identifying Information Other identifying information which may be helpful includes: (1) Echo study media location (e.g., disk or tape number, etc), (2) Date on which the study was ordered, read, transcribed – if applicable, and verified, (3) Location of the patient (e.g., outpatient, inpatient, etc.), (4) Location where study was performed, (5) Name or identifying information for person(s) performing the study (e.g., sonographer, physician), (6) Echo instrument identification, and (7) Imaging views obtained, or not obtained-especially if the study is suboptimal.
- 5. Echocardiographic and Doppler Evaluation A. CARDIAC STRUCTURES The following cardiac and vascular structures are generally be evaluated as part of a comprehensive adult transthoracic echocardiography report: 1) Left Ventricle 2) Left Atrium 3) Right Atrium 4) Right Ventricle 5) Aortic Valve 6) Mitral Valve 7) Tricuspid Valve 8) Pulmonic Valve 9) Pericardium 10) Aorta 11) Pulmonary Artery 12) Inferior Vena Cava and Pulmonary Veins
- 6. Echocardiographic and Doppler Evaluation MEASUREMENTS As a general rule, quantitative measurements are preferable. However, it is recognized that qualitative or semi-quantitative assessments are often performed and frequently adequate. The following types of measurements are commonly included in a comprehensive echocardiography report. 1) Left Ventricle: a) Size: Dimensions or volumes, at end-systole and end-diastole b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall thicknesses (at end-systole and end- diastole) and/or mass (at end-diastole) c) Function: Assessment of systolic function and regional wall motion. Assessment of diastolic function 2) Left Atrium: Size: Area or dimension
- 7. Echocardiographic and Doppler Evaluation 3) Aortic Root: Dimension 4) Valvular Stenosis: a) Valvular Stenosis: Assessment of severity. Measurements that provide an accurate assessment of severity include trans-valvular gradient and area. b) Subvalvular Stenosis: Assessment of severity. Measurement of subvalvular gradient provides the most accurate assessment of severity and is, therefore, recommended. 5) Valvular Regurgitation: Assessment of severity with semi- quantitative descriptive statements and/or quantitative measurements.
- 8. Echocardiographic and Doppler Evaluation 6) Prosthetic Valves: a) Transvalvular gradient and effective orifice area b) Description of regurgitation, if present 7) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-to systemic flow ratio) and/or orifice area or diameter of the defect are often helpful.