Interpreting Cardiac Echo Reports By: Khoa Nguyen, PGY2

Learning Objectives Understand the contents of an echocardiographic report Interpret findings from an echocardiographic report in a systematic manner Appreciate relative clinical value of various echocardiographic findings in different clinical scenarios

General Echo Report Outline Date of Procedure Left Ventricular Systolic Function Reason For Test Left Ventricular Diastolic Function Image Quality Valves Rate and Rhythm Mass or Thrombus Chamber Sizes Pericardium Hypertrophy Incidental Findings Right Ventricular Function Conclusions

Initial Quality Measures Example Name:     XXXXXXSex: F       Date/Time: 4/1/2018 1:54:04 PM MRN #:    xxxxxxxxx        DOB: xxxxx Age: 48 years ACC #:    xxxxxxxxxx        Ht:  157.50 cm BP: 123/ 94mmHg Location: IP 78            Wt:  57.00 kg  BSA: 1.57 m² Heart Rate: 92 bpm Referring Physician:  xxxxxxxxxxxxxxxxxxxxxxxxx , cc: Indications:          METH INDUCED HEART FAILURE; NEW MURMUR; Heart failure,                       unspecified I50.9; Cardiac murmur, unspecified R01.1 CPT Codes:            Complete Echocardiogram - 93306. Technical Quality:    Image quality for this study is good. Procedures Performed: Complete Echocardiogram, including 2D, m-mode, spectral                       Doppler and color Doppler was performed. Date of Procedure Reason for the test Image Quality Date of Procedure Does this report reflect the patient’s current status? Reason for the test Stated: what clinical question was to have been answered? Image Quality Can vary from excellent to uninterpretable. In technically difficulty studies, pathology “not seen” does not necessarily mean “not present”

Initial Parameters Rate and Rhythm Chamber Sizes Hypertrophy Might atrial fibrillation, bradycardia, or tachycardia have interfered with assessment of left ventricular diastolic function? Chamber Sizes Is there evidence of dilation? Hypertrophy Wall thickness indicate concentric LVH vs ASH In ASH, comment on presence or absence of dynamic outflow tract obstruction (SAM) is required Septal bulge is common in the elderly but does not have the same clinical implications that ASH has in the younger patients

Right Ventricular Values Example Right Ventricle: The right ventricular size is severely enlarged. Global RV systolic function is severely reduced. Pulmonary Artery: The tricuspid regurgitant velocity is 3.37 m/s; and with an assumed right atrial pressure of 15 mmHg, the estimated right ventricular systolic pressure is moderately elevated at 60 mmHg.. Pulmonary artery systolic function (PASP): estimated from tricuspid regurgitation jet, using modified Bernoulli’s principle PASP = Right Ventricular Systolic Pressure (RVSP) In absence of right ventricular outflow tract obstruction or pulmonic stenosis Normal Range: 16 to 39 mmHg Estimation of RV filling pressure or mean RA pressure is performed by evaluating IVC size and collapsibility Right ventricular systolic pressure estimate can be increased by hypertension and obesity, not just pulmonary HTN

Left Ventricular Function Example Left Ventricle: The left ventricular internal size is severely increased. Borderline concentric left ventricular hypertrophy. There is global severely decreased left ventricular systolic function. Spectral Doppler shows restrictive pattern of LV diastolic filling. Left ventricular ejection fraction is 15% by visual estimation. Grade 1 (normal) through 4 (severely abnormal) for systolic function Grade 2 can be “normal” in atrial fibrillation Grade 1 can be abnormal in mitral regurgitation Wall motion Global abnormalities suggest cardiomyopathy Regional abnormalities suggest infarction Comments on segmental myocardial thickness  thinned-out segment is likely to be scarred and unlikely to recovered regardless of treatment LV systolic function: Assists w/ management of fluids and ionotropic support, decisions regarding myocardial revascularization, timing and choice of valve interventions, and need for cardiac resynchronization therapy

Valves Example Valve Stenosis Valve Area (Severe) cm2 Mean Gradient (Severe) mmHg Aortic Valve < 1 >40 Mitral Valve > 10 Tricuspid Valve > 5 Pulmonic Valve / > 64 Mitral Valve: No evidence of mitral valve stenosis with a mean mitral valve gradient of 1.0 mmHg. Severe mitral valve regurgitation is seen. Tricuspid Valve: Severe tricuspid regurgitation was seen. The flow in the hepatic veins is reversed during ventricular systole. Aortic Valve: The aortic valve is tricuspid. No evidence of aortic valve regurgitation is seen. Valve Regurgitation Signs of Severe Disease Aortic Valve Central Jet, width ≥ 65% of LVOT Vena contracta > 0.6cmς Mitral Valve Vena contracta width ≥ 0.7cm with large central MR jet (area < 40% of LA)  Stenotic lesions: valve area and transvalvular gradients are the key parameters Regurgitant lesions: jet size, effective regurgitant orifice area, regurgitant volume and fraction, and impact of regurgitation on upstream and downstream cardiac chambers NOTE: Valve gradients are exacerbated in presence of tachycardia and increased CO state Regurgitant lesions are suppressed when SBP is reduced

Mass or Thrombus Ability to detect lesions is only as good as the images obtained Left atrial appendage is not visible via TTE

Pericardium Pericardial effusion: presence of RA/RV diastolic collapse, significant respiratory variation in mitral and tricuspid inflow velocities, and non-collapsing IVC suggest underlying tamponade

Echocardiographic Conclusion Statements Important cardiac findings Suggestions for follow-up or other investigations Treatment advice might be offered, but clinical decisions are made by physicians who have knowledge of their patients Summary:  1. Left atrium severely dilated.  2. The left ventricular internal size is severely increased.  3. Severely dilated right atrium.  4. Borderline concentric left ventricular hypertrophy.  5. Severe tricuspid regurgitation.  6. Severe mitral valve regurgitation.  7. No evidence of mitral valve stenosis.  8. Severely enlarged right ventricle.  9. Severely reduced RV systolic function. 10. Severely elevated pulmonary artery pressure Example

Examples of Clinical Conditions and Things to Look for on Echo Report

Key Echocardiographic Findings Cont.

Key Echocardiographic Findings Cont

Citations Bansal, M., & Sengupta, P. P. (2017). How to interpret an echocardiography report (for the non-imager)? Heart, 103(21), 1733–1744. https://doi.org/10.1136/heartjnl-2016-309443 McAlister, N. H., McAlister, N. K., & Buttoo, K. (2006). Understanding cardiac “echo” reports: Practical guide for referring physicians. Canadian Family Physician, 52(7), 869–874.