How to understand your echo report?

How to understand your echo report?

Echocardiogram, often called just echo in short is ultrasound imaging of the heart. Though the actual types of details mentioned in echo report may vary between institutions and even persons reporting it, in general there are several common aspects. Reports of children with birth defects of the heart will have a different pattern. This discussion is mainly on an echo report from a general cardiology setup rather than a specialized report.

In addition to details of identification and date of procedure, reason for the test and the quality of images are usually mentioned in the beginning of the report. Quality of images may be poor in those with lung disease and in obese individuals. Finer details in the report should be interpreted with caution when the image quality is reported as poor or as poor echo window.

Chamber sizes and measurement of thickness of chamber walls are either given as tables or the relevant picture showing the measurements printed on the report. In some reports, reference normal values are also provided. While looking at reports of children, measurements should be interpreted considering the physical size of the child as heart chambers grow in size as the child grows.

In addition to the measurements, there will also be a qualitative report on whether the chambers are enlarged or thickened and whether they are contracting well or not. An enlarged heart chamber is mentioned as dilated, while a thickened one is mentioned as hypertrophied. The important chambers are the thin walled upper and lower chambers known as right and left atrium and thicker lower chambers known as right and left ventricle.

The valves between the chambers are the tricuspid valve between right upper and lower chambers and mitral valve between the left upper and lower chambers. Aorta is the great vessel carrying oxygenated blood to the body arising from the left ventricle. Pulmonary artery carries blood to the lungs for oxygen enrichment from the right ventricle. The valve between the left ventricle and aorta is called aortic valve and that between right ventricle and pulmonary artery the pulmonary valve. The great veins returning blood from the body to the heart are the superior vena cava from the upper part and inferior vena cava from the lower part. Both join the right atrium. Blood returning from the lungs after oxygen enrichment reach the left atrium through the pulmonary veins. Pulmonary means in relation to the lung. An echo report will mention about most of these structures and their abnormalities any if found.

While coming to function of the heart, the concentration is often on the left ventricle, which pumps blood to the whole body. An important value in the report is the ejection fraction. Ejection fraction is the fraction of the blood from the full left ventricle which is ejected out during each contraction. Suppose after filling when the left ventricle relaxes in diastole, it has 100 ml of blood. If 70 ml is pumped out by the next contraction or systole, the ejection fraction will be 70%. An ejection fraction below 50% is considered below normal. The lower the ejection fraction, the poorer the pumping function of the heart. A normal left ventricular ejection fraction is usually reported as good left ventricular function. If it is severely impaired, it is noted as severe left ventricular dysfunction. When the left ventricle is stiff and relaxes poorly in diastole, it is reported as left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction is quite common as age advances.

Another important aspect is the contraction of each region of the left ventricle. If all regions of the left ventricle contracts normally, it is reported as ‘no regional wall motion abnormality’. If a particular region contracts poorly, it is reported as ‘hypokinetic’. A region which is not contracting at all is reported as ‘akinetic’. Sometimes a region might bulge out when all other regions are contracting. Such a region is called ‘dyskinetic’. Regional wall motion abnormalities are common after a heart attack. When a blood vessel supplying a region of the heart muscle is blocked, that region shows a regional wall motion abnormality of any of the above mentioned types.

Sometimes a birth defect may be present in the walls separating the heart chambers. A defect in the wall between the upper chambers is called an atrial septal defect. Ventricular septal defect is noted in the wall between the lower chambers.

Any of the heart valves can also be abnormal, either as a birth defect or acquired later in life due to diseases. If a valve is narrowed, it is called stenosis. There can be mitral stenosis, aortic stenosis, tricuspid stenosis and pulmonary stenosis or a combination of these. Leak in a valve is called regurgitation. So there can be mitral regurgitation, aortic regurgitation, tricuspid regurgitation and pulmonary regurgitation or a combination of these. There can also be stenosis and regurgitation in the same valve. Stenosis can be graded as mild, moderate and severe depending on the severity. Area of the narrowed valve may be mentioned in certain cases. Regurgitation can be graded as trivial, mild, moderate and severe. Trivial regurgitations, as the name implies, are usually ignored, especially in relation to the right sided valves (pulmonary and tricuspid). Pressure gradients across the valves will be mentioned when the valve is narrowed. The gradient increases as the severity of the narrowing increases.

When there is a leak in the tricuspid valve, the pressure difference between the right ventricle and right atrium can be calculated. This is usually mentioned as TR (tricuspid regurgitation) gradient. Usually a nominal value of 10 is added to this gradient and mentioned as the estimated right ventricular systolic pressure or RVSP. An elevated RVSP implies an increased pressure in the pulmonary artery (pulmonary hypertension), if the pulmonary valve is not obstructed.

Thickening and distortion of valve leaflets is common in diseased valves and may be noted on the echo reports. Sometimes the number of leaflets may be abnormal. For example, the aortic valve usually has three leaflets. If it has only two leaflets by birth, it is called bicuspid aortic valve.

If there is fluid collection between the covering layers of the heart, it is reported as pericardial effusion. The estimated amount of the collection will be reported as mild, moderate or large. Gross thickening of the outer covering of the heart may occur in a condition known as constrictive pericarditis.

Infective material attached to valves are called as vegetations. Clots attached or floating in the heart chambers are called thrombus in singular and thrombi in pleural. Occasionally tumors or other masses may also be noted inside the heart chambers.

After the descriptive report and the measurements, the final conclusion is usually reported at the end of the report. In case of a normal adult study it may read as: No regional wall motion abnormality, Good left ventricular systolic function. Regional wall motion abnormality may be written in short as RWMA also. If abnormalities have been detected, the conclusion part will be larger and include the salient parts of the echo study. For example, in a person with a defect in the wall between the lower chambers, it may read as: Congenital Heart Disease, Large Perimembranous Ventricular Septal Defect, Left to Right Shunt, Moderate Pulmonary Arterial Hypertension, Good Biventricular Function. This would mean that there is a large defect in the upper part of the wall between the two lower chambers and blood is leaking from the left ventricle to the right ventricle across the defect. The pressure in the blood vessels of the lungs have gone up due to the increased flow. But the pumping function of both right and left ventricles are normal.