How to interpret an echo report? Cardiology Basics

How to interpret an echo report? Cardiology Basics

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 congenital heart disease will have a different pattern. This discussion is mainly on an echo report from a general cardiology setup.

In addition to details of identification and date of procedure, indication for the study and the quality of images are usually mentioned in the beginning of the report. Quality of images may be poor in those with emphysema 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. You will need nomograms for comparison. This is especially which checking measurements of coronary arteries in a case of suspected Kawasaki disease.

In addition to the measurements, there will also be a qualitative report on whether the chambers are dilated or hypertrophied and whether they are contracting well or not. In case of the left ventricle, regional wall motion abnormalities will be mentioned in detail if present.

While coming to function of the heart, the concentration is often on the left ventricle. An important value in the report is the ejection fraction. Ejection fraction is the fraction of the end diastolic volume which is ejected out during each systole. Suppose the end diastolic volume of the left ventricle is 100 ml.  If 70 ml is ejected in systole, the ejection fraction will be 70%.

As per the Universal Definition and Classification of Heart Failure 2021, Heart Failure with Reduced Ejection Fraction (HFrEF) is with a left ventricular ejection fraction of 40% or less. Heart failure with mildly reduced ejection fraction (HFmrEF) is heart failure with left ventricular ejection fraction from 41% to 49%. Heart failure with preserved ejection fraction (HFpEF) is heart failure with left ventricular ejection fraction of 50% or more.

In addition to the quantitative reporting of the left ventricular ejection fraction, normal left ventricular systolic function is often reported as good left ventricular function. Some report both ventricles together as good biventricular function. Left ventricular dysfunction may also be visually graded to mild, moderate and severe, depending on the contraction of the left ventricle in general. Diastolic dysfunction is usually reported as just left ventricular diastolic dysfunction, without any grading. 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’. Dyskinesia is a feature of an aneurysmal segment. Regional wall motion abnormalities are common after a myocardial infarction.

If there are no defects in the interatrial or interventricular septa, it is reported as intact interatrial and interventricular septa. If there is a defect, details about the location and size of the defect will be mentioned. This echo picture shows a perimembranous ventricular septal defect in the subaortic region. It is partly closed by formation of an interventricular septal aneurysm. This is one of the methods of spontaneous closure of a VSD.

Valvular abnormalities could be regurgitation or stenosis or a combination of the two. Structural abnormalities like a cleft anterior mitral leaflet in endocardial cushion defect may also be there. Thickening, calcification, abnormal motion, perforation and vegetations if any on the valves will be mentioned. In case of mitral stenosis, subvalvular fibrosis is mentioned as subvalvar pathology.

Stenosis can be graded as mild, moderate and severe depending on the severity. Area of the stenosed may be mentioned in certain cases, mostly in mitral stenosis. 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. Pressure gradients across the valves will be mentioned when they are stenotic. The gradient increases as the severity of stenosis increases.

When there is tricuspid regurgitation, the pressure difference between the right ventricle and right atrium can be calculated. This is usually mentioned as TR or tricuspid regurgitation gradient. Usually a nominal value of 10 for the right atrial pressure is added to this gradient and mentioned as the estimated right ventricular systolic pressure or RVSP. An elevated RVSP implies pulmonary hypertension, if there is no pulmonary stenosis.

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 as a congenital abnormality, it is called bicuspid aortic valve.

If there is collection of fluid between the layers of the pericardium, it is reported as pericardial effusion. The estimated amount of pericardial effusion will be reported as mild, moderate or large. When there is cardiac tamponade, it will be noted as diastolic collapse of right atrium and right ventricle. Gross thickening and calcification of pericardium may be noted in constrictive pericarditis.

Infective material attached to valves are called as vegetations. Here is a vegetation on the aortic valve in a case of aortic valve endocarditis.

Occasionally tumours may be noted in the cardiac chambers. A left atrial myxoma, which is the commonest cardiac tumour in adults, is shown here.

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 ventricular septal defect, it may read as: Congenital Heart Disease, Large Perimembranous Ventricular Septal Defect, Left to Right Shunt, Moderate Pulmonary Arterial Hypertension, Good Biventricular Function.