Echo basics: Measurements and Reports

Assessment of heart valve structure and function

Two-Dimensional Imaging

• Image optimization is critical: use zoom, image gain adjustment, and probe angulation to achieve the clearest possible views.
• LVOT diameter should be measured routinely:
  • Use a zoomed parasternal long-axis view
  • Measurement is made inner edge to inner edge
  • Performed at the base of the aortic valve cusps during mid-systole

Doppler Techniques

General Principles

• Velocity scales should be adjusted so that the Doppler waveform fills the display, allowing for more accurate tracing and peak velocity determination.

Continuous Wave (CW) Doppler

• Used to measure high velocities (e.g., across stenotic valves).
• Ensure the Doppler cursor is aligned with the direction of blood flow.
• Peak velocity: Place the cursor at the top of the densest part of the signal.
• Mean velocity: Trace around the full spectral envelope of the Doppler waveform.

Pulsed Wave (PW) Doppler

• Allows site-specific velocity assessment.
• Adjust the sample volume location until a clear, smooth velocity curve is visualized.
• Optimal trace characteristics:
  • Clear closing click of the valve
  • Less dense central waveform
  • Avoid placing the sample too close to the valve (may show opening clicks)

Pressure Half-Time (PHT)

• Used for mitral valve assessment, particularly in mitral stenosis.
• Place the PW Doppler sample volume at the tip of the mitral leaflets.
• Draw a line from the maximum velocity down the diastolic slope of the waveform.

Color Doppler

• Box size: Use the smallest box necessary to cover the region of interest to maximize frame rate.
• Gain optimization:
  • Increase gain until random speckle noise is seen
  • Then reduce slightly until the speckle just disappears

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Reporting in valve assessment

A comprehensive echocardiography report integrates all imaging findings to form the basis of clinical decision-making and patient management, especially in cases of valve disease.

General Principles

• The report should clearly describe what was observed during the echo study.
• Abnormal valves will often require more detailed descriptions.
• Integrate findings from multiple views and modalities (2D, Doppler, Color) for a concise, coherent explanation.
• All measurements should be included and referenced against normal ranges.
• An overall conclusion should:
  • Be clear and concise
  • Summarize the key abnormality
  • Identify other relevant findings
  • Be written in a style understandable by non-specialist staff
  • Include a comparison to previous studies, if applicable

Reporting Valve Stenosis

When valve stenosis is identified, include the following details:

• Appearance of the valve (e.g. calcified, thickened, restricted mobility)
• Severity of stenosis (e.g. mild, moderate, severe based on Doppler parameters)
• Left ventricular (LV) dimensions and systolic function
• Assessment of subvalvular apparatus (especially in atrioventricular valves like the mitral and tricuspid)
• Function of other cardiac valves
• Right ventricular (RV) function and pulmonary artery pressure (PAP)

Reporting Valve Regurgitation

When valve regurgitation is present, include:

• Severity of regurgitation (qualitative and quantitative)
• Cause of regurgitation (e.g. prolapse, annular dilation, leaflet perforation)
• LV and aortic root dimensions
• LV systolic function
• Function of other valves
• RV function and pulmonary artery pressure

Reporting Prosthetic Valves

For patients with prosthetic heart valves, include:

• Valve type and position (e.g. mechanical mitral, bioprosthetic aortic)
• Any signs of obstruction (e.g. high velocity, restricted leaflet motion)
• Doppler flow measurements through the valve
• Severity and source of any regurgitation (e.g. transvalvular vs paravalvular)
• LV dimensions and function

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Radiology Library: Echocardiography basics

• Eggett C. Echo basics: Valve Views. LITFL
• Eggett C. Echo basics: Valves, Measurements and Reports. LITFL
• Eggett C. Echo basics: Mitral valve. LITFL
• Eggett C. Echo basics: Mitral Regurgitation. LITFL
• Eggett C. Echo basics: Mitral Stenosis. LITFL
• Eggett C. Echo basics: Aortic Valve. LITFL
• Eggett C. Echo basics: Aortic Stenosis. LITFL
• Eggett C. Echo basics: Aortic Regurgitation. LITFL
• Eggett C. Echo basics: Tricuspid Valve. LITFL
• Eggett C. Echo basics: Pulmonary Valve. LITFL
• Eggett C. Echo basics: Prosthetic Valves. LITFL

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Further reading

• Otto CM. Textbook of Clinical Echocardiography. Elsevier. 7e, 2023.
• Houghton AR. Making Sense of Echocardiography: A Hands-on Guide. 3e 2023
• Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD; ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):e521-643

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