Could some echocardiographic measurements be artifacts because the patient has a normal ejection fraction and normal diastolic function?

Can Normal EF and Diastolic Function Indicate Echocardiographic Artifacts?

Yes, when a patient has normal ejection fraction and normal diastolic function, certain abnormal echocardiographic measurements should raise suspicion for artifacts rather than true pathology, particularly when findings are discordant with the overall clinical picture.

Understanding the Clinical Context

The presence of preserved systolic function (normal EF) and normal diastolic parameters creates a specific clinical scenario where certain "abnormal" findings are more likely to represent technical artifacts than true disease 1. This is particularly important because image quality directly impacts the reliability of measurements, and poor quality imaging can make advanced techniques like strain and 3D measurements misleading 1.

Key Principles for Artifact Recognition

When to Suspect Artifacts

Artifacts should be strongly suspected when:

• Discordant findings exist: If EF is normal and diastolic function appears normal, but isolated parameters suggest severe pathology (e.g., apparent severe pulmonary hypertension), this discordance suggests artifact 2
• Poor image quality: Suboptimal or poor quality imaging makes measurements unreliable and advanced parameters potentially misleading 1
• Segmental strain abnormalities: Strain-curve artifacts systematically reduce segmental strain/strain-rate values (from -20.7% to -14.9%), creating false abnormalities even when global measurements remain normal 3

Common Artifact Patterns

Doppler artifacts are particularly problematic:

• High-velocity jets can create aliasing artifacts that mimic pathology (e.g., aortic insufficiency jets misinterpreted as tricuspid regurgitation) 2
• Timing is critical: Verify whether high-velocity signals occur during systole or diastole to distinguish true pathology from artifact 2

Right ventricular measurements are inherently problematic due to complex RV geometry, heavy trabeculation, and difficulty obtaining standardized imaging planes, making qualitative assessment more reliable than quantitative measures 4

Algorithmic Approach to Artifact Detection

Step 1: Assess Image Quality

• Document quality as optimal, fair, suboptimal, or poor 1
• If suboptimal/poor: Do not rely on advanced parameters (strain, 3D measurements)
• Consider alternative imaging if critical decisions depend on these measurements

Step 2: Check for Internal Consistency

When EF and diastolic function are normal, verify:

• Left atrial size: Should be normal if filling pressures are truly normal 5
• Pulmonary pressures: Should not be severely elevated with normal LV function 5
• Valve function: Should correlate with chamber sizes and function

Step 3: Validate Doppler Findings

For any high-velocity signal:

• Confirm timing (systolic vs. diastolic) 2
• Check for aliasing patterns
• Verify direction and origin of jet
• Use multiple windows to confirm findings

Step 4: Assess Segmental Strain Carefully

If using strain imaging:

• Discard segments with poor tracking (>2 segments in single view = unreliable global strain) 6
• Recognize that curve-artifacts systematically reduce values 3
• Use alternative indices (MAPSE, mitral annular s') if tracking is suboptimal 6

Clinical Pitfalls to Avoid

Critical mistake: Accepting isolated severe abnormalities when overall cardiac function appears preserved. The 2015 EACVI guidelines emphasize that in patients with preserved EF, multiple parameters are needed to confirm elevated filling pressures - isolated findings should prompt artifact consideration 7.

Vendor variability: Inter-vendor differences exist for strain measurements and even some standard Doppler parameters 1. Always report machine type and model 1.

Dynamic nature of diastolic function: Diastolic parameters vary with heart rate and preload 8. A single snapshot may not represent true baseline function, particularly if obtained during suboptimal conditions.

When Artifacts Are Less Likely

Artifacts are less likely to explain findings when:

• Multiple concordant abnormalities exist across different measurement modalities
• Image quality is optimal
• Findings are reproducible across multiple windows
• Clinical presentation strongly supports the echocardiographic findings

Practical Recommendation

In patients with normal EF and apparently normal diastolic function, any isolated severe abnormality should prompt repeat imaging with optimal technique, multiple windows, and careful attention to timing and direction of flow signals before accepting as true pathology 1, 2. When uncertainty persists, transesophageal echocardiography may be indicated if findings would alter management 4.

The standardization documents emphasize that reporting should acknowledge when findings are inconclusive rather than forcing a diagnosis based on unreliable measurements 1, 5.