Recommended Echo Measurements for Assessing Cardiac Structure and Function
Transthoracic echocardiography (TTE) is the preferred initial imaging modality for comprehensive assessment of cardiac structure and function, providing essential diagnostic information for detecting structural heart disease and guiding clinical management. 1
Standard Imaging Planes and Views
The comprehensive echocardiographic assessment should utilize three primary planes 2:
- Transverse plane: horizontal plane dividing the heart into superior and inferior segments
- Sagittal plane: vertical plane dividing the heart into right and left segments
- Coronal plane: vertical plane dividing the heart into anterior and posterior segments
Standard views should include 3:
- Parasternal long-axis and short-axis views (at multiple levels including aortic valve, mitral valve, papillary muscle, and apex)
- Apical four-chamber, two-chamber, and three-chamber views
- Subcostal views
Left Ventricular Assessment
Left ventricular size measurements 2, 4:
- LV end-diastolic diameter
- LV end-systolic diameter
- LV end-diastolic volume
- LV end-systolic volume
- LV mass
Left ventricular systolic function assessment 2, 4:
- Left ventricular ejection fraction (LVEF)
- Global longitudinal strain (GLS) using speckle tracking technology
- Regional wall motion abnormalities
- Mitral annular plane systolic excursion (MAPSE)
- Mitral annulus S' velocity
Left ventricular diastolic function assessment 4:
- E/A ratio (ratio of early to late diastolic filling velocities)
- E wave deceleration time
- e' velocity (early diastolic mitral annular velocity)
- E/e' ratio (ratio of early mitral inflow velocity to early diastolic mitral annular velocity)
- Left atrial volume index
Right Ventricular Assessment
Right ventricular size measurements 2:
- RV basal diameter
- RV mid-cavity diameter
- RV length
- RV end-diastolic area
- RV end-systolic area
Right ventricular function assessment 2:
- Tricuspid annular plane systolic excursion (TAPSE)
- RV fractional area change
- RV free wall strain
- Tricuspid annular S' velocity
- RV index of myocardial performance (RIMP)
Valvular Assessment
Mitral valve assessment 2:
- Structural evaluation (leaflet morphology, annular calcification)
- Color Doppler evaluation of regurgitation (vena contracta width, PISA method)
- Continuous wave Doppler for stenosis assessment (mean gradient, pressure half-time)
Aortic valve assessment 2:
- Structural evaluation (leaflet morphology, calcification)
- Color Doppler evaluation of regurgitation
- Continuous wave Doppler for stenosis assessment (peak velocity, mean gradient, valve area)
Tricuspid and pulmonic valve assessment 2:
- Structural evaluation
- Color Doppler evaluation of regurgitation
- Continuous wave Doppler for stenosis assessment
Additional Measurements
Pulmonary artery pressure estimation 2:
- Tricuspid regurgitation velocity for systolic pulmonary artery pressure
- Pulmonary valve acceleration time
- Right atrial pressure estimation via inferior vena cava size and collapsibility
Pericardial assessment 2:
- Presence of pericardial effusion and size
- Signs of tamponade (right atrial or ventricular diastolic collapse)
- Pericardial thickness
Aortic measurements 2:
- Aortic root dimensions
- Ascending aorta diameter
- Arch and descending aorta when visible
Advanced Echocardiographic Techniques
3D echocardiography when available 2:
- More accurate LV and RV volumes and ejection fraction
- Better visualization of valve morphology and function
- Enhanced assessment of congenital abnormalities
- Global longitudinal strain has superior prognostic value compared to LVEF alone
- Regional strain patterns can help identify specific cardiomyopathies
- Particularly useful for detecting subclinical LV dysfunction
Common Pitfalls and Limitations
Technical limitations 6:
- Poor acoustic windows (consider contrast enhancement when two or more contiguous LV segments are poorly visualized) 4
- Apical foreshortening leading to underestimation of volumes
- Off-axis imaging resulting in inaccurate measurements
Interpretation challenges 6:
- Masses and mass mimics (crista terminalis, moderator band, lipomatous hypertrophy)
- Poorly visualized apical lesions (thrombus, aneurysm)
- Limited assessment of the ascending aorta
- Suboptimal pericardial visualization
When TTE is inadequate, consider transesophageal echocardiography (TEE) for better visualization of valves, atria, and aorta 2, 7
Follow-up Imaging Recommendations
Repeat imaging is generally not recommended in less than 1 year for stable patients 2
Appropriate indications for repeat imaging include 2:
- Change in clinical status or symptoms
- After therapy with cardiotoxic agents
- Monitoring of known moderate or greater pulmonary hypertension
- Evaluation of intracardiac masses when findings would alter therapy
For patients receiving cardiotoxic therapy, regular assessment of LV function with strain imaging is recommended 2, 4