Step-by-Step Procedure for Pediatric 2D Echocardiography
A comprehensive pediatric 2D echocardiogram should follow a systematic segmental approach that includes patient preparation, standardized image acquisition across multiple views, quantitative measurements using age-appropriate Z-scores, and Doppler assessment of flow patterns and hemodynamics. 1
Pre-Examination Preparation
Patient Demographics and Vital Signs
- Record mandatory demographic data: age, weight, height, gender 1
- Document heart rate, blood pressure, oxygen saturation, and respiratory rate 1
- Include clinical indication, medical diagnosis, and ongoing therapy 1
Equipment and Sedation Considerations
- Use the highest-frequency transducer possible, even for older children, to achieve high-resolution imaging of cardiac structures and coronary arteries 2
- Consider sedation for children under 3 years of age and irritable older children to obtain high-quality images 2
- Document the ultrasound vendor and software employed for analysis, especially for innovative techniques 1
Systematic Image Acquisition
Standard Imaging Views
The examination should systematically evaluate all cardiac segments using established echocardiographic windows 1, 3:
Parasternal Views:
- Long-axis view for left ventricle, aortic valve, mitral valve, left atrium 3
- Short-axis views at multiple levels (aortic valve, mitral valve, papillary muscle, apex) 3
Apical Views:
- Four-chamber view for all four chambers, atrioventricular valves, ventricular septum 1
- Five-chamber view for left ventricular outflow tract 3
- Two-chamber view for left ventricle and left atrium 1
- Three-chamber view for left ventricular outflow and aortic valve 3
Subcostal Views:
- Four-chamber view for atrial septum evaluation 3
- Short-axis views for ventricular septum 3
- Inferior vena cava and hepatic veins for assessment of systemic venous return 1
- Abdominal aorta for systemic perfusion assessment 1
Suprasternal Views:
Quantitative Measurements and Analysis
Left Ventricular Assessment
Age-specific measurement techniques are critical: 1
- For neonates and infants: Use the area-length method for left ventricular volume quantification, as it provides better reproducibility in this age group 1
- For older children: Use the biplane Simpson method, which is now accepted as standard and allows for shape correction 1
- Measure LV dimensions, area, volumes, and calculate ejection fraction 1
- Always express measurements as Z-scores using age and body size-specific nomograms 1
Right Ventricular Assessment
- Measure RV area, length, and end-diastolic diameters at basal and mid-cavity levels in the apical four-chamber view 1
- Calculate fractional area change (FAC) from diastole to systole 1
- Measure tricuspid annular plane systolic excursion (TAPSE) using M-mode through the lateral tricuspid annulus 1
- Recognize that 2D RV evaluation has inherent limitations due to the chamber's complex geometry 1
Valve Assessment
- Anatomical details of all four valves must always be reported 1
- Quantitation is required when stenosis, regurgitation, hypoplasia, or dilatation is present 1
- Measure valve annulus dimensions at end-diastole for tricuspid and mitral valves 1
Great Vessel Evaluation
- Anatomical details of pulmonary arteries, aortic arch, and main vessels should always be reported 1
- Quantitation is required for stenosis, hypoplasia, or dilatation 1
- Measure coronary artery segments when indicated: left main, left anterior descending, left circumflex, right coronary artery (proximal, middle, distal), and posterior descending arteries 2
Doppler Assessment
Color Flow Mapping
- Systematically evaluate all four valves for regurgitation or stenosis 1, 3
- Assess for intracardiac shunts at atrial and ventricular levels 1, 4
- Evaluate great vessel flow patterns 3
Spectral Doppler
Pulsed-Wave Doppler:
- Mitral inflow velocities (E and A waves) for diastolic function assessment 1
- Pulmonary venous flow patterns 3
- Ventricular outflow tract velocities 3
Continuous-Wave Doppler:
- Peak velocities across stenotic valves to calculate gradients 1, 3
- Regurgitant jet velocities for severity assessment 3
- Tricuspid regurgitation velocity for estimating right ventricular systolic pressure 1, 3
Tissue Doppler Imaging:
- Mitral annular early diastolic velocity (e′) for diastolic function 1
- Calculate E/e′ ratio, though recognize that adult standards for diastolic dysfunction are not validated in neonates and infants 1
Advanced Modalities (When Available)
Strain Imaging
- Left ventricular global longitudinal strain (GLS) should be increasingly used when experience and good reproducibility are established 1
- Right ventricular GLS provides additional functional assessment 1
Three-Dimensional Echocardiography
- Consider in older children and teenagers for more accurate ventricular volume assessment 1
- Provides better reproducibility and closer agreement with cardiac MRI compared to 2D methods 1
- Offers semi-automated methods that reduce inter-observer variability 1
Critical Pitfalls to Avoid
Measurement Errors
- Do not apply adult diastolic dysfunction criteria to neonates and infants, where E/A inversion may be physiological and E/A fusion is common at high heart rates 1
- Avoid using outdated nomograms, as significant variability exists between different Z-score sources 1
- Recognize that LV shape and dimensions are highly variable with slight probe angulations, affecting diameter and volume measurements 1
Technical Limitations
- Document image quality in the report, as poor windows limit diagnostic accuracy 1
- Be aware that 2D methods rely on geometric assumptions that may not apply in congenital heart disease 1
- Understand that echocardiography has limitations in detecting coronary artery thrombi and stenosis 2