How should I interpret my echocardiogram?

How to Interpret Your Echocardiogram

Echocardiogram interpretation requires integrating the imaging findings with your clinical history, physical examination, and symptoms—never rely on the report numbers alone, as discrepancies between clinical findings and echo measurements are common and can lead to misdiagnosis. 1

Essential First Principle: Clinical-Echo Concordance

The physical examination establishes your "pre-test probability" and must guide interpretation of all echocardiographic findings. 1 When the echo report conflicts with clinical findings (symptoms, murmur characteristics, pulse character, lung sounds), the echo may be wrong—not the examination. 1

Common Pitfalls to Recognize:

• Overestimation of severity: Color Doppler jet area alone can overestimate regurgitation severity, especially with eccentric jets. 1, 2
• Underestimation of severity: Eccentric mitral regurgitation jets may appear small on color Doppler despite being severe; severe aortic stenosis can show falsely low gradients with poor Doppler alignment or low cardiac output. 1
• Chamber size trumps jet size: If you have severe chronic mitral regurgitation but normal left ventricular and left atrial sizes, the severity is overestimated—severe volume overload always causes chamber enlargement. 1, 2
• Late systolic jets: Mitral regurgitation from prolapse occurring only in late systole may show large PISA measurements but small regurgitant volumes; if the murmur is late and soft with normal chamber sizes, the regurgitation is not severe. 1

Systematic Interpretation Framework

Step 1: Verify Image Quality and Completeness

Review whether all standard views were adequately visualized. 1 Inadequate images limit diagnostic accuracy—even experienced readers achieve only 65% accuracy with limited views. 3 If prosthetic valves or cardiac devices are present, confirm multiplane imaging was performed to avoid artifact. 1

Step 2: Assess Cardiac Structure

Examine chamber dimensions and wall thickness systematically: 4

• Left ventricle: End-diastolic diameter >2 standard deviations above normal suggests dilated cardiomyopathy; wall thickness >15mm suggests hypertrophic cardiomyopathy. 4
• Left atrium: Severe enlargement indicates chronic volume overload (mitral regurgitation, atrial fibrillation) or elevated filling pressures. 2
• Right ventricle: Dilation suggests pulmonary hypertension, right ventricular infarction, or significant tricuspid regurgitation. 1
• Atrial enlargement with normal ventricles: Suggests restrictive cardiomyopathy or chronic atrial fibrillation. 4

Step 3: Evaluate Systolic Function

Left ventricular ejection fraction (LVEF) is the primary measure but has limitations: 4

• LVEF <40% defines systolic dysfunction. 4
• Do not rely solely on LVEF in hypertrophic cardiomyopathy—these patients maintain normal or hyperdynamic ejection fraction despite diastolic dysfunction. 4
• Regional wall motion abnormalities indicate coronary artery disease, prior infarction, or acute ischemia. 1
• Lack of compensatory hyperkinesia in non-infarcted segments suggests multivessel disease and worse prognosis. 1

Step 4: Assess Diastolic Function

Diastolic dysfunction is frequently overlooked but critically important: 4

• E/e' ratio ≥13 indicates elevated filling pressures and diastolic dysfunction. 5
• Restrictive filling pattern (E/A ratio >2, short deceleration time) indicates advanced diastolic dysfunction. 4
• Pulmonary vein flow reversal indicates severe elevation of left atrial pressure. 2

Step 5: Evaluate Valvular Function

Use multiple parameters—never rely on a single measurement: 1, 2

For Mitral Regurgitation:

• Vena contracta width: <3mm = mild, 3-7mm = moderate, >7mm = severe. 6
• Effective regurgitant orifice area (EROA): <20mm² = mild, 20-40mm² = moderate, >40mm² = severe. 6
• Regurgitant volume: <30mL = mild, 30-60mL = moderate, >60mL = severe. 6
• Chamber sizes: Normal LV/LA size excludes severe chronic MR. 1, 2
• Pulmonary vein flow: Systolic flow reversal indicates severe MR. 2

For Aortic Stenosis:

• Mean gradient: <20mmHg = mild, 20-40mmHg = moderate, >40mmHg = severe. 1
• Aortic valve area: >1.5cm² = mild, 1.0-1.5cm² = moderate, <1.0cm² = severe. 1
• Beware low-flow states: Low ejection fraction or small LV cavity can cause low gradients despite severe stenosis. 1
• Pressure recovery: Small aortic root can cause gradient overestimation. 1

Step 6: Detect Complications and Secondary Findings

Echocardiography excels at identifying structural complications: 1

• Intracardiac thrombus: Most common in dilated ventricles, anterior/apical infarctions, and atrial fibrillation. 1
• Pericardial effusion: Echo-free space around heart; right atrial/ventricular collapse indicates tamponade. 1
• Vegetations: Mobile masses on valves suggest endocarditis; TEE is more sensitive than TTE. 1
• Ventricular septal rupture: Post-MI complication requiring urgent surgical evaluation. 1
• Papillary muscle rupture: Causes acute severe mitral regurgitation post-MI. 1
• Pseudoaneurysm: Contained free wall rupture with characteristic narrow neck. 1

Step 7: Assess Pulmonary Pressures

Elevated pulmonary artery systolic pressure (PASP) indicates: 1, 4

• Left-sided heart disease (most common cause)
• Pulmonary hypertension
• Significant mitral or tricuspid regurgitation
• Chronic lung disease

When Additional Imaging Is Required

Transesophageal echocardiography (TEE) is mandatory when: 1

• Prosthetic valve dysfunction is suspected
• Endocarditis is being evaluated (TTE negative but clinical suspicion remains)
• Left atrial appendage thrombus assessment is needed before cardioversion
• Paravalvular abscess or fistula is suspected
• Transthoracic images are inadequate

Cardiac MRI provides superior tissue characterization when: 4

• Cardiomyopathy etiology is uncertain
• Fibrosis detection is needed for risk stratification
• Echocardiographic windows are inadequate
• Infiltrative disease (amyloid, sarcoid) is suspected

Stress echocardiography is indicated when: 1

• Resting echo is normal but coronary disease is suspected
• Viability assessment is needed before revascularization
• Dynamic valve obstruction needs provocation (hypertrophic cardiomyopathy)

Critical Actions Based on Findings

Immediate cardiology referral is required for: 1, 2

• Severe valvular disease (especially if symptomatic)
• New regional wall motion abnormalities suggesting acute coronary syndrome
• Suspected cardiac tamponade
• Intracardiac mass or vegetation
• Severe systolic dysfunction (LVEF <40%)
• Discordance between clinical findings and echo report

Routine cardiology follow-up for: 6

• Mild valvular regurgitation without symptoms or chamber enlargement (every 3-5 years)
• Moderate valvular disease (annually)
• Cardiomyopathy requiring optimization of medical therapy

Special Populations

In acute myocardial infarction: 1

• Echo identifies infarct location, size, and complications
• Correlates with peak creatine kinase, hemodynamics, and mortality
• Serial imaging monitors for expansion, extension, and thrombus formation

In cardiomyopathy: 4

• Dilated: LV dilation, reduced LVEF, assess for thrombus and mitral regurgitation
• Hypertrophic: Measure maximum wall thickness, assess for outflow obstruction and systolic anterior motion
• Restrictive: Biatrial enlargement, preserved LVEF, restrictive filling pattern

With cardiac devices: 1

• Visualize leads throughout their course
• Assess for vegetations using multiplane and 3D imaging
• Distinguish lead vegetations from valvular vegetations and artifacts