What elements should be included in a complete two‑dimensional transthoracic echocardiogram (2‑D echo) report?

Complete 2D Transthoracic Echocardiography Report Elements

A complete 2D transthoracic echocardiogram report must include demographic data, technical details, image quality assessment, comprehensive quantitative measurements of all cardiac chambers indexed to body surface area, valve structure and function with severity grading, diastolic function parameters, and clinical context. 1

Mandatory Demographic and Technical Information

Patient and examination context:

• Age, body height, and weight are mandatory because Doppler parameters, tissue Doppler values, and LV global longitudinal strain are strongly age-dependent 1
• Body surface area (BSA) calculation for indexing measurements 1
• Blood pressure and heart rhythm/rate at time of examination 1
• Referral diagnosis or reason for examination 1

Technical specifications:

• Echo machine vendor and model must be documented due to inter-vendor variability, particularly for advanced parameters like LV global longitudinal strain 1
• Image quality grading (optimal, fair, suboptimal, or poor) is essential because suboptimal quality can lead to inconclusive diagnosis and make advanced techniques like strain and 3D misleading 1

Left Ventricular Assessment

Dimensional measurements (2D or M-mode):

• LV internal cavity diameters (end-diastolic and end-systolic) 1
• Wall thickness measurements (interventricular septum and posterior wall) 1
• LV volumes (end-diastolic and end-systolic), preferably by biplane method of discs or 3D when available 1

Systolic function parameters:

• LV ejection fraction (LVEF) - mandatory for classification of heart failure type 1, 2
• LV global longitudinal strain (GLS) provides early detection of subclinical dysfunction, with values less negative than -18% indicating abnormality 1, 2
• Regional wall motion assessment using the 17-segment model 1

LV mass and geometry:

• LV mass indexed to BSA (or height^2.7 in overweight/obese patients) 1
• Relative wall thickness calculation to categorize hypertrophy pattern (concentric if >0.42, eccentric if ≤0.42) 1

Diastolic Function Assessment

Essential diastolic parameters:

• Mitral inflow velocities (E and A waves, E/A ratio) 1
• Tissue Doppler e' velocity (average <9 cm/s indicates impaired relaxation) 1, 2
• E/e' ratio (≥14 indicates elevated LV filling pressures) 1, 2
• LA volume index (reflects chronic diastolic burden with prognostic significance) 1, 2

Right Heart Structures

Right ventricular assessment:

• RV size and function (fractional area change, free-wall longitudinal strain) 1, 2
• Systolic pulmonary artery pressure estimation using tricuspid regurgitation velocity 1, 2
• IVC diameter and respiratory collapse (>2.1 cm with <50% collapse suggests RA pressure 15 mmHg; <2.1 cm with >50% collapse suggests 3 mmHg) 2

Right atrial evaluation:

• RA size assessment 1

Valve Assessment

Comprehensive valve evaluation must include:

• Valve morphology and structure (number of cusps, calcification, thickening) 1
• Leaflet/cusp motion abnormalities 1
• Regurgitation severity grading (trace, mild, moderate, severe) with integrated assessment of multiple parameters 1
• Stenosis severity with valve area and gradients 1

The ACC/AHA guidelines emphasize that valve assessment should integrate morphological findings with quantitative hemodynamic data rather than relying on single parameters. 1

Disease-Specific Reporting Requirements

Heart failure patients require:

• Comprehensive quantitative LVEF, longitudinal function (preferably GLS), diastolic function parameters, pulmonary pressure, and RV function 1

Coronary artery disease patients need:

• LV global and regional systolic function assessment routinely 1
• Regional wall motion abnormalities mapped to coronary territories 1

Valvular heart disease reports must:

• Integrate valve morphology with chamber geometry and function reflecting hemodynamic burden 1

Cardiomyopathy evaluation requires:

• 2D wall thickness and cavity diameters, volumes, LVEF, GLS, and diastolic parameters 1

Systemic disease with cardiac involvement needs:

• LV mass calculation for hypertrophy diagnosis, volumes, EF, wall thickness, and cavity diameters 1

Standard Imaging Views

The examination must utilize:

• Standard 2D views from parasternal, apical, subcostal, and suprasternal windows 1
• Color flow Doppler and spectral Doppler as integral components 1
• Contrast enhancement when more than 2 contiguous LV segments are not visualized 1

Critical Pitfalls to Avoid

• Failing to index measurements to BSA renders LV mass and chamber volumes uninterpretable 1
• Omitting blood pressure documentation affects interpretation of regurgitation severity 1
• Not documenting image quality can lead to overconfidence in measurements from suboptimal studies 1
• Using advanced techniques (strain, 3D) on poor-quality images produces misleading results 1