How should I perform a transthoracic echocardiogram (TTE) in an adult patient?

How to Perform a Transthoracic Echocardiogram in Adults

Perform a comprehensive transthoracic echocardiogram using a systematic, structured approach that includes standardized parasternal, apical, subcostal, and suprasternal views with focused assessment of left ventricular size and function, right ventricular size and function, valve function, and the pericardium—tailored to the clinical scenario. 1, 2

Clinical Context-Driven Approach

The European Association of Cardiovascular Imaging emphasizes that TTE should be performed with specific clinical scenarios in mind, as this determines the focus of your assessment 1:

Emergency Settings

In life-threatening situations, prioritize rapid focused assessment 1:

• Cardiac arrest: Focus on LV size and function, RV size and function, proximal aorta, and pericardium to identify tamponade, massive pulmonary embolism, tension pneumothorax, hypovolemia, or complications of acute MI 1
• Shortness of breath: Assess LV size, wall thickness and function, RV size and function, and pericardium to differentiate cardiogenic shock (requiring circulatory support) from respiratory failure (requiring ventilatory support) 1
• Chest pain: Evaluate LV size and function, RV size and function, aorta, and pericardium for acute coronary syndrome, aortic syndromes, pulmonary embolism, or pericardial disease 1

Non-Urgent First Assessment

For initial diagnostic evaluation 1:

• Heart failure: Confirm or exclude diagnosis, quantify chamber volumes, assess systolic and diastolic LV function, measure wall thickness, and identify etiology—TTE provides initial diagnosis and treatment plan in the majority of patients 1
• Valvular heart disease: Diagnose, assess severity, and evaluate hemodynamic consequences 1
• Cardiomyopathy: Diagnose and classify type (hypertrophic, dilated, arrhythmogenic, restrictive) 1

Standardized Image Acquisition Protocol

Linear Measurements

Obtain linear internal measurements in the parasternal long-axis view 1:

• Position measurements perpendicular to the LV long axis at or immediately below the mitral valve leaflet tips 1
• Place electronic calipers at the interface between myocardial wall and cavity, and between wall and pericardium 1
• Prefer 2D-guided measurements over M-mode to avoid oblique sections 1

Volumetric Measurements

Measure LV volumes from apical four-chamber and two-chamber views using 2D or 3D echocardiography 1:

• Maximize LV areas while avoiding foreshortening, which causes volume underestimation 1
• Do not use Teichholz or Quinones methods for calculating volumes from linear dimensions—these are no longer recommended due to inaccurate geometric assumptions 1
• Use contrast agents when needed to enhance endocardial border delineation 1
• 3D imaging provides more accurate and reproducible volumes without geometric assumptions, though it has lower temporal resolution 1

Minimum Dataset Requirements

The British Society of Echocardiography recommends a structured minimum dataset to confirm normal cardiac structure and function 2:

• Left ventricle: Size, wall thickness, systolic function (including ejection fraction), diastolic function 2
• Right ventricle: Size and systolic function 2
• Valves: Morphology and function of all four valves 2
• Pericardium: Presence or absence of effusion 2
• Aorta: Proximal ascending aorta dimensions 2

Common Pitfalls and Limitations

Blind Spots to Recognize

Be aware that TTE has inherent limitations that may require advanced imaging 3, 4:

• Left ventricular apex: Infarcts, aneurysms, thrombus, and apical hypertrophic cardiomyopathy are frequently missed 3, 4
• Pericardium: Thickening, calcification, and loculated effusions may be poorly visualized 3
• Aorta: Dissection, intramural hematoma, and penetrating atherosclerotic ulcer can be false positive or false negative 3, 4
• Left atrial appendage: Thrombus detection is unreliable with TTE 3
• Coronary arteries: Origins, calcifications, fistulas, and aneurysms are not well assessed 3

Mass Mimics

Normal anatomic structures can be mistaken for pathology 4:

• Crista terminalis, eustachian valve, moderator band, atrioventricular groove fat, left ventricular bands, and lipomatous hypertrophy of the interatrial septum 4
• Hiatal hernia and caseous calcification of the mitral annulus 4

Body Size Indexing

Always report chamber measurements indexed to body surface area to allow comparison among individuals with different body sizes 1

When Additional Imaging Is Needed

If the diagnosis remains unclear after comprehensive TTE, or when blind spots are suspected based on clinical context, refer for cardiac CT or MRI 1, 3, 4. This is particularly important for suspected apical lesions, aortic dissection, pericardial disease, or when evaluating for cardiac masses 3, 4.