The Report

All Echotech scans are full investigations and adhere to the BSE Education Committee recommendations for 'a minimum dataset for a standard adult transthoracic echocardiogram'. BSE Education Committee October 2005.

All reports adhere to strict reporting guidelines devised by the Echotech Clinical Lead and the Echotech Clinical Operations Director and are reviewed at monthly clinical governance meetings.

The guidelines have been devised to promote both the quality and consistency of all Echotech reports, encourage a systematic approach to reporting and facilitate the accurate comparison of echocardiograms performed by different Echotech Cardiac Physiologists at different sites.

The Echotech reporting guidelines include reference values detailed in the BSE guideline for chamber and valve quantification. BSE Education Committee May 2008.

The Echotech report is primary care focussed and is therefore written in clear, descriptive terms, stating all key findings, whether normal or abnormal, detailing both morphology and function for each cardiac structure.

The use of tick boxes is used extensively to further enhance the clarity of the report. The underlying basis for a particular box being ticked (e.g. moderate AS) is then made clear in the technical report section.

The report also states a conclusion / summary which:

• emphasises the abnormal findings and
• responds to the question(s) posed by the referring clinician
• details the LV systolic function and the LV diastolic function (where appropriate)

If the patient requires cardiology referral, following the echo, the statement 'Suggest Cardiology Referral' appears in RED BOLD lettering at the top of the report.

If the patient requires urgent cardiology referral, following the echo, the statement 'Suggest URGENT Cardiology Referral' appears in RED BOLD lettering at the top of the report.

The statements; 'suggest cardiology referral' and 'suggest urgent cardiology referral' are based on clear criteria, which are detailed in the Echotech Reporting Guidelines and GP Handbook.

For the full Echotech 'Reporting Guidelines' document please contact Echotech.

The Cardiac Physiologist's role

To write a detailed technical report, stating all findings whether normal or abnormal, answering specific questions asked by the physician.

Question: Is there Heart Failure?
Answer: Severe LV systolic dysfunction.

A technicians report will give detailed information on:

• Size (where possible) and function (systolic and diastolic) of the LV, mentioning any regional wall motion abnormalities
• The structure and function of the heart valves
• The size of the LA, size and function of the right heart
• Any other abnormal findings

Any questions from the physician will be answered in a technical report style, for example:

Technical Terms/Basic Anatomy

Valve Structure

• Aortic.
  AV has 3 cusps: non-coronary, right coronary and left coronary. Each can be named in a report. Commisures are the bases of the AV cusps. Different parts of the aortic root may be reported on, this may include; valve level, sinus of valsalva, sino-tubular junction, ascending and descending aorta, abdominal aorta or aortic arch.

• Mitral.
  Consists of 2 leaflets - posterior and anterior. Each leaflet may be reported on, sometimes including the MV chordae.

Reporting LV Systolic Dysfunction (LVSD)

In experienced hands, visual estimation of LV systolic function is reliable.

In echocardiography, LV ejection fraction (LVEF) is calculated as a marker of systolic function. Generally, an LVEF less than 55% represents impaired systolic function. This can be calculated in several ways by echocardiography.

Left ventricular end diastolic dimension (LVEDd) and left ventricular end systolic dimension (LVEDs) are usually measured from parasternal long axis M-mode recordings of the LV, with the cursor at the tips of the mitral valve. From this, LV volumes at end diastole and end systole are calculated using the Teicholz formula. The LVEF is then derived from this as a measure of the change in LV volume during systole.

LVEF may also be calculated using the modified biplane Simpson technique. The endocardial border of the LV is traced in both systole and diastole and volumes calculated using Simpson's rule.

Global LV systolic dysfunction (LVSD) may be graded as mild, moderate or severe.

LV Segments

Septum
Apex
Anterior Wall
Posterior Wall
Inferior Wall
Lateral Wall

Each wall has 3 sections/portions; basal, mid and distal, which in a report may be noted to have a degree of movement.

Reporting LV Diastolic Dysfunction (LVDD)

The assessment of diastolic dysfunction is becoming increasingly important as we recognise this as a potential cause of both symptoms and long term morbidity.

An assessment is especially useful when left ventricular systolic function is normal.

Pulsed wave Doppler of mitral valve flow is the most commonly used method of assessing diastolic function.

In the presence of sinus rhythm two waves, E and A are produced, reflecting early filling of the left ventricle in diastole and atrial contraction respectively. The E:A ratio and E deceleration time (ms) are measured.

The Doppler pattern may be either:

Normal
A slow relaxation pattern (Reversed & decreased E:A ratio <0.7, Prolonged E deceleration time >240ms)
A restrictive filling pattern (High E:A ratio >2.0, Shortened E deceleration time <140ms)

However, the normal and abnormal patterns are physiological descriptions and patients may move between them depending on the state of their disease, loading conditions or treatment.

It is therefore possible for a pseudonormal transmitral pattern Doppler pattern to occur in a patient with significant diastolic dysfunction.

Therefore, in the case of a normal transmitral Doppler pattern, other echo modes of assessment must be made before one can confidently exclude diastolic dysfunction. These include a Doppler assessment of pulmonary vein flow and an E:Ea ratio from Tissue Doppler Imaging. Their role in the assessment of LV diastolic dysfunction is detailed in the algorithm below.

 

LV diastolic dysfunction is graded in order of severity as:

Normal
Grade 1 (slow relaxation pattern)
Grade 2 (pseudonormal pattern)
Grade 3 (Restrictive filling pattern)

Left Ventricular Hypertrophy (LVH)
In echocardiography, the hypertrophy may be concentric (involving all ventricular walls) or asymmetric (involving usually the septum, apex or anterior wall only).

Common causes of LVH include: Hypertension, Aortic Stenosis, Hypertrophic Cardiomyopathy (HCM), Amyloid and Athletic Heart.

From echocardiography, it is very difficult to distinguish between LVH due to hypertension and HCM. A full clinical review is required to make this distinction.

HCM should always be suspected in (often younger) patients with LVH that cannot be explained by a potential primary cause such as hypertension, underlying valve disease, amyloidosis, renal or endocrine disease.

Distinguishing HCM from an athletic heart can be very difficult and may require complex imaging such as contrast echo, three-dimensional echo or cardiac MRI. Such patients should be investigated in a specialist cardiac unit.

Left atrium & right heart
LA size will be stated (where possible) or an estimation given. An estimation of right heart size will be stated with an estimation of RV function. Estimation of right ventricular systolic pressure (RVSP) will be given where possible.

Doppler / blood flow
Any valve leaks will be stated as regurgitant flows i.e. mitral regurgitation (MR).
Severity will be stated as trivial, mild, moderate or severe.
Tricuspid regurgitation will be measured (where possible), added to the RA pressure will give the estimated Pulmonary Artery Pressure (PAP).
Any obstructed flows i.e. aortic stenosis; a pressure gradient will be obtained and stated in mmHg.

Severity of Aortic stenosis

An aortic valve area (AVA) will only be calculated if the LV function is impaired, as the pressure gradient will under-estimate the severity.

For mitral stenosis a mean mitral valve gradient (in mmHg) will be stated.
The mitral valve area (MVA) will also be stated in cm2.

Severity of Mitral stenosis

Other abnormal findings

If any other abnormality is detected it will be reported on. This may include:

• a clot or thrombus
• pericardial or pleural effusion
• endocarditis (rare in outpatients)
• intra-cardiac shunts i.e. ASD or VSD or PFO

Technical Problems and Limitations

Due to the way echocardiography collects images, certain patients are technically difficult.

• Obese patients
  Ultrasound is refracted through the fat, image quality is reduced and accurate measurement made very difficult. Also applies to women with large breasts.

• Patients with lung disease
  In order to clearly visualise the heart, it is necessary to position the patient on their left side to swing the lung out of the way. In patients with lung disease the lungs are much less mobile, and interfere with the ultrasound.

• Immobile Patients.
  If a patient is unable to turn onto their left side, imaging is made difficult, as again the left lung obstructs the ultrasound.