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 Problems and Limitations

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

• Extremely 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. Different frequency probes can be tried but the information gathered is less accurate.

• Extremely breathless patients.
  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.

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.

Most technicians have the same terminology for reporting, but some variations do occur, e.g. a stenotic valve may also be recorded as calcified or thickened.

Reporting LV Systolic Dysfunction (LVSD)

Overall size of LV, if not measured, will be estimated and where possible an ejection fraction stated. However the EF is a measurement taken from only 2 walls (septum and posterior) therefore an EF may be stated but the report may go into more detail about any regional wall motion abnormalities or an estimation of overall function.

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)

Diastolic dysfunction is a state of increased ventricular stiffness that prevents adequate filling of the ventricles at normal atrial pressures and is due to impaired relaxation, decreased compliance, or both.

Basic echo assessment of LVDD

LA dimension of > 4.0 cm provides evidence of LVDD independent of LV ejection fraction.
Healthy elderly patients often display mild LA dilatation in association with impaired LV relaxation.

Grades of LVDD

1. Impaired relaxation (Grade 1 LVDD) would be reported in a technical echo report as:
• Reversed & decreased E:A ratio <0.7
• Prolonged E deceleration time (DT) >240ms
  
2. Pseudonormalisation (Grade 2 LVDD) occurs when decreased ventricular compliance & increased end diastolic pressure (EDP) causes an increase in LA pressure to preserve the transvalvular gradient resembling a normal diastolic filling pattern.
   Pseudonormalisation would be reported in a technical echo report as:
• E:A ratio and E deceleration time within normal ranges
• E:Ea ratio (tissue Doppler imaging) >15
• A velocity > 0.35m/s and A duration > 30ms from pulmonary vein flow
  
3. Restrictive filling pattern (Grade 3 LVDD) would be reported in a technical echo report as:
• 'High' E:A ratio >2.0
• Shortened E deceleration time (DT) <140ms

Left Ventricular Hypertrophy
Thickening of the muscle. This may be concentric - all walls or localised, which will be stated as individual walls or portions of wall.

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