A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography

in Echo Research and Practice

There have been significant advances in the field of echocardiography with the introduction of a number of new techniques into standard clinical practice. Consequently, a ‘standard’ echocardiographic examination has evolved to become a more detailed and time-consuming examination that requires a high level of expertise. This Guideline produced by the British Society of Echocardiography (BSE) Education Committee aims to provide a minimum dataset that should be obtained in a comprehensive standard echocardiogram. In addition, the layout proposes a recommended sequence in which to acquire the images. If abnormal pathology is detected, additional views and measurements should be obtained with reference to other BSE protocols when appropriate. Adherence to these recommendations will promote an increased quality of echocardiography and facilitate accurate comparison of studies performed either by different operators or at different departments.

Abstract

There have been significant advances in the field of echocardiography with the introduction of a number of new techniques into standard clinical practice. Consequently, a ‘standard’ echocardiographic examination has evolved to become a more detailed and time-consuming examination that requires a high level of expertise. This Guideline produced by the British Society of Echocardiography (BSE) Education Committee aims to provide a minimum dataset that should be obtained in a comprehensive standard echocardiogram. In addition, the layout proposes a recommended sequence in which to acquire the images. If abnormal pathology is detected, additional views and measurements should be obtained with reference to other BSE protocols when appropriate. Adherence to these recommendations will promote an increased quality of echocardiography and facilitate accurate comparison of studies performed either by different operators or at different departments.

Introduction

This Guideline aims to provide a framework for performing an adult transthoracic echocardiogram (TTE) and replaces the previous minimum datasets published. This current Guideline differs from the 2005 dataset in outlining the views and measures recommended in a fully comprehensive TTE, and in addition recognises that such studies may not be performed in all circumstances. The layout proposes a recommended sequence on how to perform a comprehensive TTE.

‘Minimum requirements’ are depicted in bold text and identify the views and measurements that should be performed in all subjects being scanned for the first time ‘recommendations’ are depicted in italics and together with the minimum requirements form the basis of a comprehensive examination. Wherever possible, a comprehensive study comprising all the views and measurements in this Guideline outlined in black italics and bold font text should be performed, provided the views and measurements can be obtained reliably. It is understood that not all the measurements in the minimum requirements dataset will be performed in all follow-up studies. It is also understood that not all measurements in the minimum requirements will be performed in focused or target studies, for example check pericardial effusion.

Both minimum requirements and recommendations may only be sufficient when the echocardiographic study is entirely normal. If abnormalities are detected, additional views may be required to supplement those outlined in the dataset.

The layout has been altered to provide a visual example of the ideal image that should be acquired in each acoustic window. This is supported by text that follows a standard layout – the acoustic window and transducer position in the first column, followed by the modality to be used, measurements to be made at that location and an explanation if additional information is deemed necessary.

A standard adult transthoracic echocardiogram

1. Benefits and general principles

A standardised approach to performing an echocardiogram is extremely important not only to ensure that pathology is not missed but to facilitate comparison between studies.

1.1. The intended benefits of this Guideline are:

  • To support cardiologists and echocardiographers to develop local protocols and quality control programmes for an adult transthoracic study. These minimum requirements and recommendations provide a template against which studies in any department should be audited.

  • To promote quality by defining a 'minimum dataset' of descriptive terms and measurements.

  • To promote quality by defining a recommended dataset of descriptive terms and measurements that departments should work toward obtaining in all studies.

  • To facilitate accurate comparison of serial echocardiograms performed in patients at the same or different sites.

  • To facilitate the transition to digital echocardiography acquisition and reporting systems that use database (software) architecture.

1.2. There is broad agreement regarding the standard views and recordings essential in an echocardiographic examination. There is, however, no evidence-base and these recommendations and requirements represent a consensus view on the components of a complete TTE study.

1.3. It is expected that a standard echocardiogram following at least these minimum requirements will be performed in all adults when an echocardiogram is requested. This type of study is expected to make up the majority of those performed within any department, whether in the community or in hospital.

It is recognised that focused studies may be appropriate in some circumstances agreed locally. Focused TTE can either mean focusing on major abnormalities predominantly in an urgent clinical situation, e.g. pericardial effusion, or focusing on a particular aspect of the heart, e.g. longitudinal monitoring of left ventricular function. The skill level required for such studies is very high and it is expected that the patient will previously have had a full-standard TTE before monitoring commences or after an emergency assessment has been completed. Such studies should be clearly identified as focused studies and are not covered by this Guideline.

1.4. When the condition or acoustic windows of the patient prevent the acquisition of one or more components of the minimum dataset, or when measurements result in misleading information (e.g. off-axis measurements) this should be stated.

It is recommended that any study is accompanied by a statement regarding the image quality achieved: good/fair/poor.

1.5. Unless the physical condition of the patient prevents transfer, all TTEs should be performed in a suitable environment, with optimal facilities to obtain the highest quality ultrasound images, including lighting, space and imaging couches, whilst guaranteeing patient privacy. These facilities demand – except in exceptional circumstances – that echocardiography is delivered in an appropriately equipped department that satisfies the requirements of the BSE Departmental Accreditation process. This ensures optimum conditions for a detailed study, reduces the risk of musculoskeletal disorders for echocardiographers (http://www.hse.gov.uk/healthservices/management-of-musculoskeletal-disorders-in-sonography-work.pdf), and may reduce the risk of hospital-acquired infection. When portable echocardiography has to be performed at the bedside, the requirements of the minimum dataset must be met.

2. Identifying information

The images acquired should be clearly labelled with patient identifiers, including the following:

  • Patient name.

  • A second unique identifier such as hospital number or date of birth.

  • Identification of the operator, e.g. initials.

3. Electocardiogram (ECG)

An ECG should be attached ensuring good tracings to facilitate the acquisition of complete digital loops. Loops should be examined and adjusted accordingly in order to ensure a clear representation of the image acquired.

4. Height/weight/haemodynamic variables

Qualitative and quantitative evaluation of chamber size and function is a major component of every echocardiographic examination. Chamber dimensions may be influenced by age, gender and body size. Therefore, consideration should be given to the use of referenced ranges indexed to height or body surface area. In addition, velocities measured using Doppler should take account of pulse rate and blood pressure. No recommendation is made to the routine use of indexed measurements, but facilities should be available to sonographers to measure height, weight, pulse rate and blood pressure at the time of an echocardiogram.

5. Duration

The average time required for performance and reporting of a fully comprehensive TTE following these recommendations is considered to be 40–45 min, although it is understood that some studies may take longer whilst others may take less time. The time taken for a standard TTE should include time to complete a report, and should also take into account the time taken for patient preparation.

6. Report

No standard TTE is complete until a report is released and is made available to the referring individual. The majority of studies performed in a department should be reported immediately on completion and a report available on discharge of a patient from the echocardiography facility.

It is recognised that there are times when a review of images and further consideration is required, for example when the individual performing the scan does not hold proficiency accreditation and the scan requires review before release, although this should be done as soon as possible.

7. Chaperones

A standard TTE is not considered as an intimate examination, but performance still requires patient sensitivity. Chaperones should not usually be required for standard TTE; however, for all TTE studies, patients should be offered a gown.

Echocardiography departments should send out an information leaflet with any appointment. This should include a statement that a relative or friend could accompany the patient to act as a chaperone during the study if preferred. If a friend or relative cannot attend, the leaflet should include an offer to provide a chaperone if requested by the patient. This leaflet should either offer a chaperone by mutual arrangement or, if facilities and personnel allow, a chaperone to be provided on request when the patient arrives.

A notice should be displayed in the Echocardiography department where it can be seen by patients repeating the offer of a chaperone if requested. In practice, it is expected that the majority of patients would not need or have a chaperone.

The minimum dataset

The minimum dataset and recommended sequence for a standard TTE is shown in Table 1. The minimum requirements are depicted in bold text and recommendations in italics. The minimum requirements are also summarised in Appendix 1.

Table 1

Minimum dataset for transthoracic echocardiography. Minimum requirements are depicted in bold text and identify the views and measurements that should be performed in all subjects being scanned for the first time provided that they can be obtained reliably. However wherever possible a comprehensive study should be performed. Recommendations are depicted in italics and together with the minimum requirements form the basis of a comprehensive examination

View (modality)MeasurementExplanatory noteImage
PLAX (2D)LVIDd/s, IVSd, LVPWd (either 2D or M mode measurement)



LA size (end ventricular systole) (either 2D or M mode measurement)
LV cavity size, wall thickness, radial function



LA appearance



MV leaflet and annulus appearance and function: thickness, mobility, calcification, commissural fusion, sub-valve apparatus
PLAX (2D)AV/LVOT appearance and function
PLAX (2D)Proximal RVOTd
PLAX (2D)Sinus of Valsalva (either 2D or M mode measurement, inner edge to inner edge at widest diameter)



Annulus, ST junction, proximal ascending aorta (inner edge to inner edge, at widest diameter)
Aortic root – appearance and function
PLAX (2D)LVOT for AV area/SVol in mid systoleApproximately same location as the PW sample volume in the A5C view (measured in the LVOT up to 1 cm from the annulus)
PLAX (2D)Proximal ascending aorta at widest diameter (inner edge to inner edge)Tilted superiorly to demonstrate mid ascending aorta
PLAX (MM)Aortic root (end diastole)



Maximum LA size (end systole), providing 2D image is on axis
Aortic valve at leaflet tips
PLAX (MM)LVIDd/s, IVSd, LVPWd (either/or 2D measurement)Left ventricle, just distal to MV leaflet tips
PLAX (CFM)Look for abnormal colour flow



Adjust Nyquist limit: 50–60 cm/s
PLAX RV inflow (2D)RV cavity size and function



RA, IVC, +/− coronary sinus



TV – appearance and function
PLAX RV inflow (CFM)TV inflow, TR
PLAX RV inflow (CW)TR VmaxIf good alignment with jet
PLAX RV outflow (2D)Distal RVOTRVOT, PV, main PA, LPA
PLAX RV outflow (CFM)RVOT, PA, PS, PR



Optional to PSAX
PLAX RV outflow (PW)Optional to PSAX
PLAX RV outflow (CW)Optional to PSAX
PSAX outflow (2D)Proximal RVOT diameterRVOT (function)



AV – appearance and function



LA/atrial septum



TV – appearance and function
PSAX outflow (2D)PV annulus, main PAPV, main PA
PSAX outflow (2D)Proximal branch PA's
PSAX outflow (CFM)Ao/LA



Atrial septum



IVC



TV inflow, TR
PSAX outflow (CFM)PA, look for abnormal colour flow
PSAX outflow (CFM)RVOT (PR)
PSAX outflow (PW)Vmax, Vmean, VTIRVOT (just proximal to PV)
PSAX outflow (CW)Vmax, VmeanPHTPA



PR density and contour of signal
PSAX outflow (CW)PR Vmax (end diastolic PA pressure)End diastole
PSAX outflow (CW)PR Vmax (mean diastolic PA pressureEarly diastole
PSAX Base (2D)MV leaflet and annulus:

– appearance and function

– thickness, mobility, calcification, commissural fusion, sub-valve apparatus
PSAX mid (2D)Sweep beam from base to apex



Radial systolic function/regional wall motion abnormalities



Integrity of ventricular septum
PSAX (CFM)Sweep beam from base to apex



Integrity of ventricular septum
PSAX (CFM)VSD's (congenital/post infarct)
A4C (2D)LV cavity size, wall thickness (Inferoseptum, anterolateral)



Longitudinal and radial function:



RWMA's (inferoseptal and anterolateral)



MV/TV appearance and function



Atrial septal mobility
A4C (2D)Area/volume (should not be done if images sub optimal)LV end diastolic area/volume (BSA indexed). Consider 3D volumes, unless images are suboptimal



Consider LV opacification contrast if poor image quality
A4C (2D)LV end systolic area/volume (BSA indexed).Consider 3D volumes, unless images are suboptimal



Consider LV opacification contrast if poor image quality
A4C (2D)LA volumeLA size (measured at end ventricular systole and BSA indexed)
A4C (MM)TAPSE

MAPSE
TV annulus



MV annulus
A4C (CFM)MV inflow, look for abnormal flow
A4C (CFM)RLPV either/or RUPV



LUPV, LLPV can also be imaged
A4C (PW)E Vmax, A VmaxLV inflow (MV tips)
A4C (PW)Deceleration time
A4C (PW)PVS/PVD



PVa



adur−Adur
Right lower pulmonary vein
A4C (CW)MR (shape and density of signal)
A4C (TDI)e'



a', s'
Septal and/or lateral LV



Lateral RV
A5C (2D)LV cavity size, wall thickness, function



LVOT



AV appearance and function
A5C (CFM)LVOT, look for abnormal colour flow
A5C (PW)Vmax



VTI (stroke volume, cardiac output)
LVOT
A5C (CW)
A2C (2D)LV cavity size, wall thickness: function (anterior, inferior)
A2C (2D)LV area/volumeLV end diastolic area/volume



Consider 3D volumes, unless images are suboptimal



Consider LV opacification contrast if poor image quality
A2C (2D)LV end systolic area/volume



Consider 3D volumes, unless images are suboptimal



Consider LV opacification contrast if poor image quality
A2C (2D)LA area/volume (measure at end ventricular systole)



Modified Simpsons or area length method
LA size
A2C (CFM)LV inflow, look for abnormal colour flow
A2C (PW)E, A, DT if not reliable from A4CLV inflow (MV tips)
A2C (CW)Vmax, Vmean if not reliable from A4C
A3C (2D)LV cavity size, wall thickness:



function (anteroseptal and inferolateral)



AV/LVOT appearance and function
A3C (CFM)LVOT, LV inflow, look for abnormal colour flow
ALAX (PW)E, A, DT,VTI if not reliable from A5CLV inflow (MV tips)

LVOT
A3C (CW)Vmax, Vmean



Vmax, Vmean
LV inflow



LVOT
Modified A4C (2D)RVID base (d)



Mid RV diameter



RV length (base to apex)



RA area
RV cavity size and function











RA size
Modified A4C (CFM)TV inflow, TR
Modified A4C (PW)E VmaxRV inflow (TV leaflet tips)
Modified A4C (CW)Vmax (RV systolic pressure, PAP)TR
SC4C (2D)Four chamber structures, atrial septum
SC4C (CFM)Atrial septum



Consider reducing Nyquist limit to detect low velocity flow
SCSAX (2D)IVC, hepatic vein (modified view)
SCSAX (MM)Size and respiratory variation (‘sniff’)IVC just proximal to hepatic vein
SCSAX (2D)SAX structures



Atrial septum, TV, RVOT, PV, PA's
SCSAX (2D)Abdominal aorta (modified view)
SCSAX (PW)Hepatic veins
SCSAX (PW)Abdominal aorta
SSN (2D)Arch
SSN (CFM)Arch, RPA, look for abnormal colour flow
SSN (CW)VmaxDescending aorta with imaging probe, if good alignment with jet



Descending aorta with non imaging probe, if poor jet alignment with imaging probe
Appendix 1

Minimum dataset measurements

1. Views to be obtained:
 PLAXParasternal long axis
 PLAXTilted RV inflow
 PSAXParasternal short axis: base, mid, apex
 A4CApical four chamber
Modified A4C for RV
 A2CApical two chamber
 A5CApical five chamber
 SCSubcostal
 SSNSuprasternal
2. Recorded and measured where appropriate
 LVIDd/sLeft ventricular internal dimension in diastole and systole
 IVSdInterventricular septal width in diastole
 LVPWdLeft ventricular posterior wall width in diastole
 LALeft atrial dimension in PLAX
 SinusSinus of valsalva
 TR VmaxTricuspid regurgitation maximal velocity
 LVEDvol d/sLeft ventricular end-diastolic and systolic volume (biplane/3D)
 LVEFLeft ventricular ejection fraction
 LA volumeLeft atrial volume at end-ventricular systole (area-length/biplane)
 TAPSETricuspid annular plane systolic excursion
 Mitral E/AMitral valve maximal velocity early and atrial filling
 e'Lateral and/or septal early myocardial relaxation velocity
 AV VmaxMaximal aortic velocity on CW
 RV baseRight ventricular basal dimension in diastole
 IVC dimensionEstimation of RA pressure

Abbreviations

Views
 A2CApical two chamber
 A4CApical four chamber
 A5CApical five chamber
 A3CApical long axis or apical three chamber
 PLAXParasternal long axis
 PSAXParasternal short axis
 SCSubcostal
 SSNSuprasternal
Modality
 CFMColour flow Doppler
 CWContinuous wave Doppler
 PWPulse wave Doppler
 TDITissue Doppler imaging
Measurement and explanatory text
 AoAorta
 AVAortic valve
 BSABody surface area
 DTDeceleration time
 IVCInferior vena cava
 IVSdInterventricular septal width in diastole
 LALeft atrium
 LLPVLeft lower pulmonary vein
 LPALeft pulmonary artery
 LUPVLeft upper pulmonary vein
 LVLeft ventricle
 LVIDd/sLeft ventricular internal dimension in diastole and systole
 LVOTLeft ventricular outflow tract
 LVPWdLeft ventricular posterior wall width in diastole
 MAPSEMitral annular plane systolic excursion
 MVMitral valve
 PAPulmonary artery
 PAPPulmonary artery pressure
 PHTPressure half-time
 PRPulmonary regurgitation
 PSPulmonary stenosis
 PVPulmonary valve
 RARight atrium
 RLPVRight lower pulmonary vein
 RUPVRight upper pulmonary vein
 RVRight ventricle
 RVIDdRight ventricular cavity diameter in diastole
 RWMARegional wall motion abnormality
 RVOTRight ventricular outflow tract
 RVOTdRight ventricular outflow tract dimension
 STJSinotubular junction
 SVolStroke volume
 TAPSETricuspid annular plane systolic excursion
 TRTricuspid regurgitation
 TVTricuspid valve
 VmaxMaximum velocity
 VSDVentricular septal defect
 VTIVelocity time integral

Declaration of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this guideline.

Funding

This guideline did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

(G Wharton is the lead author)

(R Steeds is the Guidelines Chair)

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