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How an echocardiogram is done

Echocardiography differs from other ultrasound exams in sheer volume of numbers: chamber dimensions, wall thickness, volumes, flow velocities, gradients, pulmonary artery pressure. Some of them are calculated from others. That is why the echo report takes the longest to type and is the one most often left for later. Here is how the exam goes, which values are considered normal and where the time goes.

What is examined

The patient lies in the left lateral decubitus position with the left arm under the head, which brings the heart closer to the chest wall and widens the intercostal window. A phased array probe at 2-4 MHz is used with ECG gating. The exam follows standard views: parasternal long and short axis, apical four-, two- and five-chamber, subcostal and suprasternal.

From the parasternal view the sonographer measures the aorta at the sinuses of Valsalva and the ascending aorta, the left atrium, IVSd and LVPWd, LVIDd and LVIDs. From these two diameters the machine or the report calculates volumes, stroke volume, ejection fraction and fractional shortening by Teichholz. From the apical views the same volumes are calculated by Simpson, and regional wall motion is assessed segment by segment.

Next come valves and flows: aortic valve morphology and cusp separation, mitral leaflets, regurgitation on each valve with grade and vena contracta width, peak aortic velocity and gradient. The right heart: RV dimension, RV free wall thickness, TAPSE, RA area and the pulmonary artery trunk. Systolic PA pressure is estimated from the TR peak velocity and IVC collapse.

Diastolic function is described from mitral inflow and tissue Doppler: E and A waves, their ratio, e' at the annulus and E/e'. Finally, the IVC diameter and its inspiratory collapse are measured subcostally, and the pericardium and septa are checked. Each step produces two or three numbers, and all of them belong in the report.

• Aorta: sinuses of Valsalva, ascending aorta, arch, descending aorta, walls
• Aortic valve: morphology, annulus, cusp separation, peak velocity and gradient, regurgitation
• Mitral and tricuspid valves: leaflets, regurgitation grade, vena contracta
• Left atrium: anteroposterior diameter, four-chamber dimensions, volume
• Left ventricle: LVIDd, LVIDs, IVSd, LVPWd, volumes, EF and FS by Teichholz and Simpson
• Right heart: RV, RV free wall, TAPSE, RA area, PA trunk, PA pressure
• Diastolic function: E and A waves, e', E/A and E/e' ratios
• IVC and its collapse, pericardium, septa, regional wall motion

How long it takes

The scan itself takes fifteen to twenty-five minutes: views, measurements, flows, repeated planes when the window is poor. The report is the heaviest of all routine studies: about fifty values, a dozen of them calculated, plus valve descriptions and an impression. A physician who types it themselves spends about fifteen minutes and often finishes it after the session. With ten echoes a day, that is two and a half hours of typing alone. Help with typing speeds things up, but someone still has to run the formulas, and that is where most errors happen.

The same study by voice

By voice, the report is built during the exam, not after it. The physician names the view, the measurement and the number, the service sorts the values into sections and calculates the derived fields itself: volumes, ejection fraction, pulmonary artery pressure, E/A and E/e'. Play the whole dictation or click the lines: each value lands in its own row.

Abbreviations are recognized as terms: LVIDd, LVIDs, IVSd, LVPWd and TAPSE go into their own rows, not into running text. Derived fields are not dictated at all: Teichholz volumes, ejection fraction, E/A and E/e' ratios and PA pressure are calculated from the dictated values, and the physician sees them before the report is printed. If LVIDd is corrected later, every dependent field is recalculated.

Orientation values for adults of average build. Chamber sizes and volumes are usually indexed to body surface area, so the same number means different things in a large man and a petite woman. An ejection fraction of 55% or more is considered preserved, 41-54% mildly reduced, 40% or less reduced. Interpretation always belongs to the physician.

What the finished document looks like

The finished document is built from the same data. The table is what cardiologists expect and makes comparison with a previous study easy; the narrative version is used for a discharge summary, when the report will be read by a primary care physician or by the patient.

Frequent questions

What it changes on a shift

Echo is the exam where dictation saves not only time but also errors: the formulas are calculated the same way for the first patient and the tenth, and the physician holds a probe, not a calculator.

The first 15 reports are free. After that the price depends on the pack size: from 0.42 to 0.53 USD per report, whatever the length of the dictation. No subscription.

App file

Point your phone camera: the download page with the file and its checksum.

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