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Guidelines and Standards for Performance ofa Pediatric Echocardiogram: A Report from

the Task Force of the Pediatric Council of theAmerican Society of Echocardiography

Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE, Michael M. Brook, MD,

Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;

Houston, Texas; and Philadelphia, Pennsylvania

Echocardiography has become the primary imag-ing tool in the diagnosis and assessment of congen-ital and acquired heart disease in infants, children,and adolescents. Transthoracic echocardiography(TTE) is an ideal tool for cardiac assessment, as it isnoninvasive, portable, and efficacious in providingdetailed anatomic, hemodynamic, and physiologicinformation about the pediatric heart.

Recommendations for standards in the performanceof a routine 2-dimensional (2D) echocardiogram, 1 fetalechocardiogram,2 pediatric transesophageal echocar-diogram,3 intraoperative transesophageal echocar-diogram,4 and stress echocardiogram5 exist, as doguidelines for appropriate training in various echo-cardiographic disciplines.6-12 As part of the accredi-tation process for echocardiography laboratories,the Intersocietal Commission for the Accreditationof Echocardiography Laboratories has establishedbasic performance standards for pediatric TTE, 13 butno other standards document exists for the perfor-mance of a pediatric TTE.

The pediatric echocardiogram is a unique exami-nation with features that distinguish it from otherechocardiograms. There is a wide spectrum ofanomalies encountered in patients with congenitalheart disease. Certain views are of added importance

From the Mount Sinai Medical Center, New York (W.W.L.);Children’s Hospital, Boston (T.G.); Medical University of SouthCarolina, Charleston (G.S.S.); Children’s Hospital of Wisconsin,Milwaukee (P.C.F.); Children’s Hospital of Michigan, Detroit(R.A.H.); University of San Francisco (M.M.B.); Texas Children’sHospital, Houston (R.H.P.); and Children’s Hospital of Philadel-phia (J.R.).Reprint requests: Wyman W. Lai, MD, MPH, FASE, Division ofPediatric Cardiology, Box 1201, Mount Sinai Medical Center, OneGustave L. Levy Place, New York, NY 10029 (E-mail: [email protected]).J Am Soc Echocardiogr 2006;19:1413-1430.0894-7317/$32.00Copyright 2006 by the American Society of Echocardiography.
doi:10.1016/j.echo.2006.09.001
for pediatric examinations: the subxiphoid (or sub-costal), suprasternal notch, and right parasternalviews. The acquisition and proper display of imagesfrom these views are critical aspects of the pediatricTTE. In addition, special techniques are required forimaging uncooperative infants and young children,including sedation and distraction tools that willallow performance of a complete examination.

The purposes of this document are to: (1) de-scribe indications for pediatric TTE; (2) define opti-mal instrumentation and laboratory setup for pedi-atric echocardiographic examinations; (3) provide aframework of necessary knowledge and training forsonographers and physicians; (4) establish an exam-ination protocol that defines necessary echocardio-graphic windows and views; (5) establish a base-line list of recommended measurements to beperformed in a complete pediatric echocardio-gram; and (6) discuss reporting requirements andformatting of pediatric reports.

INDICATIONS

Knowledge of indications for an echocardiogram isimportant to obtain the information required for thediagnosis and proper treatment of the pediatricpatient. The general categories of indications areprovided below, with emphasis placed on the indi-cations for a pediatric echocardiogram versus astandard adult study. For detailed age-specific lists ofindications, the reader is referred to prior publishedguidelines.14

Children with suggested or known heart diseasefrequently require serial studies to evaluate theevolution or progression of heart disease. Serialstudies may be indicated at routine intervals formonitoring of valve function, growth of cardiovas-cular structures, ventricular function, and potential
sequelae of medical or surgical intervention.15-18
1413

Journal of the American Society of Echocardiography1414 Lai et al December 2006

Congenital Heart Disease: History, Symptoms,and Signs

Indications for the performance of a pediatric echo-cardiogram span a wide range of symptoms andsigns, including cyanosis, failure to thrive, exercise-induced chest pain or syncope, respiratory distress,murmurs, congestive heart failure, abnormal arterialpulses, or cardiomegaly. These may suggest catego-ries of structural congenital heart disease includingintracardiac left-to-right or right-to-left shunts, ob-structive lesions, regurgitant lesions, transpositionphysiology, abnormal systemic or pulmonary venousconnections, conotruncal anomalies, coronary ar-tery anomalies, functionally univentricular hearts,and other complex lesions, including abnormal lat-erality (heterotaxy/isomerism). Certain syndromes,family history of inherited heart disease, andextracardiac abnormalities that are known to beassociated with congenital heart disease consti-tute clinical scenarios for which echocardiogra-phy is indicated even in the absence of specificcardiac symptoms and signs. Abnormalities onother tests such as fetal echocardiography, chestradiograph, electrocardiogram, and chromosomalanalysis constitute another group in which thesuggestion of congenital heart disease is addressedspecifically by echocardiography.

Acquired Heart Diseases and NoncardiacDiseases

An echocardiogram is indicated for the evaluation ofacquired heart diseases in children, including Ka-wasaki disease, infective endocarditis, all forms ofcardiomyopathies, rheumatic fever and carditis, sys-temic lupus erythematosus, myocarditis, pericardi-tis, HIV infection, and exposure to cardiotoxicdrugs. Pediatric echocardiography is indicated in theassessment of potential cardiac or cardiopulmonarytransplant donors and transplant recipients. Re-cently, echocardiography has been recommended inall children who are newly diagnosed with systemichypertension.19 Noncardiac disease states that affectthe heart such as pulmonary hypertension consti-tute an important indication for serial pediatricechocardiograms. Echocardiography may also beindicated in children with thromboembolic events,indwelling catheters and sepsis, or superior venacava syndrome.

Arrhythmias

Children with arrhythmias may have underlyingstructural cardiac disease such as congenitally cor-rected transposition or Ebstein’s anomaly of thetricuspid valve, which may be associated with subtleclinical findings and are best evaluated using echo-cardiography. Sustained arrhythmias or antiarrhyth-mic medications may lead to functional perturba-
tions of the heart that may only be detectable by
echocardiography and have important implicationsfor management.

INSTRUMENTATION, PATIENT PREPARATION,AND PATIENT SAFETY

Instrumentation

Ultrasound instruments used for diagnostic studiesshould include, at a minimum, hardware and softwareto perform M-mode, 2D imaging, color flow mapping,and spectral Doppler studies, including pulsed waveand continuous wave capabilities. The transducersused in pediatric studies should provide adequateimaging across the wide range of depths encounteredin pediatric cases. Multiple imaging transducers, rang-ing from low frequency (2-2.5 MHz) to high frequency(�7.5 MHz), should be available; a multifrequencytransducer that includes all these frequencies is also anoption. A transducer dedicated to the performance ofcontinuous wave Doppler studies should also be avail-able for each study.

The video screen and display should be of suitablesize and quality for observation and interpretation of allthe above modalities. The display should identify theparent institution, a patient identifier, and the date andtime of the study. The electrocardiogram should alsobe displayed in real time with the echocardiographicsignal. Range or depth markers should be available onall displays. Measurement capabilities must be presentto allow measurement of the distance between twopoints, an area on a 2D image, blood flow velocities,time intervals, and peak and mean gradients fromspectral Doppler studies.

Data Acquisition and Storage

Echocardiographic studies must be recorded andstored as moving images and must be stored on amedium that allows for playback of the recordedmoving images. This would include videotape ordigital recording media. It is unacceptable to storeor archive moving echocardiographic images on amedium that displays only a static image, such asrecording film or paper. Portions of the echocardio-graphic examination such as M-mode frames andDoppler spectral measurements may be displayedand recorded as a static image on media appropriateto the laboratory situation.

Patient Preparation and Safety

Sufficient time should be allotted for each study ac-cording to the procedure type. The performance timeof an uncomplicated, complete (imaging and Doppler)pediatric TTE examination is generally 45 to 60 min-utes (from patient encounter to departure). Additionaltime may be required for complicated studies. All
procedures should be explained to the patient and/or

Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1415

parents or guardians before the onset of the study. Thepatient should be placed in a reclining position in acomfortable environment. A darkened room is prefer-able for the performance of the study. Appropriatepillows and blankets should be used for patient com-fort and privacy. The sonographic gel should bewarmed to body temperature before the start of theexamination. It is recommended that appropriate dis-tractions be provided in echocardiographic laborato-ries performing studies on preschool children. Thesemay include toys, games, television, or movies. Aparent or guardian should accompany all childrenduring the echocardiographic study except whereprivacy issues supersede.

The laboratory should recognize the potentialneed for sedation of pediatric patients to obtain anadequate examination. Written policies including,but not limited to, the type of sedatives, appropriatedosing for age and size, and proper monitoring ofchildren during and after the examination shouldexist for the use of conscious sedation in chil-dren.20,21

Each laboratory should have a written procedurein place for handling acute medical emergencies inchildren. This should include a fully equipped car-diac arrest cart (crash cart) and other necessaryequipment for responding to medical emergenciesin pediatric patients of all sizes.

SKILLS AND KNOWLEDGE

Echocardiography of congenital and acquired pedi-atric heart disease is an operator-dependent imagingtechnique that requires high levels of technical andinterpretive skills to maximize its diagnostic accu-racy. Specialized training is required in the assess-ment of cardiovascular malformations to determinetreatment options and to assess outcomes after anever-increasing number of interventional and surgi-cal procedures.

Physicians

Because TTE is the primary diagnostic imaging mo-dality in children with heart disease, pediatric cardi-ologists must possess basic skills in performance andinterpretation of transthoracic cardiac ultrasound,including M-mode, 2D imaging, and various Dopplermethods. Physicians who specialize in echocardiog-raphy of pediatric heart disease undergo extendedtraining in this domain.

This committee reviewed and considered exist-ing guidelines for training in pediatric echocardi-ography.8,22-24 The American College of Cardiol-ogy (ACC) Pediatric Cardiology/Congenital HeartDisease Committee and the ACC Training ProgramDirectors Committee have jointly developed new
recommendations for training in pediatric cardiol-
ogy. The recommendations in the ACC/AmericanHeart Association/American Academy of PediatricsClinical Competency and Training Statement onPediatric Cardiology (Task Force 2: Pediatric Train-ing Guidelines for Noninvasive Cardiac Imaging) rep-resent the most recent guidelines and, with minormodifications, are incorporated in this document.25

Levels of expertise. Physicians who practice TTEmay have one of two levels of expertise, core oradvanced. The core level includes the basic set oftechnical and interpretive skills required for gradu-ation from a pediatric cardiology training programaccredited by ACGME. Physicians with this level ofexpertise are expected to be able to perform andinterpret TTEs in normal infants, children, andadolescents, and in those with childhood heartdisease with consultation as needed. “Advanced” is ahigh level of expertise in all aspects of pediatricechocardiography. Physicians with this level oftraining are expected to be able to perform indepen-dently and to interpret echocardiograms in patientswith all forms of congenital and acquired pediatricheart disease, and to supervise and train others.

Table 1 outlines the required knowledge for the coreand advanced levels of expertise, and Table 2 delineatesthe required skills. Table 3 outlines the training methodsrecommended for the two levels of expertise.

Evaluation of knowledge and skills. Unlike adultechocardiography, there is currently no formal testthat can be used to examine competency in pediat-ric echocardiography in North America. The optimalevaluation of clinical competence is, therefore,based on assessment of the trainee’s skills by thedirector of the pediatric echocardiography labora-tory. Direct observation of the trainee during perfor-mance of echocardiograms provides informationabout imaging skills and understanding of the ultra-sound instruments. The maintenance of a log ofechocardiograms performed by each trainee is re-quired. Conferences in which echocardiograms arepresented provide an opportunity to assess skills ininterpretation of images and Doppler recordings.Conferences may also be used to promote andevaluate skills in research design and methods, andteaching effectiveness. The laboratory director, inconsultation with the teaching staff, should evaluateeach trainee in writing on a regular basis.

Maintenance of knowledge and Skills. Clinicalcompetence in pediatric echocardiography requirescontinued practice of all forms of cardiac ultrasoundtechniques in an active program in which patientswith a wide range of pediatric heart disease are seen.To maintain core-level competence, a minimum of150 TTEs per year should be performed or inter-preted. To maintain advanced-level competence, aminimum of 500 TTEs per year should be performedor interpreted. In addition, continued participation
in intramural conferences and in continuing medical


education activities related to advances in echocar-diography is essential.

Sonographers

The committee reviewed and adopted guidelinespublished by the American Society of Echocardiog-raphy (ASE) in “Minimum Standards for the CardiacSonographer: A Position Paper” regarding the com-petence of sonographers performing echocardio-grams.26 Separate credentialing requirements applyfor sonographers in each area of subspecialization(ie, pediatric vs adult TTE). A summary of theguidelines is as follows.

The ASE believes that there are 3 primary ele-ments involved in assuring the competence of a

Table 1 Required knowledge base for core and advanced l

Level of expertise

Core ● Understanding of the basic principles of● Knowledge of the indications for transtho● Knowledge of common congenital heart● Knowledge of Doppler methods and thei

pressures● Knowledge of the limitations of echocard● Knowledge of alternative diagnostic imag● Knowledge of standard acoustic windows● Knowledge of image display and orientat● Ability to recognize normal and abnorma

the cross-sectional images with anatomic● Familiarity with standard echocardiograp● Familiarity with major developments in t

Advanced In addition to the knowledge base required● In-depth knowledge of ultrasound physic● Ability to recognize and characterize rare

variety of clinical settings● In-depth understanding of Doppler meth● Familiarity with all echocardiographic me

tion and knowledge of the strengths and● Up-to-date knowledge of recent advance

critically published research that pertains● Knowledge of current training guidelines

Table 2 Required skills for core and advanced levels of exp

Level of expertise

Core ● Ability to safely, properly, and efficiently● Ability to perform a complete transthorac

2-dimensional, and Doppler techniques itation as needed

Advanced In addition to the skills required in the core● Ability to perform independently a comp

available ultrasound techniques in patien● Ability to assess cardiovascular physiology

sound techniques● Ability to supervise and teach pediatric ec

other physicians

cardiac sonographer.

Credentialing and formal education. A cardiacsonographer must obtain a recognized credentialwithin the time frame and using the pathways speci-fied by a credentialing organization recognized by theASE. A new cardiac sonographer entering the fieldmust comply with the formal educational require-ments specified by the applicable credentialing orga-nization, and must fulfill those requirements throughparticipation in a program recognized by the ASE.

Technical competence. A cardiac sonographer mustdemonstrate and document technical competence in theperformance of those types of echocardiographic exam-inations that the sonographer performs.

Continuing education. A cardiac sonographermust maintain his or her skills through participation

f expertise

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nd physicschocardiography in pediatric patientsand surgical interventionsation for assessment of blood flow and prediction of intracardiac

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d their application to the assessment of cardiovascular physiologyvailable for assessment of global and regional ventricular func-sses of these techniquesfield of noninvasive cardiac imaging, including ability to review

fieldgulations relevant to pediatric echocardiography

Required skills

diac ultrasound equipmentcardiographic examination with proper use of M-mode,al pediatric patients and in those with heart disease, with consul-

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EXAMINATION PROTOCOL

Examination Principles

Although laboratory protocols vary, the basic ele-ments of a standard examination involve 2D imagessupplemented by Doppler and color Doppler infor-mation in multiple orthogonal imaging planes. Thestudies are organized by acoustic windows fromwhich the heart is examined. The information maybe recorded in complete sweeps, multiple selectedsingle planes, or with a combination of both tech-niques.27-29 A complete examination protocolshould outline all views to be obtained, includingtheir preferred order, the imaging modalities to bedeployed for each view, and the preferred methodsfor recording and display. A list of the structures tobe examined with each view is helpful, and therequired versus optional measurements should beclearly defined.

Many pediatric echocardiography laboratories be-gin the examination with subxiphoid, or subcostal,imaging instead of left parasternal views. This allowsfor the determination and display of visceral situs(site or location) at the beginning of an examination.Regardless of where the examination starts, thesegmental approach is used to describe all of themajor cardiovascular structures in sequence.30,31 Anabnormal finding, either structural or hemodynamic,must be fully examined. Quantification of ventricu-lar function is often an important part of the exam-ination.

For a pediatric echocardiogram, by convention,the anterior and superior structures are displayed at

Table 3 Training methods recommended for core and adv

Level of

expertise Recomm

Core ● Training should take place in a pediatric echocardiocardiology program, inpatient and outpatient facilitdiac catheterization laboratory, and a congenital he

● Supervised performance of at least 150 transthoraci● Review at least 150 transthoracic echocardiograms● Participate in didactic conferences in which echoc

discussed● Reading of textbooks, review articles, and original● Attendance at CME courses that are either dedicat

Advanced In addition to the training methods described in the c● Perform at least 200 additional transthoracic echoc

critique of the examinations by the responsible staff● Review at least 200 additional transthoracic echoc● Trainees should gradually attain a high level of ind

should be determined by the director of the labor● Prepare and present echocardiographic data at clin● Active participation in research that involves echo

CME, Continuing medical education.*The recommended numbers of examinations outlined here represent mini

the top of the video screen, and the rightward

structures are generally placed on the left side of theimage display. Therefore, the preferred method ofdisplay is with the image apex “inverted,” with theimage apex at the bottom of the video screen,during subxiphoid and apical imaging to demon-strate structures in their correct anatomic orienta-tion. This is important because of the wide range ofanatomic variations frequently seen in patients withcongenital heart disease. The one exception to theleft-right rule of orientation is the parasternal long-axis view, in which the apex of the heart is dis-played on the left side of the video screen in bothlevocardia and dextrocardia.

The diagnostic accuracy of an examination de-pends greatly on the image quality. Technical adjust-ments must be made by the operator to improvesignal-to-noise ratio and image resolution. The ap-propriate probe and optimal transducer frequencyare selected to image the structures in question, andadjustments of the electronic (acoustic) focus depthare made throughout the study as necessary. Center-ing of structures of interest, using an appropriatedegree of magnification, and optimizing of windowsfor imaging and Doppler interrogation are critical forimage quality. Patient position, comfort, and level ofanxiety are important considerations throughout theexamination.

As a pediatric echocardiogram is progressing, thesonographer or echocardiographer must keep inmind the indications for the study and the need toaddress issues that may affect treatment as theyarise. A complete examination may require thatcustom, or in-between, planes be used to investigateor display an abnormality. Whatever method of

levels of expertise

methods of training

laboratory that serves a hospital with an accredited pediatricnatal and pediatric intensive care departments, a pediatric car-ery programardiograms (at least 50 in infants age � 1 y)*qualified staff pediatric echocardiographer*

raphic data are reviewed and their clinical applications are

ch on pediatric echocardiographyr include pediatric echocardiography

el:ams (at least 50 in infants age � 1 y) with subsequent review andric echocardiographer*ams with a qualified staff pediatric echocardiographer*nce; the degree and rate at which independence is attained

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standard, complete sweeps of the heart should bemade during the examination to rule out abnormal-ities at its base or apex or on one of its surfaces. Inaddition, the major vascular structures must beevaluated as part of a complete examination.

Extracardiac structures are visualized during astandard TTE examination. Mediastinal abnormali-ties such as masses and cysts, if present, should benoted. Careful attention to symmetry and amplitudeof diaphragm motion and screening for pleuraleffusions from subxiphoid and flank windows isparticularly important in postoperative cardiaccases.

Multiple Orthogonal Imaging Planes

The standard views of a 2D echocardiogram, asdefined early on by the ASE,32 are all used as part ofa pediatric echocardiogram. In addition, there areimaging planes that are more commonly associatedwith a routine pediatric study: subxiphoid (subcos-tal), suprasternal notch, and right sternal border.These imaging planes provide unique informationregarding cardiovascular malformations that are of-ten seen in childhood. A complete examinationrequires that the cardiovascular structures be im-aged from multiple orthogonal planes. This practiceminimizes artifacts caused by false dropout of struc-tures imaged parallel to the beam of interrogation orshadowing from reflective structures proximal tothe area of interest.

The imaging planes are identified by transducerlocation (subxiphoid, apical, parasternal, supraster-nal notch, and right parasternal) and by the plane ofexamination relative to the heart (4-chamber,2-chamber, long-axis, and short-axis). In addition,imaging planes may be described as anatomic planes(sagittal, parasagittal, transverse, or coronal).

The views and structures presented below aredescribed as seen in a patient with normal ornear-normal cardiovascular anatomy. Table 4 liststhe structures that should be visualized from thestandard examination views.

Subxiphoid (subcostal) views. Subxiphoid imag-ing33,34 begins with the determination of abdominalvisceral situs in the transverse plane. In addition tovisualization of the liver and stomach, the spleenshould be sought in patients with abnormal abdom-inal visceral situs. The location of the hepatic seg-ment of the inferior vena cava and descending aortain relation to the midline and one another are thendetermined. As the plane of imaging is angled fromthe abdomen to the thorax, the connections of thehepatic veins to the inferior vena cava are visualized,followed by the connection of the inferior vena cavato the right atrium. The patency of the inferior venacava should be documented; if a dilated azygos veinis seen posterior to the descending aorta, interrup-
tion of inferior vena cava should be suspected. The
descending aorta at the level of the diaphragmshould be interrogated by Doppler. Any additionalvascular structures crossing the diaphragm shouldbe fully investigated.

The subxiphoid long-axis sweep (Figure 1) beginsin the transverse plane and passes the inferior/posterior surface of the heart, which includes thecoronary sinus. The position of the left coronaryostium is well visualized as the ascending aorta isimaged. The posterior descending coronary arterymay be seen in the posterior interventricular groove.

Table 4 Structures viewed from standard examinationviews

Subxiphoid (subcostal) views Left parasternal viewsInferior vena cava Inferior vena cavaHepatic veins Superior vena cavaAbdominal aorta Left atriumDiaphragm Right atriumSuperior vena cava Atrial septumLeft atrium Coronary sinusRight atrium Pulmonary veinsAtrial septum Mitral valveCoronary sinus Tricuspid valvePulmonary veins Left ventricleMitral valve Right ventricleTricuspid valve Ventricular septumLeft ventricle Left ventricular papillary musclesRight ventricle Aortic valveVentricular septum Pulmonary valveLeft ventricular papillary

musclesAscending aortaCoronary arteries

Aortic valvePulmonary valve

Main and branch pulmonaryarteries

Ascending aorta PericardiumCoronary arteriesMain and branch pulmonary

arteriesSuprasternal notch viewsSuperior vena cava

Pericardium Left atriumPulmonary veins

Apical viewsInferior vena cava

Ascending aortaSuperior thoracic aorta

Left atrium Main and branch pulmonaryarteriesRight atrium

Atrial septum Aortic archCoronary sinus Proximal brachiocephalic arteriesSelected pulmonary veins Left innominate veinMitral valveTricuspid valve Right parasternal viewsLeft ventricle Inferior vena cavaRight ventricle Superior vena cavaVentricular septum Right atriumLeft ventricular papillary

musclesAtrial septumRight pulmonary veins

Aortic valve Ascending aortaPulmonary valve Right pulmonary arteryAscending aortaMain and branch pulmonary

arteries

The long-axis view allows for good visualization of


the atrial septum and color Doppler mapping of theanterior muscular septum.

The subxiphoid short-axis sweep (Figure 2) startsin a parasagittal plane that includes the inferior andsuperior venae cavae. Imaging normally begins tothe right, allowing visualization of the right upperpulmonary vein as it passes lateral and posterior tothe superior vena cava and then proceeds from thebase to the apex of the heart. The transducerposition may need to be repositioned (generallymore rightward) during the sweep to maintain ashort-axis imaging plane as the apex of the heart isvisualized.

Apical views. Standard apical35 4-chamber andlong-axis (3-chamber)–and, in some laboratories,apical 2-chamber–views are obtained. The apical4-chamber view (Figure 3) includes a sweep thatbegins posteriorly to demonstrate the coronary si-nus and the entrance of the inferior vena cava intothe right atrium. The sweep ends at the anteriorsurface of the heart after passing through the

Figure 1 Subxiphoid long-axis views demonstratransverse plane. 1, Right ventricular (RV) inflowinferior angulation, long axis of left ventricle (LV)vena cava (SVC) is seen to right of ascending AConnection of SVC to right atrium (RA) is dabdomen, atrial septum and pulmonary venous cowith permission from: Geva T. EchocardiographFisher DJ, Neish SR, editors. The science and prWilkins; 1997, p. 789-843).

5-chamber view demonstrating the left ventricular

(LV) outflow tract (OT) and ascending aorta. Theapical muscular septum may also be magnified in the4-chamber view for color Doppler interrogation.

Repositioning of the transducer medially towardthe lower left sternal border brings the right ventric-ular (RV) inflow and RV free wall more into align-ment with the beam of interrogation. Superior andanterior angulation from this position brings the RVOT into alignment and often offers an optimal anglefor Doppler interrogation of the RV OT.

Imaging of the LV OT (LVOT) from the apexallows for visualization of subaortic structures ori-ented perpendicular to the plane of insonation. Theapical long-axis (3-chamber) view (Figure 4) allowsfor optimal Doppler interrogation of the LVOT andascending aorta. Modified views foreshortening theLV may allow clearer visualization of the LVOT.Apical 2-chamber views are used primarily for as-sessment of global ventricular function or regionalwall motion.

Parasternal (left parasternal) views. The trans-

sweep from nearly coronal plane back towardoutflow are seen with pulmonary valve. 2, Withc (Ao) valve, and ascending Ao are seen. Superior

main pulmonary artery (MPA) is seen to left.trated. 3, As transducer is angled back towardions to left atrium (LA) are viewed. (ReproducedDoppler ultrasound. In: Garson A, Bricker JT,of pediatric cardiology. Baltimore: Williams and

ted inand

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ducer in the parasternal36,37 long-axis view (Figure

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5) is positioned over the LVOT, allowing visualiza-tion of the aortic and mitral valves. The long-axissweep includes the RV inflow and outflow. Thelong-axis or modified parasagittal view of the aortabest demonstrates the position of the right coronaryartery ostium relative to the sinotubular junction.The parasternal short-axis view (Figure 6) at the baseof the heart can provide detailed imaging of aorticvalve morphology and views of the RV infundibu-lum, pulmonary valve, and main/proximal branchpulmonary arteries. The short-axis view also allowsfor visualization of the coronary ostia, and imagingand color flow mapping of the proximal coronaryarteries. Clockwise rotation of the transducer into atransverse view elongates the left coronary arteryand often demonstrates its bifurcation. The mor-phology of the mitral leaflets and valve apparatus isoften best seen on a parasternal short-axis view. Inlarger hearts, color flow mapping of the ventricularseptum may require separate short-axis sweeps of

Figure 2 Subxiphoid short-axis views. 1, At riginferior vena cava enter right atrium (RA). RightSVC and above left atrium (LA). 2, With leftward(RV) and atrioventricular valves are seen. Aortic (leftward angulation reveals cross-sectional view opulmonary valve (PV). 4, Sweep then passes thtoward apical portions of both ventricles. (Reprodand Doppler ultrasound. In: Garson A, Bricker JTof pediatric cardiology. Baltimore: Williams and W

the anterior and posterior portions of the septum.

Examination of the apical muscular septum mayrequire repositioning of the transducer toward theapex during the short-axis sweep.

A ductal view is obtained from imaging in aparasagittal plane from a high left parasternal win-dow. This window lines up the ultrasound beamwith the main pulmonary artery-ductus continuumand allows for exclusion of a normally located smallpatent ductus arteriosus. The distal aortic arch andsuperior thoracic aorta may also be visualizedthrough the heart and the main pulmonary artery,and, in larger individuals, the aortic isthmus issometimes best seen from this position. Clockwiserotation of the transducer to a high left parasternaltransverse plane may better demonstrate the leftpulmonary veins in some larger individuals.

Suprasternal notch views. Imaging from the su-prasternal notch38-40 includes positioning of thetransducer in the right supraclavicular region andoccasionally in the left supraclavicular region. In

aspect of heart, superior vena cava (SVC) andnary artery (RPA) is seen in cross section behindtion, base of left ventricle (LV) and right ventriclelve is seen in cross section at this level. 3, Furthernd mitral valve (MV), and RV outflow tract andmidmuscular septum and LV papillary musclesith permission from: Geva T. Echocardiography

r DJ, Neish SR, editors. The science and practices; 1997, p. 789-843).

htwardpulmoangulaAo) vaf LV aroughuced w, Fishe

the coronal, or short-axis, plane (Figure 7), the


Figure 3 Apical 4-chamber views demonstrated in anterior/superior to posterior/inferior sweep. 1, Withanterosuperior angulation, left ventricular (LV) outflow tract and proximal ascending aorta (Ao) aredemonstrated. 2, apical 4-chamber view shows atria, atrioventricular valves, and ventricles in cross section.3, With posterior angulation, coronary sinus (CS) is seen along posterior left atrioventricular groove.(Reproduced with permission from: Geva T. Echocardiography and Doppler ultrasound. In: Garson A,Bricker JT, Fisher DJ, Neish SR, editors. The science and practice of pediatric cardiology. Baltimore:
Williams and Wilkins; 1997, p. 789-843).
Figure 4 From apical 4-chamber view, clockwise rotation of transducer into apical long-axis view profilesleft atrium (LA), left ventricular (LV) outflow tract, and proximal ascending aorta (Ao). (Reproduced withpermission from: Geva T. Echocardiography and Doppler ultrasound. In: Garson A, Bricker JT, Fisher DJ,Neish SR, editors. The science and practice of pediatric cardiology. Baltimore: Williams and Wilkins;
1997, p. 789-843).

kins; 1


connection of the left innominate vein to thesuperior vena cava is visualized. The leftwardextent of the left innominate vein should beexamined by color flow mapping to exclude a leftsuperior vena cava or an anomalous pulmonaryvenous connection. In smaller individuals, boththe right and left pulmonary venous connectionsto the left atrium are well visualized in the far fieldof the suprasternal notch view (crab view). Supe-rior (cranial) angulation of the transducer demon-strates the branching pattern of the aorta. Thesidedness of the aortic arch may be determined asopposite of the direction, or sidedness, of the firstbrachiocephalic artery. A normal branching pat-tern of the aortic arch should be documented bydemonstration of a normally bifurcating first bra-

Figure 5 Left parasternal long-axis views demsweep. 1, Rightward and inferior angulation towand right ventricular (RV) inflow. Coronary sinulong-axis view shows left atrium (LA), left ventriclAo. 3, Leftward and superior angulation toward land main pulmonary artery (PA). (ReproducedDoppler ultrasound. In: Garson A, Bricker JT, Fipediatric cardiology. Baltimore: Williams and Wil

chiocephalic artery.

Demonstration of the left aortic arch in its longaxis (Figure 8) is achieved by counterclockwiserotation of the transducer from the coronal planein the suprasternal notch window. Further coun-terclockwise rotation and leftward angulation of-ten best demonstrates the left pulmonary artery.

Right parasternal views. The rightward extent ofthe atrial septum may be well visualized in a parasag-ittal imaging plane from the right parasternal border. 41

Superior (Figure 9) and inferior right parasternal win-dows may be sought, and positioning of the patient ina right lateral decubitus position is often helpful. Fromthis view, the atrial septum is oriented perpendicularto the plane of insonation, and less dropout artifact ispresent. Rotation into a short-axis (transverse) imagingplane from a superior right parasternal window allows

ted in rightward/inferior to leftward/superiorht hip shows right atrium (RA), tricuspid valve,be followed into RA in this view. 2, Parasternal, mitral and aortic (Ao) valves, RV, and ascendingulder depicts RV outflow tract, pulmonary valve,ermission from: Geva T. Echocardiography andJ, Neish SR, editors. The science and practice of997, p. 789-843).

onstraard rigs can

e (LV)eft showith psher D

visualization and color flow mapping of the right


upper pulmonary vein and perpendicular interroga-tion of the right pulmonary artery and its upper lobebranch. Doppler interrogation of the LVOT should alsobe performed from the right upper parasternal win-dow if indicated.

MEASUREMENTS

The measurement of cardiac structures and flows iscritical to the interpretation of a pediatric echocar-diogram. An abnormally small or large structure canbe a clue to otherwise silent pathology, and isimportant to the planning of surgical procedures.Mild forms of obstruction can be diagnosed only byaccurate measurement of flow velocities. In general,it is recommended that all relevant measurementsbe made as part of a complete pediatric echocardio-gram. Recent guidelines have been published for theechocardiographic assessment of valvar regurgita-tion42 and the quantification of chamber size, ven-tricular mass, and function in adult patients.43 Themeasurements that are relevant in pediatric patients,

Figure 6 Parasternal short-axis views. 1, Sweep isatrium (LA), atrial septum, aortic valve, tricuspulmonary valve (PV) seen. 2, Cross-sectional vie3, Further angulation toward LV apex depicts LV ppermission from: Geva T. Echocardiography and DNeish SR, editors. The science and practice of p1997, p. 789-843).

however, will vary depending on the specifics of

their cardiovascular anatomy. The examination pro-tocol of a laboratory should specify which measure-ments to perform and the laboratory procedure forobtaining each measurement. The following sectionis a brief discussion of the recommended measure-ments for a pediatric echocardiogram. The reader isreferred to other resources for a more detaileddiscussion of the theoretic principles for these mea-surements and for the technical aspects of theirperformance.43-50 The recommended measurementsare grouped into measurements of cardiovascularstructures, ventricular size and function measure-ments, hemodynamic measurements, and miscella-neous measurements.

Measurements of Cardiovascular Structures

To normalize the measurements of cardiovascularstructures, an assessment of body size is necessary.Normative data for many cardiovascular structuresexist,44-50 and are generally adjusted to a calculation ofbody surface area using the height and weight of thepatient. Valve and vascular diameters relate linearly tothe square root of body surface area, whereas valve

d at base of heart, with right atrium (RA) and leftlve (TV), right ventricular (RV) outflow, anditral valve (MV) and RV are then demonstrated.

ry muscles (PMs) and RV apex. (Reproduced withr ultrasound. In: Garson A, Bricker JT, Fisher DJ,ic cardiology. Baltimore: Williams and Wilkins;

initiatepid vaw of mapillaoppleediatr

and vascular areas relate to body surface area.18 The


relationship between LV volume and body size fits acomplex model predicted by the nonlinear decrease of

Figure 7 Suprasternal short-axis view. In transversuperior vena cava (SVC). Distal ascending aorta (artery (RPA), which is seen along its length aboveLA. (Reproduced with permission from: Geva T.A, Bricker JT, Fisher DJ, Neish SR, editors. TheWilliams and Wilkins; 1997, p. 789-843).

Figure 8 Suprasternal aortic (Ao) arch (long-axisInnom artery. Right pulmonary artery (RPA) is swith permission from: Geva T. EchocardiographFisher DJ, Neish SR, editors. The science and prWilkins; 1997, p. 789-843).

heart rate with growth.18 The 2D measurements have

supplanted those obtained by M-mode as the standardfor most cardiac structures. At a minimum, all struc-

e, left innominate vein (Innom V) connects withseen in cross section superior to right pulmonaryrium (LA). Note pulmonary veins (PVs) enteringardiography and Doppler ultrasound. In: Garsone and practice of pediatric cardiology. Baltimore:

Left innominate (Innom) vein is seen anterior tocross section behind ascending Ao. (ReproducedDoppler ultrasound. In: Garson A, Bricker JT,of pediatric cardiology. Baltimore: Williams and

se planAo) isleft at

Echocscienc

) view.een iny andactice

tures should be imaged adequately so that measure-

7, p. 7


ments could be performed from the recorded image ifrequired. As a rule, outflow measurements should beobtained during ventricular systole and inflow mea-sures during ventricular diastole. Table 5 provides a listof standard measurements of cardiovascular structuresalong with the appropriate time of measurement andsuggested view.

Ventricular Size and Function Measurements

Assessment of cardiac size and function is an integralpart of the evaluation of the cardiac status. There-

Figure 9 High right parasternal view. Superior veand atrial septum are demonstrated. Right pulm(RUPV) cross behind SVC. (Reproduced with peultrasound. In: Garson A, Bricker JT, Fisher DJ,cardiology. Baltimore: Williams and Wilkins; 199

Table 5 Recommended measurements of cardiovascularstructures

Measurement Timing View(s)

Tricuspid valve annulus Diastole Apical 4-chamberPulmonary valve annulus Systole PSAX/PLAXMain pulmonary artery Systole PSAX/PLAXLeft/right pulmonary

arterySystole PSAX/PLAX

Left atrial diameter Diastole PLAXMitral valve diameter Diastole PLAX/apical 4-chamberAortic valve annulus Systole PLAXAortic root Systole PLAXAscending aorta Systole PLAXTransverse aortic arch Systole SSNAortic isthmus Systole SSN

PLAX, Parasternal long-axis; PSAX, parasternal short-axis; SSN, supraster-nal notch.

fore, an objective assessment of cardiac function is

recommended. M-mode, 2D imaging, and Dopplermethods can be used to assess ventricular function.Newer modalities such as 3-dimensional echocardi-ography, Doppler tissue imaging, and strain andstrain rate calculations are promising new tech-niques that are currently under investigation. Eachtechnique for ventricular function assessment hasstrengths and weaknesses that must be consideredand balanced to meet the needs of the individualpatient.

LV size and systolic function. Measurement of LVdimensions in diastole and systole by M-mode and/or2D imaging is recommended for a complete study.The parasternal short axis at the midpapillary level isthe preferred site for measurement of LV chambersize and wall thickness, but the subcostal short axiscan be used as well. The ventricular septum, LVdimension, and LV posterior wall are used to deter-mine LV size and exclude hypertrophy. LV mass, theestimated weight of the ventricular muscle that canbe assessed by several techniques,43 may be helpfulin patients with long-standing hypertension or otherforms of LV hypertrophy. The standard M-modemethod of LV systolic function assessment is theshortening fraction, which is affected by loadingconditions, altered LV geometry, and regional wall-motion abnormalities. However, relatively load-inde-pendent indices of myocardial performance basedon M-mode measurements are useful for the serialassessment of patients at high risk for diminished

a (SVC), right atrium (RA) and left atrium (LA),artery (RPA) and right upper pulmonary veinn from: Geva T. Echocardiography and Doppler

SR, editors. The science and practice of pediatric89-843).

na cavonary

rmissioNeish

function, such as those undergoing chemotherapy.


The velocity of circumferential fiber shortening nor-malized for heart rate is a measure of contractilitythat is independent of preload and inversely relatedto afterload in a linear fashion.51 Two of the morecommonly used 2D methods of LV systolic functionassessment are the biplane Simpson and the area-length measurements of the ejection fraction. Thebiplane Simpson method, or the method of disks,calculates a volume based on diastolic and systolicarea measurements of the LV from the apical 4- and2-chamber views. The apical long-axis (3-chamber)view may be substituted for the apical 2-chamberview.52,53 The area-length method is calculated us-ing the ventricular length from the apical 4-chamberview and the midpapillary parasternal short-axis areato yield a ventricular volume based on an assumedshape. Both have been validated in children ofvarious sizes.54 Calculation of LV wall stress-velocityindex has been shown to be a more accurateassessment of the cardiac muscle function and re-serve than the ejection fraction, because it incorpo-rates and accounts for the afterload of the ventriclein its evaluation. It may be appropriate for somepatients with significant systolic dysfunction orother complicated clinical situations.55-57

RV size and systolic function. Because of its com-plex geometry, the RV is difficult to accuratelyassess in short axis, and is often not of benefit in theevaluation of patients. Recommendations for thequantification of the RV and RV OT have beenproposed43 but not completely validated in chil-dren. Because of the RV’s nongeometric shape, no2D method of shortening or ejection fraction hasbeen consistently applied. The above-mentionednewer modalities (3-dimensional echocardiography,Doppler tissue imaging, and strain and strain ratecalculations) are free of geometric assumptions andmerit further investigation as techniques for assess-ing the RV.

Diastolic function. The measurement of ventricu-lar diastolic function is playing an increasingly im-portant role in the evaluation of cardiac dynamics aswe learn more about the mechanics of diastole andits impact on overall cardiac status. Ventriculardiastolic dysfunction often precedes systolic dys-function in disease states. Traditional measures haveincluded Doppler indices of LV filling and pulmo-nary venous flow (Table 6).58 The value of additionalmeasurements–including Doppler tissue imaging ofthe septal and lateral ventricular walls, inflow prop-agation, isovolumic relaxation time, and Tei index–for assessing diastolic function are beingexamined.59,60

Hemodynamic Measurements

Measurements of flow through all of the cardiacvalves should be part of a complete pediatric echo-
cardiogram. At a minimum, spectral Doppler flow
images should be recorded so that measurements ofthe gradients across all intracardiac valves and greatarteries can be performed. Table 6 lists Dopplermeasurements that should be considered for inclu-sion in a complete examination protocol. If evi-dence of flow obstruction is present, more completemeasurement of cardiovascular dimensions (subval-var, valvar, supravalvar, vascular, or a combinationof these) and flow gradients should be performed.To properly evaluate the intracardiac and intravas-cular pressures, a representative blood pressuremeasurement must be obtained. In some patients,repeated measurement may be appropriate if thereis changing physiology or if an exact comparison isrequired at the time of a particular measurement. Inpatients with congenital heart disease, it is particu-larly important to estimate RV and pulmonary arterypressures and to note their estimated values relativeto systemic pressures.

Miscellaneous and Pathology-relatedMeasurements

There are measurements that may be appropriatefor certain patients with specific types of pathol-ogy. For example, in patients with Marfan syn-drome, the aorta should be measured at multiplelevels. Patients with a ventricular septal defectrequire assessment of defect size and flow velocityas part of their evaluation. Likewise, assessment ofdescending aortic flow is important in patientswith aortic insufficiency or aortopulmonary com-munications. However, the breadth and variabilityof these measurements is beyond the scope of

Table 6 Doppler measurements

Structure Measurements*

Tricuspid valve E wave velocity, A wave velocity,deceleration time, IVRT, meangradient, regurgitant jet velocity

RV outflow Peak gradient, mean gradient, VTIPulmonary valve Peak gradient, mean gradient,

regurgitant jet velocity, VTIBranch pulmonary artery Peak gradient, mean gradient, VTIMitral valve E wave velocity, A wave velocity,

deceleration time, IVRT, meangradient

LV outflow Peak gradient, mean gradient, VTIAortic valve Peak gradient, mean gradient, VTI,

pressure half-timeAortic arch Peak gradient, mean gradient, VTI

IVRT, Isovolumic relaxation time; LV, left ventricular; RV, right ventricu-lar; VTI, velocity time integral.*Recording of images adequate for the measurements listed should beconsidered for inclusion in a complete examination protocol. This is notintended to be a comprehensive list of recommended Doppler measure-ments.

these guidelines.


REPORTING

Information obtained from pediatric echocardio-grams is frequently used by nonechocardiographicpersonnel, including surgeons, pediatricians, anes-thesiologists, and other patient caretakers. Convey-ance of the echocardiographic findings in a clearand cogent manner is important. Abbreviationsshould be avoided but when used should be unam-biguous.

Minimal elements of the pediatric echocardiogra-phy report are listed in Table 7. Basic identifierinformation should be listed. A statement relating tothe indication for study is required. The reportfindings section can be configured in a variety ofways but should include information on: (1) struc-tural findings; (2) measurements of cardiovascularstructures made; and (3) Doppler echocardio-graphic data. Positive findings and pertinent nega-tive findings should be listed.

Information pertaining to cardiovascular anatomyand structure can be conveyed using the segmentalapproach. In addition to reporting the absolutevalues, it is useful to report quantitative measureswithin the context of age- or size-appropriate norms(eg, z-score values).61,62 Doppler information con-cerning the atrioventricular valves, semilunar valves,and any shunt sites should be provided. QuantitativeDoppler information such as velocity data, patternsof spectral flow, and color jet dimensions, andsemiquantitative estimates of insufficiency or steno-sis, where appropriate, should be included in thereport. Any technical or other limitations that mightcompromise the diagnostic accuracy of the echocar-diographic examination should be specified in thereport. Examples include suboptimal acoustic win-dows, heart rate constraints, and excessive patient

Table 7 Minimal elements for a pediatricechocardiography report

Patient identifier dataNameDate of birthMedical record identifier

Date of studyLocation of studyReferring physicianSedation usedIndications for pediatric echocardiographic studySonographer/physician who performed the studyFindings section

Structural/anatomic featuresQuantitative dataDoppler (hemodynamic) findings

Summary section

motion during the examination.

A standardized pediatric echocardiography reportshould be generated for every echocardiographicstudy performed. The final report may be generatedelectronically with the option of a printable papercopy. The report should be easily accessible toappropriate personnel and readily available for re-view at all times. Reports should be searchable andavailable for serial comparison.

NEWER MODALITIES

The recent advent of echocardiographic modalitiessuch as Doppler imaging of tissue velocities, includ-ing strain and strain rate imaging, color M-modeassessment of atrioventricular valve inflows, and live3-dimensional echocardiography portends greatpromise for the near future.63-90 The quantitativeapproaches available from the application of thesemodalities promise to provide a new paradigm forthe echocardiographic assessment of myocardialand valvar function. Other innovative technologies,such as handheld echocardiography scanners, mayexpand the applicability of pediatric echocardiogra-phy.91-93 This document does not seek to establishstandards for these newer modalities.

Conclusion

The pediatric echocardiogram is a unique ultra-sound examination, which differs in important waysfrom the conventional echocardiogram in the adult.A standardized approach and specialized skills andknowledge are required to perform and interpretthis test appropriately. This statement outlines indi-cations, details the unique features and essentialcomponents of the pediatric echocardiogram, andestablishes standards for the performance, interpre-tation, and reporting of this important test.

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