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The performance of complete, quality diagnostic echocardiograms demonstrates the laboratory's ability to provide excellence in patient care. Diagnostic imaging is often the sole link between a patient and his or her clinical management. Cardiac sonographers, thinking and functioning in their role as diagnosticians, facilitate the physician's clinical decision through the performance of careful and thorough echocardiograms. The combination of a quality echocardiogram and its corresponding final report cannot be underestimated in measuring the quality of care afforded to cardiovascular patients.

Part II, Section 3 of the 2007 ICAEL Standards, Part II Echocardiography Laboratory Operations - Adult Transthoracic Echocardiography Testing describes the components of a complete transthoracic echocardiogram. Although it is recognized that a limited or targeted examination is sometimes appropriate, the great majority of echocardiograms should be performed as directed by these standards. While the required views, measurements and Doppler are part of every standard echocardiogram, additional images and measurements may be required to properly interrogate any pathology noted in the study.

Standard 2D Views, Tips and Pitfalls

Parasternal Long Axis (PLAX) - Conventionally, the PLAX will appear first in the study. A "textbook" PLAX does not visualize the apex; if the apex appears in the image, attempt to image from a higher intercostal space. From this view, the septal and posterior walls will be oriented for optimal 2D or M-mode measurements, and the proximal ascending aorta can be seen. The left ventricular outflow tract diameter should be measured from this view for the most accurate measurement. A lower (more apically-oriented) PLAX view may optimize color interrogation through the mitral and aortic valves.

Right Ventricular Inflow View (RV Inflow) - The RV inflow view is one of the most commonly omitted standard views. This view, obtained by tilting the transducer inferiorly and medially from the PLAX, is an excellent view from which to visualize the tricuspid leaflets and interrogate the tricuspid regurgitation velocity. Parasternal Short Axis (PSAX) - The PSAX must be obtained from four levels; the base, at which the aortic valve leaflets are visualized in cross section, the mitral valve level, the papillary muscle level, and the apical level. The apical short axis level is also omitted from many representative case studies. Note that an off-axis PSAX view may often result from rotation from an off-axis [low] PLAX. From the basal PSAX view, standard spectral Doppler of the forward pulmonic valve flow may be obtained and the proximal pulmonary branches may be imaged. Apical 4- and 5-Chamber Views - The apical 4-chamber and 5-chamber views provide opportunities for well-aligned color and spectral Doppler interrogation of the mitral, tricuspid and aortic forward and regurgitant flows. The ICAEL Standards require that regurgitant flow be visualized in color in two or more imaging planes, and that spectral Doppler be obtained for all forward flows.
		FIGURE 1: RV INFLOW. The right ventricular inflow view, obtained by tilting the transducer inferiorly and medially from the PLAX view, may be optimized by starting from a lower PLAX.
		FIGURE 2: PSAX AT APEX. The PSAX at the apical level images the short axis of the left ventricle distal to the papillary muscles.

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