Making Sense of Echocardiography

Echocardiography is one of the most useful and powerful diagnostic tools in the assessment of cardi-
ac structure and function. It remains a rapidly expanding modality, with new techniques constantly
developing and maturing. Building on the success of the second edition, the third edition of Making
Sense of Echocardiography: A Hands-on Guide provides a timely overview for those learning echo-
cardiography for the first time as well as an accessible handbook that experienced sonographers can
refer to. The strong clinical focus and concentration on real-life scenarios make this book relevant
in day-to-day practice. Key updates for this edition include the latest guidelines for the evaluation
of diastolic function and pulmonary hypertension and fully updated reference intervals throughout.

Key Features
• Covers not only the fundamentals of echocardiography, including ultrasound physics, but also
new technologies such as 3D echocardiography
• Provides a comprehensive approach for the echo trainee, and serves as a useful reference for
more seasoned echocardiographers
• Incorporates current guidelines and reference intervals throughout
Making Sense of Echocardiography
About the Series
The Making Sense series covers a variety of medical topics and subjects allied to medicine. Some
of them are practical and technique-based, some provide professional advice, and some relate to
professional development. All titles are easy to navigate for quick reference and include plenty of
features such as ‘summary boxes’, ‘pearls of wisdom’, and ‘clinical considerations’. Easy to under-
stand, written in a jargon-free style, and convenient for carrying around, the Making Sense series
provides hands-on guidance to be referred to often in both clinical and reference contexts.
Making Sense of the ECG: A Hands-on Guide, 5th Edition
Andrew R. Houghton
Making Sense of Fluids and Electrolytes: A Hands-on Guide, 1st Edition
Zoja Milovanovic, Abisola Adeleye
Making Sense of Exercise Testing, 1st Edition
Robert B. Schoene, H. Thomas Robertson
Making Sense of Clinical Teaching: A Hands-on Guide to Success, 1st Edition
Samy A Azer
Making Sense of Clinical Examination of the Adult Patient: A Hands-on Guide, 1st Edition
Douglas Model
Making Sense of Critical Appraisal, 1st Edition
Olajide Ajetunmobi
Making Sense of Sleep Medicine: A Hands-on Guide
Karuna Datta and Deepak Shrivastava
Making Sense of Echocardiography: A Hands-on Guide, 3rd Edition
Andrew R. Houghton
 Making Sense of
Echocardiography
A Hands-on Guide
Third Edition

Andrew R Houghton
Designed cover image: Shutterstock
Third edition published 2024
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2024 Andrew R Houghton
First edition published by Hodder Arnold 2009
Second edition published by Taylor & Francis 2014
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal
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necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and
the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
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ISBN: 9781032303574 (hbk)

ISBN: 9781032303543 (pbk)
ISBN: 9781003304654 (ebk)
DOI: 10.1201/9781003304654

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by KnowledgeWorks Global Ltd.
 Dedication

This book is dedicated to the British Society of Echocardiography for their leading role in
promoting best practice and high standards of professional competence in echocardiography,
and the advancement of education, training and research.
Contents

Preface ix
Acknowledgements xi
Author xiii
Acronyms and Abbreviations xv

PART I Essential principles 1

1 History of echocardiography 1
2 Cardiac anatomy and physiology 3
3 Physics and instrumentation 11
4 Doppler physics 21
5 Myocardial mechanics 31
6 Service provision 35

PART II Cardiac imaging techniques 39

7 The standard transthoracic echo study 39
8 Transoesophageal echo 59
9 Stress echo 67
10 Contrast echo 77
11 Tissue Doppler imaging 81
12 Speckle tracking 85
13 3D echo 89
14 Intravascular ultrasound and epicardial echo 99
15 Alternative cardiac imaging techniques 101

PART III Clinical cases 107

16 The left ventricle and its systolic function 107
17 Coronary artery disease and regional left ventricular function 121
18 Left ventricular diastolic function 127
19 The left atrium 135
20 The aortic valve 139
21 The mitral valve 155
22 The right ventricle 173
23 The right atrium 181

vii
viii    Contents

24 The tricuspid valve 185

25 The pulmonary valve 195
26 Pulmonary hypertension 201
27 Heart valve repair and replacement 207
28 Endocarditis 217
29 The cardiomyopathies 225
30 The pericardium 235
31 The aorta 245
32 Cardiac masses 255
33 Congenital heart disease 263
34 Common echo requests 277

Appendix: Echo resources 287

Index 291
Preface

Since the publication of the second edition of Making Sense of Echocardiography, there have been
many advancements in the field of echo. The quality and sophistication of echo technology contin-
ues to improve, and techniques such as 3D/4D echo and speckle tracking are now firmly incorpo-
rated into clinical practice.
There have also been major updates of many of the key echo guidelines, and these updates have
been incorporated throughout the text. Updated key references for further reading are provided
for each chapter, and these reflect the latest guidelines and papers in each field. Several new figures
have been included, and several chapters have been restructured to provide even greater clarity to
the text.
The primary aim of this third edition of Making Sense of Echocardiography remains the same as
that of its predecessors – to provide the echo trainee with a comprehensive yet readable introduc-
tion to echo and to provide more experienced sonographers with an accessible handbook for refer-
ence when required. Information not just on performing echo but also on the supporting topics
of ultrasound physics, anatomy, physiology and clinical cardiology is interwoven throughout the
book.
The approach to echo studies taken in this book is based on guidelines published by national echo
societies, principally the British Society of Echocardiography (BSE), and I am particularly grateful
to the BSE for granting permission to use their recommended reference intervals throughout the
book. I am also grateful to everyone who has taken the time to comment on draft copies of the text
and to all those who have provided echo images for this book. Finally, I would like to thank all the
staff at CRC Press/Taylor & Francis who have contributed to the success of the Making Sense…
series of books.

Andrew R Houghton

ix
Acknowledgements

I would like to thank everyone who provided suggestions and constructive criticism while I pre-
pared the third edition of Making Sense of Echocardiography.
I would like to thank Cara Mercer, Stephanie Baker, Nigel Dewey and Sophie Beech in the
Cardiology Department at Grantham & District Hospital for their invaluable help in the prepara-
tion of this book. I am also grateful to the following colleagues for assisting me in acquiring the
images that illustrate this book:
Mookhter Ajij Lawrence Green Prashanth Raju
Denise Archer Prathap Kanagala Nimit Shah
Mark Philip Cassar Jane Kemm Kay Tay
Tina Dale Jeffrey Khoo Upul Wijayawardhana
Paul Gibson David O’Brien Bernadette Williamson
Catherine Goult Heidi Pleasance

I am indebted to Jo Sopala at the British Society of Echocardiography (BSE) for permission to quote
the society’s recommended echo reference intervals which, where applicable, form the basis of the
reference intervals used in this book.
I am grateful to Dr Grant Heatlie at the University Hospital of North Staffordshire in Stoke on
Trent and to Dr Thomas Mathew at the Trent Cardiac Centre in Nottingham for their contribu-
tions to the previous edition of this book, and for the images which have been carried forward to
this new edition.
I would like to thank my wife, Kathryn Ann Houghton, for her support and patience during the
preparation of this book.
Finally, I would also like to express my gratitude to everyone at CRC Press/Taylor & Francis for
their guidance and support.

xi
Author

Dr Andrew R Houghton studied medicine at the University of Oxford and undertook postgraduate
training in Nottingham and Leicester. He was appointed as a consultant cardiologist at Grantham
& District Hospital in Lincolnshire, UK, in 2002. His subspecialty interest is in non-invasive car-
diac imaging, in particular echocardiography and cardiovascular MRI. He has been a member of
the British Society of Echocardiography’s departmental accreditation committee and a lecturer at
BSE annual congresses.
Dr Houghton has co-authored a number of textbooks, including Making Sense of the ECG (now in
its fifth edition) and its companion volume Making Sense of the ECG: Cases for Self-Assessment, and
is also a faculty member at the Medmastery online medical education website. Making Sense of the
ECG has won several awards, including the Royal Society of Medicine’s Richard Asher prize and the
British Medical Association’s Student Textbook Award, while Making Sense of Echocardiography
was highly commended at the BMA Medical Book Awards.

xiii
Acronyms and Abbreviations

2D two-dimensional
3D three-dimensional
4D four-dimensional
a′ atrial contraction velocity on tissue Doppler imaging of mitral annulus
A peak A wave velocity
ACE angiotensin-converting enzyme
Adur duration of atrial reversal in pulmonary vein flow
AF atrial fibrillation
Ao aorta
AR aortic regurgitation
ARVC arrhythmogenic right ventricular cardiomyopathy
AS aortic stenosis
ASD atrial septal defect
ASE American Society of Echocardiography
AV aortic valve or atrioventricular
BCS British Cardiovascular Society
BSA body surface area
BSE British Society of Echocardiography
CI cardiac index
CO cardiac output
CRT cardiac resynchronization therapy
CSA cross-sectional area
CTRCD cancer therapy–related cardiac dysfunction
CW continuous wave (Doppler)
Cx circumflex (coronary) artery
DCM dilated cardiomyopathy
e′ early myocardial velocity on tissue Doppler imaging of mitral annulus
E peak E wave velocity
EACVI European Association of Cardiovascular Imaging
ECG electrocardiogram
EDV end-diastolic volume
EF ejection fraction
ESC European Society of Cardiology
ESV end-systolic volume
ET ejection time
FS fractional shortening
HCM hypertrophic cardiomyopathy
HFmrEF heart failure with mildly reduced ejection fraction
HFpEF heart failure with preserved ejection fraction
HFrEF heart failure with reduced ejection fraction
HID half-intensity depth
HOCM hypertrophic obstructive cardiomyopathy
HR heart rate
ICD implantable cardioverter defibrillator
ICt isovolumic contraction time

xv
xvi    Acronyms and Abbreviations

INR international normalized ratio

IRT or IVRT isovolumic relaxation time
IV intravenous
IVC inferior vena cava
IVNC isolated ventricular non-compaction
IVS interventricular septum
IVSd interventricular septal thickness in diastole
IVSs interventricular septal thickness in systole
JVP jugular venous pressure
LA left atrium
LAA left atrial appendage
LAD left anterior descending (coronary artery)
LCA left coronary artery
LCC left coronary cusp
LLPV left lower pulmonary vein
LMS left main stem
LUPV left upper pulmonary vein
LV left ventricle
LVEDV left ventricular end-diastolic volume
LVEDVi left ventricular end-diastolic volume (indexed)
LVEF left ventricular ejection fraction
LVESV left ventricular end-systolic volume
LVESVi left ventricular end-systolic volume (indexed)
LVH left ventricular hypertrophy
LVIDd left ventricular internal diameter in diastole
LVIDs left ventricular internal diameter in systole
LVOT left ventricular outflow tract
LVMi left ventricular mass (indexed)
LVPW left ventricular posterior wall
LVPWd left ventricular posterior wall thickness in diastole
LVPWs left ventricular posterior wall thickness in systole
MCE myocardial contrast echo
MI mechanical index or myocardial infarction
MPSE myocardial perfusion stress echo
MR mitral regurgitation
MS mitral stenosis
MV mitral valve
NCC non-coronary cusp
NSTEMI non-ST elevation myocardial infarction
NT-pro-BNP N-terminal-pro-B-type natriuretic peptide
OM obtuse marginal (coronary artery)
P½T pressure half-time
PA pulmonary artery
PADP pulmonary artery diastolic pressure
PASP pulmonary artery systolic pressure
PBMV percutaneous balloon mitral valvuloplasty
PDA persistent ductus arteriosus or posterior descending artery
PFO patent foramen ovale
PG pressure gradient
PISA proximal isovelocity surface area
Pmax peak pressure
Pmean mean pressure
PR pulmonary regurgitation
 Acronyms and Abbreviations   xvii

PRF pulse repetition frequency

PS pulmonary stenosis
PV pulmonary valve or pulmonary vein
PVa peak atrial reversal (‘A’ wave) velocity in pulmonary vein
PVD peak diastolic (‘D’ wave) velocity in pulmonary vein
PVS peak systolic (‘S’ wave) velocity in pulmonary vein
PW pulsed-wave (Doppler)
RA right atrium
RAP right atrial pressure
RCA right coronary artery
RF regurgitant fraction
RIMP right ventricular index of myocardial performance
RLPV right lower pulmonary vein
RT3D real-time three-dimensional
RT3DFV real-time three-dimensional full volume
RUPV right upper pulmonary vein
RV regurgitant volume or right ventricle
RVDP right ventricular diastolic pressure
RVOT right ventricular outflow tract
RVSP right ventricular systolic pressure
RWT relative wall thickness
S′ systolic myocardial velocity on tissue Doppler imaging of mitral annulus
SD stroke distance
SV stroke volume
SVi stroke volume index
STEMI ST elevation myocardial infarction
SVC superior vena cava
SVI stroke volume index
TAVI transcatheter aortic valve implantation
TDI tissue Doppler imaging
TGC time-gain compensation
TIA transient ischaemic attack
TOE transoesophageal echo
ToF tetralogy of Fallot
TR tricuspid regurgitation
TS tricuspid stenosis
TTE transthoracic echo
UEA ultrasound enhancing agent
Vmax peak velocity
Vmean mean velocity
VSD ventricular septal defect
VTI velocity time integral
WHO World Health Organization
Zva valvular–arterial impedance
PART I: ESSENTIAL PRINCIPLES

Chapter 1
History of echocardiography

The first application of diagnostic ultrasound in medicine was in the late 1930s, when Karl Dussik,
an Austrian psychiatrist and neurologist, became interested in the potential use of ultrasound for
brain imaging. Ultrasound was already in use at that time by mariners for underwater imaging
and also by engineers for flaw detection in metals. The piezoelectric effect was already well known,
having been discovered more than half a century earlier, and the concept of using a piezoelectric
crystal to both transmit and receive ultrasound was described in 1917.
Dussik’s brain imaging technique was different to today’s ultrasound, in that it was based on the
transmission of ultrasound waves through an object, rather than detecting waves reflected from an
object. His technique, which he called hyperphonography, involved placing a transmitter on one
side of the head and a receiver on the other, and using this apparatus, he was able to produce images
of the ventricles of the brain. Echo transmission was also the first ultrasound technique used for
cardiac imaging, by the German physiologist Wolf-Dieter Keidel, in order to make measurements
of the heart and thorax.
Echo reflection was first used by Inge Edler and Carl Hellmuth Hertz in Sweden. One weekend in
1953, they borrowed an industrial device, used to detect flaws in metals by the Kockum shipyard in
Malmö, to conduct their work on human subjects. By a fortunate coincidence, the frequency of the
echo transducer happened to be one that was suitable for cardiac imaging. The image of the heart
they produced was known as an amplitude mode (A-mode) scan and it was thought to show the
posterior wall of the left ventricle (LV). They were soon granted an ultrasound machine of their
own and began to produce motion mode (M-mode) scans, with which they were able to examine
the mitral valve and also detect atrial thrombus, myxoma and pericardial effusion.
Nonetheless, it was not until the early 1960s that the potential value of cardiac ultrasound became
more widely recognized. The first dedicated cardiac ultrasound machine, developed by Jack Reed
and Claude Joyner, appeared and the term ‘echocardiography’ was coined for the first time.
Real-time 2D echo followed in the 1960s, spurred on by advances in electronics, and by the early
1970s, mechanical transducers were available that could produce 2D images by steering the trans-
ducer back and forth, sweeping the ultrasound beam across the heart. Phased-array transducers
soon followed, in which the mechanical beam-steering mechanism was replaced by solid-state
electronics.
The 1970s also saw rapid developments in the use of Doppler techniques, and by the early 1980s,
colour Doppler imaging was becoming a common feature of echo studies. During the 1980s, the
technique of transoesophageal echo started to enter clinical practice, initially with monoplane
probes but later with biplane probes, multiplane probes and, ultimately, the use of 3D transoesoph-
ageal imaging.

DOI: 10.1201/9781003304654-1 1
2    Making Sense of Echocardiography

The 1990s saw a gradual change in archiving methods, with a move away from recording studies
on videotape towards more versatile digitally based archiving. There were also refinements in the
quality of echo, with the introduction of harmonic imaging and the growing use of echo contrast
agents to enhance endocardial border definition. Tissue Doppler imaging entered mainstream
practice towards the end of the 1990s, adding a new modality that has proven particularly valuable
in the assessment of LV diastolic function.
The new millennium saw the increasing adoption of 3D/4D echo, in both transthoracic and
transoesophageal studies. The use of speckle-tracking echo provided valuable insights into myocar-
dial mechanics and soon moved from the research setting into routine clinical practice. Meanwhile,
echo machines have gradually shrunk, initially to the size of laptop computers and subsequently to
the size of handheld devices, greatly increasing the portability and availability of echo technology.
The growing use of echo has reinforced the need for professional regulation, and the past few years
have seen the publication of many key national and international guidelines that set clear quality
standards for the performance of echo in the years ahead.

Further reading
Coman IM. Christian Andreas Doppler: the man and his legacy. European Journal of Echocardiography
(2005). PMID 157449.

Edler I et al. The use of ultrasonic reflectoscope for the continuous recording of the movements of heart walls.
Kungliga Fysiografiska Sällskapets i Lund Förhandlingar (1954). PMID 15165281.

Fraser AG et al. A concise history of echocardiography: timeline, pioneers, and landmark publications.
European Heart Journal – Cardiovascular Imaging (2022). PMID 35762885.

Iskander J et al. Advanced echocardiography techniques: the future stethoscope of systemic diseases. Current
Problems in Cardiology (2022). PMID 33992429.

Roelandt JRTC. Seeing the invisible: a short history of cardiac ultrasound. European Journal of
Echocardiography (2000). PMID 11916580.
History of echocardiography
Coman IM . Christian Andreas Doppler: the man and his legacy. European Journal of Echocardiography (2005).
PMID 157449.
Edler I et al. The use of ultrasonic reflectoscope for the continuous recording of the movements of heart walls.
Kungliga Fysiografiska Sällskapets i Lund Förhandlingar (1954). PMID 15165281.
Fraser AG et al. A concise history of echocardiography: timeline, pioneers, and landmark publications.
European Heart Journal – Cardiovascular Imaging (2022). PMID 35762885.
Iskander J et al. Advanced echocardiography techniques: the future stethoscope of systemic diseases. Current
Problems in Cardiology (2022). PMID 33992429.
Roelandt J.R.T.C. Seeing the invisible: a short history of cardiac ultrasound. European Journal of
Echocardiography (2000). PMID 11916580.

Cardiac anatomy and physiology

Anderson RH et al. Anatomic basis of cross-sectional echocardiography. Heart (2001). PMID 11359762.
Anderson RH et al. Development of the heart: (2) septation of the atriums and ventricles. Heart (2003). PMID
12860885.
Anderson RH et al. Development of the heart: (3) formation of the ventricular outflow tracts, arterial valves, and
intrapericardial arterial trunks. Heart (2003). PMID 12923046.
Moorman A et al. Development of the heart: (1) formation of the cardiac chambers and arterial trunks. Heart
(2003). PMID 12807866.
Mori S et al. What is the real cardiac anatomy? Clinical Anatomy (2021). PMID 30675928.

Physics and instrumentation

Bertrand PB et al. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed
diagnosis. Journal of the American Society of Echocardiography (2016). PMID 26969139.
Edelman SK . Understanding ultrasound physics. 4th edition (ESP Ultrasound, 2012).
Gibbs V et al. Ultrasound physics and technology: how, why and when (Churchill Livingstone, 2009).
Le HT et al. Imaging artifacts in echocardiography. Anesthesia and Analgesia (2016). PMID 26891389.

Doppler physics
Edelman SK . Understanding ultrasound physics. 4th ed. (ESP Ultrasound, 2012).
Gibbs V et al. Ultrasound physics and technology: how, why and when (Churchill Livingstone, 2009).

Myocardial mechanics
Moharram MA et al. Myocardial tissue characterisation using echocardiographic deformation imaging.
Cardiovascular Ultrasound (2019). PMID 31730467.
Mor-Avi V et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac
mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society
of Echocardiography. European Journal of Echocardiography (2011). PMID 21385887.
Shah AM et al. Myocardial deformation imaging: current status and future directions. Circulation (2012). PMID
22249531.
Waggoner AD et al. Tissue Doppler imaging: a useful echocardiographic method for the cardiac sonographer to
assess systolic and diastolic ventricular function. Journal of the American Society of Echocardiography (2001).
PMID 11734780.
Service provision
Ingram TE . A patient-centred model to quality assure outputs from an echocardiography department:
consensus guidance from the British Society of Echocardiography. Echo Research & Practice (2018). PMID
30400064.
Masani N. The Echocardiography Quality Framework: a comprehensive, patient-centred approach to quality
assurance and continuous service improvement. Echo Research & Practice (2018). PMID 30400065.
NHS England . (2020). https://www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-
renewal-independent-review-of-diagnostic-services-for-nhs-england-2.pdf
Ritzmann S. British Society of Echocardiography departmental accreditation standards 2019 with input from the
Intensive Care Society. Echo Research & Practice (2020). PMID 32190342.

The standard transthoracic echo study

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR . Appropriate use criteria for echocardiography.
Journal of the American Society of Echocardiography (2011). PMID 21338862.
Hindocha R et al. A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British
Society of Echocardiography. Echo Research and Practice (2020). PMCID PMC7354713.
Mitchell C et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in
adults: recommendations from the American Society of Echocardiography. Journal of the American Society of
Echocardiography (2019). PMID 30282592.
Robinson S et al. A practical guideline for performing a comprehensive transthoracic echocardiogram in adults:
the British Society of Echocardiography minimum dataset. Echo Research and Practice (2020). PMID
33112828.
Steeds RP et al. EACVI appropriateness criteria for the use of transthoracic echocardiography in adults: a
report of literature and current practice review. European Heart Journal – Cardiovascular Imaging (2017). PMID
28329307.

Transoesophageal echo
Hilberath JN et al. Safety of transesophageal echocardiography. Journal of the American Society of
Echocardiography (2010). PMID 20864313.
Sharma V et al. A safety checklist for transoesophageal echocardiography from the British Society of
Echocardiography and the Association of Cardiothoracic Anaesthetists. Echo Research and Practice (2015).
PMID 26798486.
Wheeler R et al. A minimum dataset for a standard transoesophageal echocardiogram: a guideline protocol
from the British Society of Echocardiography. Echo Research and Practice (2015). PMID 26798487.

Stress echo
Lancellotti P et al. The clinical use of stress echocardiography in non-ischaemic heart disease:
recommendations from the European Association of Cardiovascular Imaging and the American Society of
Echocardiography. European Heart Journal – Cardiovascular Imaging (2016). PMID 27880640.
Pellikka PA et al. Guidelines for performance, interpretation, and application of stress echocardiography in
ischemic heart disease: from the American Society of Echocardiography. Journal of the American Society of
Echocardiography (2020). PMID 31740370.
Steeds RP et al. Stress echocardiography in coronary artery disease: a practical guideline from the British
Society of Echocardiography. Echo Research and Practice (2019). PMID 30921767.
Contrast echo
Montrief T et al. Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a
narrative review. Canadian Journal of Anaesthesia (2020). PMID 32944839.
Muskula PR et al. Safety with echocardiographic contrast agents. Circulation: Cardiovascular Imaging (2017).
PMID 28377467.
Porter TR et al. Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American
Society of Echocardiography guidelines update. Journal of the American Society of Echocardiography (2018).
PMID 29502588.
Senior R et al. Clinical practice of contrast echocardiography: recommendation by the European Association of
Cardiovascular Imaging (EACVI) 2017. European Heart Journal – Cardiovascular Imaging (2017). PMID
28950366.

Tissue Doppler imaging

Chahal NS et al. Normative reference values for the tissue Doppler imaging parameters of left ventricular
function: a population-based study. European Journal of Echocardiography (2010). PMID 19910319.
Kadappu KK et al. Tissue Doppler imaging in echocardiography: value and limitations. Heart, Lung and
Circulation (2015). PMID 25465516.
Nagueh SF et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography:
an update from the American Society of Echocardiography and the European Association of Cardiovascular
Imaging. European Heart Journal – Cardiovascular Imaging (2016). PMID 27037982.
Pellerin D et al. Tissue Doppler, strain, and strain rate echocardiography for the assessment of left and right
systolic ventricular function. Heart (2003). PMID 14594870.
Waggoner AD et al. Tissue Doppler imaging: a useful echocardiographic method for the cardiac sonographer to
assess systolic and diastolic ventricular function. Journal of the American Society of Echocardiography (2001).
PMID 11734780.

Speckle tracking
Collier P et al. A test in context: myocardial strain measured by speckle-tracking echocardiography. Journal of
the American College of Cardiology (2017). PMID 28231932.
Dobson R et al. British Society for Echocardiography and British Cardio-Oncology Society guideline for
transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or
trastuzumab. Echo Research and Practice (2021). PMID 34106116.
Johnson C et al. Practical tips and tricks in measuring strain, strain rate and twist for the left and right ventricles.
Echo Research and Practice (2019). PMID 31289687.
Moharram MA et al. Myocardial tissue characterisation using echocardiographic deformation imaging.
Cardiovascular Ultrasound (2019). PMID 31730467.
Shah AM et al. Myocardial deformation imaging: current status and future directions. Circulation (2012). PMID
22249531.
Voigt JU et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus
document of the EACVI/ASE/Industry task force to standardize deformation imaging. European Heart Journal –
Cardiovascular Imaging (2015). PMID 25525063.
Yingchoncharoen T et al. Normal ranges of left ventricular strain: a meta-analysis. Journal of the American
Society of Echocardiography (2013). PMID 23218891.

3D echo
Lang RM et al. EAE/ASE recommendations for image acquisition and display using three-dimensional
echocardiography. European Heart Journal: Cardiovascular Imaging (2012). PMID 22275509.
Lang RM et al. 3-Dimensional echocardiography: latest developments and future directions. Journal of the
American College of Cardiology: Cardiovascular Imaging (2018). PMID 30522687.
Simpson J et al. Three-dimensional echocardiography in congenital heart disease: an expert consensus
document from the European Association of Cardiovascular Imaging and the American Society of
Echocardiography. European Heart Journal: Cardiovascular Imaging (2016). PMID 27655864.
Vegas A. Threedimensional transesophageal echocardiography: principles and clinical applications. Annals of
Cardiac Anaesthesia (2016). PMID 27762247.

Intravascular ultrasound and epicardial echo

Mintz GS et al. American College of Cardiology clinical expert consensus document on standards for
acquisition, measurement and reporting of intravascular ultrasound studies (IVUS). A report of the American
College of Cardiology Task Force on Clinical Expert Consensus Documents. Journal of the American College
of Cardiology (2001). PMID 11300468.
Neumann FJ et al. 2018 ESC/EACTS guidelines on myocardial revascularization. European Heart Journal
(2019). PMID 30165437.
Räber L et al. Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions.
An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions.
European Heart Journal (2018). PMID 29790954.
Reeves ST et al. Guidelines for performing a comprehensive epicardial echocardiography examination:
recommendations of the American Society of Echocardiography and the Society of Cardiovascular
Anesthesiologists. Journal of the American Society of Echocardiography (2007). PMID 17400124.

Alternative cardiac imaging techniques

Kelion A et al. Nuclear Cardiology. 2nd ed. (Oxford University Press, 2017).
Mitchell A et al. Cardiac Catheterization and Coronary Intervention. 2nd ed. (Oxford University Press, 2020).
Pfeiffer MP et al. Cardiac MRI: a general overview with emphasis on current use and indications. Medical
Clinics of North America (2015). PMID 26042886.
Serruys PW et al. Coronary computed tomographic angiography for complete assessment of coronary artery
disease: JACC state-of-the-art review. Journal of the American College of Cardiology (2021). PMID 34384554.
Stirrup J et al. Cardiovascular Computed Tomography. 2nd ed. (Oxford University Press, 2019).

The left ventricle and its systolic function

Harkness A et al. Normal reference intervals for cardiac dimensions and function for use in echocardiographic
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Iyengar SS et al. Concentric vs. eccentric left ventricular hypertrophy: does it matter? It is all “blood pressure
centered”. American Journal of Hypertension (2021). PMID 33950166.
Lang RM et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update
from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
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McDonagh TA et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.
European Heart Journal (2021). PMID 34447992.
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Coronary artery disease and regional left ventricular function

Collet JP et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation. European Heart Journal (2020). PMID 32860058.
Damluji AA et al. Mechanical complications of acute myocardial infarction: a scientific statement from the
American Heart Association. Circulation (2021). PMID 34126755.
Ibanez B et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting
with ST-segment elevation. European Heart Journal (2017). PMID 28886621.
Knutti J et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.
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Left ventricular diastolic function

Henein MY et al. Diastolic function assessment by echocardiography: a practical manual for clinical use and
future applications. Echocardiography (2020). PMID 32426907.
Nagueh SF et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography:
an update from the American Society of Echocardiography and the European Association of Cardiovascular
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Sunil Kumar S et al. Impact of updated 2016 ASE/EACVI vis-à-vis 2009 ASE recommendation on the
prevalence of diastolic dysfunction and LV filling pressures in patients with preserved ejection fraction. Journal
of Cardiovascular Imaging (2021). PMID 33511798.

The left atrium

Badano LP et al. Left atrial volumes and function by three-dimensional echocardiography: reference values,
accuracy, reproducibility, and comparison with two-dimensional echocardiographic measurements. Circulation:
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Rosca M et al. Left atrial function: pathophysiology, echocardiographic assessment, and clinical applications.
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The aortic valve

Baumgartner H et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a
focused update from the European Association of Cardiovascular Imaging and the American Society of
Echocardiography. Journal of the American Society of Echocardiography (2017). PMID 28363204.
Ring L et al. Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of
Echocardiography. Echo Research and Practice (2021). PMID 33709955.
Vahanian A et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. European Heart
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the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular
Magnetic Resonance. Journal of the American Society of Echocardiography (2017). PMID 28314623.

The mitral valve

Robinson S et al. The assessment of mitral valve disease: a guideline from the British Society of
Echocardiography. Echo Research and Practice (2021). PMID 34061768.
Vahanian A et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart
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the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular
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The right ventricle
Lang RM et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update
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Journal of the American Society of Echocardiography (2015). PMID 25559473.
Park JB et al. Quantification of right ventricular volume and function using single-beat three-dimensional
echocardiography: a validation study with cardiac magnetic resonance. Journal of the American Society of
Echocardiography (2016). PMID 26969137.
Zaidi A et al. Echocardiographic assessment of the right heart in adults: a practical guideline from the British
Society of Echocardiography. Echo Research & Practice (2020). PMID 32105053.

The right atrium

Humbert M et al. 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension.
European Heart Journal (2022). PMID 36017548.
Lang RM et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update
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Journal of the American Society of Echocardiography (2015). PMID 25559473.
Lang RM et al. Imaging assessment of the right atrium: anatomy and function. European Heart Journal –
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Magnino C et al. Inaccuracy of right atrial pressure estimates through inferior vena cava indices. American
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Zaidi A et al. Echocardiographic assessment of the right heart in adults: a practical guideline from the British
Society of Echocardiography. Echo Research & Practice (2020). PMID 32105053.

The tricuspid valve

Arsalan M et al. Tricuspid regurgitation diagnosis and treatment. European Heart Journal (2017). PMID
26358570.
Go YY et al. The conundrum of tricuspid regurgitation grading. Frontiers in Cardiovascular Medicine (2018).
PMID 30474032.
Lancellotti P et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an
executive summary from the European Association of Cardiovascular Imaging. European Heart Journal –
Cardiovascular Imaging (2013). PMID 23733442.
Zaidi A et al. Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from
the British Society of Echocardiography. Echo Research and Practice (2020). PMID 33339003.
Zoghbi WA et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from
the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular
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The pulmonary valve

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Zaidi A et al. Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from
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Zoghbi WA et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from
the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular
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Pulmonary hypertension
Augustine DX et al. Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the
British Society of Echocardiography. Echo Research and Practice (2018). PMID 30012832.
Galiè N et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the joint
task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology
(ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and
Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European
Heart Journal (2016). PMID 26320113.
Humbert M et al. 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension.
European Respiratory Journal (2022). PMID 36028254.

Heart valve repair and replacement

Baumgartner H et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. European
Heart Journal (2017). PMID 28886619.
Bilkhu R et al. Patient–prosthesis mismatch following aortic valve replacement. Heart (2019). PMID 30846522.
Chambers JB . The echocardiography of replacement heart valves. Echo Research and Practice (2016). PMID
27600454.
Chambers JB et al. Appropriateness criteria for the use of cardiovascular imaging in heart valve disease in
adults: a European Association of Cardiovascular Imaging report of literature review and current practice.
European Heart Journal – Cardiovascular Imaging (2017). PMID 28586420.
Chambers JB et al. Indications for echocardiography of replacement heart valves: a joint statement from the
British Heart Valve Society and British Society of Echocardiography. Echo Research and Practice (2019). PMID
30763277.
Lancellotti P et al. Recommendations for the imaging assessment of prosthetic heart valves: a report from the
European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the
Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging.
European Heart Journal – Cardiovascular Imaging (2016). PMID 27143783.
Otto CM et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive
summary: a report of the American College of Cardiology/American Heart Association Joint Committee on
Clinical Practice Guidelines. Circulation (2021). PMID 33332149.
Zoghbi WA et al. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler
ultrasound. Journal of the American Society of Echocardiography (2009). PMID 19733789.

Endocarditis
Afonso L et al. Echocardiography in infective endocarditis: state of the art. Current Cardiology Reports (2017).
PMID 29071426.
Durack DT et al. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic
findings. Duke Endocarditis Service. American Journal of Medicine (1994). PMID 8154507.
Habib G et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the
management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European
Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM).
European Heart Journal (2015). PMID 26320109.
Rajani R et al. Infective endocarditis: a contemporary update. Clinical Medicine (2020). PMID 31941729.
Xie P et al. An appraisal of clinical practice guidelines for the appropriate use of echocardiography for adult
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The cardiomyopathies
Agha AM et al. Role of cardiovascular imaging for the diagnosis and prognosis of cardiac amyloidosis. Open
Heart (2018). PMID 30305910.
Ghadri JR et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical
Characteristics, Diagnostic Criteria, and Pathophysiology. European Heart Journal (2018). PMID 29850871.
Jenni R et al. Echocardiographic and pathoanatomical characteristics of isolated left ventricular non-
compaction: a step towards classification as a distinct cardiomyopathy. Heart 2001. PMID 11711464.
Marcus FI et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification
of the task force criteria. European Heart Journal (2010). PMID 20172912.
Maron BJ et al. Contemporary definitions and classification of the cardiomyopathies. Circulation (2006). PMID
16567565.
Mathew T et al. Diagnosis and assessment of dilated cardiomyopathy: a guideline protocol from the British
Society of Echocardiography. Echo Research and Practice (2017). PMID 28592613.
Ommen SR et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic
cardiomyopathy: executive summary: a report of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines. Circulation (2020). PMID 33215938.
Turvey L et al. Transthoracic echocardiography of hypertrophic cardiomyopathy in adults: a practical guideline
from the British Society of Echocardiography. Echo Research and Practice (2021). PMID 33667195.

The pericardium
Adler Y et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the task force for
the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC). Endorsed
by: The European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal (2015). PMID
26320112.
Garcia MJ . Constrictive pericarditis versus restrictive cardiomyopathy? Journal of the American College of
Cardiology (2016). PMID 27126534.
Klein AL et al. American Society of Echocardiography clinical recommendations for multimodality
cardiovascular imaging of patients with pericardial disease. Journal of the American Society of
Echocardiography (2013). PMID 23998693.

The aorta
Curtis AE et al. The mystery of the Z-score. Aorta (2016). PMID 28097194.
Erbel R et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering
acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the
Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart
Journal (2014). PMID 25173340.
Evangelista A et al. Echocardiography in aortic diseases: EAE recommendations for clinical practice. European
Journal of Echocardiography (2010). PMID 20823280.
Evangelista A et al. The current role of echocardiography in acute aortic syndrome. Echo Research and
Practice (2019). PMID 30921764.
Gawinecka J et al. Acute aortic dissection: pathogenesis, risk factors and diagnosis. Swiss Medical Weekly
(2017). PMID 28871571.
Goldstein SA et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society
of Echocardiography and the European Association of Cardiovascular Imaging: endorsed by the Society of
Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. Journal of the
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Harkness A et al. Normal reference intervals for cardiac dimensions and function for use in echocardiographic
practice: a guideline from the British Society of Echocardiography. Echo Research and Practice (2020). PMID
32105051.
Loukas M et al. The anatomy of the aortic root. Clinical Anatomy (2014). PMID 24000000.
Spanos K et al. Guidelines on aortic disease management. Journal of Endovascular Therapy (2020). PMID
32813588.
Upadhyaya K et al. Echocardiographic evaluation of the thoracic aorta: tips and pitfalls. Aorta (Stamford)
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Cardiac masses
L'Angiocola PD et al. Cardiac masses in echocardiography: a pragmatic review. Journal of Cardiovascular
Echocardiography (2020). PMID 32766100.
Mankad R et al. Cardiac tumors: echo assessment. Echo Research and Practice (2016). PMID 27600455.
Tyebally S et al. Cardiac Tumors: JACC CardioOncology State-of-the-Art Review. JACC CardioOncology
(2020). PMID 34396236.

Congenital heart disease

Baumgartner H et al. 2020 ESC guidelines for the management of adult congenital heart disease. European
Heart Journal (2021). PMID 32860028.
Pristipino C et al. European position paper on the management of patients with patent foramen ovale. General
approach and left circulation thromboembolism. European Heart Journal (2019). PMID 30358849.
Simpson J et al. Three-dimensional echocardiography in congenital heart disease: an expert consensus
document from the European Association of Cardiovascular Imaging and the American Society of
Echocardiography. Journal of the American Society of Echocardiography (2017). PMID 27838227.
Stout KK et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report
of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
Journal of the American College of Cardiology (2019). PMID 30121240.

Common echo requests

Afari HA et al. Echocardiography for the pregnant heart. Current Treatment Options in Cardiovascular Medicine
(2021). PMID 34075291.
Dabbouseh NM et al. Role of echocardiography in managing acute pulmonary embolism. Heart (2019). PMID
31439657.
Dobson R et al. British Society for Echocardiography and British Cardio-Oncology Society guideline for
transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or
trastuzumab. Echo Research and Practice (2021). PMID 34106116.
Regitz-Zagrosek V et al. 2018 ESC Guidelines for the management of cardiovascular diseases during
pregnancy: the task force for the management of cardiovascular diseases during pregnancy of the European
Society of Cardiology (ESC). European Heart Journal (2018). PMID 30165544.
Saric M et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism.
Journal of the American Society of Echocardiography (2016). PMID 26765302.