Performing a Comprehensive Pediatric Transthoracic Echocardiogram
Summary of Key Points and Recommendations
- AUC are available for pediatric TTE, and published AUC guidelines should be considered when ordering TTE.
- TTE should be performed in children with suspected heart disease, established acquired or CHD, systemic or genetic disorders with known cardiac involvement, and significant family history of cardiovascular disease.
- Several different transducers should be available with the full array of functionalities needed to perform pediatric TTE.
- A protocol should be in place outlining all the necessary components of patient preparation, image acquisition, and image storage in a system that allows easy review and comparison with prior studies, offline quantification, encryption and data security, and backup redundancy.
- Pediatric TTE laboratories should follow standard practices for image quality optimization.
- Every standard view in pediatric TTE involves focused and optimized evaluation of specific cardiovascular segments and connections, particularly in the setting of CHD.
- A protocol should be established outlining the required elements and preferred order for all the standard views of a comprehensive pediatric TTE, understanding that modified views are often needed to evaluate abnormal findings.
- Z scores for echocardiographic measurements are available for growing children.
- Different published Z score models can provide variable Z scores for the same measurement in the same patient.
- Echocardiographic Z scores should be used in children, recognizing the need to use the same Z score model when trending measurements over time in the same patient and when assessing risk in a particular patient population.
- Agitated saline contrast injection should be considered when evaluating intracardiac and intrapulmonary shunting.
- UEA use has been approved for children.
- A UEA may be considered when delineation of the LV endocardium to evaluate function by 2DE alone is challenging.
- Three-dimensional echocardiography is useful in the evaluation of the atrial and ventricular septum, ventricular outflow tracts, AV and semilunar valves, and ventricles.
- Three-dimensional echocardiography should be considered when evaluating septal defects, outflow tract abnormalities, valvar morphology and function, and ventricular volumes.
- STE has become standard practice in many pediatric TTE laboratories.
- Measurement of LV GLS may be incorporated into LV functional protocols.
- RV and single ventricular GLS, LV circumferential strain, and regional strain pattern analysis may be useful in targeted populations.
- Optimal STE requires high frame rates, and serial evaluations should use a single ultrasound platform.
- Evaluation of the systemic and pulmonary veins by 2DE, color mapping, and spectral Doppler interrogation should be performed for all initial pediatric TTE.
- The atrial septum should be evaluated in subcostal or right parasternal views.
- When possible, LA volumes should be measured, particularly when there is MV dysfunction, LV volume overload or hypertrophy, or suspected LV diastolic dysfunction.
- AV valve morphology and function should be evaluated in multiple views.
- Assessment of AV valve stenosis may not be accurate in children with faster heart rates or intracardiac shunts.
- Quantitative Doppler assessment of the severity of AV valve stenosis should be performed, recognizing the limitations in children.
- Quantitative assessment of the severity of AV valve regurgitation is limited in children, so qualitative assessment or other indirect surrogates of severity should be used.
- Three-dimensional echocardiography may be useful in the evaluation of AV valve morphology in targeted populations.
- Most RV systolic functional parameters do not account for the contribution of the RV outflow tract.
- RV systolic function should be evaluated by a combination of qualitative assessment and quantitative parameters.
- TAPSE and FAC are useful indices of RV systolic function.
- Three-dimensional echocardiographic measurements of RV volumes and EF as well as longitudinal strain analysis may be performed when feasible in certain conditions.
- LV short-axis linear measurements by 2DE or M-mode are limited when the LV cross-sectional shape is not circular or when there is abnormal regional wall motion.
- LV assessment should be performed in all TTE studies, including 2DE and Doppler echocardiography to measure LV size, mechanics, and systolic and diastolic function.
- The evaluation may also include a combination of Mmode, 3DE, and STE.
- Two-dimensional echocardiographic and 3DE volumetric measurements and STE are preferable to 2DE or M-mode linear measurements in the setting of abnormal LV shape or regional wall motion abnormalities.
- The RV outflow tract should be evaluated in subcostal, apical, and parasternal views, noting the view used when measuring gradients.
- The LV outflow tract should be evaluated in apical, right parasternal, and suprasternal views, noting the view used when measuring gradients.
- The AoV ‘‘annulus’’ is more of a virtual diagnostic construct than a true anatomic entity because of the semilunar attachments of the AoV leaflets.
- The LV outflow tract and PV and AoV annular diameters should be measured in parasternal long-axis views.
- AoV morphology is best evaluated with en face 2DE and 3DE images in parasternal short-axis views.
- The main and branch PAs, aortic segments, and arch branches should be evaluated in parasternal and suprasternal views.
- The CAs should be evaluated in parasternal views.
- Sweeps with color mapping in a high left parasternal sagittal or suprasternal long-axis view should be used to evaluate for a patent ductus arteriosus.
- Multiple nomenclature systems are available to describe CHDs.
- TTE reports should use nomenclature that everyone understands in a center.
- Standardized TTE reports should contain a succinct and focused summary, measurements with Z scores and/or normal reference ranges, and a description of all findings organized in a segmental fashion.
- Reports should be available in a reasonable period after study performance, and all critical findings should be communicated promptly to the appropriate caregiver.
- Centers and practices should develop and implement QA and QI programs to periodically review and measure the quality of echocardiographic services.
- 3DE: Three Dimensional Echocardiography
- ASE: American Society Of Echocardiography
- AUC: Appropriate Use Criteria
- STE: Speckle Tracking Echocardiography
- TTE: Transthoracic Echocardiography
Performing a Comprehensive Pediatric Transthoracic Echocardiogram
February 1, 2024
Last Updated Month/Year
February 2, 2024
Supplemental Implementation Tools
Country of Publication
Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
Male, Female, Adolescent, Child, Infant
Health Care Settings
Hospital, Outpatient, Radiology services, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
Diagnosis, Assessment and screening, Management
D004452 - Echocardiography
Leo Lopez, Daniel L. Saurers, Piers C.A. Barker, Meryl S. Cohen, Steven D. Colan, Jeanine Dwyer, Daniel Forsha, Mark K. Friedberg, Wyman W. Lai, Beth F. Printz, Ritu Sachdeva, Neha R. Soni-Patel, Dongngan T. Truong, Luciana T. Young, Carolyn A. Altman, Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography, Journal of the American Society of Echocardiography, Volume 37, Issue 2, 2024, Pages 119-170, ISSN 0894-7317, https://doi.org/10.1016/j.echo.2023.11.015