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INDICATIONS

Knowledge of indications for an echocardiogram is

FroChCaMi(R.HophiRePedGulaiJ A08Codoimportant 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-

m the Mount Sinai Medical Center, New York (W.W.L.);ildrens Hospital, Boston (T.G.); Medical University of Southrolina, Charleston (G.S.S.); Childrens Hospital of Wisconsin,lwaukee (P.C.F.); Childrens Hospital of Michigan, DetroitA.H.); University of San Francisco (M.M.B.); Texas Childrensspital, Houston (R.H.P.); and Childrens Hospital of Philadel-a (J.R.).print requests: Wyman W. Lai, MD, MPH, FASE, Division ofiatric Cardiology, Box 1201, Mount Sinai Medical Center, Onestave L. Levy Place, New York, NY 10029 (E-mail: wyman.@mssm.edu).m Soc Echocardiogr 2006;19:1413-1430.94-7317/$32.00Guidelines and Standaa Pediatric Echocardio

the Task Force of the PAmerican Society oWyman W. Lai, MD, MPH, FASE, TalPeter C. Frommelt, MD, Richard A. Hum

Ricardo H. Pignatelli, MD, and Jack Rychik, MBoston, Massachusetts; Charleston, South Carolina; Milwauk

Houston, Texas; and Ph

chocardiography has become the primary imag-tool in the diagnosis and assessment of congen-

l and acquired heart disease in infants, children,d adolescents. Transthoracic echocardiographyTE) is an ideal tool for cardiac assessment, as it isninvasive, portable, and efficacious in providingtailed anatomic, hemodynamic, and physiologicormation about the pediatric heart.Recommendations for standards in the performancea routine 2-dimensional (2D) echocardiogram, 1 fetalhocardiogram,2 pediatric transesophageal echocar-gram,3 intraoperative transesophageal echocar-gram,4 and stress echocardiogram5 exist, as doidelines for appropriate training in various echo-rdiographic disciplines.6-12 As part of the accredi-ion process for echocardiography laboratories,e Intersocietal Commission for the AccreditationEchocardiography Laboratories has establishedsic performance standards for pediatric TTE, 13 butother standards document exists for the perfor-nce of a pediatric TTE.The pediatric echocardiogram is a unique exami-tion with features that distinguish it from otherhocardiograms. There is a wide spectrum ofcuse

pyright 2006 by the American Society of Echocardiography.i:10.1016/j.echo.2006.09.001for Performance ofam: A Report fromiatric Council of thehocardiography

MD, FASE, Girish S. Shirali, MD,D, FASE, Michael M. Brook, MD,riting Committee, New York, New York;sconsin; Detroit, Michigan; San Francisco, California;hia, Pennsylvania

pediatric examinations: the subxiphoid (or sub-stal), suprasternal notch, and right parasternalws. The acquisition and proper display of imagesm these views are critical aspects of the pediatricE. In addition, special techniques are required foraging uncooperative infants and young children,luding sedation and distraction tools that willow performance of a complete examination.The purposes of this document are to: (1) de-ribe indications for pediatric TTE; (2) define opti-l instrumentation and laboratory setup for pedi-ic echocardiographic examinations; (3) provide amework of necessary knowledge and training fornographers and physicians; (4) establish an exam-tion protocol that defines necessary echocardio-phic windows and views; (5) establish a base-e list of recommended measurements to berformed in a complete pediatric echocardio-am; and (6) discuss reporting requirements andrmatting of pediatric reports.lar structures, ventricular function, and potentialquelae of medical or surgical intervention.15-18

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Journal of the American Society of Echocardiography1414 Lai et al December 2006ngenital Heart Disease: History, Symptoms,d Signs

ications for the performance of a pediatric echo-rdiogram span a wide range of symptoms andns, including cyanosis, failure to thrive, exercise-uced chest pain or syncope, respiratory distress,rmurs, congestive heart failure, abnormal arteriallses, or cardiomegaly. These may suggest catego-s of structural congenital heart disease includingracardiac left-to-right or right-to-left shunts, ob-uctive lesions, regurgitant lesions, transpositionysiology, abnormal systemic or pulmonary venousnnections, conotruncal anomalies, coronary ar-y anomalies, functionally univentricular hearts,d other complex lesions, including abnormal lat-lity (heterotaxy/isomerism). Certain syndromes,ily history of inherited heart disease, and

tracardiac abnormalities that are known to beociated with congenital heart disease consti-te clinical scenarios for which echocardiogra-y is indicated even in the absence of specificrdiac symptoms and signs. Abnormalities onher tests such as fetal echocardiography, chestiograph, electrocardiogram, and chromosomalalysis constitute another group in which theggestion of congenital heart disease is addressedecifically by echocardiography.

quired Heart Diseases and Noncardiacseases

echocardiogram is indicated for the evaluation ofquired heart diseases in children, including Ka-saki disease, infective endocarditis, all forms ofrdiomyopathies, rheumatic fever and carditis, sys-ic lupus erythematosus, myocarditis, pericardi-

, HIV infection, and exposure to cardiotoxicugs. Pediatric echocardiography is indicated in theessment of potential cardiac or cardiopulmonarynsplant donors and transplant recipients. Re-ntly, echocardiography has been recommended inchildren who are newly diagnosed with systemicpertension.19 Noncardiac disease states that affecte heart such as pulmonary hypertension consti-e an important indication for serial pediatrichocardiograms. Echocardiography may also beicated in children with thromboembolic events,welling catheters and sepsis, or superior venava syndrome.

rhythmias

ildren with arrhythmias may have underlyinguctural cardiac disease such as congenitally cor-ted transposition or Ebsteins anomaly of thecuspid valve, which may be associated with subtlenical findings and are best evaluated using echo-rdiography. Sustained arrhythmias or antiarrhyth-

c medications may lead to functional perturba-ns of the heart that may only be detectable by

timprhocardiography and have important implicationsmanagement.

STRUMENTATION, PATIENT PREPARATION,D PATIENT SAFETY

strumentation

trasound instruments used for diagnostic studiesould include, at a minimum, hardware and softwareperform M-mode, 2D imaging, color flow mapping,d spectral Doppler studies, including pulsed waved continuous wave capabilities. The transducersed in pediatric studies should provide adequateaging across the wide range of depths encounteredpediatric cases. Multiple imaging transducers, rang-from low frequency (2-2.5 MHz) to high frequency7.5 MHz), should be available; a multifrequencynsducer that includes all these frequencies is also antion. A transducer dedicated to the performance ofntinuous wave Doppler studies should also be avail-le for each study.The video screen and display should be of suitablee and quality for observation and interpretation of allabove modalities. The display should identify the

rent institution, a patient identifier, and the date ande of the study. The electrocardiogram should alsodisplayed in real time with the echocardiographicnal. Range or depth markers should be available ondisplays. Measurement capabilities must be presentallow measurement of the distance between twoints, an area on a 2D image, blood flow velocities,e intervals, and peak and mean gradients fromectral Doppler studies.

ta Acquisition and Storage

hocardiographic studies must be recorded andred as moving images and must be stored on adium that allows for playback of the recordedving images. This would include videotape orital recording media. It is unacceptable to storearchive moving echocardiographic images on adium that displays only a static image, such asording film or paper. Portions of the echocardio-phic examination such as M-mode frames andppler spectral measurements may be displayedd recorded as a static image on media appropriatethe laboratory situation.

tient Preparation and Safety

fficient time should be allotted for each study ac-rding to the procedure type. The performance timean uncomplicated, complete (imaging and Doppler)diatric TTE examination is generally 45 to 60 min-s (from patient encounter to departure). Additional

e may be required for complicated studies. Allocedures should be explained to the patient and/or

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1415rents or guardians before the onset of the study. Thetient should be placed in a reclining position in amfortable environment. A darkened room is prefer-le for the performance of the study. Appropriatelows and blankets should be used for patient com-t and privacy. The sonographic gel should bermed to body temperature before the start of theamination. It is recommended that appropriate dis-ctions be provided in echocardiographic laborato-s performing studies on preschool children. Thesey include toys, games, television, or movies. Arent or guardian should accompany all childrenring the echocardiographic study except whereivacy issues supersede.The laboratory should recognize the potentialed for sedation of pediatric patients to obtain anequate examination. Written policies including,t not limited to, the type of sedatives, appropriatesing for age and size, and proper monitoring ofildren during and after the examination shouldist for the use of conscious sedation in chil-en.20,21

Each laboratory should have a written procedureplace for handling acute medical emergencies inildren. This should include a fully equipped car-c arrest cart (crash cart) and other necessaryuipment for responding to medical emergenciespediatric patients of all sizes.

ILLS AND KNOWLEDGE

hocardiography of congenital and acquired pedi-ic heart disease is an operator-dependent imaginghnique that requires high levels of technical anderpretive skills to maximize its diagnostic accu-y. Specialized training is required in the assess-nt of cardiovascular malformations to determineatment options and to assess outcomes after aner-increasing number of interventional and surgi-l procedures.

ysicians

cause TTE is the primary diagnostic imaging mo-lity in children with heart disease, pediatric cardi-gists must possess basic skills in performance anderpretation of transthoracic cardiac ultrasound,luding M-mode, 2D imaging, and various Dopplerthods. Physicians who specialize in echocardiog-hy of pediatric heart disease undergo extendedining in this domain.This committee reviewed and considered exist-guidelines for training in pediatric echocardi-

raphy.8,22-24 The American College of Cardiol-y (ACC) Pediatric Cardiology/Congenital Heartsease Committee and the ACC Training Program

rectors Committee have jointly developed newcommendations for training in pediatric cardiol-

oriny. The recommendations in the ACC/Americanart Association/American Academy of Pediatricsinical Competency and Training Statement ondiatric Cardiology (Task Force 2: Pediatric Train-Guidelines for Noninvasive Cardiac Imaging) rep-ent the most recent guidelines and, with minordifications, are incorporated in this document.25

Levels of expertise. Physicians who practice TTEy have one of two levels of expertise, core orvanced. The core level includes the basic set ofhnical and interpretive skills required for gradu-on from a pediatric cardiology training programcredited by ACGME. Physicians with this level ofpertise are expected to be able to perform anderpret TTEs in normal infants, children, andolescents, and in those with childhood heartease with consultation as needed. Advanced is ah level of expertise in all aspects of pediatrichocardiography. Physicians with this level ofining are expected to be able to perform indepen-ntly and to interpret echocardiograms in patientsth all forms of congenital and acquired pediatricart disease, and to supervise and train others.Table 1 outlines the required knowledge for the cored advanced levels of expertise, and Table 2 delineates required skills. Table 3 outlines the training methodsommended for the two levels of expertise.Evaluation of knowledge and skills. Unlike adulthocardiography, there is currently no formal testat can be used to examine competency in pediat-echocardiography in North America. The optimalaluation of clinical competence is, therefore,sed on assessment of the trainees skills by theector of the pediatric echocardiography labora-y. Direct observation of the trainee during perfor-nce of echocardiograms provides informationout imaging skills and understanding of the ultra-und instruments. The maintenance of a log ofhocardiograms performed by each trainee is re-ired. Conferences in which echocardiograms areesented provide an opportunity to assess skills inerpretation of images and Doppler recordings.nferences may also be used to promote andaluate skills in research design and methods, andching effectiveness. The laboratory director, innsultation with the teaching staff, should evaluatech trainee in writing on a regular basis.Maintenance of knowledge and Skills. Clinicalmpetence in pediatric echocardiography requiresntinued practice of all forms of cardiac ultrasoundhniques in an active program in which patientsth a wide range of pediatric heart disease are seen.maintain core-level competence, a minimum of0 TTEs per year should be performed or inter-eted. To maintain advanced-level competence, animum of 500 TTEs per year should be performed

interpreted. In addition, continued participationintramural conferences and in continuing medical

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Journal of the American Society of Echocardiography1416 Lai et al December 2006ucation activities related to advances in echocar-graphy is essential.

nographers

e committee reviewed and adopted guidelinesblished by the American Society of Echocardiog-hy (ASE) in Minimum Standards for the Cardiacnographer: A Position Paper regarding the com-tence of sonographers performing echocardio-ms.26 Separate credentialing requirements applysonographers in each area of subspecialization

, pediatric vs adult TTE). A summary of theidelines is as follows.The ASE believes that there are 3 primary ele-

ble 1 Required knowledge base for core and advanced lev

el of expertise R

re Understanding of the basic principles of ult Knowledge of the indications for transthora Knowledge of common congenital heart de Knowledge of Doppler methods and their apressures

Knowledge of the limitations of echocardio Knowledge of alternative diagnostic imagin Knowledge of standard acoustic windows an Knowledge of image display and orientation Ability to recognize normal and abnormal cthe cross-sectional images with anatomic str

Familiarity with standard echocardiographic Familiarity with major developments in the

vanced In addition to the knowledge base required in In-depth knowledge of ultrasound physics Ability to recognize and characterize rare anvariety of clinical settings

In-depth understanding of Doppler method Familiarity with all echocardiographic methtion and knowledge of the strengths and we

Up-to-date knowledge of recent advances incritically published research that pertains to

Knowledge of current training guidelines an

ble 2 Required skills for core and advanced levels of exper

el of expertise

re Ability to safely, properly, and efficiently us Ability to perform a complete transthoracic2-dimensional, and Doppler techniques in ntation as needed

vanced In addition to the skills required in the core le Ability to perform independently a completavailable ultrasound techniques in patients w

Ability to assess cardiovascular physiology asound techniques

Ability to supervise and teach pediatric echoother physiciansnts involved in assuring the competence of ardiac sonographer.

muinCredentialing and formal education. A cardiacnographer must obtain a recognized credentialthin the time frame and using the pathways speci-d by a credentialing organization recognized by theE. A new cardiac sonographer entering the fieldst comply with the formal educational require-nts specified by the applicable credentialing orga-ation, and must fulfill those requirements throughrticipation in a program recognized by the ASE.Technical competence. A cardiac sonographermustmonstrate and document technical competence in therformance of those types of echocardiographic exam-tions that the sonographer performs.Continuing education. A cardiac sonographer

xpertise

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physicsocardiography in pediatric patientsd surgical interventionsion for assessment of blood flow and prediction of intracardiac

and Doppler techniquesiquessducer positionsn pediatric echocardiographyscular structures by 2-dimensional imaging and to correlate

ds of ventricular function assessmentnoninvasive diagnostic imaging

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plex congenital and acquired cardiovascular abnormalities in a

heir application to the assessment of cardiovascular physiologyilable for assessment of global and regional ventricular func-es of these techniquesld of noninvasive cardiac imaging, including ability to reviewdlations relevant to pediatric echocardiography

quired skills

c ultrasound equipmentrdiographic examination with proper use of M-mode,pediatric patients and in those with heart disease, with consul-

horacic echocardiographic examination with proper use of alltypes of congenital heart diseaseal and regional ventricular function using a variety of ultra-

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1417AMINATION PROTOCOL

amination Principles

hough laboratory protocols vary, the basic ele-nts of a standard examination involve 2D imagespplemented by Doppler and color Doppler infor-tion in multiple orthogonal imaging planes. Thedies are organized by acoustic windows fromich the heart is examined. The information mayrecorded in complete sweeps, multiple selectedgle planes, or with a combination of both tech-ues.27-29 A complete examination protocolould outline all views to be obtained, includingeir preferred order, the imaging modalities to beployed for each view, and the preferred methodsrecording and display. A list of the structures toexamined with each view is helpful, and theuired versus optional measurements should bearly defined.Many pediatric echocardiography laboratories be-the examination with subxiphoid, or subcostal,

aging instead of left parasternal views. This allowsthe determination and display of visceral situs

te or location) at the beginning of an examination.gardless of where the examination starts, thegmental approach is used to describe all of thejor cardiovascular structures in sequence.30,31 Annormal finding, either structural or hemodynamic,st be fully examined. Quantification of ventricu-function is often an important part of the exam-tion.For a pediatric echocardiogram, by convention,

ble 3 Training methods recommended for core and advan

vel of

pertise Recommen

re Training should take place in a pediatric echocardiogrcardiology program, inpatient and outpatient facilitiesdiac catheterization laboratory, and a congenital heart

Supervised performance of at least 150 transthoracic e Review at least 150 transthoracic echocardiograms w Participate in didactic conferences in which echocar

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

vanced In addition to the training methods described in the cor Perform at least 200 additional transthoracic echocardcritique of the examinations by the responsible staff pe

Review at least 200 additional transthoracic echocard Trainees should gradually attain a high level of indep

should be determined by the director of the laborato Prepare and present echocardiographic data at clinic Active participation in research that involves echoca

E, Continuing medical education.e recommended numbers of examinations outlined here represent minimae anterior and superior structures are displayed ate top of the video screen, and the rightward

orrecuctures are generally placed on the left side of theage display. Therefore, the preferred method ofplay is with the image apex inverted, with theage apex at the bottom of the video screen,ring subxiphoid and apical imaging to demon-ate structures in their correct anatomic orienta-n. This is important because of the wide range ofatomic variations frequently seen in patients withngenital heart disease. The one exception to thet-right rule of orientation is the parasternal long-is view, in which the apex of the heart is dis-yed on the left side of the video screen in bothocardia and dextrocardia.The diagnostic accuracy of an examination de-nds greatly on the image quality. Technical adjust-nts must be made by the operator to improvenal-to-noise ratio and image resolution. The ap-opriate probe and optimal transducer frequencyselected to image the structures in question, and

justments of the electronic (acoustic) focus depthmade throughout the study as necessary. Center-of structures of interest, using an appropriate

gree of magnification, and optimizing of windowsimaging and Doppler interrogation are critical forage quality. Patient position, comfort, and level ofxiety are important considerations throughout theamination.As a pediatric echocardiogram is progressing, thenographer or echocardiographer must keep innd the indications for the study and the need todress issues that may affect treatment as theyse. A complete examination may require thatstom, or in-between, planes be used to investigate

vels of expertise

thods of training

boratory that serves a hospital with an accredited pediatrictal and pediatric intensive care departments, a pediatric car-y programiograms (at least 50 in infants age 1 y)*ualified staff pediatric echocardiographer*hic data are reviewed and their clinical applications are

on pediatric echocardiographynclude pediatric echocardiography

s (at least 50 in infants age 1 y) with subsequent review andechocardiographer*s with a qualified staff pediatric echocardiographer*e; the degree and rate at which independence is attained

didactic conferencesphy of pediatric heart disease

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somiadaricudisplay an abnormality. Whatever method ofording or display is selected as the laboratory

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Journal of the American Society of Echocardiography1418 Lai et al December 2006ndard, complete sweeps of the heart should bede during the examination to rule out abnormal-s at its base or apex or on one of its surfaces. Indition, the major vascular structures must bealuated as part of a complete examination.Extracardiac structures are visualized during andard TTE examination. Mediastinal abnormali-s such as masses and cysts, if present, should beted. Careful attention to symmetry and amplitudediaphragm motion and screening for pleuralusions from subxiphoid and flank windows isrticularly important in postoperative cardiacses.

ltiple Orthogonal Imaging Planes

e standard views of a 2D echocardiogram, asfined early on by the ASE,32 are all used as part ofpediatric echocardiogram. In addition, there areaging planes that are more commonly associatedth a routine pediatric study: subxiphoid (subcos-), suprasternal notch, and right sternal border.ese imaging planes provide unique informationarding cardiovascular malformations that are of-seen in childhood. A complete examination

uires that the cardiovascular structures be im-ed from multiple orthogonal planes. This practicenimizes artifacts caused by false dropout of struc-es imaged parallel to the beam of interrogation oradowing from reflective structures proximal toe area of interest.The imaging planes are identified by transduceration (subxiphoid, apical, parasternal, supraster-l notch, and right parasternal) and by the plane ofamination relative to the heart (4-chamber,hamber, long-axis, and short-axis). In addition,aging planes may be described as anatomic planesgittal, parasagittal, transverse, or coronal).The views and structures presented below arescribed as seen in a patient with normal orar-normal cardiovascular anatomy. Table 4 listse structures that should be visualized from thendard examination views.Subxiphoid (subcostal) views. Subxiphoid imag-33,34 begins with the determination of abdominalceral situs in the transverse plane. In addition toualization of the liver and stomach, the spleenould be sought in patients with abnormal abdom-l visceral situs. The location of the hepatic seg-nt of the inferior vena cava and descending aortarelation to the midline and one another are thentermined. As the plane of imaging is angled frome abdomen to the thorax, the connections of thepatic veins to the inferior vena cava are visualized,lowed by the connection of the inferior vena cavathe right atrium. The patency of the inferior venava should be documented; if a dilated azygos vein

seen posterior to the descending aorta, interrup-n of inferior vena cava should be suspected. The

maThscending aorta at the level of the diaphragmould be interrogated by Doppler. Any additionalscular structures crossing the diaphragm shouldfully investigated.The subxiphoid long-axis sweep (Figure 1) beginsthe transverse plane and passes the inferior/sterior surface of the heart, which includes theronary sinus. The position of the left coronarytium is well visualized as the ascending aorta isaged. The posterior descending coronary artery

ble 4 Structures viewed from standard examinationws

bxiphoid (subcostal) views Left parasternal viewserior vena cava Inferior vena cavapatic veins Superior vena cavadominal aorta Left atriumphragm Right atriumerior vena cava Atrial septumt atrium Coronary sinusht atrium Pulmonary veinsial septum Mitral valveronary sinus Tricuspid valvelmonary veins Left ventricletral valve Right ventriclecuspid valve Ventricular septumt ventricle Left ventricular papillary musclesht ventricle Aortic valventricular septum Pulmonary valvet ventricular papillaryuscles

Ascending aortaCoronary arteries

rtic valvelmonary valve

Main and branch pulmonaryarteries

ending aorta Pericardiumronary arteriesin and branch pulmonaryrteries

Suprasternal notch viewsSuperior vena cava

icardium Left atriumPulmonary veins

ical viewserior vena cava

Ascending aortaSuperior thoracic aorta

t atrium Main and branch pulmonaryarteriesht atrium

ial septum Aortic archronary sinus Proximal brachiocephalic arteriesected pulmonary veins Left innominate veintral valvecuspid valve Right parasternal viewst ventricle Inferior vena cavaht ventricle Superior vena cavantricular septum Right atriumt ventricular papillaryuscles

Atrial septumRight pulmonary veins

rtic valve Ascending aortalmonary valve Right pulmonary arteryending aortain and branch pulmonaryrteriesy be seen in the posterior interventricular groove.e long-axis view allows for good visualization of

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1419e atrial septum and color Doppler mapping of theterior muscular septum.The subxiphoid short-axis sweep (Figure 2) startsa parasagittal plane that includes the inferior andperior venae cavae. Imaging normally begins toe right, allowing visualization of the right upperlmonary vein as it passes lateral and posterior toe superior vena cava and then proceeds from these to the apex of the heart. The transducersition may need to be repositioned (generallyre rightward) during the sweep to maintain aort-axis imaging plane as the apex of the heart isualized.Apical views. Standard apical35 4-chamber andg-axis (3-chamber)and, in some laboratories,ical 2-chamberviews are obtained. The apicalhamber view (Figure 3) includes a sweep thatgins posteriorly to demonstrate the coronary si-s and the entrance of the inferior vena cava intoe right atrium. The sweep ends at the anterior

Figure 1 Subxiphoid long-axis views demonstratetransverse plane. 1, Right ventricular (RV) inflow ainferior angulation, long axis of left ventricle (LV), avena cava (SVC) is seen to right of ascending Ao,Connection of SVC to right atrium (RA) is demabdomen, atrial septum and pulmonary venous connwith permission from: Geva T. EchocardiographyFisher DJ, Neish SR, editors. The science and pracWilkins; 1997, p. 789-843).rface of the heart after passing through thehamber view demonstrating the left ventricular du) outflow tract (OT) and ascending aorta. Theical muscular septum may also be magnified in thehamber view for color Doppler interrogation.Repositioning of the transducer medially towarde lower left sternal border brings the right ventric-r (RV) inflow and RV free wall more into align-nt with the beam of interrogation. Superior andterior angulation from this position brings the RVinto alignment and often offers an optimal angleDoppler interrogation of the RV OT.

Imaging of the LV OT (LVOT) from the apexows for visualization of subaortic structures ori-ted perpendicular to the plane of insonation. Theical long-axis (3-chamber) view (Figure 4) allowsoptimal Doppler interrogation of the LVOT andending aorta. Modified views foreshortening themay allow clearer visualization of the LVOT.ical 2-chamber views are used primarily for as-ssment of global ventricular function or regionalll motion.

weep from nearly coronal plane back towardtflow are seen with pulmonary valve. 2, WithAo) valve, and ascending Ao are seen. Superiorain pulmonary artery (MPA) is seen to left.ted. 3, As transducer is angled back towards to left atrium (LA) are viewed. (Reproducedoppler ultrasound. In: Garson A, Bricker JT,pediatric cardiology. Baltimore: Williams and(LVap4-c

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d in snd ouortic (and monstraectionand Dtice ofParasternal (left parasternal) views. The trans-cer in the parasternal36,37 long-axis view (Figure

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Journal of the American Society of Echocardiography1420 Lai et al December 2006 is positioned over the LVOT, allowing visualiza-n of the aortic and mitral valves. The long-axiseep includes the RV inflow and outflow. Theg-axis or modified parasagittal view of the aortast demonstrates the position of the right coronaryery ostium relative to the sinotubular junction.e parasternal short-axis view (Figure 6) at the basethe heart can provide detailed imaging of aorticlve morphology and views of the RV infundibu-, pulmonary valve, and main/proximal branchlmonary arteries. The short-axis view also allowsvisualization of the coronary ostia, and imaging

d color flow mapping of the proximal coronaryeries. Clockwise rotation of the transducer into ansverse view elongates the left coronary arteryd often demonstrates its bifurcation. The mor-ology of the mitral leaflets and valve apparatus isen best seen on a parasternal short-axis view. Inger hearts, color flow mapping of the ventricular

Figure 2 Subxiphoid short-axis views. 1, At rightwinferior vena cava enter right atrium (RA). Right puSVC and above left atrium (LA). 2, With leftward an(RV) and atrioventricular valves are seen. Aortic (Aoleftward angulation reveals cross-sectional view of Lpulmonary valve (PV). 4, Sweep then passes throutoward apical portions of both ventricles. (Reproducand Doppler ultrasound. In: Garson A, Bricker JT, Fof pediatric cardiology. Baltimore: Williams and Wiptum may require separate short-axis sweeps ofe anterior and posterior portions of the septum.

octhamination of the apical muscular septum mayuire repositioning of the transducer toward theex during the short-axis sweep.A ductal view is obtained from imaging in arasagittal plane from a high left parasternal win-w. This window lines up the ultrasound beamth the main pulmonary artery-ductus continuumd allows for exclusion of a normally located smalltent ductus arteriosus. The distal aortic arch andperior thoracic aorta may also be visualizedrough the heart and the main pulmonary artery,d, in larger individuals, the aortic isthmus ismetimes best seen from this position. Clockwisetation of the transducer to a high left parasternalnsverse plane may better demonstrate the leftlmonary veins in some larger individuals.Suprasternal notch views. Imaging from the su-asternal notch38-40 includes positioning of thensducer in the right supraclavicular region and

spect of heart, superior vena cava (SVC) andry artery (RPA) is seen in cross section behindn, base of left ventricle (LV) and right ventricleis seen in cross section at this level. 3, Furthermitral valve (MV), and RV outflow tract andidmuscular septum and LV papillary musclesh permission from: Geva T. EchocardiographyJ, Neish SR, editors. The science and practice997, p. 789-843).Exreqap

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1421Figure 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 andDoppler 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).

cosuexexsuvethtoofriostrsidopbrterdech

Journal of the American Society of Echocardiography1422 Lai et al December 2006nnection of the left innominate vein to theperior vena cava is visualized. The leftwardtent of the left innominate vein should beamined by color flow mapping to exclude a leftperior vena cava or an anomalous pulmonarynous connection. In smaller individuals, bothe right and left pulmonary venous connectionsthe left atrium are well visualized in the far fieldthe suprasternal notch view (crab view). Supe-r (cranial) angulation of the transducer demon-ates the branching pattern of the aorta. Theedness of the aortic arch may be determined asposite of the direction, or sidedness, of the firstachiocephalic artery. A normal branching pat-n of the aortic arch should be documented by

Figure 5 Left parasternal long-axis views demonsweep. 1, Rightward and inferior angulation towardand right ventricular (RV) inflow. Coronary sinuslong-axis view shows left atrium (LA), left ventricle (Ao. 3, Leftward and superior angulation toward leftand main pulmonary artery (PA). (Reproduced wiDoppler ultrasound. In: Garson A, Bricker JT, Fishpediatric cardiology. Baltimore: Williams and Wilkinmonstration of a normally bifurcating first bra-iocephalic artery.

plavisDemonstration of the left aortic arch in its longis (Figure 8) is achieved by counterclockwisetation of the transducer from the coronal planethe suprasternal notch window. Further coun-clockwise rotation and leftward angulation of-best demonstrates the left pulmonary artery.

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

perior (Figure 9) and inferior right parasternal win-ws may be sought, and positioning of the patient inight lateral decubitus position is often helpful. Froms view, the atrial septum is oriented perpendicularthe plane of insonation, and less dropout artifact isesent. Rotation into a short-axis (transverse) imaging

in rightward/inferior to leftward/superiorhip shows right atrium (RA), tricuspid valve,followed into RA in this view. 2, Parasternalitral and aortic (Ao) valves, RV, and ascendingder depicts RV outflow tract, pulmonary valve,mission from: Geva T. Echocardiography andNeish SR, editors. The science and practice of7, p. 789-843).axrointerten

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1423per pulmonary vein and perpendicular interroga-n of the right pulmonary artery and its upper lobench. Doppler interrogation of the LVOT should alsoperformed from the right upper parasternal win-w if indicated.

ASUREMENTS

e measurement of cardiac structures and flows istical to the interpretation of a pediatric echocar-gram. An abnormally small or large structure cana clue to otherwise silent pathology, and is

portant to the planning of surgical procedures.ld forms of obstruction can be diagnosed only bycurate measurement of flow velocities. In general,is recommended that all relevant measurementsmade as part of a complete pediatric echocardio-m. Recent guidelines have been published for thehocardiographic assessment of valvar regurgita-n42 and the quantification of chamber size, ven-cular mass, and function in adult patients.43 The

Figure 6 Parasternal short-axis views. 1, Sweep is iniatrium (LA), atrial septum, aortic valve, tricuspidpulmonary valve (PV) seen. 2, Cross-sectional view3, Further angulation toward LV apex depicts LV pappermission from:Geva T. Echocardiography andDoNeish SR, editors. The science and practice of ped1997, p. 789-843).asurements that are relevant in pediatric patients,wever, will vary depending on the specifics of

theaneir cardiovascular anatomy. The examination pro-ol of a laboratory should specify which measure-nts to perform and the laboratory procedure fortaining each measurement. The following sectiona brief discussion of the recommended measure-nts for a pediatric echocardiogram. The reader iserred to other resources for a more detailedcussion of the theoretic principles for these mea-rements and for the technical aspects of theirrformance.43-50 The recommended measurementsgrouped into measurements of cardiovascular

uctures, ventricular size and function measure-nts, hemodynamic measurements, and miscella-ous measurements.

asurements of Cardiovascular Structures

normalize the measurements of cardiovasculaructures, an assessment of body size is necessary.rmative data for many cardiovascular structuresist,44-50 and are generally adjusted to a calculation ofdy surface area using the height and weight of thetient. Valve and vascular diameters relate linearly to

at base of heart, with right atrium (RA) and left(TV), right ventricular (RV) outflow, and

ral valve (MV) and RV are then demonstrated.muscles (PMs) and RV apex. (Reproduced withltrasound. In: Garson A, Bricker JT, Fisher DJ,cardiology. Baltimore: Williams and Wilkins;thtocmeobismerefdissupearestrmene

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of mitillaryppler uiatricsquare root of body surface area, whereas valved vascular areas relate to body surface area.18 The

relcohe

Journal of the American Society of Echocardiography1424 Lai et al December 2006ationship between LV volume and body size fits a

Figure 7 Suprasternal short-axis view. In transversesuperior vena cava (SVC). Distal ascending aorta (Aartery (RPA), which is seen along its length above leLA. (Reproduced with permission from: Geva T. EcA, Bricker JT, Fisher DJ, Neish SR, editors. The sciWilliams and Wilkins; 1997, p. 789-843).

Figure 8 Suprasternal aortic (Ao) arch (long-axis) vInnom artery. Right pulmonary artery (RPA) is seenwith permission from: Geva T. EchocardiographyFisher DJ, Neish SR, editors. The science and pracWilkins; 1997, p. 789-843).mplexmodel predicted by the nonlinear decrease ofart rate with growth.18 The 2D measurements have

forturpplanted those obtained by M-mode as the standard

left innominate vein (Innom V) connects withen in cross section superior to right pulmonarym (LA). Note pulmonary veins (PVs) enteringiography and Doppler ultrasound. In: Garsonnd practice of pediatric cardiology. Baltimore:

eft innominate (Innom) vein is seen anterior toss section behind ascending Ao. (Reproducedoppler ultrasound. In: Garson A, Bricker JT,pediatric cardiology. Baltimore: Williams andsu

iew. Lin cro

and Dtice ofplane,o) is seft atriuhocardence amost cardiac structures. At a minimum, all struc-es should be imaged adequately so that measure-

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1425nts could be performed from the recorded image ifuired. As a rule, outflow measurements should betained during ventricular systole and inflow mea-res during ventricular diastole. Table 5 provides a liststandard measurements of cardiovascular structuresng with the appropriate time of measurement andggested view.

ntricular Size and Function Measurements

sessment of cardiac size and function is an integral

Figure 9 High right parasternal view. Superior venaand atrial septum are demonstrated. Right pulmo(RUPV) cross behind SVC. (Reproduced with permultrasound. In: Garson A, Bricker JT, Fisher DJ, Necardiology. Baltimore: Williams and Wilkins; 1997,

ble 5 Recommended measurements of cardiovasculaructures

Measurement Timing View(s)

cuspid valve annulus Diastole Apical 4-chamberlmonary valve annulus Systole PSAX/PLAXin pulmonary artery Systole PSAX/PLAXt/right pulmonaryrtery

Systole PSAX/PLAX

t atrial diameter Diastole PLAXtral valve diameter Diastole PLAX/apical 4-chamberrtic valve annulus Systole PLAXrtic root Systole PLAXending aorta Systole PLAXnsverse aortic arch Systole SSNrtic isthmus Systole SSN

X, Parasternal long-axis; PSAX, parasternal short-axis; SSN, supraster-notch.rt of the evaluation of the cardiac status. There-e, an objective assessment of cardiac function is

assfunommended. M-mode, 2D imaging, and Dopplerthods can be used to assess ventricular function.wer modalities such as 3-dimensional echocardi-raphy, Doppler tissue imaging, and strain andain rate calculations are promising new tech-ues that are currently under investigation. Eachhnique for ventricular function assessment hasengths and weaknesses that must be consideredd balanced to meet the needs of the individualtient.LV size and systolic function. Measurement of LVensions in diastole and systole by M-mode and/orimaging is recommended for a complete study.e parasternal short axis at the midpapillary level ise preferred site for measurement of LV chambere and wall thickness, but the subcostal short axisn be used as well. The ventricular septum, LVension, and LV posterior wall are used to deter-

ne LV size and exclude hypertrophy. LV mass, thetimated weight of the ventricular muscle that can assessed by several techniques,43 may be helpfulpatients with long-standing hypertension or otherms of LV hypertrophy. The standard M-modethod of LV systolic function assessment is theortening fraction, which is affected by loadingnditions, altered LV geometry, and regional wall-tion abnormalities. However, relatively load-inde-ndent indices of myocardial performance basedM-mode measurements are useful for the serial

SVC), right atrium (RA) and left atrium (LA),rtery (RPA) and right upper pulmonary veinfrom: Geva T. Echocardiography and Doppler, editors. The science and practice of pediatric-843).ogstrniqtecstranpa

dim2DThthsizcadimmiesbeinformeshcomopeonessment of patients at high risk for diminishedction, such as those undergoing chemotherapy.

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Journal of the American Society of Echocardiography1426 Lai et al December 2006e velocity of circumferential fiber shortening nor-lized for heart rate is a measure of contractilityat is independent of preload and inversely relatedafterload in a linear fashion.51 Two of the moremmonly used 2D methods of LV systolic functionessment are the biplane Simpson and the area-gth measurements of the ejection fraction. Thelane Simpson method, or the method of disks,lculates a volume based on diastolic and systolica measurements of the LV from the apical 4- andhamber views. The apical long-axis (3-chamber)w may be substituted for the apical 2-chamberw.52,53 The area-length method is calculated us-the ventricular length from the apical 4-chamberw and the midpapillary parasternal short-axis areayield a ventricular volume based on an assumedape. Both have been validated in children ofrious sizes.54 Calculation of LV wall stress-velocityex has been shown to be a more accurateessment of the cardiac muscle function and re-rve than the ejection fraction, because it incorpo-es and accounts for the afterload of the ventricleits evaluation. It may be appropriate for sometients with significant systolic dysfunction orer complicated clinical situations.55-57

RV size and systolic function. Because of its com-x geometry, the RV is difficult to accuratelyess in short axis, and is often not of benefit in thealuation of patients. Recommendations for theantification of the RV and RV OT have beenoposed43 but not completely validated in chil-en. Because of the RVs nongeometric shape, nomethod of shortening or ejection fraction has

en consistently applied. The above-mentionedwer modalities (3-dimensional echocardiography,ppler tissue imaging, and strain and strain ratelculations) are free of geometric assumptions andrit further investigation as techniques for assess-the RV.

Diastolic function. The measurement of ventricu-diastolic function is playing an increasingly im-rtant role in the evaluation of cardiac dynamics aslearn more about the mechanics of diastole andimpact on overall cardiac status. Ventricularstolic dysfunction often precedes systolic dys-ction in disease states. Traditional measures haveluded Doppler indices of LV filling and pulmo-ry venous flow (Table 6).58 The value of additionalasurementsincluding Doppler tissue imaging ofe septal and lateral ventricular walls, inflow prop-ation, isovolumic relaxation time, and Tei index

assessing diastolic function are beingamined.59,60

modynamic Measurements

asurements of flow through all of the cardiac

lves should be part of a complete pediatric echo-rdiogram. At a minimum, spectral Doppler flow

ofthages should be recorded so that measurements ofe gradients across all intracardiac valves and greateries can be performed. Table 6 lists Dopplerasurements that should be considered for inclu-n in a complete examination protocol. If evi-nce of flow obstruction is present, more completeasurement of cardiovascular dimensions (subval-r, valvar, supravalvar, vascular, or a combinationthese) and flow gradients should be performed.properly evaluate the intracardiac and intravas-lar pressures, a representative blood pressureasurement must be obtained. In some patients,eated measurement may be appropriate if therechanging physiology or if an exact comparison isuired at the time of a particular measurement. Intients with congenital heart disease, it is particu-ly important to estimate RV and pulmonary arteryessures and to note their estimated values relativesystemic pressures.

scellaneous and Pathology-relatedasurements

ere are measurements that may be appropriater certain patients with specific types of pathol-y. For example, in patients with Marfan syn-ome, the aorta should be measured at multipleels. Patients with a ventricular septal defectquire assessment of defect size and flow velocitypart of their evaluation. Likewise, assessment ofscending aortic flow is important in patientsth aortic insufficiency or aortopulmonary com-nications. However, the breadth and variability

ble 6 Doppler measurements

Structure Measurements*

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

outflow Peak gradient, mean gradient, VTIlmonary valve Peak gradient, mean gradient,

regurgitant jet velocity, VTInch pulmonary artery Peak gradient, mean gradient, VTItral valve E wave velocity, A wave velocity,

deceleration time, IVRT, meangradient

outflow Peak gradient, mean gradient, VTIrtic valve Peak gradient, mean gradient, VTI,

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

T, Isovolumic relaxation time; LV, left ventricular; RV, right ventricu-VTI, velocity time integral.cording of images adequate for the measurements listed should besidered for inclusion in a complete examination protocol. This is notnded to be a comprehensive list of recommended Doppler measure-nts.these measurements is beyond the scope ofese guidelines.

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Journal of the American Society of EchocardiographyVolume 19 Number 12 Lai et al 1427PORTING

ormation obtained from pediatric echocardio-ms is frequently used by nonechocardiographicrsonnel, including surgeons, pediatricians, anes-esiologists, and other patient caretakers. Convey-ce of the echocardiographic findings in a cleard cogent manner is important. Abbreviationsould be avoided but when used should be unam-uous.Minimal elements of the pediatric echocardiogra-y report are listed in Table 7. Basic identifierormation should be listed. A statement relating toe indication for study is required. The reportdings section can be configured in a variety ofys but should include information on: (1) struc-al findings; (2) measurements of cardiovasculaructures made; and (3) Doppler echocardio-phic data. Positive findings and pertinent nega-e findings should be listed.Information pertaining to cardiovascular anatomyd structure can be conveyed using the segmentalproach. In addition to reporting the absolutelues, it is useful to report quantitative measuresthin the context of age- or size-appropriate norms, z-score values).61,62 Doppler information con-rning the atrioventricular valves, semilunar valves,d any shunt sites should be provided. Quantitativeppler information such as velocity data, patternsspectral flow, and color jet dimensions, and

miquantitative estimates of insufficiency or steno-, where appropriate, should be included in theort. Any technical or other limitations that mightmpromise the diagnostic accuracy of the echocar-graphic examination should be specified in theort. Examples include suboptimal acoustic win-

ble 7 Minimal elements for a pediatricocardiography report

ient identifier dataameate of birthedical record identifier

te of studycation of studyferring physicianation usedications for pediatric echocardiographic studyographer/physician who performed the studydings sectiontructural/anatomic featuresuantitative dataoppler (hemodynamic) findingsmary sectionws, heart rate constraints, and excessive patienttion during the examination.A standardized pediatric echocardiography reportould be generated for every echocardiographicdy performed. The final report may be generatedctronically with the option of a printable paperpy. The report should be easily accessible topropriate personnel and readily available for re-w at all times. Reports should be searchable andailable for serial comparison.

WER MODALITIES

e recent advent of echocardiographic modalitiesch as Doppler imaging of tissue velocities, includ-strain and strain rate imaging, color M-mode

essment of atrioventricular valve inflows, and liveimensional echocardiography portends greatomise for the near future.63-90 The quantitativeproaches available from the application of thesedalities promise to provide a new paradigm fore echocardiographic assessment of myocardiald valvar function. Other innovative technologies,ch as handheld echocardiography scanners, maypand the applicability of pediatric echocardiogra-y.91-93 This document does not seek to establishndards for these newer modalities.

nclusion

e pediatric echocardiogram is a unique ultra-und examination, which differs in important waysm the conventional echocardiogram in the adult.standardized approach and specialized skills andowledge are required to perform and interpretis test appropriately. This statement outlines indi-tions, details the unique features and essentialmponents of the pediatric echocardiogram, andtablishes standards for the performance, interpre-ion, and reporting of this important test.

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Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of EchocardiographyINDICATIONSCongenital Heart Disease: History, Symptoms, and SignsAcquired Heart Diseases and Noncardiac DiseasesArrhythmias

INSTRUMENTATION, PATIENT PREPARATION, AND PATIENT SAFETYInstrumentationData Acquisition and StoragePatient Preparation and Safety

SKILLS AND KNOWLEDGEPhysiciansLevels of expertiseEvaluation of knowledge and skillsMaintenance of knowledge and Skills

SonographersCredentialing and formal educationTechnical competenceContinuing education

EXAMINATION PROTOCOLExamination PrinciplesMultiple Orthogonal Imaging PlanesSubxiphoid (subcostal) viewsApical viewsParasternal (left parasternal) viewsSuprasternal notch viewsRight parasternal views

MEASUREMENTSMeasurements of Cardiovascular StructuresVentricular Size and Function MeasurementsLV size and systolic functionRV size and systolic functionDiastolic function

Hemodynamic MeasurementsMiscellaneous and Pathology-related Measurements

REPORTINGNEWER MODALITIESConclusion

REFERENCES