A complete echocardiography exam is a protocol-driven transthoracic study, not a set of isolated still frames. Sonographers and interpreting clinicians need a consistent sequence of windows, required views, core measurements, and Doppler recordings, plus enough artifact awareness to know when a finding is real. This article walks through an adult transthoracic echocardiography (TTE) examination in typical scanner order, following widely used ASE-style practice. Where cutoffs differ by sex, body size, or guideline edition, commonly cited ranges are given rather than a single number.
Patient Setup and Acoustic Windows
Confirm the indication, prior studies, and whether the patient can lie in the left lateral decubitus position with the left arm raised. Apply ECG leads so you can time end-diastole and end-systole, and record blood pressure when gradients or filling pressures will be interpreted. Use a darkened room and the highest transducer frequency that still reaches the far field.
The four standard windows are left parasternal (usually the third or fourth intercostal space), apical (the true apex), subcostal, and suprasternal notch. Held expiration often helps parasternal imaging; inspiration can open the subcostal window. If endocardial borders remain incomplete, an ultrasound enhancing agent can restore quantification and wall-motion assessment, as outlined in contrast-enhanced echocardiography.
Echocardiography Exam Protocol by Standard View
Record 2D from each window, color Doppler on the valves and septa, and spectral Doppler aligned as parallel to flow as possible. M-mode helps with timing but does not replace on-axis 2D. Fundamentals of these modes are covered in Introduction to Echocardiography.
Parasternal long- and short-axis views
On a true PLAX image, the left ventricle, mitral and aortic valves, aortic root, and left atrium should be coaxial, with the septum nearly horizontal. A high or low interspace elongates the septum and can mimic hypertrophy. Include 2D PLAX, zoomed aortic and mitral valves, right ventricular inflow (tilt toward the right hip), and right ventricular outflow with the pulmonary valve (tilt toward the left shoulder). Add color Doppler on the valves and interventricular septum.
Measure linear left ventricular dimensions at the mitral leaflet tips, perpendicular to the cavity, at end-diastole and end-systole, using the 2D blood-tissue interface as in current ASE chamber quantification guidance. Measure LVOT diameter in mid-systole, inner edge to inner edge, at aortic cusp insertion, from a zoomed loop. State the aortic root convention, because leading-edge and inner-edge methods still coexist. Sweep short-axis from the great vessels to the apex; mid-papillary level is the workhorse for cavity size and regional wall motion.
Apical views
Place the transducer on the true apex so the left ventricle is long, not spherical and truncated. Foreshortening underestimates volumes and can overestimate ejection fraction. Obtain four-, five-, two-, and three-chamber views. The four-chamber view should show both ventricles and atria without an overly posterior coronary sinus or an anterior swing into the LVOT.
Color the mitral, tricuspid, and aortic valves. Record pulsed-wave mitral inflow at the leaflet tips, pulsed-wave LVOT velocity about 5 mm on the ventricular side of the aortic valve, and continuous-wave Doppler of aortic and regurgitant jets. Keep the beam parallel to flow; angle correction does not replace a better window.
Subcostal and suprasternal views
Subcostal four-chamber imaging is often the best look at the interatrial septum and a useful view for pericardial effusion and the right ventricular free wall. Rotate to the long-axis IVC for diameter and inspiratory collapse as a rough right atrial pressure estimate, and survey the abdominal aorta. Suprasternal notch views show the aortic arch and proximal descending aorta; color Doppler may detect coarctation flow acceleration.
Core Measurements and Doppler Assessment
Unless a limited protocol is ordered, document:
- Left ventricular size, wall thickness, regional wall motion, and quantitative systolic function such as biplane disks. Methods and pitfalls are reviewed in echocardiography for ejection fraction.
- Left atrial volume from dedicated apical views, indexed to body surface area. A commonly cited 2D biplane upper reference is about 34 mL/m2; sex-specific and 3D values differ.
- Right ventricular size and a simple systolic parameter (TAPSE, annular s', or fractional area change).
- Aortic root and ascending aorta when visualized, with the method stated.
- Valve morphology and Doppler grading of stenosis and regurgitation. Velocity, dimensionless index, and area all matter in aortic stenosis; see aortic stenosis echocardiography techniques.
- Diastolic function from an integrated set of findings (mitral E and A, annular e', E/e', tricuspid regurgitant velocity, and left atrial volume), not a single ratio.
- Pulmonary pressure from peak tricuspid regurgitant velocity plus estimated right atrial pressure, labeled limited when the jet is incomplete.
Common Pitfalls That Reduce Diagnostic Quality
- Off-axis PLAX. An oblique cut thickens walls and mismeasures cavity size.
- Foreshortened apex. Volumes fall and ejection fraction rises. Reposition until the apex is the farthest point from the mitral annulus.
- LVOT diameter error. Measuring too far into the ventricle inflates stroke volume and valve area.
- Doppler angulation. Underestimated velocities undergrade stenosis and regurgitation. Use multiple windows, including right parasternal for aortic stenosis.
- Color scale and gain. Overgain inflates jets; a low Nyquist limit creates aliasing mistaken for turbulence.
- Beam-width artifact and incomplete envelopes. Apparent valve masses need a second window. Tracing a faint tricuspid regurgitant signal overestimates pulmonary pressure.
Label technically limited studies as limited. When transthoracic windows cannot answer the question, additional imaging may be required based on clinical judgment and current guidelines.
IAME offers accredited ultrasound CME courses on echocardiography technique, valvular disease, and related cardiac ultrasound topics.
Frequently Asked Questions
What is an echocardiography exam?
In clinical use, an echocardiography exam is diagnostic ultrasound of the heart, most often a transthoracic study with 2D and Doppler that evaluates structure, function, valves, the pericardium, and estimated pulmonary pressures. It is not the same as a written board or registry test, which measures knowledge rather than imaging a specific patient.
What is the procedure for an echocardiogram?
The patient is positioned, ECG leads are applied, and the sonographer records standard windows and views with a transducer and gel on the chest. A complete adult TTE commonly takes 30 to 60 minutes and is not painful, though apical and subcostal pressure can be briefly uncomfortable.
What is the difference between an echocardiogram and an electrocardiogram?
An echocardiogram uses ultrasound to display anatomy and blood flow, whereas an electrocardiogram records electrical activity from skin electrodes and does not image chambers or valves. The tests are complementary: the ECG helps time the echo, but a normal ECG does not exclude structural disease, and a normal echo does not exclude arrhythmia.
If an echo is normal, does that mean the heart is healthy?
A high-quality rest TTE that is truly normal is reassuring for many structural and valvular diagnoses, but it does not prove the heart is free of disease. Resting wall motion can be normal in significant coronary disease, early cardiomyopathy can be subtle, and a technically limited study should not be reported as normal.
