Acta Cardiol Sin 2025;41:50-54

Editorial Comment doi: 10.6515/ACS.202501_41(1).20241128A

How To Perform Comprehensive Transthoracic

Echocardiography?
Kuang-Tso Lee1,2 and Chun-Li Wang1,2

Abbreviations interpretations. The quality of images is influenced by the

AS Aortic stenosis patient’s condition, the examiner’s skill, and the quality
LV Left ventricular of the equipment used. With proper patient positioning
MR Mitral regurgitation and cooperation, it is crucial to individually adjust ma-
PISA Proximal isovelocity surface chine settings such as sector width, gain, compression,
TEE Transesophageal echocardiography frame rate, and frequency to achieve optimal clarity and
2D Two-dimensional
contrast. When searching for the best imaging windows,
3D Three-dimensional
operators should avoid applying excessive pressure on
patients; instead, making positional adjustments and
Echocardiography serves as an essential tool for as- utilizing respiratory maneuvers can help obtain higher
sessing cardiac structure and function. In the past five quality images. Ideally, all images should be recorded as
decades, the progress in this field has been remarkable. dynamic clips and stored in a suitable database for fu-
Beginning with A-mode, the technology progressed to ture clinical and research purposes.3
B-mode and two-dimensional (2D) imaging, and then ad- Measurement techniques have also evolved over the
vanced further to speckle tracking and three-dimensional past decades. Since 2015, the Journal of the American
(3D) imaging.1-5 It has matured significantly and is now Society of Echocardiography has consistently released
evolving into the era of artificial intelligence.6-11 Modern guidelines regarding measurement standards and refer-
techniques have expanded the scope of echocardiogra- ence data for chamber size, valvular heart disease, spec-
phy, enabling its use in cardiac monitoring for cancer kle tracking, and various specific conditions.4,20-23 How-
therapies and supporting transcatheter structural heart ever, despite these reference data have been adjusted
interventions.12-19 Additionally, these clinical applications for body surface area, it remains unclear whether these
contribute to ongoing innovations in cardiac imaging. As data can directly apply to our population. This issue re-
echocardiography has evolved into a specialized field, the quires further researches by local scholars to yield defin-
importance of nurturing skilled professionals has become itive conclusions.
increasingly critical. In this issue of Acta Cardiologica Sinica, Meiling
The process of conducting an echocardiogram em- Chen, Hsin-Yueh Liang, and colleagues present the 2024
phasizes several essential aspects: 1. obtaining high- Recommendations for the Diagnostic Requirements in
quality images; 2. ensuring standardized and accurate Routine Practices of Transthoracic Echocardiography,
measurements; and 3. making correct and reasonable highlighting the need for standardized guidelines to im-
prove accuracy and consistency in echocardiographic
practices across Taiwan. These recommendations, ba-
sed on observational studies and expert consensus,
Received: November 15, 2024 Accepted: November 28, 2024 aim to address report variability and facilitate the es-
1
Division of Cardiology, Linkou Medical Center, Chang Gung Memorial
Hospital; 2College of Medicine, Chang Gung University, Taoyuan, tablishment of a national echocardiography database,
Taiwan. making a significant contribution to the field and align-
Corresponding author: Dr. Chun-Li Wang, Division of Cardiology, Linkou ing more closely with daily practice compared to the
Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Tel: 886-3-328-1200 ext. 8162; Fax: 886-3-327-1192; E-mail: wang3015 2019 Journal of the American Society of Echocardiogra-
@cgmh.org.tw phy guidelines.3

Acta Cardiol Sin 2025;41:50-54 50

 Comprehensive Transthoracic Echo

Here, we have provided comments on various topics for calculating aortic valve area remains the standard
addressed in these recommendations. approach. However, it is crucial to carefully adjust du-
plex quality is necessary to prevent bias in measuring
1. Left ventricular (LV) volume and systolic function signals from the aortic valve and LV outflow tract.22,29 In
Traditionally, the M-mode in the parasternal long cases of low-flow-low-gradient and normal-flow-low-
axis view has been used to measure LV size and func- gradient AS, data correction is necessary. Advanced te-
tion. This method allows for continuous detection of chniques such as stress echocardiography or calcium
blood-tissue interface but can be affected by axis and scoring may also be used to confirm the final diagnosis.30
longitudinal ventricular motion distortions. Therefore, In terms of regurgitant valvular diseases, it is known
2-dimensional images should be employed for correc- that primary and secondary mitral regurgitation (MR)
tion or direct measurement, ensuring that the reference have distinct etiologies and clinical presentations. Sec-
line aligns with the tips of the mitral leaflets, and that ondary MR typically arise from changes in the left ven-
the LV dimension includes non-compacted myocardium.20 tricle or mitral annulus, resulting in regurgitant orifices
2D volumetry provides high resolution and accurately that are rarely circular. The proximal isovelocity surface
identifies the tissue-blood interface. However, relying (PISA) tends to be more ellipsoidal than spherical, and
solely on apical four-chamber and apical two-chamber relying on PISA-derived effective regurgitant orifice can
views only captures two longitudinal axes of the left significantly underestimate the true severity. Although 3D
ventricle, which may not adequately represent the over- transesophageal echocardiography (TEE) can use vena
all ventricular shape, particularly in cases of ventricular contracta area to estimate the regurgitant orifice, as-
remodeling. In cases of asymmetric contraction, this li- sessing regurgitant volume and fraction (RF) is necessary.21
mitation can lead to over- or under-estimation of ven- When calculating regurgitant volume, the trabecula-in-
tricular size and function. Although 3D echocardiogra- clusion method should be used to measure changes in LV
phy offers a more comprehensive assessment, it has volume. Additionally, contrast or model-based 3D echo-
lower spatial and temporal resolution, and requires im- cardiography may provide a more accurate approach. It
age quality and advanced equipment. Regardless of the is important to recognize that PISA-derived regurgitant
methods used, measuring LV volume must include tra- volume in primary MR can be substantially overesti-
beculae and non-compacted myocardium, and care should mated, warranting special attention.14,31-38 In cases of
be taken to avoid apical foreshortening.1,2,24-27 Currently, tricuspid regurgitation, where the majority are second-
model-based 3D echocardiographic measurements of LV ary, it is important to utilize multiple parameters, such
volume closely approximate those obtained through car- as PISA-derived effective orifice area, vena contracta, or
diac magnetic resonance imaging.24,27 Accurate and re- 3D TTE vena contracta area, for a comprehensive assess-
producible measurements are crucial for determining the ment.16,19,39-46 It is advised to adopt the updated classifi-
severity of valvular disease and monitoring patients with cation of etiology and severity when planning interven-
structural heart diseases. tions for structural heart disease.

2. Valvular heart disease 3. Speckle tracking strain imaging

In 2D echocardiography, it is advisable to avoid ex- The advancement of speckle tracking strain imaging
cessive reliance on qualitative methods to determine has been significant. Historically, its application in rou-
the severity of valvular disease, such as using pressure tine TTE faced challenges due to limitations of machine
half-time in cases of mitral stenosis and aortic regurgita- capabilities, resulting in issues with reproducibility and
tion.21,22 The guideline highlights the use of 3D echocar- variability stemming from different vectors. However,
diography for mitral planimetry, which is currently re- with recent technological improvements, strain imaging
garded as the most accurate method for determining in can now effectively and reliably assess LV, left atrial, and
rheumatic mitral stenosis, avoiding the effects of pres- right ventricular longitudinal strains in a semi-automatic
sure half time by LV diastolic function and heart rate.28 fashion using TTE. Currently, one of the most common
For aortic stenosis (AS), the continuity equation method applications is the assessment of LV hypertrophy, espe-

51 Acta Cardiol Sin 2025;41:50-54

 Kuang-Tso Lee et al.

cially by identifying the apical sparing pattern in longitu- 7. Davis A, Billick K, Horton K, et al. Artificial intelligence and echo-
dinal strain analysis, which aids in the diagnosis of amy- cardiography: a primer for cardiac sonographers. J Am Soc Echo-
cardiogr 2020;33:1061-6.
loidosis.4,12,13,47,48 Furthermore, right ventricular strain
8. Slivnick JA, Gessert NT, Cotella JI, et al. Echocardiographic detec-
has shown superior prognostic value in a range of condi-
tion of regional wall motion abnormalities using artificial intelli-
tions when compared to conventional metrics such as gence compared to human readers. J Am Soc Echocardiogr 2024;
tricuspid annular plane systolic excursion or fractional 37:655-63.
area change.43,49,50 LV global longitudinal strain and myo- 9. Krishna H, Desai K, Slostad B, et al. Fully automated artificial in-
cardial work can also be used to predict and monitor re- telligence assessment of aortic stenosis by echocardiography. J
sponses to cardiac resynchronization therapy.5,51 Over- Am Soc Echocardiogr 2023;36:769-77.
10. Tseng AS, Lopez-Jimenez F, Pellikka PA. Future guidelines for arti-
all, the potential for strain imaging in routine TTE is pro-
ficial intelligence in echocardiography. J Am Soc Echocardiogr
mising.
2022;35:878-82.
11. Peck D, Rwebembera J, Nakagaayi D, et al. The use of artificial in-
telligence guidance for rheumatic heart disease screening by
CONCLUSIONS novices. J Am Soc Echocardiogr 2023;36:724-32.
12. Plana JC, Galderisi M, Barac A, et al. Expert consensus for multi-
TTE is an essential diagnostic and therapeutic tool. modality imaging evaluation of adult patients during and after
cancer therapy: a report from the American Society of Echocar-
We anticipate that practitioners will benefit from consis-
diography and the European Association of Cardiovascular Imag-
tent and region-specific guidelines to follow. As more
ing. J Am Soc Echocardiogr 2014;27:911-39.
evidence emerges and technology advances, the incor- 13. Rhea IB, Uppuluri S, Sawada S, et al. Incremental prognostic va-
poration of new techniques will further improve the con- lue of echocardiographic strain and its association with mortality
venience, accuracy, and reproducibility of TTE. in cancer patients. J Am Soc Echocardiogr 2015;28:667-73.
14. Gheorghe LL, Mobasseri S, Agricola E, et al. Imaging for native
mitral valve surgical and transcatheter interventions. JACC Car-
DECLARATION OF CONFLICT OF INTEREST diovasc Imaging 2021;14:112-27.
15. Vainrib AF, Harb SC, Jaber W, et al. Left atrial appendage occlu-
sion/exclusion: procedural image guidance with transesopha-
All the authors declare no conflict of interest.
geal echocardiography. J Am Soc Echocardiogr 2018;31:454-74.
16. Welle GA, Hahn RT, Lindenfeld J, et al. New approaches to assess-
ment and management of tricuspid regurgitation before inter-
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