<Insert Facility Name Here> Echocardiography Laboratory
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms
PURPOSE: To provide a standard for performing quality echocardiograms.
GENERAL GUIDELINES:
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No echocardiograms will be performed without a written order (for stat requests, a verbal order is sufficient;
however, obtain the written order ASAP). Examine the order for type of exam and indication.
o In addition to patient’s name and MRN/IDN, the following must be obtained for every exam:
 Date of Birth
 Height/Length
 Weight
All echocardiograms should contain the images and Doppler measurements listed under “Routine
Echocardiograms.” In addition, the sonographer should obtain any images and/or Doppler measurements
pertinent to the patient’s particular pathology. If the sonographer is unable to obtain an image, the attempt must
be documented.
All echocardiograms will be captured digitally and stored in the <INSERT SYSTEM NAME HERE> digital
reading system. Two to 10 beat loops and/or a combination of 2 second to indefinitely-timed captures will be
obtained; for arrhythmia cases, obtain five-beat loops or 5 second captures of the PLAX, PSAX at pap level,
A4C and A2C, M-mode and Doppler waveforms when indicated.
Two-beat digital captures will be obtained of each view, 2D measurement, color Doppler view, spectral
waveform and waveform measurement. For each measurement, calipers and tracings must be visible.
Images will be obtained from standard on-axis imaging planes; measurements will be made from standard
orthogonal views.
Ultrasound system settings, transducer selection and patient position will be adjusted as needed to optimize
images (according to the patient’s size, body habitus, pathological and post operative conditions), color Doppler
and spectral Doppler.
PATIENT PREPARATION:
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Introduce yourself to patient, parent(s), family and guardian(s).
Verify patient identity according to hospital procedure.
Explain the test
o For infants and toddlers: A pre-assessment for sedation is required, consult with the designated sedation
nursing and supervising physician staff. All sedation orders must be conducted by the designated sedation
nursing staff and/or ordering physician. NOTE: Please refer to the Pediatric Sedation Protocol for
additional sedation requirements and information.
Allow privacy for the patient to change into hospital gown.
When the patient is ready, attach EKG leads, from the echo machine, and automatic BP cuff to the patient.
o NOTE: If sedated, a pulse oximetry sensor must be used.
Position patient in the left lateral recumbent position.
o NOTE: Use and position warming pad underneath infants and toddlers.
Use gown, blanket, and/or towel to keep patient warm and maintain patient’s modesty during scanning.
Music, movies and books may be used to entertain patients during their echocardiogram
ROUTINE ECHOCARDIOGRAMS:
(Note: The order in which the following views are obtained may be altered depending on the cooperation level of the patient)
Parasternal long-axis view (PLAX) and related views:
1.
2.
3.
4.
Obtain a PLAX view
Perform a 2D sweep beginning at the aortic valve, to the tricuspid valve and then to the pulmonary valve.
Use increased depth to rule out effusions, and then decrease depth
Measure the following in M-mode or 2D:
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)
a.
In end-diastole, measure the anterior septum, left ventricular (LV) internal diameter, and posterior
wall.
b. In systole, measure the LV internal diameter.
c. The aortic annulus will be measured in the standard PLAX view in early to mid-systole at its maximum
diameter. Acquire three additional 2D measurements in mid-systole to include the aortic root,
sinotubular junction, and ascending aorta (for these measurements, the aortic root should be positioned
perpendicular to the beam and Zoom or RES modes should be implemented).
d. The left atrium will be measured in end-systole, at its greatest anterior-posterior dimension.
e. The pulmonary valve annulus (RVOT view) will be measured in systole at its greatest dimension (leaflets
open). A magnification mode should be used when acquiring measurement.
f. The mitral valve (PLAX view) and tricuspid valve (RVIT view) will be measured in diastole at their
greatest dimension (leaflets open).
5. Interrogate the aortic and mitral valves with color Doppler.
6. Interrogate the pulmonic valve with color Doppler.
7. Obtain a right ventricular inflow view (RVIT).
8. Interrogate the tricuspid valve with color Doppler.
9. If tricuspid regurgitation (TR) is present, use continuous wave (CW) Doppler to obtain the RA/RV gradient, to
calculate the pulmonary artery pressure (Obtain and record/annotate BP with image store at this time).
10. Interrogate the interventricular septum with color Doppler.
11. At the end of the parasternal long evaluation, the following anatomy must have been evaluated or attempted with
a note providing the reason the evaluation could not be made:
a. Left atrium
b. Coronary sinus
c. LVOT
d. Aortic valve, STJ, aortic root and ascending aorta
e. Left ventricle
f. Mitral valve
g. Right atrium
h. Right ventricle
i. Tricuspid valve
j. RVOT
k. Pulmonic valve
l. Interventricular septum
Parasternal short-axis view (PSAX):
12.
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Obtain a PSAX view
Perform a 2D sweep beginning at the base of the heart, to the apex and back to the base.
By 2D, at the level of the aortic valve, demonstrate aortic, pulmonic and tricuspid valve leaflet morphology.
Use color Doppler to individually interrogate the pulmonic, aortic and tricuspid valves.
Obtain pulsed wave (PW) spectral Doppler of the tricuspid valve inflow. If TR is present, obtain the gradient
with CW Doppler.
Obtain a PSAX of the LV at the level of the mitral valve.
Obtain a PSAX of the LV at the level of the papillary muscles.
Obtain a PSAX of the LV at the level of the apex.
Measure the following in M-mode or 2D (at the level of the papillary muscles):
a. In end-diastole
i. RVd
ii. IVSd
iii. LVIDd
iv. LVPWd
b. In end-systole
i
IVSs
ii LVIDs
iii LVPWs
Using the magnification mode on the aortic valve, demonstrate cusp/leaflet architecture/morphology and leaflet
mobility. Document structure and function with 2D and color Doppler.
Document coronary artery origin, size, distribution and flow direction.
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)
a.
Acquire 2D measurements of the proximal right main coronary artery, proximal left main coronary artery,
proximal left anterior descending coronary artery, distal left anterior descending coronary artery, and
proximal circumflex coronary artery.
b. Document flow direction with color Doppler.
c. Attempt documentation of flow velocity with (PW/HPRF) Doppler.
23. Use the magnification mode to demonstrate the main pulmonary artery and right and left pulmonary arteries.
a. 2D measurements of the MPA and the origins of the LPA and RPA will be obtained in systole at the
greatest dimension (PV leaflets open).
b. Document flow direction with color Doppler.
c. Interrogate the MPA, LPA and MPA with (PW) Doppler.
d. Obtain peak velocity across pulmonary valve and/or of the MPA and branch PA’s with (CW) Doppler.
Consider use of the non-imaging dedicated transducer from multiple imaging planes (image annotation
required when documenting velocities obtained with this transducer).
24. Interrogate the interventricular and interatrial septae with color Doppler.
25. At the end of the parasternal short evaluation, the following anatomy must have been evaluated or attempted
with a note providing the reason the evaluation could not be made:
a. Left atrium
b. Coronary sinus
c. Aortic valve
d. Coronary arteries
e. Left ventricle
f. Mitral valve
g. Right atrium
h. Right ventricle
i. Tricuspid valve
j. RVOT
k. Pulmonic valve
l. Main pulmonary artery
m. Left pulmonary artery
n. Right pulmonary artery
o. Interventricular septum
p. Interatrial septum
Apical four-chamber and five-chamber views (A4C)
(With image inverted and displayed anatomically correct)
26. Obtain a non-foreshortened A4C view.
27. Perform a 2D sweep beginning with the standard four chamber view and slowly sweep posteriorly to show the
coronary sinus, back to the A4C view, anteriorly to the level of the LVOT and aorta, more anteriorly to
demonstrate the RVOT, MPA and branch PAs and then back to the standard A4C view of the heart. Repeat this
sweep with color Doppler.
28. Use color Doppler to individually interrogate the mitral, aortic, tricuspid, and pulmonic valves.
29. If regurgitation/insufficiency is present of any valve, obtain the gradient with CW.
30. Obtain spectral Doppler of each valve with CW.
31. Use the magnification mode to demonstrate the LVOT.
a. Obtain spectral Doppler of the LVOT with PW just above the aortic valve.
b. Obtain spectral Doppler across the aortic valve with CW.
c. Obtain a time measurement for MPI
32. Use the magnification mode to demonstrate the RVOT.
a. Obtain spectral Doppler of the RVOT with PW just above the pulmonic valve.
b. Obtain spectral Doppler across the pulmonic valve with CW.
33. Use the magnification mode to demonstrate the mitral valve to include the LA. In cases of mitral stenosis
include LV.
a. Interrogate the mitral valve with color Doppler.
b. Obtain spectral Doppler with PW at the leaflet tips.
c. Obtain spectral Doppler with CW to be parallel antegrade or regurgitant flow.
d. Obtain a time measurement for MPI.
e. Measure the mitral valve annulus in its maximum dimension (valve open).
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)
34. Use the magnification mode to demonstrate the tricuspid valve to include the RA. In cases of tricuspid stenosis
include RV.
a. Interrogate the tricuspid valve with color Doppler.
b. Obtain spectral Doppler with PW at the leaflet tips.
c. Obtain spectral Doppler with CW to be parallel antegrade or regurgitant flow.
d. Measure the mitral valve annulus in its maximum dimension (valve open).
35. Interrogate the interventricular and interatrial septae with color Doppler.
36. Visualize the pulmonary venous return and systemic venous return with color Doppler.
37. Use the magnification mode to demonstrate the left atrium.
a. Obtain a 2D image focusing on the right upper and left lower pulmonary veins (Image should include the
interatrial septum and the mitral valve).
b. Obtain spectral Doppler of the right upper and left lower pulmonary veins with PW.
38. Obtain 2D A3C (Apical Long)
a. Interrogate with color Doppler.
b. Obtain spectral Doppler of the LVOT with PW and across the aortic valve with CW.
39. Obtain 2D A2C
a. Interrogate with color Doppler.
b. Obtain spectral Doppler of the MV with PW and CW if TR is present.
40. Obtain 2D A5C
a. Interrogate with color Doppler.
b. Obtain spectral Doppler of the LVOT with PW and across the aortic valve with CW.
c. Obtain spectral Doppler of the RVOT with PW and across the pulmonic valve with CW.
41. At the end of the apical evaluation, the following anatomy must have been evaluated or attempted with a note
providing the reason the evaluation could not be made:
a. Left atrium
b. Coronary sinus
c. LVOT
d. Aortic valve and ascending aorta
e. Left ventricle
f. Mitral valve
g. Right atrium
h. Right ventricle
i. Tricuspid valve
j. RVOT
k. Pulmonic valve
l. Main pulmonary artery
m. Left pulmonary artery
n. Right pulmonary artery
o. Interventricular septum
p. Interatrial septum
q. Right upper pulmonary vein
r. Left lower pulmonary vein
Subcostal view
42. Establish and document visceral (abdominal) situs.
a. 2D of the abdominal viscera (structural relationship)
b. 2D, color and PW Doppler of the abdominal aorta (longitudinal view)
c. 2D, color and PW Doppler of the inferior vena cava (longitudinal view)
NOTE: velocity-time integrals and hepatic and pulmonary vein flow spectra are optional
Subcostal view (long axis) four-chamber view
(With image inverted and displayed anatomically correct)
43. Obtain a long axis four-chamber view
44. Perform a 2D sweep beginning with a transverse abdominal view demonstrating the aorta and IVC in cross
section. Slowly sweep anteriorly showing the entrance of the IVC into the RA, continue to sweep anteriorly
through the heart to the branch pulmonary arteries. Reverse the sweep.
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)
45. Repeat the long axis sweep with color Doppler. Perform a continuous sweep prior to isolating anatomy for
additional interrogation.
46. From the long axis, document the following (obtain in a logical order):
a. Interrogate the pulmonary venous return with 2D, color and PW Doppler
b. Interrogate the interatrial and interventricular septae with 2D, color Doppler (PW and CW Doppler if
shunt is present).
c. Interrogate the mitral and tricuspid valves with 2D, color and PW Doppler
i
If regurgitation or stenosis is present, obtain the gradient(s) with CW
d. Interrogate the LVOT, aortic root, ascending aorta, (aortic arch, if possible), RVOT, MPA and branch
pulmonary arteries with 2D, color and PW Doppler
i
If regurgitation or stenosis is present, obtain the gradient(s) with CW
ii If present, document flow direction of the patent ductus arteriosus
47. See line 52 for a list of the required subcostal imaging anatomy, see line 52.
Subcostal view short axis view
(With image inverted and displayed anatomically correct)
48. Obtain a short axis view
49. Perform a 2D sweep beginning with a longitudinal abdominal view demonstrating the aorta and IVC in long axis
Slowly sweep showing the entrance of the IVC into the RA, continue to sweep anteriorly through the heart to the
branch pulmonary arteries. Reverse the sweep.
50. Repeat the short axis sweep with color Doppler. Perform a continuous sweep prior to isolating anatomy for
additional interrogation.
51. From the short axis, document the following (obtain in a logical order):
a. Interrogate the SVC and IVC/hepatic vein connections to the RA and document the azygous vein with
2D, color and PW Doppler (velocity-time integrals and hepatic and pulmonary vein flow spectra are
optional)
b. Interrogate the pulmonary venous return with 2D, color and PW Doppler
c. Interrogate the interatrial and interventricular septae with 2D, color Doppler (PW and CW Doppler if
shunt is present).
i
Obtain an enface view of the interatrial septum with 2D and color Doppler
d. Interrogate the mitral and tricuspid valves with 2D, color and PW Doppler
i
If regurgitation or stenosis is present, obtain the gradient(s) with CW
ii Obtain an enface view of the mitral valve with 2D and color Doppler
e. Interrogate the LVOT, aortic root, ascending aorta, RVOT, MPA and branch pulmonary arteries with
2D, color and PW Doppler
i
If regurgitation or stenosis is present, obtain the gradient(s) with CW
ii Document flow direction of the patent ductus arteriosus
52. At the end of the subcostal imaging, the following anatomy must have been evaluated or attempted with a note
providing the reason the evaluation could not be made:
a. Left atrium
b. Coronary sinus
c. LVOT
d. Aortic valve and ascending aorta
e. Left ventricle
f. Mitral valve
g. Right atrium
h. Right ventricle
i. Tricuspid valve
j. RVOT
k. Pulmonic valve
l. Main pulmonary artery
m. Left pulmonary artery
n. Right pulmonary artery
o. Interventricular septum
p. Interatrial septum
q. Right upper pulmonary vein (right lower pulmonary view, if visible)
r. Left sided pulmonary veins (if visible)
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)
s.
t.
u.
SVC
IVC/hepatic vein
Azygous vein
Suprasternal Notch view (SSN)
53. Reposition patient , which may require a bolster under the neck, shoulders or upper back to optimize SSN
images.
54. Obtain transverse image (short axis) of the aortic arch. Follow the aorta superiorly to demonstrate arch
sidedness with 2D and color Doppler.
55. Demonstrate the right pulmonary artery with 2D and color Doppler.
56. If the ductus arteriosus is present, document with 2D, color, PW and CW Doppler
57. Use the magnification mode to obtain a transverse view of the LA and the pulmonary veins. Document with
2D, color Doppler (investigate with PW and CW Doppler if stenotic).
58. Obtain a longitudinal image (long-axis) of the aortic arch and interrogate with 2D color, PW and CW
Doppler (demonstrate ascending transverse and descending thoracic aorta separately if necessary).
59. Obtain arch measurements with the aorta in its largest dimension:
a. Proximal transverse aorta
b. Distal transverse arch
c. Aortic isthmus
60. At the end of the apical evaluation, the following anatomy must have been evaluated or attempted with a note
providing the reason the evaluation could not be made:
a. Aortic arch
b. Aortic arch sidedness
c. Left atrium
d. Right pulmonary veins
e. Left pulmonary veins
f. Right pulmonary artery
g. Optional: Main pulmonary artery
h. Optional: Left pulmonary artery
i. Optional: patient ductus arteriosus
Use of the Dedicated Non-imaging Transducer
In addition, to the above protocol, it is suggested we make an attempt to acquire additional Doppler information with the
use of the dedicated non-imaging transducer. This suggested requirement may be applied to all stenotic valves and/or
suspicious flows velocities.
Protocol for Performing Complete Pediatric Transthoracic Echocardiograms (SAMPLE)