The Routine Echocardiogram Protocol

The Routine Echocardiogram Protocol

©Walter Rasmussen, R.D.C.S.

Each workplace has an established protocol for performing a routine echocardiogram.  Most protocols are based upon guidelines established by the American Society of Echocardiography and the Intersocietal Accreditation Commission, which are accessible on the internet.

Echocardiography is intended to be a scientific study of the heart and as such, is best crafted with as much precision and consistency as possible.  The collection of images should follow an established sequence so that the reader knows where in the study, certain anatomical areas will be found.  Every image should be of the highest quality for the conditions under which the exam was made, and labeled when necessary, so that the anatomy is clearly identifiable.

Components of a routine echocardiographic Examination:

  1. Enter patient’s name, MRN, DOB, height, weight, BP, and exam indication into appropriate fields.
  2. Apply the ECG leads
  3. PROCEDURE – Standard Protocol-TTE/Echo
  4. Parasternal Windows
    1. Long axis (LAX) views
  5. 2D of standard view -Left ventricle (LV), Mitral Valve (MV), Aortic valve (AV) and left atrium (LA)
  6. Color flow Doppler of AV, MV, and inter-ventricular septum
  7. M-mode of Aortic root and left atrium (LA)
    1. Specific focus and multiple view of LVOT for any TAVR patient
  8. M-mode of MV
  9. M-mode of IVSd, LVd, PWd, and LVs
    1. 2D measurement of IVSd, LVd, PWd, and LVs if M-Mode is not obtained/off axis (if physician indicated)
  10. Parasternal long axis plane view of the PV
    1. 2D view of the PV from the RV outflow view
    2. Color flow over the PV
    3. CW of the PV(100mm/sec sweep speed)
    4. PW if needed to calculate PVA(100mm/sec sweep speed)
    5. RVOT diameter if accurate
  11. Ascending Aorta
    1. 2D view and measurement of the ascending aorta
  12. RV inflow
    1. 2D of the RV inflow
    2. Color flow Doppler of Tricuspid valve (TV)
    3. CW Doppler measurement of regurgitant jet, if any(100mm/sec sweep speed).
  1. Short axis (SAX) views
  1. 2D, Base (AV, PV, TV)
    1. Enlarged view of AV
      1. Color flow over zoomed view, including area of membranous septum
      2. Attempt to visualize coronary ostia
    2. PV
      1. Color flow over PV and RVOT outflow tract
      2. PW Doppler of RVOT (100mm/sec sweep speed)
  • CW Doppler measurement of PV(100mm/sec sweep speed)
    1. Trace of PV VTI
  1. TV
    1. CW Doppler through TV, regardless of jet presence(100mm/sec)
  2. 2D at the MV level
    1. Color flow Doppler over MV to assess any MR origin
    2. M-Mode through valve if suspect MVP, SAM
  3. 2D at the papillary muscle level
    1. M-mode of IVSd, LVd, PWd, and LVs (if not obtained in parasternal window)
  4. 2D at the apical level


  1. Apical Windows
    1. Four Chamber (4-CH) Views
    2. 1. 2D of 4-CH, LV (both at 16cm and Zoomed)
    3. Color flow of MV
    4. PW Doppler at MV leaflet (100mm/sec)
      1. E/A ratio
      2. DT (Deceleration Time)
  • Pressure ½ time
  1. TDI (Tissue Doppler imaging-mitral annulus and lateral wall –basal level)
  2. PW at 25mm/s sweep to look for respiratory variation (for pericardial effusion/cardiac tamponade)-100mm/sec
  1. CW Doppler at MV inflow (MVA measurement if valve is stenotic, measurement of regurgitant jet, if any) -100mm/sec
  2. PW of pulmonary vein (for diastolic dysfunction, look at flow reversal) 100mm/sec
  3. Measure end diastolic/ end systolic areas to allow for the calculation of the ejection fraction
  4. Measure apical 4 LA end systolic area to obtain LA end systolic volume


  1.   2D of 4-CH, RV
  2. Color flow of Tricuspid Valve (TV)
  1. CW Doppler through TV regardless of jet presence, 100mm/sec
    1. Measurement of TR, if present
  2. PW Doppler, if stenotic or repaired
  3. 2D measurement of right ventricle and right atrium
  4. M-Mode (or systolic and diastolic area calculations) through lateral TV annulus (TAPSE measurement)
  5. Tissue Doppler (TDI) through lateral annulus to assess TASV (tricuspid annular systolic velocity), if TAPSE abnormal or indicated by diagnosis


  1. Five Chamber (5-CH)Views
  2. 2D of 5-CH, LVOT
  3. Color flow of AV
  1. PW Doppler of LVOT -100 mm/sec
    1. Simultaneous recording of MV/LVOT for IVRT measurement
  2. CW Doppler of AV(AVA measurement for all valves)
    1. Record and measure AI, if present
    2. Pedoff probe use
    3. Pedoff is to be used for any Aortic Stenosis
    4. Obtain standard apical CW
    5. Obtain Right Sternal Border CW
    6. Two Chamber (2-CH)Views
      1. 2D and color flow of 2-CH, MV
      2. Measure end diastolic/ end systolic areas to allow for the calculation of the ejection fraction
      3. Measure apical 2 LA end systolic area to obtain LA end systolic volume
    7. Three Chamber/ Apical Long (3-CH) Views
    8. 2D and color flow of 3-CH, MV and AV
    9. Subcostal Views (supine with knees bent)
    10. 2D of 4-CH
    11. Color flow of MV, TV
    12. Color flow of IAS (PW of shunt if suspected)
    13. 2D of IVC
    14. Color flow of IVC
    15. PW of hepatic IVC, hepatic vein
    16. Perform “sniff” test to show collapse
    17. Abdominal Aorta (long axis).
    18. Short axis views
    19. perform as needed
    20. Color flow Doppler over IAS if indicated, color flow Doppler at abdominal aorta if significant aortic insufficiency is suspected.
  1. Suprasternal Notch
    1. 2D of the distal ascending, arch, and proximal distal aorta
    2. Color flow visualization to assess for AI
    3. PW in prox. Descending to assess AI reversal
    4. 2D short-axis of the descending and PA, if able
    5. Exam Specific Views
    6. Saline contrast study with previously unknown RV enlargement or pulmonary hypertension
    7. Saline contrast for TR jet enhancement also
    8. LV opacification contrast indicated when <80% of endocardium visible
    9. 3D views as needed or specified by exam indication/physician order
    10. LV Strain imaging for all chemotherapy patients or pre-chemotherapy patients.

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