|
The IAC Standards
and Guidelines |
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Echocardiography Standards |
1.1B Cardiac
Ultrasound Systems
1.1.1B Ultrasound
instruments utilized for diagnostic studies must include, at a minimum,
hardware and software to perform:
1.1.1.2B 2-D
imaging. The system must
include harmonic capabilities.
1.1.1.3B Spectral
display for pulsed (PW) and continuous wave (CW) Doppler and tissue Doppler imaging;
1.1.1.5B Monitor
or other display method of suitable size and quality for observation and
interpretation of all modalities.
Comment: The display or DICOM header must identify the parent institution, the name of the patient, second patient identifier (such as MRN or DOB), the date and time of the study. The ECG must also be displayed.
1.1.1.8B Range
or depth markers must be available on all displays.
1.1.1.9B Capabilities
to measure the distance between two points, an area on a 2-D image, blood flow
velocities, time intervals, and peak and mean gradients from spectral Doppler
studies.
1.1.1.10B At least two imaging transducers, one of low
frequency (2-2.5 MHz) and one of high frequency (3.5 MHz or higher); or a
multi-frequency transducer which includes a range of frequencies specific to
the clinical needs in adult echo.
Comment: A transducer
dedicated to the performance of non-imaging continuous wave Doppler must be
available at each site.
1.1.1.11B An
audible output must be present at the time of acquisition.
1.1.1.12B Machines
with some, but not all of the above, equipment may be used for limited or
directed echocardiographic examinations. However, machines utilized for
complete diagnostic procedures must include all of the above listed
capabilities.
1.2B The
annual procedure volume must be sufficient to maintain proficiency in
examination performance and interpretation.
(See
Guidelines below for further recommendations.)
1.3B Transthoracic
Echocardiography testing is performed for appropriate indications.1
1.3.1B Verification
of the Indication – A process must be in place in the facility for
obtaining and recording the indication. Before a study is performed, the
indication must be verified and any additional
1.4B
Transthoracic echocardiography testing is appropriately ordered and
scheduled. Appropriate Use Criteria (AUC) documents pertaining to echocardiography must be available for review in the facility.
1.4.1B Ordering
Process – The echocardiogram order and requisition must clearly
indicate the type of study to be performed, the reason(s) for the study and the
clinical question(s) to be answered. The signed (electronic or handwritten)
order/requisition must be present in the medical record of the patient.
1.4.2B Definition
of Procedure Types and Protocols –
i. A
complete imaging study is one that examines all of the cardiac chambers and
valves and the great vessels from multiple views, then uses the available
ii. A
complete Doppler study is one that examines every cardiac valve, and the atrial
and ventricular septa for antegrade and/or retrograde flow. In addition, a
complete Doppler study provides functional hemodynamic data.
1.4.2.2B Limited
Study: A limited study is generally only performed when the patient has
undergone a complete recent examination and there is no clinical reason to
suspect any changes outside the specific area of interest. A limited study
generally examines a single area of the heart or answers a single clinical
question.
1.4.3B Scheduling
– Sufficient time must be allotted for each study according to the
procedure type. The performance time allotted for a complete (imaging and
Doppler) transthoracic examination is 45 to 60 minutes from patient encounter
to departure. An additional 15 to 30 minutes may be required for complicated
studies.
1.4.3.1B An
urgent study must be performed in the next available time period.
1.4.3.2B A
stat study must be performed as soon as possible, preempting routine studies.
1.4.3.3B Availability
for Emergencies: Qualified personnel and equipment must be available for urgent or stat studies outside normal working
hours in inpatient facilities or where appropriate.
(See
Guidelines below for further recommendations.)
1.5B Examination
performance must include proper technique.
1.5.1B All
procedures must be explained to the patient and/or parents or guardian. The
patient’s height, weight and blood pressure must be measured and recorded prior to or during the examination.
1.5.2B Echocardiography examinations of the heart must examine all cardiac chambers and structures. The course and extent of disease must be documented.
1.5.3B Elements
of study performance include, but are not limited to:
1.5.3.1B proper
patient positioning;
1.5.3.2B transducer
selection and placement;
1.5.3.3B optimization
of equipment gain and display settings;
1.5.3.4B utilization
of appropriate Doppler technique (including proper Doppler alignment) and
measurements;
1.5.3.5B representative
image storage of all images and data;
1.5.3.6B timely
report generation and communication of results; and
1.5.3.7B performance
of a 2-D/M-Mode/Doppler examination according to the facility specific and
appropriate protocol that incorporate all views and imaging planes mandated by
the Standards 1.5.1B, 1.5.2B.
1.5.4B Elements
of study quality include, but are not limited to:
1.5.4.1B definition
of endocardium;
1.5.4.2B display
of standard (on axis) imaging planes (e.g., avoidance of foreshortening);
1.5.4.3B delineation
of the details of valvular anatomy;
1.5.4.4B measurements of left heart chamber dimensions and volumes (indexed when appropriate) from standard imaging planes;
1.5.4.5B optimal
recording and evaluation of Doppler flows (which are aligned to the Doppler beam
and parallel to flow);
1.5.4.6B accurate
spectral Doppler recording and recording of abnormal Doppler flow signals in
multiple views; and
1.5.4.7B adherence
to the facility specific protocol including sequence with allowances for
additional views.
1.6B Transthoracic
echocardiograms must be comprehensive and include standard components.
1.6.1B Components
of the Examination – A protocol must be in place that defines the
components of the standard examination. Indications for performance of a
complete and/or limited examination must be included.
1.6.1.1B Complete
Examination: Includes standard views from multiple planes including views of
all cardiac structures and selected extracardiac structures. These include, but
are not limited to:
i. left
ventricle;
ii. right
ventricle;
iii. left
atrium;
iv. right
atrium;
v. aortic
valve;
vi. pulmonic
valve;
vii. mitral
valve;
viii. tricuspid
valve;
ix. proximal
ascending aorta;
x. aortic
arch;
xi. inferior
vena cava; and
xii. pericardium.
1.6.1.2B Complete
Doppler Study: Includes spectral Doppler and/or color flow interrogation of all
normal and abnormal flows within the heart including the valves, the great
vessels and the atrial and ventricular septa.
1.6.1.3B Limited
Examination: A limited study is generally only performed when the patient has
undergone a complete recent examination and there is no clinical reason to
suspect any changes outside the specific area of interest. A limited study
generally examines a single area of the heart or answers a single clinical
question. 7
(See
Guidelines below for further recommendations.)
1.6.2B The
complete exam must include (except where technically unobtainable), but not be
limited to:
1.6.2.1B The
following standard 2-D views:
i. parasternal long axis view;
ii. right ventricular outflow tract view;
iii. right
ventricular inflow view ;
iv.
parasternal short axis views (at the level of the aortic valve, left
ventricle at the basal, mid and apical levels);
v. apical four-chamber view;
vi. focused view of the right ventricle;
vii. apical five-chamber view;
viii. apical two-chamber view;
ix. apical long axis view (three-chamber);
x. subcostal four-chamber view;
xi. subcostal short axis view (when indicated);
xii. subcostal IVC/hepatic vein view; and
xiii. suprasternal notch view.
1.6.2.2B The
following 2-D, 3-D
or M-Mode measurements of the left heart:
i. left
ventricular internal dimension and/or volume at end-diastole;
ii. left
ventricular internal dimension and/or volume at end-systole;
iii. left
ventricular posterobasal free wall thickness at
end-diastole;
iv. ventricular
septal thickness at end-diastole;
v. left
atrial dimension at end-systole or left atrial volume index; and
vi. aorta at the level of the sinuses of Valsalva; measurements of sinotubular junction and mid-ascending, as clinically indicated;
vii. left ventricular ejection fraction.
Comment: Quantitated ejection fraction by 3-D volumes or 2-D biplane method of discs is preferred over visual estimate.
1.6.2.3B The
following standard Doppler flow evaluations:
i. four
cardiac valves – forward flow spectra for each valve, and any
regurgitation, shown in at least two imaging planes with color Doppler;
ii. also
use of non-imaging Doppler Transducer to assess stenotic valves, valvular regurgitation or whenever indicated;
iii. tricuspid
regurgitation spectrum must always be sought with CW Doppler from multiple
views for estimation of systolic right ventricular pressure when tricuspid
regurgitation is present;
iv. atrial
and ventricular septa – color Doppler screening for defects;
v. left
ventricular outflow tract velocity;
vi. velocity-time integrals of the left ventricular outflow tract and the aortic valve, when clinically indicated;
vii. hepatic and pulmonary vein flow spectra, when clinically indicated;
viii. For aortic stenosis, the
systolic velocity must be evaluated from multiple transducer positions (e.g.,
apical, suprasternal and right parasternal). This must include interrogation
from multiple views with a dedicated non-imaging continuous wave Doppler
transducer (at least one clear envelope must be obtained).
ix. Diastolic Function Evaluation
– LV diastolic function must be evaluated through a combination of PW and
tissue Doppler techniques.
1.6.2.4B Use of Ultrasound Enhancing Agents (UEAs) for Suboptimal Image Quality – UEAs are indicated for use when two or more LV segments cannot
be visualized adequately for the assessment of LV function (LVEF and
regional wall motion assessment) and/or in settings in which the study
indication requires accurate analysis of regional wall motion. [10][11]
i. If UEAs are used, there must be a written policy for the use of UEAs.
Although hypersensitivity reactions are rare, laboratories that use
UEAs must have policies in place for emergent resuscitation of patients
who may experience serious side effects.
ii. Cardiopulmonary
resuscitation personnel and equipment must be readily available prior
to ultrasound enhancing agent administration.
Comment: Poor endocardial border definition is defined as the inability to detect two or more segments.
(See Guidelines below for further
recommendations.)
1.6.3B Use
of Contrast for Suboptimal Image Quality: Contrast is indicated for use when
two contiguous segments are not visualized in any three of the apical views (poor
endocardial border definition) as it provides greater accuracy in
determining left ventricular function.
1.6.3.1B If
contrast is used, there must be a written policy for the use of contrast
agents.
1.6.3.2B If
contrast is not able to be used there must be a policy for alternative imaging.
Comment: Poor endocardial border
definition is defined as the inability to detect two or more contiguous
segments in any three of the apical views.
(See
Guidelines below for further recommendations.)
1.4.3B Additional time should be allocated for technical staff to complete analysis and documentation for each study.
A routine study on an inpatient should be performed on the same working day as ordered, unless otherwise specified. Outpatient studies should be assigned priority as defined by the referring physician and/or the indication of the study.
1.4.3.2B The facility should have a policy defining STAT echocardiogram indications.
1.6.1B For all imaging protocols, if any required view or Doppler signal cannot be adequately obtained, it should be recorded and labeled in order to demonstrate that it was attempted.
1.6.2B
Strain imaging should be
considered when clinically indicated. If strain is performed it should
be reported. 3D imaging should be performed when clinically indicated,
and should be reported.
• Parasternal short axis view of the aorta and branch pulmonary arteries
• Apical four-chamber view focused on atria
• Apical two-chamber view focused on the left atrium
1.6.2.2B Additional measurements that should be considered include:
• Linear measurement of the right ventricle, when clinically indicated
• Measurement and description of the response of the IVC to respiration, when clinically indicated
1.6.2.3B Velocity-time intergrals of hepatic and pulmonary vein flow spectra, when clinically indicated.
1.6.2.4B UEAs
should be used in the presence of poor endocardial border definition
for quantification of chamber dimensions, volumes, ejection fraction
and assessment of regional wall motion.
UEAs should also be used to assess conditions such as hypertrophic
cardiomyopathy or when left ventricular thrombus is suspected.
Allergy kits should be available and easily accessible in all areas
where UEAs are in use and expiration dates should be checked on a
regular basis in accordance with local institutional or lab policies.