Sample Transthoracic Echocardiogram Protocol: An Echo Protocol That Is ICAEL Approved

For the official IAC sample echo protocol, you can the IAC Prototocol for Adult TTE Echocardiography here.

For a real world example of an Adult echocardiogram protocol, continue reading.

Why Be ICAEL Accredited Echo Lab

Every day, more and more echo labs are choosing to follow the specific guidelines set forth by ICAEL, or the Intersocietal Accreditation Commission (IAC). The reason these echo labs are choosing to be ICAEL accredited is to demonstrate the high level of patient care that they provide at their facility.

Is ICAEL a Requirement?

Currently, some US states already require or strongly recommend that echo labs be ICAEL accredited in order to receive reimbursement from echo exams performed on patients covered by Medicare insurance plans. And it’s clear that the trend of government regulation regarding the accreditation of echo labs will only continue.

That’s why it’s important to start following an ICAEL approved echo protocol in your echo lab, even if it’s not yet required in your state.

By following an ICAEL echo protocol, you will ensure that you as an imaging professional are providing thorough and complete exams for your patients.  Keep in mind, our patients are paying hard earned money for a service.  And they deserve a complete and thorough exam in exchange.

About The ICAEL Echo Protocol

If you’re already familiar with performing complete 2D echocardiograms, then adopting the ICAEL echo protocol shouldn’t be too much of a change for you.  The fact is, the ICAEL echo protocol is not a difficult echo protocol to follow.

The echo guidelines set forth by the Intersocietal Accreditation Commission are quite basic.  The more advanced areas of echocardiography have been left out of the requirements, which leaves advanced echo procedures up to the individual echo labs discretion.

Sample Echocardiogram Protocol

Below is a sample echo protocol that has been previously approved by the Intersocietal Accreditation Commission. This is not the sample echo protocol that is listed on the IAC website, however, this complete 2D echo protocol was based of the that protocol.  

To see the official IAC sample echo protocol, you can the IAC Prototocol for Adult TTE Echocardiography here.

Complete Adult Transthoracic Echo Protocol

Purpose: To provide standards for performing quality echocardiograms

General Guidelines:

• No echocardiograms shall be performed without a written order. For STAT or emergent echocardiograms, a verbal order is sufficient. A written order shall be obtained as soon as possible.
• All Echocardiograms should consist of 2D images and Doppler measurements. The cardiac sonographer should obtain all images and Doppler measurements that are pertinent to the patient’s particular pathology. If the sonographer is unable to obtain and image, the attempt must be documented.
• All echocardiograms will be captured digitally and stored in a PACS system.
• For each measurement, calipers and tracings must be visible.
• A complete cardiac cycle must be captured of each echo view. In the case of arrhythmias  such as Afib, at least 3 cardiac cycles will be captured.
• Images shall be obtained from standard, on axis imaging planes. Measurements will be made from standard orthogonal views.
• Machine settings, transducer selection and patient positioning will be adjusted as needed to optimize images, which is to include valvular morphology and endocardial border definition, color Doppler and spectral Doppler.

Patient Preparation:

• Introduce self to patient
• Verify patient identity according to facility policy
• Describe the exam and answer any questions
• Provide privacy to patient and allow to change into gown
• Attach ECG electrodes to patient and verify good quality signal
• Position the patient in the left lateral recumbent position
• Use a gown or a towel to cover female patients chest area throughout the exam

Routine Adult Transthoracic Echocardiogram:

Parasternal Long Axis View:

• Begin with increased depth of field to rule out effusions posterior to the heart. Decrease depth of field once this has been documented.
• Make the following 2D measurements:
  • End Diastole:
    • Anterior septum
    • left ventricular internal dimension
    • posterior wall
    • Aortic root at the level of the sinus of valsalva
  • End Systole:
    • Left ventricular internal dimension
    • Left atrium at its greatest anterior-posterior dimension
• Interrogate the ascending aorta. Image as distally as possible and measure the diameter of the ascending aorta.
• Zoom in on the mitral valve and the aortic valves to interrogate them more closely.
• Interrogate the mitral valve and the aortic valve with color Doppler.
• Obtain a right ventricular inflow view (RVIT), also called the RA/RV view.
• Interrogate the tricuspid valve with color Doppler.
  • If tricuspid valve regurgitation is present, use continuous wave Doppler (CW Doppler) to obtain the maximum TR pressure gradient. This will be used to calculate the pulmonary artery pressure.
• Obtain a right ventricular outflow tract view (RVOT). Interrogate the pulmonic valve with and without color Doppler.
  • If a good Doppler angle exists, you may obtain the maximum pulmonic valve velocity.

Parasternal Short Axis View (PSAX):

• • Obtain a parasternal short axis image of the heart at the level of the aortic valve (base).
    • Demonstrate aortic, pulmonic and tricuspid valve leaflet function and morphology.
  • Zoom in on the aortic valve
    • Interrogate the aortic valve with color Doppler
  • Interrogate the tricuspid valve and pulmonic valve with color Doppler
    • If TR is present, obtain the peak gradient with CW Doppler.
  • Obtain peak velocity across the pulmonic valve with spectral Doppler.
  • Obtain a parasternal short axis image at the level of the mitral valve
    • Interrogate the mitral valve with color Doppler.
  • Obtain a parasternal short axis image at the level of the papillary muscles.
  • Obtain a parasternal short axis image at the level of the apex.

Apical Views:

• Obtain an apical 4 chamber view (AP4) from the apex of the heart. Be sure to optimize the image to show good endocardial definition.
  • Take care not to foreshorten the image.
• From The Apical 4 Chamber View:
  • Measure Left Ventricular Ejection Fraction by Simpson’s bi-plane method and/or by 3D volume if endocardium is adequately visualized.
  • Measure right ventricular length, base and mid dimensions in end-diastole.
  • Measure Left Atrium and Right Atrium volumes.
  • Measure LV strain if indicated
  • Measure TAPSE if indicated
• Obtain an apical 5 chamber view to clearly visualize the aortic valve.
• Obtain an apical 2 chamber view.
  • measure Left Ventricular Ejection Fraction
  • measure left atrial volume
• Obtain an apical 3 chamber, or apical long axis view.
• Interrogate the mitral valve and aortic valve with color Doppler from the apical 3 chamber view.
• Return to the apical 2 chamber view and interrogate the mitral valve with color Doppler.
• Return to the apical 4 chamber view.
  • Interrogate the mitral valve with color Doppler.
  • Interrogate the left ventricular outflow tract and aortic valve with color Doppler
  • Interrogate the tricuspid valve with color Doppler.
    • If TR is present, obtain the peak TR gradient with CW Doppler.
  • Obtain the left ventricular (LVOT) velocity with PW Doppler.
  • Obtain the peak aortic valve velocity with CW Doppler.
  • With PW Doppler, obtain spectral Doppler of the left ventricular inflow pattern at the level of the mitral valve leaflet tips.
    • Measure the E and A velocities.
    • Measure the deceleration time of the E wave.
  • Measure medial and/or lateral mitral annular e’ velocity with spectral tissue Doppler.

Subcostal View:

• Obtain a subcostal 4 chamber view.
• Interrogate the mitral valve and tricuspid valve with color Doppler.
• If TR is present, attempt to obtain the peak TR pressure gradient with CW Doppler.
• Interrogate the interatrial and interventricular septa with color Doppler for evidence of a shunt.
• Obtain an image of the inferior vena cava (IVC) where it enters the right atrium.
  • Document the IVC size and collapse with and without inspiration.

Suprasternal Notch View (SSN):

*When Indicated

• Position the patient onto their back. Place a pillow under their shoulders and/or neck to help optimize the suprasternal notch images.
• Obtain the SSN image to view the aortic arch and head vessels when possible.
• Interrogate the aortic arch with color Doppler
• Obtain spectral Doppler of the descending aorta with PW Doppler.
• Measure the suprasternal notch diameter.
• If coarctation is suspected, use CW Doppler to obtain peak gradients in the descending aorta.

Additional Imaging Requirements For Aortic Stenosis And Mitral Stenosis:

Aortic Stenosis:

• Zoom on the aortic valve in the parasternal long axis and measure the LVOT diameter at end systole.
• View the aortic valve in the parasternal short axis to visualize aortic valve morphology.
•  From the apical 5 chamber view, obtain multiple CW Doppler tracings of the peak aortic valve velocity.
•  From the apical 5 chamber view, obtain multiple PW Doppler tracings of the peak LVOT velocity.
• Interrogate the aortic valve velocities with the dedicated CW Pedoff probe from the apical, SSN and right parasternal border views.
  • For the right parasternal border, ask the patient to turn onto their right side for optimum Doppler signal quality.
• Annotate each Pedoff location.

Mitral Valve Stenosis

• In cases of Mitral Stenosis. From the apical 4 chamber:
  • Obtain a CW Doppler tracing of the mitral valve inflow. Trace multiple waveforms to obtain the mean pressure gradient.
  • From the mitral valve tracings, measure the pressure half time to calculate the mitral valve area.