Echocardiography

The module Echocardiography is used to document parameters of transthoracic echocardiography examinations.
These examinations ought to be performed according to DZHK-SOP-K-08 .

Content

Examination details
Examination
Image quality
Dimensions (long axis: M-mode parasternal)
2-D measurements (4CH and 2CH apical, subcostal)
Mitral valve Doppler (PW)
Tissue Doppler (TDI)
Pulmonary venous flow
Valve

Examination details

Was the echocardiography performed?

  Fieldname: echo_janein
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Date of examination

  Fieldname: echo_date
  Data type: Timestamp with day, month and year

Quality level

Level 1: The examination is performed in accordance with the guidelines of the medical associations.

Level 2: The examination is performed in accordance with the specifications of the DZHK SOP. Minimum requirements to ensure the quality of the implementation and the examiners are defined in the SOP.

Level 3: The examination is performed in accordance with the specifications of the DZHK SOP and certification of the examiners: Definition of intr-observer and interobserver-variability (standard of epidemiological studies).

DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: gehtest_qualitaet
  Data type: Integer with following options
    1
    2
    3

Examination

Heart rate

  Fieldname: echo_frequenz 
  Data type: Integer with maximum 3 digits in min

Rhythm

Sinus rhythm

  Fieldname: echo_sinus
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Atrial fibrillation

  Fieldname: echo_vorhof
  Data type: String wit following options
    yes
    no
    unknown
    not assessed

Pacemaker

  Fieldname: echo_schritt
  Data type: String with following options
    yes
    no
    unknown
    not assessed

  Fieldname: echo_schritttyp
  Data type: String with following options
    PM+sinus rhythm 
    PM+atrial fibrillation 
    stimulation mode

other rhythm

  Fieldname: echo_rhythm_andere
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Image quality

Imaging modalities for all settings

1. For patients with sinus rhythm, 3 cardiac cycles are recorded (this applies to still images and Cineloop/sequence) and stored digitally; for patients with atrial fibrillation, 5 cardiac cycles are recorded and saved

2. ES measurement means end of the T-wave or largest thickness of the myocardium

3. ED measurement means near the Q-peak or start of the QRS complex

4. Throughput speed 50-100/min

5. Throughout the examination, ensure a simultaneous ECG curve with correct rendering of the P-wave (if available) and QRS complex

6. In patients with sinus rhythm, ideally 3 measurements of the predefined parameters are carried out, or 3 values are calculated; in patients with atrial fibrillation, ideally 5 measurements/calculations are carried out; in case of extrasystoles, ideally 3 measurements of normal heartbeats are also carried out not before or after an extrasystole.
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

System of examination requirements

For all standard sections recorded during echocardiography, the following chapters summarise recommendations for the data collection with regard to the modality (e.g. M-mode, 2D), the structures to be imaged, the quality criteria and the reading. The following abbreviat ions are used:
A: Recording

S: Structures to be visualised and assessed

Q: Quality criteria

R: Reading

DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Parasternal long axis

  Fieldname: echo_para_lang
  Datat type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Parasternal short axis

  Fieldname: echo_para_kurz
  Data type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Apical four-chamber view

4-CH (with LA/ RA)

A: 2D mode(sequece)

S: 1. Atrial and ventricular septum
2. Lateral wall of the LV
3. LA+RA area
4. Tricuspid valve (anterior and septal leaflet) and mitral valve (anterior and posterior leaflet)
5. LVEF (visual estimation)

Q: 1. The septum should be perpendicular
2. The septal mitral valve insertion should be at the same height as the tricuspid valve insertion
3. The left ventricle should be visualised in such a way that an axis as long as possible (from the middle of the connecting line of the mitral leaflet insertion points to the apex) is displayed
4. The depth should be minimised in order to visualise the LA as large as possible and in its entirety
R: Measurements (see Table 12 - Measurements in the apical four-chamber view)
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

4-CH (without LA/ RA)

A: 2D mode(sequence)

S: 1. Ventricular septum
2. Lateral wall of the LV
3. Tricuspid valve (anterior and septal leaflet)
4. Mitral valve (anterior and posterior leaflet)
5. LVEF (biplane according to Simpson, see also 2-CH)
6. RV area and function
7. Assessment: pericardium/ pericardial border

Q: 1. The LV should be displayed along its long axis to avoid shortening. If necessary, take separate images to allow for an assessment of the LV and RV, as an optimal simultaneous visualisation is not always possible. (image optimised for the right side for right-ventricular measurements)
2. The penetration depth should be minimised in order to visualise the LV as large as possible and with the complete apex (the LA should be cut off)
R: 1. Visual assessment of the LV function / kinetics of the septal and lateral wall (wall motion disorder: yes, no, unknown, not assessed)
2. Measurements (see Table 13-Measured values for the left and right ventricular diameter, Table 14–Heart valve parameters on the 2D image and Table 15-Calculated parameters from the planimetry)
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: echo_apik_vier
  Data type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Apical three-chamber view

A: 2D (sequence)

S:Left atrium and left ventricle (septal and inferolateral segments), aortic valve (right coronary and non-coronary cusp) as well as A2- and P2-segments of the mitral valve, measurements of the aortic valve/mitral valve in the three-chamber view only complementary, performance as previously outlined

Q: 1. The left ventricle should be visualised in the optimal length and completely stretched
2. The septum should be perpendicular to the lower part of the image
R: Visual assessment of the anteroseptal and inferolateral wall sections, the measurements of the aortic valve are performed analogously to the measurements in the apical five-chamber view.
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: echo_apik_drei
  Data type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Apical two-chamber view

A: 2D (sequence)

S: Complete visualisation of the anterior and inferior part of the LV and of the left atrium as well as of the mitral valve, segment P1, A2 and P3 (optionally coronary sinus/left atrial appendage), measurements of the mitral valve as outlined in the section on the four-chamber view

Q: 1. The left ventricle should be visualised in the optimal length and completely stretched
2. The septum should be perpendicular to the lower part of the image
R: Visual assessment of the kinetics of the anterior and inferior wall sections, the measurements in the area of the mitral valve are performed analogously to the measurement in the four-chamber view. The LA volumetry (end-systolic) should be recorded biplane (from the insonation in the four-and two-chamber view)
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: echo_apik_zwei
  Data type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Subcostal

  Fieldname: echo_subkos
  Data type: String with following options
    proper axial alignment with good image quality
    axis deviation with good image quality
    unknown (limited possibility of assessment)
    not assessed

Dimensions (long axis: M-mode parasternal)

Parameters of 2D image rendition/M-mode

Depending on the manufacturer's specifications, always use the lowest sound output power at which ultrasound images with sufficient quality can be obtained. Adjust the overall gain and depth regulation until the structures in the 2D image sector are optimally delimited. The same applies to the gain in the longitudinal direction or lateral direction; adjust the settings depending on the cross-sectional plane and the desired image quality. To achieve an optimal contrast on the images, also adjust the compression individually depending on the examination conditions. A frame rate of 50 frames/second is advisable.
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

M-mode measured in

  Fieldname: echo_mmode
  Data type: String with following options
    parasternal long axis
    parasternal short axis
    2D
    anatomical M-mode
    unknown (impossible to locate)
    not assessed

Aortic root diameter (endsystolic) (AO)

  Fieldname: echo_aorta
  Data type: Integer with maximum 2 digits in mm

Left atrium (end-systolic) (LA diam)

  Fieldname: echo_ladiam
  Data type: Integer with maximum 2 digits in mm

Interventricular septum (end-diastolic) (IVS_d)

  Fieldname: echo_ivsd
  Data type: Integer with maximum 2 digits in mm

Leftventricular end-diastolic diameter (LVED_d)

  Fieldname: echo_ivedd
  Data type: Integer with maximum 2 digits in mm

Left ventricular posterior wall (LVPW_d)

  Fieldname: echo_lvpwd
  Data type: Integer with maximum 2 digits in mm

Left ventricular end-systolic diameter (LVED_s)

  Fieldname: echo_lveds
  Data type: Integer with maximum 2 digits in mm

2-D measurements (4CH and 2CH apical, subcostal)

Left ventricular ejection fraction (LV-EF)

  Fieldname: echo_lvef
  Data type: Integer with maximum 2 digits in %

Method

  Fieldname: echo_methode
  Data type: String with following options
    Simpson biplane
    Simpson monoplane (4CH)
    visual
    unknown
    not assessed

Left ventricular end-diastolic volume (LVEDV)

  Fieldname: echo_lvedv
  Data type: Integer with maximum 3 digits in ml

Left ventricular end-systolic volume (LVESV)

  Fieldname: echo_lvesv
  Data type: Integer with maximum 3 digits in ml

Left atrium AP longitudinal (end-systolic) (LA_{s (ap.längs)})

  Fieldname: echo_laes_lang
  Data type: Integer with maximum 2 digits in mm

Left atrium AP transversal (end-systolic) (LA_{s (ap.quer)})

  Fieldname: echo_laes_quer
  Data type: Integer with maximum 2 digits in mm

Left atrial area 4-chamber view (end-systolic) (LA-area(4CH))

  Feldname: echo_la_area_4ch
  Data type: Floating point number with 2 places before and 1 place after comma in cm

Left atrial area 2-chamber view (end-systolic) (A2 LA area (2CH)_s)

  Fieldname: echo_la_area_2ch
  Data type: Floating point number with 2 places before and 1 place after comma in cm

Wall motion disorder

  Fieldname: echo_wandbeweg
  Data type: String with following options
    yes
    no
    unknown
    not assessed

RV dilatation (mid-ventricular)

RV dilation is defined by means of the mid-ventricular end-diastolic diameter (RVED2). RV dilation is defined as RVED2 > 34 mm
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: echo_rv
  Data type: String with following options
    yes
    no
    unknown
    not assessed

TAPSE (tricuspid annular plane systolic excursion)

A: M-mode

S: Distance between the end-diastolic and end-systolic movement of the lateral insertionof the tricuspid valve

Q: The M-mode beam should be positioned in the lateral tricuspid valve annulus. The direction of movement of the lateral tricuspid annulus has to be parallel to the M-mode scan line; the angle of insonation may have to be adjusted for this

R: Measurements

Measured parameter (unit) Measuring time Position of the measuring points
TAPSE (mm) ES to ED Endocardial border line (ES)
Endocardial border line (ED)
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Measured parameter (unit)	Measuring time	Position of the measuring points
TAPSE (mm)	ES to ED	Endocardial border line (ES) Endocardial border line (ED)

  Fieldname: echo_tapse
  Data type: Integer with maximum 2 digits in mm

MAPSE (mitral annular plane systolic excursion) lateral

  Fieldname: echo_mapse_lat
  Data type: Integer with maximum 2 digits in mm

MAPSE septal

  Fieldname: echo_mapse_sep
  Data type: Integer with maximum 2 digits in mm

Pericardial effusion

EPericardial effusion is present when echo free pericardial separation is demonstrated at the end of the diastole (>1 mm )
A pericardial effusion should always be evaluated in different cross-sectional planes, usually in the parasternal long axis, in the apical 4-chamber view and in the subcostal cross-section. The width of the effusion can be measured at the end of the diastole using the M-mode recording in the parasternal long axis, if possible orthogonally to the separation caused by the effusion or alternatively by means of apical cross-sectional images. Effusions that are visible at the end of the diastole can be classified as small (20 mm).

DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

  Fieldname: echo_perikarderguss
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Vena cava diameter

  Fieldname: echo_vencava_dm
  Data type: Integer with maximum 2 digits in mm

Vena cava response to breathing (>50% decrease on inspiration)

  Fieldname: echo_venacava_atem
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Parameters of Doppler procedures

The gain of the colour Doppler should only be slightly in front of the background; adjust the gain of the spectral Doppler curves until the respective envelope curves are optimally visualised. Adjust the zero line and velocity range until the flow profiles to be measured are complete; the velocity range should be slightly above the maximum velocity. The sample volume of the PW Doppler should be 3 mm, the sample volume of the tissue Doppler 5 mm. Recommendations for adjusting the wall filter and for adjusting the pulse repetition rate of the colour Doppler may be found in the individual settings.
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Recording speed

For the 2D image/M-mode and colour Doppler, a recording speed of 50 mm/s should be selected; for spectral and tissue Doppler, a speed of 100 mm/s should be selected. For M-mode colour recordings (propagation velocity) 100-200 mm/s should be selected.
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Mitral valve Doppler (PW)

E-wave

  Fieldname: echo_e_welle
  Data type: Integer with maximum 3 digits in m/s

A-wave

  Fieldname: echo_a_welle
  Data type: Integer with maximum 3 digits in m/s

Tissue Doppler (TDI)

E and A wave (lateral)

Measured paramters Measuring times Position of the measuring points
E'lat (cm/s) Early diastole V_maxof the E'-wave
A'lat (cm/s) Late diastole V_max of the A'-wave
S'lat (cm/s) Systolic V_max of the S'-wave
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Measured paramters	Measuring times	Position of the measuring points
E'lat (cm/s)	Early diastole	V_maxof the E'-wave
A'lat (cm/s)	Late diastole	V_max of the A'-wave
S'lat (cm/s)	Systolic	V_max of the S'-wave

E'-wave (lateral)

  Fieldname: echo_e_welle_lateral
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

A'-wave (lateral)

  Fieldname: echo_a_welle_lateral
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

S' (lateral)

  Fieldname: echo_s_lateral
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

TDI lat cannot be measured

  Fieldname: echo_lateral_nicht
  Data type: Checkbox

E and A (medial)

Measured paramter Measuring time Position of the measuring
E'med (cm/s) Early diastole V_max of the E'-wave
A'med (cm/s) Late diastole V_max of the A'-wave
S'med (cm/s) Systolic V_max of the S'-wave
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Measured paramter	Measuring time	Position of the measuring
E'med (cm/s)	Early diastole	V_max of the E'-wave
A'med (cm/s)	Late diastole	V_max of the A'-wave
S'med (cm/s)	Systolic	V_max of the S'-wave

E'-Wave (medial)

  Fieldname: echo_e_welle_medial
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

A'-Welle (medial)

  Fieldname: echo_a_welle_medial
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

S' (medial)

  Fieldname: echo_s_medial
  Data type: Floating point number with 2 places before and 1 place after comma in cm/s

TDI sep cannot be measured

  Fieldname: echo_septal_nicht
  Data type: Checkbox

Pulmonary venous flow

Systolic flow

Pulmonary venous systolic velocity (PVsVel)

  Fieldname: echo_sys_fluss
  Data type: Integer with maximum 2 digits in cm/s

Diastolic flow

Pulmonary venous diastolic velocity (PVdVel)

  Fieldname: echo_dia_fluss
  Data type: Integer with maximum 2 digits in cm/s

Valves

Quantification of valve defects

The listed criteria that are used to quantify defects are always based on different parameters. The assessment of whether and to what extent a defect is present is incumbent upon the examiner, who has to take into account the various parameters. The criteria should be applied to "native heart valves", not after replacement (biological or mechanical).
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Mitral valve

  Fieldname: echo_mitral
  Data type: String with following options
    native
    post-surgical
    unknown
    not assessed

Status post mitral valve surgery

  Fieldname: echo_mitral_op
  Data type: String with following options
    mitral valve reconstruction
    biological mitral valve replacement
    mechanical mitral valve replacement
    interventional reconstruction/clipping
    unknown
    not assessed

Mitral valve morphology

  Fieldname: echo_mitral_morpho
  Data type: String with following options
    normal
    abnormal
    unknown
    not assessed

Sclerosis

  Fieldname: echo_msklerose
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Mitral leaflet calcification

  Fieldname: echo_msegel
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Mitral annular calcification

  Fieldname: echo_mring
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Separation disorder

  Fieldname: echo_mseparat
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Flail leaflet

  Fieldname: echo_mleaflet
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Myxomatous prolapse

  Fieldname: echo_mprolaps
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Prolapse due to fibroelastic deficiency

  Fieldname: echo_mprolaps_defiz
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Pseudo-prolapse

  Fieldname: echo_mpseudo
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Mitral valve insufficiency (MI)

Severity
Criteria 1 (mild) 2 (moderate) 3 (severe)
Qualitative
Mitral valve morphology Normal/ abnormal Normal/ abnormal Flail leaflet/ ruptured papillary muscles
Colour Doppler of the insufficiency jet small, central intermediate Very large central jet or eccentric jet adhering swirling and reaching the posterior wall of the LA
Flow convergence zone (Nyquist 50-60 cm/s) None or small intermediate large
CW Signal of the insufficiency jets Faint/parabolic Dense/parabolic Dence/ triangular
Semi-quantitative
Vena contracta width (mm) >3 intermediate ≥7 (>8 for the mean of a biplane measurement)
Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversal
Mitral inflow A-wave dominant variable E-wave dominant (>1,5 cm/s)
TVI with/ TVI Ao >1 intermediate >1,4
Quantitative
EROA (mm²) <20 20-29; 30-39 ≥40
R Vol (mL) <30 30-44; 45-59 ≥60
+ LV and LA size and the systolic pulmonary arterial pressure
Abbreviations:: CW, contious wave; LA, left atrium, EROA, effective regurgitant orifice area; LV linker ventrikel; MR, mitral regurgitation; R Vol, regurgitant volume; VC, Vena contracta
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Criteria	1 (mild)	2 (moderate)	3 (severe)
Qualitative
Mitral valve morphology	Normal/ abnormal	Normal/ abnormal	Flail leaflet/ ruptured papillary muscles
Colour Doppler of the insufficiency jet	small, central	intermediate	Very large central jet or eccentric jet adhering swirling and reaching the posterior wall of the LA
Flow convergence zone (Nyquist 50-60 cm/s)	None or small	intermediate	large
CW Signal of the insufficiency jets	Faint/parabolic	Dense/parabolic	Dence/ triangular
Semi-quantitative
Vena contracta width (mm)	>3	intermediate	≥7 (>8 for the mean of a biplane measurement)
Pulmonary vein flow	Systolic dominance	Systolic blunting	Systolic flow reversal
Mitral inflow	A-wave dominant	variable	E-wave dominant (>1,5 cm/s)
TVI with/ TVI Ao	>1	intermediate	>1,4
Quantitative
EROA (mm²)	<20	20-29; 30-39	≥40
R Vol (mL)	<30	30-44; 45-59	≥60

  Fieldname: echo_mitral_insuf
  Data type: String with following options
    no MI
    mild MI
    moderate MI
    severe MI
    unknown (cannot be determined)
    not assessed

Mitral valve stenosis (MS)

Severity
Criteria 1 (mild) 2 (moderate) 3 (severe)
Specific findings
Valve opening area (cm²) >1,5 1,0-1,5 <1,0
Supportive findings
Mean gradient (mmHg) <5 5-10 >10
Pulmonary artery pressure (mmHg) <30 30-50 >50
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Criteria	1 (mild)	2 (moderate)	3 (severe)
Specific findings
Valve opening area (cm²)	>1,5	1,0-1,5	<1,0
Supportive findings
Mean gradient (mmHg)	<5	5-10	>10
Pulmonary artery pressure (mmHg)	<30	30-50	>50

  Fieldname: echo_mitral_sten
  Data type: String with following options
    no MS
    mild MS
    moderate MS
    severe MS
    unknown (cannot be determined)
    not assessed

Aortic valve

Assessed parameter (unit) Visual assessment of the valve
Aortic valve Native, post-surgical (status post biological view)
replacement (yes/no), status post mechanical view
replacement (yes/no), status post interventional valve
replacement (yes/no), unknown, not assessed
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

Assessed parameter (unit)	Visual assessment of the valve
Aortic valve	Native, post-surgical (status post biological view) replacement (yes/no), status post mechanical view replacement (yes/no), status post interventional valve replacement (yes/no), unknown, not assessed

  Fieldname: echo_aorte
  Data type: String with following options
    native
    post-surgical
    unknown
    not assessed

Status post aortic valve

  Fieldname: echo_aorten_op
  Data type: String with following options
    status post biological aortic valve replacement surgery
    status post mechanical aortic valve replacement surgery
    status post interventional aortic valve replacement surgery
    unknown
    not assessed

Aortic valve morphology

  Fieldname: echo_aorten_morpho
  Data type: String with following options
    normal
    abnormal
    unknown
    not assessed

Sclerosis

  Fieldname: echo_asklerose
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Calcification

  Fieldname: echo_akalk
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Separation disorder

  Fieldname: echo_aseparat
  Data type: String with following options
    yes
    no
    unknown
    not assessed

bicuspid

  Fieldname: echo_abikuspid
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Aortic valve insufficiency (AI)

Severity
Parameters 1 (mild) 2 (moderate) 3 (severe)
Qualitative
Aortic valve morphology Normal/ abnormal Normal/ abnormal Abnormal/ flail/ large coaptation defect
Colour flow AR jet width (at Nyquist 50-60 cm/s) small, central intermediate large in central jet, variable in eccentric jets
CW signal of AR jets Incomplete/ faint Dense Dense
Diastolic flow reversal in the descending aorta Brief, protodiastolic flow reversal Intermediate Holodiastolic flow reversal (end-diastolic velocity >20 cm/s)
Semiquantitative
Vena contracta width (mm) >3 intermediate >6
Pressure half-time (ms) >500 intermediate <200
Quantitativ
EROA (mm²) <10 10-19; 20-29 ≥30
R Vol (mL) <30 30-44; 45-59 ≥60
+ LV size
Abbreviations: AR Aortic regurgitation, CW, continuous wave; LA, linker atrium; EROA, effective regurgitant orifice area; IVC, inferiore Vena cava; LV, linker ventricle; R Vol, regurgitant volume; VC, Vena contracta
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Parameters	1 (mild)	2 (moderate)	3 (severe)
Qualitative
Aortic valve morphology	Normal/ abnormal	Normal/ abnormal	Abnormal/ flail/ large coaptation defect
Colour flow AR jet width (at Nyquist 50-60 cm/s)	small, central	intermediate	large in central jet, variable in eccentric jets
CW signal of AR jets	Incomplete/ faint	Dense	Dense
Diastolic flow reversal in the descending aorta	Brief, protodiastolic flow reversal	Intermediate	Holodiastolic flow reversal (end-diastolic velocity >20 cm/s)
Semiquantitative
Vena contracta width (mm)	>3	intermediate	>6
Pressure half-time (ms)	>500	intermediate	<200
Quantitativ
EROA (mm²)	<10	10-19; 20-29	≥30
R Vol (mL)	<30	30-44; 45-59	≥60
+ LV size

  Fieldname: echo_aorten_insuf
  Data type: String with following options
    no AI
    mild AI
    mild AI
    severe AI
    unknown (cannot be determined)
    not assessed

Aortic valve stenosis (AS)

Severity
Criteria Aortic sklerosis 1 (mild) 2 (moderate) 3 (severe)
Aortic valve jet velocity (Vmax)(m/s) ≤2,5m/s 2,6-2,9 3,0-4,0 >4,0
Mean gradient (mmHg) - <20 (<30) 20-40 (30-50) >40 (>50)
AVA-Valve opening area (cm²) >1,5 1,0-1,5 <1,0
Indexed Valve opening area per body surface area (cm²/m²) >0,85 0,60-0,85 <0,6
Velocity ratio >0,5 0,25-0,50 <0,25
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Criteria	Aortic sklerosis	1 (mild)	2 (moderate)	3 (severe)
Aortic valve jet velocity (Vmax)(m/s)	≤2,5m/s	2,6-2,9	3,0-4,0	>4,0
Mean gradient (mmHg)	-	<20 (<30)	20-40 (30-50)	>40 (>50)
AVA-Valve opening area (cm²)		>1,5	1,0-1,5	<1,0
Indexed Valve opening area per body surface area (cm²/m²)		>0,85	0,60-0,85	<0,6
Velocity ratio		>0,5	0,25-0,50	<0,25

  Fieldname: echo_aorten_sten
  Data type: String with following options
    no AS
    mild AS
    moderate AS
    severe AS
    unknown (cannot be determined)
    not assessed

Pulmonary valve

  Fieldname: echo_pulm
  Data type: String with following options
    native
    post-surgical
    unknown
    not assessed

Pulmonary valve morphology

  Fieldname: echo_pulm_morpho
  Data type: String with following options
    normal
    abnormal
    unknown
    not assessed

Sclerosis

  Fieldname: echo_psklerose
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Calcification

  Fieldname: echo_pkalk
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Separation disorder

  Fieldname: echo_pseparat
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Pulmonary valve insufficiency (PI)

Severity
Criteria 1 (mild) 2 (moderate) 3 (severe)
Qualitative
Pulmonary valve morphology Normal Normal/ abnormal abnormal
Colour flow PR jet width (at Nyquist 50-60 cm/s) Small, usually <10 mm in length with a narrow origin intermediate Large, with a wide origin; may be brief in duration
CW signal of PR jet Faint/ slow deceleration Dense/variable Dense/ steep deceleration eraly termination of diastolic flow
Pulmonic vs. aortic flow by PW Doppler Normal or slightly increased intermediate Greatly increased
Semiquantitative
Vena contracta width (mm) Not defined Not defined Not defined
Quantitativ
EROA (mm²) Not defined Not defined Not defined
R Vol (mL) Not defined Not defined Not defined
+ RV size
Abbreviations: AR Aorten regurgitation, CW, contious wave; LA, linker Vorhof; EROA, effective regurgitant orifice area; IVC, inferiore Vena cava; LV, linker Ventrikel; R Vol, Regurgitant volume; VC, Vena contracta
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Criteria	1 (mild)	2 (moderate)	3 (severe)
Qualitative
Pulmonary valve morphology	Normal	Normal/ abnormal	abnormal
Colour flow PR jet width (at Nyquist 50-60 cm/s)	Small, usually <10 mm in length with a narrow origin	intermediate	Large, with a wide origin; may be brief in duration
CW signal of PR jet	Faint/ slow deceleration	Dense/variable	Dense/ steep deceleration eraly termination of diastolic flow
Pulmonic vs. aortic flow by PW Doppler	Normal or slightly increased	intermediate	Greatly increased
Semiquantitative
Vena contracta width (mm)	Not defined	Not defined	Not defined
Quantitativ
EROA (mm²)	Not defined	Not defined	Not defined
R Vol (mL)	Not defined	Not defined	Not defined

  Fieldname: echo_pulm_insuf
  Data type: String with following options
    no PI
    mild PI
    moderate PI
    severe PI
    unknown (cannot be determined)
    not assessed

Tricuspid valve

  Fieldname: echo_trikus
  Data type: String with following options
    native
    post-surgical
    unknown
    not assessed

Trikuspid valve morphology

  Fieldname: echo_trikus_morpho
  Data type: String with following options
    normal
    abnormal
    unknown
    not assessed

Sclerosis

  Fieldname: echo_tsklerose
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Calcification

  Fieldname: echo_tkalk
  Data type: String with following options
    Yes
    no
    unknown
    not assessed

Ebstein

  Fieldname: echo_tebstein
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Anomaly

  Fieldname: echo_tanomalie
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Separation disorder

  Fieldname: echo_tseparat
  Data type: String with following options
    yes
    no
    unknown
    not assessed

Tricuspid valve insufficiency (TI)

Severity
Criteria 1 (mild) 2 (moderate) 3 (severe)
Qualitative
Trikuspid valve morphology Normal/ abnormal Normal/ abnormal Abnormal/ flail/ large coaptation defect
Colour flow TR jet (at Nyquist 50-60 cm/s) small,central intermediate Very large central jet or eccentric wall-impinging jet
CW signal of TR Jets Faint/ parabolic Dense/ parabolic Dense/ triangular with early peak (peak <2m/s in massive TR)
Semiquantitative
Vena contracta width (mm) Not defined <7 ≥7
PISA radius (mm) ≥5 6-9 >9
Hepatic vein flow Systolic dominance Systolic blunting Systolic flow reversal
Trikuspid inflow normal normal E-wave dominant (≥1cm/s)
Quantitative
EROA (mm²) Not defined Not defined ≥40
R Vol (mL) Not defined Not defined ≥45
+ RA/RV/IVC Größe
Abbreviations: CW, contious wave; LA, left atrium, EROA, effective regurgitant orifice area; LV linker ventrikel; MR, mitral regurgitation; R Vol, regurgitant volume; VC, Vena contracta
DZHK-SOP-K-08: Transthoracic echocardiography, Version: V1.0, Valid as of: 01.09.2014

	Severity
Criteria	1 (mild)	2 (moderate)	3 (severe)
Qualitative
Trikuspid valve morphology	Normal/ abnormal	Normal/ abnormal	Abnormal/ flail/ large coaptation defect
Colour flow TR jet (at Nyquist 50-60 cm/s)	small,central	intermediate	Very large central jet or eccentric wall-impinging jet
CW signal of TR Jets	Faint/ parabolic	Dense/ parabolic	Dense/ triangular with early peak (peak <2m/s in massive TR)
Semiquantitative
Vena contracta width (mm)	Not defined	<7	≥7
PISA radius (mm)	≥5	6-9	>9
Hepatic vein flow	Systolic dominance	Systolic blunting	Systolic flow reversal
Trikuspid inflow	normal	normal	E-wave dominant (≥1cm/s)
Quantitative
EROA (mm²)	Not defined	Not defined	≥40
R Vol (mL)	Not defined	Not defined	≥45

  Fieldname: echo_trikus_insuf
  Data type: String with following options
    no TI
    mild TI
    moderate TI
    severe TI
    unknown
    not assessed

Echocardiography

Content

Examination details

Was the echocardiography performed?

Date of examination

Quality level

Examination

Heart rate

Rhythm

Sinus rhythm

Atrial fibrillation

Pacemaker

other rhythm

Image quality

Imaging modalities for all settings

System of examination requirements

Parasternal long axis

Parasternal short axis

Apical four-chamber view

4-CH (with LA/ RA)

4-CH (without LA/ RA)

Apical three-chamber view

Apical two-chamber view

Subcostal

Dimensions (long axis: M-mode parasternal)

Parameters of 2D image rendition/M-mode

M-mode measured in

Aortic root diameter (endsystolic) (AO)

Left atrium (end-systolic) (LA diam)

Interventricular septum (end-diastolic) (IVSd)

Leftventricular end-diastolic diameter (LVEDd)

Left ventricular posterior wall (LVPWd)

Left ventricular end-systolic diameter (LVEDs)

2-D measurements (4CH and 2CH apical, subcostal)

Left ventricular ejection fraction (LV-EF)

Method

Left ventricular end-diastolic volume (LVEDV)

Left ventricular end-systolic volume (LVESV)

Left atrium AP longitudinal (end-systolic) (LAs (ap.längs))

Left atrium AP transversal (end-systolic) (LAs (ap.quer))

Left atrial area 4-chamber view (end-systolic) (LA-area(4CH))

Left atrial area 2-chamber view (end-systolic) (A2 LA area (2CH)s)

Wall motion disorder

RV dilatation (mid-ventricular)

TAPSE (tricuspid annular plane systolic excursion)

MAPSE (mitral annular plane systolic excursion) lateral

MAPSE septal

Pericardial effusion

Vena cava diameter

Vena cava response to breathing (>50% decrease on inspiration)

Parameters of Doppler procedures

Recording speed

Mitral valve Doppler (PW)

E-wave

A-wave

Tissue Doppler (TDI)

E and A wave (lateral)

E'-wave (lateral)

A'-wave (lateral)

S' (lateral)

TDI lat cannot be measured

E and A (medial)

E'-Wave (medial)

A'-Welle (medial)

S' (medial)

TDI sep cannot be measured

Pulmonary venous flow

Systolic flow

Pulmonary venous systolic velocity (PVsVel)

Diastolic flow

Pulmonary venous diastolic velocity (PVdVel)

Valves

Quantification of valve defects

Mitral valve

Status post mitral valve surgery

Mitral valve morphology

Sclerosis

Mitral leaflet calcification

Mitral annular calcification

Separation disorder

Interventricular septum (end-diastolic) (IVS_d)

Leftventricular end-diastolic diameter (LVED_d)

Left ventricular posterior wall (LVPW_d)

Left ventricular end-systolic diameter (LVED_s)

Left atrium AP longitudinal (end-systolic) (LA_{s (ap.längs)})

Left atrium AP transversal (end-systolic) (LA_{s (ap.quer)})

Left atrial area 2-chamber view (end-systolic) (A2 LA area (2CH)_s)