Elizabeth McIlwain, MHS, RDCS, RCS, FASE

The question of how long it should take to perform an echocardiogram is frequently discussed in the echo world. Throughout this summer and fall it has been an ongoing topic on connect@ASE and on other echocardiography discussion venues. According to published recommendations and standards, one would think the answer is very straightforward—45 to 60 minutes. However, when the question was posed, answers ranged from a few minutes to an hour or more. I found the responses disheartening, encouraging—INTRIGUING! So, how long should it take to perform a complete echocardiogram?

The ASE’s Recommendations for Quality Echocardiography Laboratory Operations state that “Forty-five to 60 minutes should be allotted for the acquisition of the images for a complete transthoracic echocardiogram (TTE) study. An additional 15 to 30 minutes may be required for complicated cases”. The Intersocietal Accreditation Commission for Echocardiography (IAC Echocardiography) standards require an accredited echocardiography lab to schedule a minimum of 45 minutes for a TTE.

It seems that answer is not as clear cut as it appears. Echocardiography is not a “cookie cutter” procedure. Each patient is unique. Some patients are challenging to image (clinical condition, body habitus) and more time is required to optimize the image in order to obtain diagnostic information. Other patients are very “echogenic,” allowing quality diagnostic images to be obtained quickly, with minimal optimization.

Each patient also presents with a unique clinical situation, a question we are seeking to answer with the echocardiogram. Some studies are normal and require only standard views and Doppler interrogation. Other situations are more complicated. These studies require additional views and more detailed interrogation of Doppler flows to ensure accurate and appropriate information is obtained.

A complete TTE, whether easy, difficult, normal, or complicated, should include images, spectral and color Doppler, from all standard imaging planes. Two-dimensional imaging should provide definition of chambers, walls, valves, and great vessels that allows for accurate assessment of structure and function. Doppler evaluation (color and spectral) should assess flow across all valves and septa. A complete study also includes measurements providing further structural, functional, and hemodynamic assessment of the heart. The ASE recommends two-dimensional images, spectral and color Doppler, be assessed from parasternal long axis (including RV inflow), parasternal short axis at four different levels (aortic valve/RV outflow tract, mitral valve, mid-papillary, and apex), apical 4-chamber, apical 2-chamber, apical long axis, subcostal (four chamber, short axis, and IVC assessment), suprasternal notch, and other views as clinically indicated. Acquiring all of this information and ensuring it is done properly and accurately takes more than a few minutes, even on the easiest of patients.

In this era of decreasing reimbursement and increasing quality initiatives, it is vitally important that sonographers take the time to perform complete and accurate echocardiographic studies. Cardiovascular sonographers must be more than just picture-takers. We must be investigators and sleuths! We are responsible to assess structure and function—anatomy and physiology—and provide images and information to the cardiologist that present an accurate, comprehensive assessment of the heart from an ultrasound perspective. If we do not use our technology fully, we run the risk of becoming irrelevant and making echocardiography irrelevant as well.

Leaders and respected experts in our field have provided recommendations and guidelines that speak to the content of a complete echocardiogram and make comments regarding how long it should generally take to obtain the recommended information. As sonographers, if the work we are producing is not coming close to those recommendations in content and time invested, then we should be asking ourselves if we are properly caring for our patients by performing complete studies, or are we just taking pictures.

During the ASE’s annual Scientific Sessions this year, Dr. Alan Pearlman referred to the fact that we used to do echocardiograms to find answers. I believe the answer to “How long should an echocardiogram take?” lies in that statement. Every patient who comes into the echo lab brings a clinical question that needs an answer. The echocardiogram should take the length of time required to find and verify the answer. If we are following the recommendations and standards that have been provided, then the time it takes to perform a complete echo will generally fall within the 45–60 minutes that are suggested by the guidelines.

So, as this conversation continues in our labs and forums, how would you answer the question? Are you taking pictures or looking for answers?