Transthoracic Echocardiogram Report

Transthoracic Echocardiogram (TTE) Report

Patient: [Name, MRN, DOB/Age, Sex]

Height/Weight/BSA: [Height / Weight / BSA]

Study Date/Time: [Date and time]

Ordering Clinician: [Name, credentials]

Sonographer: [Name, credentials]

Interpreting Physician: [Name, credentials]

BP at Exam: [Systolic/Diastolic mmHg]

HR/Rhythm: [Rate bpm, rhythm] (Note significant rhythm variability if present)

Indication

[Clinical question(s) and relevant history] (State primary clinical question(s) without abbreviations. Include pertinent history such as prior valve surgery, known cardiomyopathy, implanted devices, and date of prior echocardiogram if available.)

Summary Statement

(Provide 4–6 bullets ordered by clinical importance, most urgent first.)

• [LV systolic function and LVEF with method]
• [RV systolic function summary with key metric]
• [Significant valvular abnormalities with severity and mechanism]
• [Other important findings: effusion, thrombus/mass, vegetation, aortic dilation, elevated pressures, shunt results]
• [Pertinent negatives addressing the indication] (Only include if structure was adequately visualized)
• [Comparison to prior study: date, images vs report-only reviewed, interval changes] (If none available, state "No prior echocardiogram available for comparison")

CRITICAL RESULT: [Critical finding and communication documentation: recipient, date/time, method] (Only include if critical result identified)

Technique & Image Quality

• Study type: [comprehensive / limited / focused]
• Modalities: [2D / M-mode / color Doppler / spectral Doppler / tissue Doppler / 3D / strain]
• Contrast: [None / Agent, dose, indication, reaction if any]
• Agitated saline study: [Not performed / Performed with maneuvers and shunt interpretation] (Include timing, direction, and intra- vs extracardiac if determined)
• Image quality: [good / adequate / poor] (List key limiting factors if applicable)
• Limitations: [Structures or measurements not obtained with reason] (Use terms: "not visualized," "technically limited," "not assessed," or "indeterminate")

Measurements

(Retain row and enter "Not obtained—[reason]" when a required measurement cannot be obtained.)

Parameter	Value	Units	Indexed
Left Ventricle
LVIDd	[value]	cm	—
LVIDs	[value]	cm	—
IVSd	[value]	cm	—
LVPWd	[value]	cm	—
LV EDV (biplane)	[value]	mL	[mL/m²]
LV ESV (biplane)	[value]	mL	[mL/m²]
LVEF (method)	[value, method]	%	—
Global longitudinal strain	[value]	%	—
LV mass	[value]	g	[g/m²]
Right Ventricle
RV basal diameter	[value]	cm	—
RV mid diameter	[value]	cm	—
RV longitudinal dimension	[value]	cm	—
TAPSE	[value]	cm	—
RV S' (TDI)	[value]	cm/s	—
RV FAC	[value]	%	—
Atria
LA volume (biplane)	[value]	mL	[mL/m²]
RA area (4C)	[value]	cm²	—
Diastolic Function
MV E velocity	[value]	m/s	—
MV A velocity	[value]	m/s	—
E/A ratio	[value]	—	—
Septal e'	[value]	cm/s	—
Lateral e'	[value]	cm/s	—
Average E/e'	[value]	—	—
Deceleration time	[value]	ms	—
TR velocity (peak)	[value]	m/s	—
Diastolic function	[normal / grade I / grade II / grade III / indeterminate]	—	—
Valvular Hemodynamics (when stenosis or significant regurgitation present)
AV Vmax	[value]	m/s	—
AV mean gradient	[value]	mmHg	—
AVA (continuity)	[value]	cm²	[cm²/m²]
Dimensionless index	[value]	—	—
MR vena contracta	[value]	cm	—
MR EROA	[value]	cm²	—
MR regurgitant volume	[value]	mL	—
MV mean gradient	[value]	mmHg	—
MV area (method)	[value, method]	cm²	—
TR vena contracta	[value]	cm	—
PR end-diastolic gradient	[value]	mmHg	—
Pulmonary Pressures & IVC
IVC diameter	[value]	cm	—
IVC collapsibility	[value]	%	—
Estimated RAP	[value / unable to assess]	mmHg	—
RVSP/PASP	[value]	mmHg	—
Aorta
Annulus	[value]	cm	[cm/m²]
Sinus of Valsalva	[value]	cm	[cm/m²]
Sinotubular junction	[value]	cm	[cm/m²]
Proximal ascending aorta	[value]	cm	[cm/m²]

Findings

(Provide qualitative summary with severity, key quantitative values, and mechanism. Do not label a structure "normal" unless adequately visualized.)

Left Ventricle: [Size, geometry, wall thickness, systolic function with LVEF and method, regional wall motion, diastolic function with filling pressure estimate, LVOT obstruction, thrombus/mass if present]

Right Ventricle: [Size, systolic function, pressure or volume overload signs]

Atria & Septa: [LA and RA size, interatrial septum morphology, shunt findings if bubble study performed]

Aortic Valve: [Morphology, stenosis severity, regurgitation severity, mechanism] (For prosthetic valves: type, size, gradients, paravalvular leak. Use "at least moderate" or "indeterminate due to [limitation]" when data insufficient.)

Mitral Valve: [Morphology, stenosis/regurgitation severity with mechanism] (For prosthetic valves: type, size, gradients, paravalvular leak)

Tricuspid Valve: [Morphology, regurgitation severity and mechanism, stenosis if present]

Pulmonic Valve: [Morphology, regurgitation/stenosis severity]

Aorta: [Segmental dimensions, dilation/aneurysm, atheroma if visualized] (Note segments not visualized)

IVC: [Size, respiratory variation, estimated RAP]

Pericardium: [Effusion presence/absence, size, distribution, tamponade physiology if present]

Devices: [Lead position, valve interaction, associated findings] (Only include if pacemaker/ICD/mechanical support present)

Extracardiac: [Pleural effusions, incidental findings] (Only include if present)

Interpreting Physician: [Name, credentials, electronic signature, date/time]

Report Status: [Preliminary / Final]