Echocardiography core measures — structured viva

Stem

Practice viva. The examiner hands you a transthoracic echocardiogram report and asks how you classify the ejection fraction, how you read diastolic function and the left atrium, how you judge the right ventricle and the probability of pulmonary hypertension, and how you size a pericardial effusion.^[1][5][6]

Branch A — Ejection fraction

Examiner: The LVEF is 44% in a woman with symptoms and signs of HF. What do you call it?^[1]

Strong answer:

• Under ESC 2026 HF it is HFrEF: the diagnosis requires current or prior symptoms and/or signs of HF and an LVEF <50%, and the 2026 task force has eliminated the HFmrEF phenotype.^[1]
• Under AHA/ACC 2022, 44% sits in the HFmrEF range: Table 4 defines HFmrEF as an LVEF of 41%–49% with evidence of spontaneous or provokable increased LV filling pressures, so I would look for that evidence; HFrEF there is an LVEF ≤40%.^[2]
• ESC 2026 HF adds that a single LVEF cut-point is somewhat arbitrary and has to be evaluated in the clinical situation, as measurement varies with the modality and the interpreter, and that LVEF may be falsely high in mitral regurgitation.^[1]

Follow-up: Her LVEF rises to 52% on treatment. What changes?^[1][2]

• ESC 2026 HF defines improved LVEF as an increase of at least 10% in LVEF (absolute) to at least above 40% (often normal); from 44% to 52% is a rise of 8 points, so she does not meet that definition.^[1]
• AHA/ACC 2022 HFimpEF needs a previous LVEF ≤40% and a follow-up LVEF >40%, which her earlier 44% does not meet.^[2]
• ESC 2026 HF says it is important to ensure that patients with HFrEF and improved LVEF are still managed with optimal medical therapy, except for selected patients.^[1]

Branch B — HFpEF echo criteria and the left atrium

Examiner: A different patient has symptoms and signs of HF and an LVEF of 62% that has never been below 50%. How do you look for objective evidence of HFpEF on echo?^[1]

• ESC 2026 HF Table 10 (simplified echocardiographic criteria supporting objective evidence of HFpEF): LV mass index ≥95 g/m² (female) or ≥115 g/m² (male), or relative wall thickness >0.42; LA volume indexed to BSA >34 mL/m² in sinus rhythm or >40 mL/m² in AF; E/e′ >9 at rest; estimated systolic PA pressure >35 mmHg or TR velocity at rest >2.8 m/s.^[1]
• The probability rises with the number of parameters in the pathological range, and E/e′ ≥15 is more specific but less sensitive (ESC 2026 HF).^[1]
• ESC 2026 HF requires that objective evidence to be supported by raised natriuretic peptides.^[1]
• If doubt remains, ESC 2026 HF says CPET, exercise stress echocardiography or invasive haemodynamic assessment may be considered, and calls invasive haemodynamic exercise testing the gold standard confirmatory test.^[1]

Follow-up: Does the American guideline use the same LA threshold?^[2]

• No: AHA/ACC 2022 Appendix 3 suggests LAVI ≥29 mL/m², and its ventricular diastolic function thresholds include average E/e′ ≥15 for increased filling pressures, septal e′ <7 cm/s and lateral e′ <10 cm/s.^[2]
• NHFA/CSANZ 2018 calls a left atrial volume index of more than 34 mL/m² a consequence of high left-sided filling pressure.^[10]

Branch C — The right ventricle and pulmonary pressure

Examiner: The TR velocity is 3.0 m/s. Does this patient have pulmonary hypertension?^[4]

• ESC/ERS 2022 says a peak TRV >2.8 m/s may suggest PH, but TRV alone cannot reliably determine whether PH is present.^[4]
• ESC/ERS 2022 recommends using the peak TRV (and not the estimated sPAP) as the key variable for assigning the echocardiographic probability of PH, and recommends assigning that probability based on an abnormal TRV and the presence of other echocardiographic signs suggestive of PH (Class I, Level B) and maintaining the current TRV threshold (>2.8 m/s) for echocardiographic probability of PH under the updated haemodynamic definition (Class I, Level C).^[4][5]
• I look for Table 10 signs in three categories (the ventricles, the pulmonary artery, the IVC and RA); signs from at least two categories must be present to alter the probability level.^[4]
• Echocardiography alone cannot confirm PH; that requires right heart catheterisation (ESC/ERS 2022).^[4]

Follow-up: How would you report RV function in confirmed acute PE?^[9]

• AHA/ACC 2026 (COR 1, LOE B-NR): in acute PE with TTE, RV dysfunction should be assessed and reported by RV/LV end-diastolic ratio, RV end-diastolic diameter, TAPSE, estimated RV systolic pressure, McConnell’s sign, tricuspid systolic velocity, paradoxical septal motion and IVC respirophasic collapse, to assist with risk stratification.^[9]
• AHA/ACC 2026 Table 4 calls TAPSE ≤1.7 cm and TDI S′ ≤9.5 cm/s abnormal and uses RV/LV >0.9; ESC 2019 says RV/LV ≥1.0 and TAPSE <16 mm are the findings most frequently reported with an unfavourable prognosis.^[9][8]

Branch D — Pericardial effusion

Examiner: How do you size a pericardial effusion and when do you worry?^[6]

• ESC 2025 measures the end-diastolic distance of the echo-free space between the epicardium and parietal pericardium, and grades it mild <10 mm, moderate 10–20 mm and large >20 mm.^[6]
• A large effusion (>20 mm on echocardiography) is a major high-risk feature in acute pericarditis (ESC 2025 Table 16).^[6]
• Tamponade is a clinical diagnosis based on the combination of a suggestive history, symptoms, signs and imaging confirmation by echocardiography; in ESC 2025 Table 17, a duration of RA diastolic collapse as a ratio of the cardiac cycle length >0.34 has >90% sensitivity and 100% specificity.^[6]
• ESC 2025 recommends pericardiocentesis (echocardiography-, CT- or fluoroscopy-guided) for cardiac tamponade, suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large effusion despite medical therapy (Class I, Level C).^[6]