Cross-Sectional Analysis of Echocardiography Reports in Light of Guideline Recommendations

Abstract

Objective:

The aim of this study is to identify discrepancies in pediatric echocardiography reports across centers and emphasize the significance of establishing a standardized reporting approach.

Materials and Methods:

In this study, pediatric echocardiography reports from various institutions (university hospitals [UHs], training and research hospitals [TRHs], and private healthcare facilities) (33 reports from 29 centers) were evaluated for adherence to key criteria outlined in consensus guidelines by the European Association of Cardiovascular Imaging of the European Society of Cardiology and the Association for European Paediatric and Congenital Cardiology. Each echocardiography report was systematically categorized into distinct sections, including patient information, medical records, echocardiographic findings, and conclusions.

Results:

Systemic and pulmonary venous return was reported in 58.3% of cases from UHs, 77.7% from TRHs, and 66.7% from private healthcare institutions (PHIs). Pulmonary artery and aortic arch were documented in 83.3% of reports from PHIs, 88.8% from TRHs, and 25% from UHs. Coronary artery dimensions and course were reported in 58.3% of reports from UHs, 77.7% from TRHs, and 16.7% from PHIs. Physician interpretations and diagnoses were present in all reports. However, information regarding environmental factors, such as whether the patient was awake or agitated during the examination, was reported in 66.6% of cases from TRHs but was entirely absent in reports from other institutions.

Conclusion:

This study demonstrates important variability in pediatric echocardiography reports. Adopting international guidelines may facilitate standardized reporting, ensure consideration of underassessed parameters, and promote a unified terminology across institutions.

What is already known on this topic?

• Transthoracic echocardiography is a fundamental imaging modality in pediatric cardiac assessment, enabling a comprehensive evaluation of anatomical, hemodynamic, and physiological parameters.

• There is important variability in pediatric echocardiography reports across different healthcare institutions.

What this study adds on this topic?

• Adoption of international guidelines may help standardize pediatric echocardiography reporting practices.

• The findings highlight the need for standardized reporting practices and may contribute to the development of a unified terminology and structured reporting framework at the national level.

Introduction

Transthoracic echocardiography (TTE) is a noninvasive imaging modality that facilitates a comprehensive evaluation of the heart’s anatomical structure, hemodynamic parameters, and physiological functions. Owing to its high diagnostic accuracy and practical utility, it is regarded as a cornerstone in cardiac assessment.¹ The widespread clinical use of pediatric echocardiography highlights the importance of standardized and comprehensive reporting. However, variations in reporting methodologies across different centers pose significant challenges to data standardization and comparability.

The clinical consensus statement published by the European Association of Cardiovascular Imaging/European Society of Cardiology (EACVI/ESC) and Association for European Paediatric and Congenital Cardiology (AEPC) emphasizes the importance of standardizing pediatric echocardiography reports.² The standards emphasized in this consensus statement suggest that variations in the content of echocardiography reports used in pediatric cardiology centers may hinder the establishment of a common terminology and a standardized reporting approach across institutions, thereby potentially compromising consistency in clinical practice.

Despite the availability of such international guidelines, real-world adherence to these recommendations remains uncertain, particularly in countries with diverse healthcare settings. There is limited data evaluating the extent to which standardized reporting practices are implemented in routine pediatric echocardiography. Understanding these variations is essential not only for ensuring diagnostic quality but also for facilitating inter-institutional collaboration, data sharing, and benchmarking efforts.

Accordingly, the investigation aims to systematically evaluate the variability in pediatric echocardiography reporting practices across healthcare institutions. Specifically, it explores the extent to which key anatomical and functional components are included in routine reports, stratified by institution type. By identifying inconsistencies relative to standardized frameworks, this study seeks to support the development of uniform documentation practices and improve inter-institutional comparability in clinical care.

Materials and Methods

Study Design

This study was designed as a cross-sectional, retrospective analysis aimed at evaluating variability in pediatric echocardiography reporting practices across different types of healthcare institutions. The analysis included reports from patients referred to the institution Gazi University Faculty of Medicine, Department of Pediatric Cardiology between January 2022 and January 2023. These referrals originated from university hospitals (UHs), training and research hospitals (TRHs), and private healthcare institutions (PHIs). Patients were referred to pediatric cardiology outpatient clinics for further evaluation of cardiac murmurs detected during routine pediatric examinations, as well as for longitudinal follow-up of previously diagnosed congenital or acquired cardiac conditions, and other non-urgent cardiologic indications. Ethical approval was obtained from the Gazi University Ethics Committee Clinical Research Ethics Committee on June 6, 2023 (Approval No.: 2023-843). Written informed consent was obtained from the parents and/or legal guardians of all participants. The study was conducted in accordance with the principles of the Declaration of Helsinki. This study did not assess patient-specific diagnostic pathways, but instead analyzed the content and structure of echocardiography reports in a multi-institutional context.

Data Collection

Pediatric echocardiography reports were retrospectively collected in written form. Reports were eligible for inclusion if they involved patients aged 0 to 18 years and were authored by a board-certified pediatric cardiologist. Reports were excluded if they were duplicated or issued by non-specialists. Since the study utilized anonymized medical records, referring centers were not contacted during data collection, and no identifiable patient or institutional information was included. All included reports were independently reviewed by a single pediatric cardiologist with substantial experience in congenital and pediatric heart disease.

Evaluation of Echocardiography Reports

Reference Guidelines

The evaluation framework was adapted from the clinical consensus statement of the EACVI/ESC and AEPC.² The structured reporting template presented in Table 1 reflects the recommended elements from this guideline.

Table 1.

Recommended Reporting Framework for Pediatric Echocardiography According to the European Association of Cardiovascular Imaging/European Society of Cardiology and Association for European Paediatric and Congenital Cardiology Clinical Consensus Statement²

Patient Name: Date of Birth: Examination Date: Age (Years/Months): Weight (kg): Height (cm): Body Surface Area (m2): Arterial Blood Pressure (mmHg): Heart Rate (beats/min): Oxygen Saturation (%): Rhythm: Department: Physician: Echocardiography Device: Software Utilized (e.g., Three dimensional, Strain Analysis):
Basic Anatomical/Functional Detail		Basic Measures/Functional Parameters
Situs Cardiac position Atrioventricular concordance Ventriculoarterial concordance Pulmonary venous return Systemic venous return Interatrial septum Interventricular septum Atriums Left ventricle Right ventricle	Solitus, ambiguous, inversus levocardia, mesocardia, dextrocardia concordant, discordant position of the aorta Position of the pulmonary artery Concordant discordant Normal, abnormal - Right veins - Left veins Normal, abnormal - Inferior vena cava, superior vena cava, left superior vena cava Bulging, size and direction of shunt Bulging, size and direction of shunt Dimensions Dimensions Wall thickness, systolic/diastolic functions Dimensions Wall thickness, systolic function	Volume M-mod and biplane volumes Two-dimensional measures, functional indices
Valves - Tricuspid valve - Mitral valve - Aortic valve -Pulmonary valve Great vessels - Main pulmonary artery - Right pulmonary artery - Left pulmonary artery - Aortic arch Ductus arteriosus and collaterals Coronary arteries Pericardium/pleura Abdominal aorta Inferior vena cava/hepatic veins	Anatomy Regurgitation: none, trivial, mild, moderate, severe Stenosis: none, mild, moderate, severe Anatomy Regurgitation: none, mild, moderate, severe Stenosis: none, trivial, mild, moderate, severe Anatomy Regurgitation: none, trivial, mild, moderate, severe Stenosis: none, mild, moderate, severe Aortic root and ascending aorta: Anatomy Regurgitation: none, trivial, mild, moderate, sever Stenosis: none, mild, moderate, severe Sidedness Origin Effusion/others Flow pattern: normal, demodulated, retrograde, vasoconstriction pattern Excursion Congestion, reversal flow	Right ventricle–right atrium pressure difference, annulus diameter, regurgitant parameters, stenotic parameters, power Doppler data Left ventricle–left atrium pressure difference, annulus diameter, regurgitant parameters, stenotic parameters, power Doppler data Maximum velocity, maximum and mean gradient, diameters (annulus, root, junction), ascending aorta, subaortic region,regurgitation parameters, stenosis parameters: Maximum velocity, maximum and mean gradient, annulus diameter,regurgitation parameters, stenosis parameters: Maximum velocity, maximum and mean gradient, diameter Maximum velocity, maximum and mean gradient, diameter Maximum velocity, maximum and mean gradient, diameter Functional parameters, maximum velocity, maximum and mean gradient, run-off, retrograde flow, diameters at different points Diameters Systolic and diastolic diameters Maximum velocity, acceleration and deceleration time Systolic and diastolic diameters
Others Quality of the examination Conclusions: Signature: Z-Score sources:	Acoustic window: poor, sufficient, good, excellent Patient’s collaboration: poor, sufficient, good, excellent Completeness of the examination: partial, sufficient, good, excellent

AEPC, Association for European Paediatric and Congenital Cardiology; EACVI, European Association of Cardiovascular Imaging; ESC, European Society of Cardiology.

Assessment Parameters

In the pediatric echocardiography reports analyzed within the scope of this study, the completeness of patient identifying information and clinical records, along with the diversity and frequency of reported echocardiographic parameters and conclusions, were systematically evaluated. The distribution of these reporting components across different types of healthcare institutions is summarized in Table 2.

Table 2.

Comparison of Pediatric Echocardiographic Reporting Elements Across Healthcare Institution Types

		University Hospital (UH)	Training and Research Hospital (TRH)	Private Healthcare Institution (PHI)
Patient information	Name and surname	12/12	9/9	12/12
	Date of birth	12/12	8/9	12/12
	Sex	8/12	7/9	6/12
	Body weight	2/12	4/9	4/12
	Height	1/12	0/9	1/12
	Blood pressure	1/12	1/9	0/12
	Rhythm - Oxygen saturation	3/12	5/9	4/12
	Identification number	5/12	4/9	3/12
	Phone number	3/12	0/9	4/12
	Email	0/12	0/9	0/12
Medical records	Date	12/12	9/9	12/12
	Time	4/12	7/9	2/12
	Sedation	0/12	0/9	1/12
	Indication	2/12	5/9	1/12
	Physician’s name	12/12	9/9	12/12
	Imaging quality	0/12	0/9	0/12
	Clinical information	2/12	5/9	2/12
	Procedure location	0/12	4/9	0/12
	Device information (type/model)	1/12	2/9	0/12
Echocardiographic findings	Situs	7/12	7/9	9/12
	Cardiac position	2/12	4/9	4/12
	Apex orientation	2/12	5/9	5/12
	Atrioventricular (AV) concordance	9/12	7/9	9/12
	Ventriculoarterial (VA) concordance	9/12	7/9	9/12
	Venous return (systemic and pulmonary)	7/12	7/9	8/12
	Interatrial septum	11/12	9/9	11/12
	Interventricular septum	12/12	9/9	11/12
	Atria (diameters)	9/12	5/9	9/12
	Ventricles (diameter, volume, wall thickness, systolic and diastolic functions)	8/12	7/9	9/12
	Tricuspid valve	12/12	7/9	11/12
	Mitral valve	12/12	7/9	11/12
	Aortic valve	12/12	8/9	11/12
	Pulmonary valve	12/12	8/9	11/12
	Main pulmonary artery	3/12	8/9	10/12
	Right pulmonary artery	3/12	3/9	7/12
	Left pulmonary artery	4/12	3/9	7/12
	Aortic arch	3/12	8/9	10/12
	Ductus arteriosus / collaterals	10/12	9/9	10/12
	Coronary artery size and course	7/12	7/9	2/12
	Pericardium	9/12	6/9	8/12
	Abdominal aorta	0/12	0/9	0/12
	Inferior vena cava / hepatic vein	2/12	0/9	0/12
	Shunt direction (if present)	5/6	4/6	5/8
Conclusion	Diagnosis	12/12	9/9	12/12
	Physician’s interpretation	5/12	7/9	9/12
	Examination conditions (awake, agitated, imaging limitations)	0/12	6/9	0/12

Reports were evaluated for the presence and completeness of 4 main sections: patient information, medical records, echocardiographic findings, and conclusions.

Patient information included data such as name, surname, date of birth, and sex. Supplementary variables such as body weight, height, blood pressure, national ID number, phone number, and email address were also recorded when available.

Medical record evaluation included documentation of the examination date and time, sedation status, clinical indications, name of the performing physician, image quality, clinical details, and the type and model of the imaging equipment used.

Echocardiographic findings were examined for both anatomical and functional parameters, including: situs, apical orientation, cardiac position, systemic and pulmonary venous return, atria and interatrial septum, ventricles and interventricular septum, atrioventricular and ventriculoarterial concordance, cardiac valves, main pulmonary artery and branches, aortic arch, patent ductus arteriosus (PDA) and collaterals, coronary artery anatomy, pericardium, abdominal aorta, inferior vena cava, hepatic veins, and shunt direction.

In the conclusion section, the inclusion of interpretative statements, technical limitations, and patient behavior during the examination (e.g., agitation, sedation) was noted.

Statistical Analysis

All statistical analyses were performed using SPSS Statistics for Windows, version 17.0 (SPSS Inc.; Chicago, IL, USA). Descriptive statistics, including frequencies and percentages, were used to summarize the distribution of reporting parameters. The completeness of reporting content and the variability in adherence to international guidelines were quantified using numerical and percentage values and were visually presented in tabular format.

Results

Overview of Reporting Standards

To contextualize the analysis, the key components recommended by the EACVI/ESC and the AEPC were first outlined. These components form the basis for evaluating the completeness and consistency of pediatric echocardiography reports. The recommended reporting framework is summarized in Table 1.

Institutional Distribution of Reports

A total of 33 pediatric echocardiography reports from 29 healthcare institutions were included in the analysis. Of these, 12 were from UHs, 9 from TRHs, and 12 from PHIs.

Documentation of Patient Demographics and Vital Information

Basic patient information such as name, surname, and date of birth was consistently documented across all institutions. In contrast, sex was recorded less frequently in PHI reports (50%). Parameters such as body weight, height, blood pressure, identification number, and phone number were documented at notably low rates across all institution types. No report included patient email information. Additionally, heart rhythm and oxygen saturation were the least reported in UH reports (25%) and most frequently in TRH reports (55.5%).

Clinical Information and Procedural Context

Sedation status was scarcely documented, appearing only in 8.3% of PHI reports. Clinical indications were reported at a low rate in PHI reports (16.62%) but were noted in 55.55% of TRH reports. Information on the location of the procedure was included in 44.4% of TRH reports but was absent in UH and PHI reports. Detailed clinical information was found in 55.5% of TRH reports and in only 16.6% of UH and PHI reports.

Reporting of Anatomical and Functional Echocardiographic Findings

The reporting patterns of basic anatomical/functional details, basic measurements, and functional parameters exhibit important variability among institutions. Atrial situs was reported in 58.3% of UH reports, 77.7% of TRH reports, and 75% of PHI reports. However, cardiac position was documented at notably low rates across all institutions (UH: 16.6%, TRH: 44.4%, PHI: 33.3%). Atrioventricular and ventriculoarterial concordance was reported at similar rates across all institutions (UH: 75%, TRH: 77.7%, PHI: 75%). Systemic and pulmonary venous return was documented at comparable rates in UH (58.3%) and PHI (66.7%), whereas it was reported at a higher rate in TRH (77.7%).

The aortic and pulmonary valves were included in all UH reports and were also reported at high rates in PHI and TRH, at 91.6% and 88.8%, respectively. Tricuspid and mitral valves were documented in all UH reports but were reported at the lowest rate in TRH reports (77.7%). The main pulmonary artery and aortic arch were least frequently reported in UH reports (25%), whereas they were documented at similar rates in PHI and TRH, at 83.3% and 88.8%, respectively.

Ventricular function was reported at similar rates in TRH and PHI, at 77.7% and 75%, respectively, whereas it was documented at a lower rate in UH (66.6%). Hemodynamic parameters, such as the presence and direction of shunts, were most frequently reported in UH reports (83.3%), while they were documented at lower rates in TRH and PHI, at 66.6% and 62.5%, respectively. PDA and collateral vessels were reported at a rate of 83.3% in both UH and PHI, whereas they were included in all TRH reports. Coronary artery size and course were reported in UH, TRH, and PHI at 58.3%, 77.7%, and 16.7%, respectively. None of the reports from any institution included measurements of the abdominal aorta. The inferior vena cava and hepatic vein were documented in 16.6% of cases solely in UHs.

Diagnostic Findings, Physician Interpretations, and Examination Conditions

Diagnoses were included in all reports analyzed in this study. However, specific physician interpretation notes—beyond the final diagnosis—were documented in only 5 out of 12 reports (41.7%) from UH, 7 out of 9 reports (77.8%) from TRH, and 9 out of 12 reports (75.0%) from PHI. Notably, information regarding environmental factors, such as whether the patient was awake or agitated during the examination, was reported exclusively in TRH reports (66.6%) and was entirely absent in those from UH and PHI. The comparative distribution of documented echocardiographic elements across different types of healthcare institutions is presented in Table 2.

Discussion

Although the widespread applicability of echocardiography across different centers provides significant advantages, variations in the content and interpretation of reports among institutions pose challenges in establishing a standardized reporting language.

In the echocardiography reports included in the study, fundamental patient details such as name, surname, and date of birth were consistently documented; however, the incomplete reporting of anthropometric parameters, such as body weight and height, is noteworthy. Data on blood pressure, heart rhythm, and oxygen saturation were also reported at low rates in echocardiography reports. This observation is particularly important given that Corbett et al,³ in their practical guideline developed by the British Society of Echocardiography, emphasize the inclusion of such clinical parameters to enhance the accuracy and interpretability of pediatric echocardiographic assessments. Corbett et al³ recommend recording parameters such as height, weight, body surface area, heart rhythm, oxygen saturation, and blood pressure to optimize the accuracy of echocardiographic measurements, functional assessments, and hemodynamic evaluations.

In this study, although TRH had the highest rate of reporting clinical information and echocardiography indications (55.5%), this rate remains considerably low. This observation aligns with the concerns addressed in the recent clinical consensus statement by Cantinotti et al,² published by the EACVI/ESC and AEPC. It highlights the clinical importance of systematically including core patient data—such as examination indications, previous cardiac interventions, and ongoing treatments—not only to ensure accurate interpretation of echocardiographic findings but also to support longitudinal patient management and inter-institutional communication. The comprehensive inclusion of this data in the report guides the physician in determining which parameters require more detailed evaluation during the echocardiographic examination, thereby contributing positively to patient survival.

Segmental analysis enables the systematic evaluation of cardiac segments (atria, ventricles, great arteries) and their connections (atrioventricular and ventriculoarterial connections), thereby reducing the risk of overlooking significant pathologies. The literature emphasizes that this approach is incorporated into international standards and serves as a fundamental method for enhancing diagnostic accuracy. Therefore, guidelines recommend segmental analysis as a standard practice for comprehensive TTE assessment in patients with congenital heart disease and advise that this evaluation should be performed at least once in every patient.^2-4 In this study, important differences were identified among institutions in the reporting of anatomical and functional details, basic measurements, and functional parameters. As shown in Table 2, there is a lack of consistent application of the segmental analysis approach in accordance with established standards across the cases. Atrial situs, cardiac position, atrioventricular and ventriculoarterial concordance, as well as systemic and pulmonary venous return, were reported at varying rates across different healthcare institutions. While atrial situs and atrioventricular-ventriculoarterial concordance were generally documented at higher rates, cardiac position was reported at lower frequencies.

The aortic and pulmonary valves were reported at high rates across all institutions included in this study. These findings suggest that bicuspid aortic valve, aortic and pulmonary valve stenosis, and regurgitation are clinically significant pathologies emphasized in echocardiographic evaluations. The marked variations in the reporting rates of the main pulmonary artery and aortic arch observed in the study highlight the lack of standardization in pediatric echocardiography practices. Guidelines from the EACVI/ESC and AEPC, and the American Society of Echocardiography emphasize that the detailed reporting of great vessels not only enhances diagnostic accuracy but also contributes to treatment and follow-up processes.^2,3

The echocardiographic assessment of ventricular function is crucial for the objective evaluation of cardiac performance and plays a key role in the diagnosis, treatment, and management of follow-up processes. Lai et al⁵ stated that a detailed evaluation of ventricular function not only enhances diagnostic accuracy but also improves treatment decision-making. The 72% reporting rate of this critical parameter across all institutions in the study highlights the need for further refinement in assessment and reporting practices.

Variations in the reporting of coronary artery size and course indicate a lack of homogeneity in practice approaches across institutions. The inadequate documentation of this parameter, which plays a crucial role in the diagnosis and follow-up of various acquired and congenital heart diseases, represents a significant gap in reporting practices. The absence of abdominal aorta measurements in all institutions and the documentation of the inferior vena cava and hepatic veins solely in UHs at a rate of 16.6% highlight a widespread deficiency in the assessment of extracardiac structures. These inconsistencies likely reflect institutional differences in documentation practices and clinical focus but also represent a diagnostic limitation that may lead to missed findings of systemic venous anomalies or abdominal vascular abnormalities. As shown in Table 2, these findings highlight the imperative for standardized pediatric echocardiography reporting to enhance the thoroughness and consistency of documentation, particularly regarding commonly underreported anatomical structures.

A comprehensive evaluation of the overall reporting frequencies of echocardiographic parameters revealed that key anatomical structures such as the interatrial and interventricular septum, valvular morphology, and the presence or absence of a PDA and collateral vessels were consistently documented at high rates across all participating institutions.

The underreporting of structures that are optimally visualized through the subcostal window, such as the abdominal aorta, inferior vena cava, and hepatic veins, may be attributed to several factors. First, in routine pediatric echocardiographic examinations, the primary focus often remains on intracardiac anatomy and hemodynamics, while extracardiac structures may receive comparatively less attention unless clinically indicated. Second, technical challenges such as limited patient cooperation, agitation during the procedure, or suboptimal acoustic windows due to body habitus (e.g., obesity or abdominal distension) may impair subcostal imaging quality. Third, institutional and operator-related variability in training or time constraints may lead to the omission of less prioritized views. As a result, sonographers may be less inclined or able to thoroughly assess and report these structures. Together, these factors reflect real-world diagnostic limitations that can affect the completeness and clinical utility of pediatric echocardiography.

All echocardiography reports analyzed in this study included a final diagnosis, indicating general adherence to this fundamental reporting element across all institution types. However, specific physician interpretation notes—providing additional clinical insights beyond the final diagnosis—were inconsistently documented, with lower reporting frequencies observed in UH (41.7%) compared to TRH (77.8%) and PHI (75.0%). Furthermore, documentation of environmental factors—such as whether the patient was awake or agitated during the examination—was observed exclusively in reports from TRHs (66.6%), and was entirely absent in reports from university and private institutions. This discrepancy underscores the need to promote more comprehensive and standardized reporting practices that not only include diagnostic conclusions but also incorporate relevant contextual factors that may affect image quality and interpretation. Despite its contributions, the present study has several limitations that may influence the interpretation and generalizability of the findings. These include its retrospective design, the restriction to externally referred reports, and potential selection bias. Furthermore, the content of the reports may not fully reflect actual clinical practice, as documentation habits vary across institutions. For instance, coronary artery findings are typically documented when coronary pathology is suspected (e.g., Kawasaki disease or anomalous left coronary artery from the pulmonary artery), and their absence in other cases may reflect clinical context rather than reporting deficiencies. Additionally, in academic centers, reports may be drafted by residents and later signed by pediatric cardiologists, which could further contribute to variability in reporting. In conclusion, the study highlights both strengths and weaknesses of current reporting patterns in pediatric echocardiography and emphasizes the importance of harmonization with international recommendations.

Conclusion

Our study demonstrates important variability among pediatric echocardiography reports from different healthcare institutions. The integration of international guidelines, such as the recommendations of the EACVI/ESC and AEPC, could facilitate the establishment of a standardized reporting framework, ensuring the systematic inclusion of less frequently assessed parameters during echocardiographic evaluations and promoting uniformity in reporting practices across institutions. Efforts to implement guideline-based templates and nationwide training are essential to ensure consistency, improve diagnostic accuracy, and ultimately enhance patient care in pediatric cardiology.

Funding Statement

The authors declare that this study received no financial support.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author.