Echo Reports for Valvular Heart Disease: What to Include

A useful echocardiogram report for valvular heart disease measures each lesion instead of labelling it. For a narrowed valve it gives the orifice area, indexed to body surface area, the pressure gradients and the pressure half-time. For a leaking valve it gives the jet area, the vena contracta and the flow dynamics. It then stages the disease. Phrases such as "bulky heart" give a specialist nothing to act on.

Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, reviews a steady stream of echo reports and referral notes from doctors in Africa. In his masterclass on valvular heart disease in emerging countries, he singled out the quality of that paperwork as a barrier to timely treatment. A specialist on another continent can only decide whether a patient needs medication, a valvotomy, surgery or urgent transfer if the report in front of him contains the numbers that answer those questions.

This article covers what the report and the referral package should contain, how often patients need monitoring, and how to share images. The complete guide to valvular heart disease in emerging countries explains the wider burden, and the four T's article covers referral timing and treatment.

Why the echocardiogram decides the referral, and what it costs

Echocardiography, an ultrasound scan of the heart, remains the gold standard for diagnosing valvular heart disease. It shows which valve is affected, whether it is narrowed or leaking, how severe the lesion is and what it is doing to the heart chambers. Every downstream decision depends on it.

Access is the first problem. Dr. Purkayastha describes a severe shortage of echocardiography machines and of trained echocardiography technicians, and a cost that most patients cannot meet. He cited a figure of about US$250 for a quality echocardiogram and report in parts of Africa, against an average monthly income of about US$150 in sub-Saharan Africa. A patient would need to spend nearly two months of wages on a single scan.

That makes the second problem more costly still. When a family has stretched to pay for an echocardiogram, a report that cannot be interpreted wastes the money and the time. Dr. Purkayastha described one young patient with advanced heart-lung failure who had been seen by specialists for years and had undergone multiple echocardiograms, all of them, in his words, completely irrelevant.

What an echo report must include for mitral and aortic stenosis

Stenosis means a valve that does not open fully, so the heart must push blood through a narrowed opening. For mitral stenosis and aortic stenosis, Dr. Purkayastha expects the report to give numbers, not adjectives:

• Valve orifice area, the size of the opening, and the orifice area indexed to body surface area, which matters because a given valve area means more in a small adult than in a large one.
• Pressure gradients across the valve, the pressure difference the heart must generate to drive blood through the narrowing.
• Pressure half-time, the time taken for the pressure gradient across the valve to fall to half its starting value. In mitral stenosis it is a standard way of estimating the valve area.
• Flow restriction and the patient's overall haemodynamics, meaning the effect of the lesion on pressures and flow throughout the heart.

These measurements tell the reader how tight the valve is, whether the narrowing is likely to be causing symptoms and whether the patient is approaching the point at which a valvotomy or valve replacement is indicated.

What an echo report must include for valve regurgitation

Regurgitation means a valve that does not close fully, so blood leaks backwards. For mitral, aortic and tricuspid regurgitation, Dr. Purkayastha asks for:

• Jet surface area, the size of the backward jet of blood on colour Doppler imaging, the part of the scan that shows the direction and speed of blood flow in colour.
• Vena contracta, which he defines as the narrowest part of the regurgitant jet, the neck of the cone. It is one of the more reliable single measures of how large the leak is.
• Pressure half-time, which in aortic regurgitation helps grade severity.
• Flow dynamics, with the significance, percentages or numbers that place the lesion against a specific guideline.

Regurgitant lesions deserve particular care. Dr. Purkayastha notes that leaking valves are often dismissed because they are assumed to progress slowly. Without measurements, nobody notices when a moderate leak becomes severe, and the patient arrives years later in heart failure.

Staging valvular heart disease in the echocardiogram report

Beyond individual measurements, Dr. Purkayastha wants reports to place the patient within the American Heart Association staging of valvular heart disease, so that the reader knows at a glance where the patient sits on the disease course.

The American College of Cardiology and American Heart Association (ACC/AHA) guideline uses four stages:

A report that says "stage C mitral stenosis, valve area indexed to body surface area, mean gradient and pressure half-time" tells a specialist far more than a paragraph of description.

Phrases that should not appear in an echo report

Dr. Purkayastha was direct about the reporting habits that frustrate him. Atrioventricular valve regurgitation, meaning a leak at the mitral or tricuspid valve, is too often recorded haphazardly as "mild mitral regurgitation" or "mild tricuspid regurgitation with hypertensive heart disease". "Mild mitral stenosis with hypertensive heart disease", he said, makes no sense. Terms such as "hypertensive heart disease" or "bulky heart" attached to a valve lesion carry minimal significance for anyone trying to read the report and make a decision.

The fix is not more equipment. It is a reporting standard: the parameters above, recorded every time, with the stage of disease.

What a valve disease referral package should contain

The echo report is one part of the referral. Dr. Purkayastha described what he wants to receive from the general practitioner or community nurse, and what he does not.

What it should contain:

1. A good referral note, written with due diligence by the referring doctor or nurse.
2. A good echocardiography finding, reported to the standard above.
3. The salient blood results, and nothing more.

What it should not look like: a bundle that opens with an electrolyte report, followed by a blood gas, a full blood count and a urine analysis, with a short clinic note at the very end. A patient's potassium or phosphate on a given morning may matter to that patient's care in an intensive care unit, but it does not help a specialist decide how to manage valve disease.

Organised referrals, he argues, only happen when nurses and general practitioners are taught how to report these problems to the colleagues trying to help them. At present they are often unsure when intervention is needed, what to do and what information to pass on.

Six-monthly monitoring for patients in heart failure

Patients in heart failure due to valvular heart disease need a structured blood work-up once every six months. Dr. Purkayastha's list:

• Brain natriuretic peptide (BNP), a hormone released by a strained heart and a marker of how heart failure is progressing.
• C-reactive protein (CRP), a marker of inflammation.
• Kidney function, because most of these patients take diuretics, which affect the kidneys and electrolytes.
• Liver function tests and the blood coagulation profile.
• A general blood work-up to make sure nothing significant is being missed.

Two obstacles stand in the way. Many areas have too few laboratories able to process microbiological and other samples, including tests to identify streptococcal infection. And reports go stale: Dr. Purkayastha sees patients in 2026 whose most recent reports date from October 2024, which tells him nothing reliable about their current state.

Sharing scans in DICOM format

The same principle applies to imaging. Dr. Purkayastha receives very rudimentary CT images, with the bed sheet or a child playing visible in the background. From such an image it is close to impossible to judge, for example, whether a patient needs a lung transplant.

The alternative is straightforward. Scans should be shared in DICOM format, the standard digital file format for medical images, which preserves the full study and allows the specialist to scroll through it. Even gigabytes of imaging now take minutes to transfer, and a shared cloud folder is enough. He offered to give interested doctors an email address to which they can share uploaded scans.

Screening for valvular heart disease in the community

Reports can only be as good as the access to scanning. Dr. Purkayastha's model for diagnosis has three parts:

• Accessible, affordable echocardiography that can support screening programmes.
• Point-of-care ultrasound and portable echocardiography devices taken out into the community to screen people at high risk and socioeconomically challenged communities.
• Artificial intelligence, which is now being used to support the diagnosis of valvular heart disease in the community.

Screening finds disease while the valve can still be protected with penicillin prophylaxis and follow-up, rather than replaced. The four T's article covers what to do once disease is found and when to refer. Questions raised after the session are on the Live Discussion page, and Dr. Purkayastha's separate masterclass on pulmonary hypertension diagnosis explains why an echocardiogram screens for, but does not confirm, raised lung pressures.