My Dad's Heart Murmur and The Botched Echocardiogram

My dad was recently told he had a heart murmur by his internist. An echocardiogram (ultrasound of the heart) was ordered.
A heart murmur is basically any unusual sound that the doctor hears when he/she places a stethoscope on the anterior chest  in the vicinity of the heart.  Blood flows across various valves as it makes its way through the cardiac chambers. If the valves are functioning normally we usually can’t hear anything because the blood velocity is low and the flow is not disordered.
The majority of murmurs that are detected are due to either:
(1) narrowing (stenosis) of a valve that results in an acceleration of blood velocity.
(2) failure of a valve to close properly (insufficiency or regurgitation) and prevent back flow.
Cardiologists have developed an absolutely awesome tool for  both visualizing the valves anatomical structure and movement, and precisely measuring the flow of blood through the heart.
The full name of this awesome tool is Doppler-echocardiography. The echocardiogram constructs a moving two-dimensional (more recently three-dimensional) “movie” from analyzing the time and intensity of sound waves reflected off the various valves, walls and structures within the heart.

The Doppler principle is utilized to precisely measure the location and velocity of blood flowing through the heart from high frequency sound waves reflected off red blood cells.
I call this test an echo or TTE (Transthoracic Echocardiogram)

The Importance of Being Expert in Echo Performance and Interpretation

I considered asking him to have the echocardiogram done at my hospital here in St. Louis. I’m the medical director of the laboratory and spend a lot of time making sure that we get high quality echocardiograms and that they are interpreted correctly.
When an echocardiogram is done elsewhere, I have no guarantees that it has been performed and/or interpreted properly.
One would hope that a TTE done in a doctor’s office in Tulsa, Oklahoma and one done in a hospital outpatient facility in St. Louis on the same patient would yield identical results on key findings, but this is often not the case.
On a regular basis, I see serious and highly significant errors made in the findings of TTEs performed elsewhere on patients that come to me for a second opinion or due to moving from another city.

Causes of Errors in Echos

The heart alone, among the body’s organs, is constantly moving. This means that standard ultrasound and x-ray techniques, which work great for static body parts, are useless. The techniques in a modern TTE that have evolved to fully evaluate all of the heart’s highly dynamic functions are complicated and require state-of-the art ultrasound equipment, as well as a sonographer who has been fully and expertly trained in using such equipment.
Such sonographers typically go through a two year program that is specific for cardiac ultrasound. To verify their knowledge and skills, they have a certification from either RDMS or CCT.
Will a competent, registered sonographer perform my dad’s exam? He and I have no way of knowing short of calling up the lab and asking very specific questions.

There is no government or insurance company mandate that a TTE be performed by a qualified, competent sonographer!

This, alone, is quite shocking, but it gets worse.
Who will read my dad’s TTE? Will it be read by a cardiologist trained like me who has gone through an additional year of cardiology training specifically in echocardiography, and who has reached what is termed Level III training?
Does that reading doctor have, like I do, verification of the acquisition and maintenance of the incredibly complicated knowledge base for echocardiography by taking and passing the National board of Echocardiography examinations?
Is he/she keeping up to date on new techniques and scientific findings in the field by attending regular CME sessions?
Does he/she regularly try to correlate the findings from the TTEs he/she reads with findings from other imaging techniques and surgical pathology?
Chances are the answers to all of the above questions will be no.

There is currently no country-wide government or insurance company mandate requiring the reader of a TTE to be competent to get reimbursed!

Thus, we have no guarantees that the TTE on my dad will be competently performed and interpreted.
This sad situation is the cause of the serious and significant errors in TTE results that I regularly encounter.
Dr. Kiran Sagar presented findings confirming this at the 2010 scientific meeting of the American Society of Echocardiography. According to news reports, she was fired shortly afterwards.

The study reported at the ASE meeting involved a review of 235 echocardiograms done at St. Luke’s hospital in Milwaukee, WI (not related at all to my St. Lukes hospital in Chesterfield, MO) from August 2007 to October 2008:

“Of the 35 physicians who performed clinical readings of the echocardiograms reviewed in the study, only three were Level 3 specialists within cardiology.
Sagar’s analysis revealed that 68 of the 235 imaging studies, or 29 percent, were misread.
In at least five of those cases, patients actually went into the operating room with a faulty diagnosis, although the problem was discovered before surgery was done.
In addition, 18 patients were subjected to more invasive echocardiography in which a probe was inserted down the throat and 19 underwent invasive coronary angiography. The misreadings also resulted in increased healthcare costs for the patients”

How Can You Be Sure Your Echo Is Competently Recorded And Interpreted.

I have no good answer to this question.

The only organization that provides any method for evaluation of individual echo labs is the Intersocietal Accreditation Commission. According to the IAC website “The purpose of the IAC Echocardiography accreditation program is “to ensure high quality patient care and to promote health care by providing a mechanism to encourage and recognize the provision of quality echocardiographic diagnostic evaluations by a process of accreditation.””
Echo labs that are accredited by IAC go through a process every three years that insures that they are following the IAC guidelines on acquisition and reporting. This means that the report from an IAC accredited echo lab will comment on all the structures of the heart that should be commented on and will report out basic, rudimentary measurements.
The IAC requires that the medical director of the echo lab have advanced training in echocardiography, but does not require the sonographers who perform the exams to be accredited.
There is no IAC requirement for significant evidence of competence or adequate training for the physicians who read echocardiograms. I quote from their documentation which states that a physician qualifies as a reader:

“if echocardiography training was completed prior to 1998 – three years of echocardiography practice experience and interpretation of at least 1200 echocardiogram/Doppler examinations…”
This type of physician reader does not have to document any significant training or competence, just that he/she has been reading echos for a while and has reached a certain volume.

My Dad’s Echo

We decided to let my dad get his echo done at the facility his primary care physician utilized. It was done at one of the largest hospitals in Tulsa, Oklahoma and I had him obtain both the report and the actual echo recordings for me to review.
The results were quite disappointing as several key elements of the exam were misinterpreted.
As I feared, my dad’s echo was botched.

What Americans Should Demand For Quality and Consistency in Echos

The payers in healthcare should mandate the following if an echo is to be reimbursed:

  • It is performed in an IAC accredited echo laboratory
  • It is performed by a registered sonographer
  • It is interpreted by a cardiologist with advanced training and competence in echocardiography (how advanced and how that is measured or certified can be debated)

Until this kind of quality assurance is tied to reimbursement, it won’t happen voluntarily.

You, as the consumer, have to make sure you are getting the best quality echocardiogram you can.
Ask questions about the lab, the sonographer and the reader who will be doing your exam.
A faulty interpretation of your echocardiogram could result in unnecessary and dangerous testing and surgery.
Failure to identify significant cardiac pathology could delay appropriate treatment.
To my dad, and all you other dads.
May your hearts keep pumping efficiently and may all your tests be interpreted correctly.

19 thoughts on “My Dad's Heart Murmur and The Botched Echocardiogram”

  1. I had a cardiac echo 3 days ago that says the aortic, tricuspid & pulmonary valves were not optimally visualized & there is mild mitral valve regurg. Cardiologist says I have an aortic murmur. I’m wondering what the point was of having this test if they can’t “optimally” read it. My cardiologists reply was “I’m not worried”. Thank you.

    • Jennifer,
      Cardiac echocardiograms, unlike imaging utilizing x-rays, are heavily dependent for quality on a number of factors ranging from the kind of ultrasound machine to patient-related factors (size, lung disease, etc.). The most important factor is the skill of the sonographer.
      Thus, it is not uncommon to encounter studies and reports that indicate “limited quality” or “not optimally visualized.” In addition, these assessments of quality vary from reader to reader.
      If you have a good cardiologist who feels the echo study plus his clinical assessment indicate not problems then it is highly likely everything is OK with your valves. Major valve problems are almost always detected by echo even if technically difficult.
      Also, a good cardiologist would have reviewed the echo and made an independent determination of the quality and confidence in normality.
      Dr. P

  2. Hi Dr. AnthonyP,
    I am concerned I had a botched echocardiogram back in May. My ekg had right atrial enlargement, low voltage QRS, non specific t wave inversion. The echo is supposedly ‘normal’ with mild tricuspid and mitral regurgitation. The pulmonologist wHo ordered it was concerned I had pulmonary hypertension. The rsvp came back normal, and he sent me to a cardiologist bc I had continuing chest pain and my heart rate was too fast. Since I was in the ‘clear’, I only just saw the cardiologist. My cardiologist noticed I had developed an rbbb pattern on my newest ekg. He told me the echo is not reliable for ruling out PH and I will need a heart catheritization. He said ‘ I think you have pulmonary hypertension.’ Looking back on my echo report, there is NOTHING about the right atrium or right ventricle on my report. No report on size or anything except the mild tricuspid regurgitation. They commented that the left ventricle was normal in size. It’s almost like they were purposefully leaving the right side of the heart out. I had the echo at an accredited IAC which means they should have at least commented on it. Why would they leave something like that out with my ekg findings????? I’m very frustrated that this potentially delayed life saving treatment.

    • Also, the doctor who signed off on the report is an internist not a cardiologist, and he is not certified in echocardiography.

    • One of the few things that IAC accreditation monitors is the completeness of echo reports. Every report should include a comment on RA an RV. Lack of such documentation is a marker for poor quality. Also, in about 75% of echos we can make a pretty good estimate of pulmonary hypertension but in some individuals there is not enough leakage from the tricuspid valve to make this estimate.
      And basically anyone can pretend to read an echo and provide a report and collect payment. No organization actually checks the accuracy of readers or requires a minimum level of competency for reimbursement.

      • Thank you for the response. I’m getting the heart cath test at a different hospital that is nationally renowned for their PH program so hopefully I will be in good hands now. This has definitely been a learning experience. I’m thinking about writing to the IAC about my report and it’s missing information.

  3. Ejection fraction is our primary method for measuring how effectively the main pumping chamber of the heart (the left ventricle) is contracting or squeezing out blood to the rest of the body.
    In my echo lab the technicians performing the examination carefully measure the volume of the left ventricle when it is full and when it is empty from two different views and that determines the measured ejection fraction.
    I, as the reader of the echo, usually agree with what my excellent and well-trained technicians measure and that is reported out.
    If I disagree I will give an estimated ejection fraction. My reports specify whether it was a measured EF or estimated.
    There are many sources of variability in the EF.
    It is entirely possible that two cardiologists looking at the same echo would yield an estimated EF that varied by 9%
    It’s more likely if the echo was poor quality or the rhythm was irregular or if the tech made a poor measurement.
    When there is this much discrepancy, however, you have to wonder which EF is the right one and should demand some explanation as to why the first one was abnormal and much lower.
    A second opinion is not unreasonable

    • Thank you for your blog — I am a new reader and very impressed (and grateful). You mention that variability in estimated EF happens — is there an amount of variance that is established as reasonable vs. not reasonable? It sounds like you think 9% could be reasonable — what about 15%? 20%? And if EF is measured during the echo, why (and how) would that more objective value (one hopes) be superseded by opinion? THANK YOU!

  4. Hi, is it reasonable to accept that an echo can be read by 2 different “cardiologists specialized in imaging” and 2 different ejection fractions be determined. The first echo showed an EF of 46 and then after they had it reread it was 55. I like 55 much better but now I’m leaning towards a second opinion from a different health system because this seems like too big of a variation to be a normal margin of error.

  5. Hi,
    Would a MRI be more accurate in comparison to an echocardiogram? Or is it still be subject to erroneous interpretations?
    The reason I ask is I was found to have a LVEF of 45 with an echocardiogram a month ago and recently told the LVEF is actually only 28 with an MRI. The 2 procedures were performed at 2 different hospitals. My cardiologist just deemed the echo to be overly generous in measuring my LVEF without reviewing the echocardiogram CD.

    • MRI is generally considered to be the gold standard for determination of EF. Images (if done properly) are very crisp and clear. I would not expect that much of a discrepancy, however. Given that the two tests were a month apart it is also possible that your true EF has declined over that time period.

  6. How I wish there were more doctors like you who would truly provide the best for their patients. Sometimes that means directing the patient elsewhere for a particular procedure. Sadly some doctors are limited by the profit motives of the hospital to the detriment of the patients. Someone needs to take the lead and get the practice of medicine back on track. We are grateful for what you do.


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