Echocardiography (ECHO): Procedure, Types, Uses and Results

Echocardiography (ECHO) is a safe imaging method that does not involve radiation and visualizes the chambers, valves, and vascular connections of the heart using high-frequency sound waves. ECHO imaging is performed by applying a conductive gel to the patient’s chest wall and moving a technological device called a “probe” over this area, allowing echoes reflected from the heart to be displayed on the screen instantly as moving images. This completely painless and side-effect-free procedure is performed by pediatric cardiology specialists to detect structural heart anomalies and the contraction performance of the heart within seconds. Thanks to this advanced technology, the anatomical integrity of the heart can be examined in the finest detail without requiring any interventional procedure, enabling a definitive diagnosis.

What Is ECHO (Echocardiography) and How Does It Work?

The basic working principle of echocardiography is based on a physical logic very similar to the navigation systems of bats in nature or submarines in the depths of the ocean. A technological device that produces vibrations and sound waves at frequencies too high for the human ear to hear is used. During the procedure, the special and small instrument placed in contact with the child’s chest is called a probe. This probe sends the high-frequency sound waves it produces through the chest wall directly to the heart. These invisible waves, which strike the heart muscles, moving valves, and blood cells, create echoes of different intensities depending on the structure of the tissues and return to the device. Advanced computer systems collect these thousands of echoes within a very small fraction of a second and convert them into a moving and very clear image of the heart on the screen. Perhaps the most reassuring aspect of this procedure for families is that it does not contain radiation-containing rays that may damage tissues, such as X-rays or computed tomography. Since it is based entirely on sound waves, it has no side effects or danger. It causes no physical harm to patients and can be repeated as often as needed. Even if it needs to be performed more than once a day, it does not cause any damage, pain, or radiation accumulation in the body. Thanks to this safe and practical structure, it is an indispensable procedure frequently preferred in the follow-up of childhood heart diseases.

Why Is ECHO (Echocardiography) Imaging in Infants and Children Different From Adults?

Since the anatomical structures of children are very different from those of adults, the techniques used are also designed specifically for their tiny bodies. Image quality is directly related to the frequency of the sound wave used and how deeply it can penetrate the tissue. The higher the frequency, the greater the detail of the image obtained, but penetration into deeper tissues becomes more difficult. In adults, the heart is deep, so it is necessary to use low-frequency devices. However, in children and especially infants, the heart is located very close to the chest wall. In addition, since children’s rib cage is cartilaginous, it has a much more flexible structure. These physical advantages allow the use of much higher-frequency probes in children. Thus, even the millimetric curves of the microscopic vessels feeding the heart can be examined very clearly.

The main groups into which the probes used are divided according to age are:

• Premature infants and the neonatal period
• Infants and primary school-age children
• Adolescence

This sensitive distinction ensures that the clearest image specific to that patient is obtained, regardless of the size of the heart. Each child’s weight, chest structure, and body surface area are carefully evaluated, and the most appropriate technique is selected with great care.

Which Imaging Methods Does the ECHO (Echocardiography) Device Use?

The general condition of the heart is not evaluated from a single angle or with a single technique. During the procedure, multiple imaging modes are used simultaneously to understand both the anatomical structure of the heart and to mathematically measure its working dynamics.

The main imaging modes of the device are:

• Two-dimensional imaging (2D Doppler)
• Motion tracking (B-mode)
• Color flow mapping (Color Doppler)
• Blood velocity measurement (CW, PW Doppler)

The two-dimensional mode displays the internal chambers and valves of the heart on the screen instantly like a real-time film. With motion mode, the contraction power of the heart is plotted with millimetric lines, and heart wall thicknesses are measured with extraordinary precision. Systems that evaluate blood flow work just like a weather radar, showing the direction of blood flow. The red and blue colors seen on the screen are often thought by families to represent deoxygenated or oxygenated blood, but this is not correct. These colors are only a color mapping system showing whether the blood is moving toward or away from the device. Thanks to this color system, leaks in the valves, regurgitations, or abnormal blood flows passing through holes in the heart can be detected within seconds and easily reported.

How Should Preparation Be Before Echocardiography (ECHO) Imaging in Children?

It is medically expected that children may be afraid of the hospital environment, start crying when they see a white coat, and become restless. For a standard imaging procedure, children absolutely do not need to fast, follow a diet, or use any sedative medication beforehand. However, for the procedure to be successful, it is very important for the child to lie as still as possible on the examination table. Therefore, examination rooms are arranged with an approach far from clinical coldness, in a way that makes children feel safe. The doctor speaking in a very gentle tone of voice and the family holding the child’s hand throughout the procedure make the process much easier.

Supportive elements that help the child relax in the imaging room include:

• Colorful pictures
• Attention-grabbing toys
• Cartoon screens
• Relaxing music
• Various reward stickers
• Having the child’s own favorite toy nearby

Feeding small babies with a bottle, breastfeeding them, or using a pacifier during the procedure also gives very beneficial results. The aim is not to force the child or make them cry, but to gain their trust and make the most accurate medical diagnosis in an extremely comfortable environment.

How Is ECHO (Echocardiography) Imaging Performed Step by Step in Children?

The procedure progresses step by step, completely centered on the patient’s physical comfort and emotional well-being. First, the child’s upper clothing is removed and the child is gently helped to lie on the back on the examination table. Sometimes the patient may be asked to turn slightly toward the left side so that the heart comes closer to the chest wall and the bones move out of the way. This small position change significantly improves image quality. Small adhesive patches are placed on the chest area to synchronize the heart rhythm with the ultrasound images obtained. These patches directly reflect the heartbeats on the screen.

The basic steps applied during the procedure are:

• Positioning the patient correctly
• Attaching the electrodes
• Applying conductive gel to the skin
• Recording images from windows
• Taking numerical measurements

Since sound waves cannot pass through air, a water-based, colorless, and odorless ultrasound gel is applied to the skin. This liquid gel is usually kept at room temperature or slightly warmed so that the child does not startle. The device called a probe is gently moved over this gel, and every corner of the heart is carefully examined. The procedure lasts on average between fifteen and thirty minutes and is completely painless.

Is It Necessary for the Child to Be Put to Sleep During the ECHO (Echocardiography) Procedure?

Babies and young children sometimes cannot be calmed despite all the fun toys or songs in the room. When a child cries intensely and struggles, the lungs inflate with much more air than normal. When the lungs are fully inflated with air in this way, they cover the front of the heart like a wall and prevent the passage of sound waves. In this case, only darkness appears on the device screen and the measurements may be completely incorrect. Performing the procedure by forcefully holding or pressing the child on the table creates psychological trauma and is also medically useless because of muscle contractions.

Patient situations in which sedation is necessarily preferred include:

• Uncontrollable crying episodes
• Excessive hyperactivity
• Young age group with whom communication cannot be established
• Complex examinations that will take a very long time

In such cases, a mild sedative syrup or medication is used under specialist supervision. This practice is not anesthesia for a major surgical operation; the child simply relaxes by falling into a deep and natural sleep. Shortly after the procedure is finished, the child wakes up and returns to normal life without remembering anything. For children who will be given medication, remaining completely fasting for several hours before the procedure is an indisputable rule for a safe sleep process.

From Which Angles Is the Heart Examined During ECHO (Echocardiography) Imaging?

The heart is a complex, multidimensional, and constantly moving remarkable organ located right in the center of the body. It is absolutely impossible to understand the entire internal structure of the heart by looking from only one point. The doctor uses the tiny spaces between the ribs to observe the heart from completely different angles. These special viewing points are called imaging windows in medicine.

The main examination points and windows used are:

• Left edge of the sternum
• The lowest tip of the heart
• Upper part of the abdominal cavity
• Suprasternal notch area

When viewed from the left edge of the sternum, the general structure of the heart, its main contraction power, and the thickness of the wall between the ventricles are seen very clearly. When viewed from the tip of the heart, all four chambers appear on the screen at the same time and the closure status of the valves is evaluated. Since ribs are very flexible in children, possible holes between the atria are revealed with excellent clarity, especially when viewed upward from the abdominal region. From the neck region, congenital narrowings in the largest arteries leaving the heart and distributing blood to the body are investigated in detail.

Why Is Echocardiography (ECHO) Important in Congenital Heart Diseases?

Congenital heart diseases are structural anatomical differences that occur during the delicate developmental process in the womb and are seen more frequently than is commonly believed. Echocardiography is the primary method that leaves no doubt and provides the most definitive results in diagnosing these structural differences.

Common structural heart differences in society include:

• Holes in the ventricular wall
• Openings in the atrial wall
• Unclosed vascular connections
• Adhesions occurring in the valves

Congenital holes in the heart cause blood to pass uncontrollably to the right or left between the chambers. Thanks to the device, how close this hole is to the valve and how many millimeters in size it is are measured perfectly. In addition, how much harmful pressure this hole creates on the lungs is calculated. While some small holes may close completely on their own over time, others may require surgical operation or intervention with the angiography method. In very complex conditions such as transposition of the great vessels, this ultrasound examination provides surgeons with a perfect and complete roadmap showing what to do on the operating table.

How Is Fetal ECHO (Echocardiography) Performed on the Baby in the Womb?

The baby’s heart completes its anatomical formation and begins beating regularly very early in the womb. Fetal echocardiography is the process of examining the baby’s heart in great detail before birth, only through the mother’s abdominal wall. The clearest and most efficient results for this evaluation are usually obtained around the twentieth week of pregnancy. Although routine ultrasound screenings performed by obstetricians are very valuable, examining all the valves of a tiny heart is an entirely different field of expertise.

Pregnancy situations in which this vital examination must be performed include:

• The mother having diabetes
• Family history of congenital heart disease
• Suspicious heart appearance on routine ultrasound
• Irregularities observed in the baby’s rhythm

This examination, which lasts approximately forty-five minutes to one hour, is completely painless for the mother and does not harm the baby in any way. Making an early diagnosis in the womb is a very major medical advantage. If a serious problem is detected, the baby’s birth is planned not in an ordinary hospital, but in a fully equipped major health center with pediatric cardiac surgery. Thus, as soon as the baby is born, necessary interventions can be performed safely without losing any time, and the chance of survival is increased at an incredible rate.

If ECHO Performed Through the Chest Is Insufficient, How Is Echocardiography Performed Through the Esophagus?

The standard imaging performed through the chest surface in outpatient clinics is completely sufficient for many diseases. However, at certain special moments, the child’s sternum structure, excessive air in the lungs, or a millimetric detail sought in the most remote corner of the heart may significantly reduce the clarity of the standard method. In such frustrating situations, a very different and special method performed through the esophagus is used. The esophagus is the immediate posterior neighbor of the heart. A very soft tube with a small ultrasound camera at its tip is slowly and gently advanced through the mouth into the esophagus. In this way, even the rearmost parts of the heart are visualized with extraordinary resolution without obstacles such as ribs or lung tissue in between.

Medical situations in which this special method is indispensable include:

• Diagnosis of heart valve infections
• Searching for clots inside the heart
• Instant checks during open-heart surgery
• Catheter-based hole closure procedures

Children must be safely sedated under the supervision of specialist physicians so that they do not feel any pain, nausea, or fear during this process. The stomach is required to be completely empty before the procedure. Anesthetic sprays and special softening medical gels are used to prevent throat irritation.

How Is Heart Performance Measured With Echocardiography (ECHO)?

The heart muscle is not simply a structure consisting of chambers and channels; it is a gigantic pump that sends blood to the most distant parts of the body and works without stopping. During imaging, how successfully the heart works as a pump is calculated within seconds using advanced mathematical formulas loaded into the device. The percentage of the fresh blood filling the heart that it can successfully eject to the body is clearly determined. The contraction power of a healthy heart must remain above a certain level. If there is a significant decrease in this power, this may immediately show that the heart muscle has weakened or has undergone serious virus-induced inflammation. These vital numerical values play the most important role in determining the dose of the heart medication to be given.

The main factors reflected on the device during performance measurement are:

• Left ventricular contraction percentage
• Heart muscle relaxation capacity
• Aortic blood ejection volume
• Pressures inside the pulmonary artery

Since children grow continuously with each passing month, heart measurements cannot be evaluated with fixed limits as in adults. Naturally, the vessel diameter of a tiny three-month-old baby and that of a ten-year-old primary school child cannot be the same. Therefore, all millimetric measurements made on the screen are calculated by placing them into international standard tables according to the child’s current height and weight.

Why Is Echocardiography (ECHO) Necessary in Cases of Innocent Murmur or Chest Pain?

The most common reason families bring their children to the hospital in great panic and anxiety is hearing a heart murmur with a stethoscope during a routine pediatric examination. A murmur is not a fatal disease by itself, but only an extra sound heard. It is a situation similar to the whistling of wind as it passes through a narrow gap. The vast majority of these sounds are harmless conditions called innocent murmurs. In childhood, the rapid and very lively flow of blood within the vessels causes these sounds.

Physiological conditions that cause the murmur to be heard more intensely include:

• Periods of high fever illness
• Severe anemia conditions
• Rapid height growth and development phases
• Excessive excitement and exertion

It may sometimes be difficult to distinguish with absolute certainty by listening alone whether this strange sound is completely innocent or caused by a hidden small hole in the heart. With the ultrasound examination performed, it is fully proven that the heart contains no holes, and the great stress that families have experienced for days is relieved immediately. Likewise, whether chest pains, which are frequent reasons for emergency visits, are muscle-related or heart-related is clarified within minutes, and a safe treatment path is established.

What Is Stress Echocardiography (ECHO) and In Which Situations Is It Performed?

Some insidious heart conditions do not show any signs of danger while the child is resting in bed, that is, while the heart is beating quite slowly and calmly. All vascular structures and valve pressure values on the screen may appear completely normal. However, when that child runs in the park, plays football, or exerts effort, hidden problems may suddenly appear. The procedure of revealing these hidden problems by tiring the heart in a very controlled manner is called a stress test in medical language.

Medical methods used to safely accelerate the heart include:

• Inclined treadmill exercise
• Stationary steady-tempo exercise bicycle
• Accelerating medications administered intravenously

At those sweaty moments when the heart rate is forced to reach its peak, recordings are taken very quickly with the device. Our main purpose here is to observe live whether enough oxygen reaches the heart muscle while the heart is sprinting at a high tempo. Serious pressure changes occurring in the valves are also understood much more clearly under exertion. Especially in the annual follow-up of children who want to start professional sports or who have mild valve stenosis, this exercise-based method provides very reliable decisions about their future.

What Do the Details in an Echocardiography (ECHO) Report Tell Us?

After this entire detailed examination process is completed, hundreds of moving images and complex numerical data obtained are carefully evaluated by an expert eye. All this important data is brought together and presented as a written result report to be given to the family. At first glance, this report may seem quite frightening because it contains highly complex medical terms, foreign words, and many decimal numbers. At the beginning of the report, it is clearly confirmed that the arteries entering the heart and the right and left chambers are structurally connected to the correct places. Then millimetric calculations of wall thicknesses, blood pressures, and heart size are listed in long tables. Doppler data determine how many meters per second blood passes through the valves and the amount of any backward leakage if present.

The result sections in the report that directly concern the family are:

• Summary of the current medical condition
• Definitive diagnosis, if any
• Recommended medication treatment to be started
• Date of the next outpatient clinic follow-up