What Does an Echocardiogram Check? Heart Ultrasound Explained

What exactly does an echocardiogram look at?

An echocardiogram uses high-frequency sound waves (ultrasound) to create real-time moving images of the heart. A cardiac sonographer places a handheld probe against the chest wall, and the returning sound waves build a picture of the heart's anatomy and motion in real time. A standard transthoracic echocardiogram (TTE) evaluates:

• Heart chambers: The size, shape, and wall thickness of all four chambers (right and left atria, right and left ventricles). An enlarged or thickened chamber can signal that the heart is under abnormal stress.
• Heart valves: All four valves — mitral, aortic, tricuspid, and pulmonary — are assessed for narrowing (stenosis) and leakage (regurgitation). Valve abnormalities are among the most common clinically significant echo findings.
• Pumping function (ejection fraction): The percentage of blood the left ventricle squeezes out with each beat. A normal ejection fraction is roughly 55–70%; values below 40% indicate reduced heart-muscle function and are a core criterion in the diagnosis and staging of heart failure 1Ref 1Heidenreich PA, Bozkurt B, Aguilar D, et al. (2022).2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Echocardiography as the primary diagnostic tool for evaluating left ventricular ejection fraction, classifying heart failure (HFrEF vs HFpEF), and guiding management decisions.
• Wall motion: Each segment of the heart wall should contract and relax in a coordinated pattern. Segments that move abnormally (hypokinesis, akinesis) may have been damaged by a prior heart attack or reduced blood supply.
• Pericardium: The sac surrounding the heart is assessed for excess fluid (pericardial effusion), which appears as a dark space around the heart on the image.
• Aortic root: The origin of the main artery leaving the heart can be measured for enlargement (dilatation).

What conditions can an echocardiogram detect?

Echocardiography is one of the most versatile cardiac imaging tools in clinical practice. It can identify or characterize:

• Heart failure: Reduced systolic function (low ejection fraction) or impaired relaxation (diastolic dysfunction) — echocardiography is the primary modality for diagnosing and classifying heart failure 1Ref 1Heidenreich PA, Bozkurt B, Aguilar D, et al. (2022).2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Echocardiography as the primary diagnostic tool for evaluating left ventricular ejection fraction, classifying heart failure (HFrEF vs HFpEF), and guiding management decisions
• Valvular heart disease: Mitral valve prolapse, aortic stenosis and regurgitation, mitral regurgitation, and other valve disorders
• Cardiomyopathy: Dilated, hypertrophic, restrictive, and infiltrative diseases of the heart muscle
• Congenital heart defects: Structural abnormalities present from birth, including atrial or ventricular septal defects
• Pericardial effusion and pericarditis: Fluid around the heart or inflammation of the pericardial sac
• Left atrial thrombus: Blood clots in the left atrial appendage are a serious risk in atrial fibrillation — transesophageal echocardiography is the standard tool for detecting them before cardioversion 2Ref 2Joglar JA, Chung MK, Armbruster AL, et al. (2024).2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.Transesophageal echocardiography recommended for detecting left atrial appendage thrombus in atrial fibrillation prior to cardioversion or catheter ablation
• Pulmonary hypertension: Elevated pulmonary artery pressure estimated from Doppler flow measurements
• Right heart strain: Suggesting acute pulmonary embolism or chronic lung disease

What are the different types of echocardiogram?

Several variations exist, each suited to different clinical questions:

• Transthoracic echocardiogram (TTE): The standard examination — probe on the chest wall, no sedation, typically 30–60 minutes. This is the most commonly ordered type.
• Transesophageal echocardiogram (TEE): A smaller probe is passed into the esophagus under light sedation to obtain clearer views, particularly of the mitral valve and left atrial appendage. Recommended by the 2023 AFib guideline for thrombus detection before cardioversion or catheter ablation 2Ref 2Joglar JA, Chung MK, Armbruster AL, et al. (2024).2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.Transesophageal echocardiography recommended for detecting left atrial appendage thrombus in atrial fibrillation prior to cardioversion or catheter ablation.
• Stress echocardiogram: Images are obtained before and immediately after exercise (or a pharmacological stress agent) to identify wall motion abnormalities that emerge when the heart is under increased demand — useful for detecting coronary artery disease.
• Doppler echocardiogram: Blood flow velocity and direction measurements are standard in most TTEs, enabling quantification of valve gradients, pressures, and regurgitant volumes.

Who orders and performs an echocardiogram?

Echocardiograms are ordered by cardiologists, primary care physicians, and other specialists when a cardiac condition is suspected or needs monitoring. The test is performed by a cardiac sonographer — a technologist with specialized heart-ultrasound training — and the images are formally interpreted by a cardiologist.

Echocardiography is performed in cardiology offices, hospital cardiac imaging departments, and some cardiology-affiliated outpatient centers. A Gale primary care clinician can evaluate your symptoms, determine whether an echocardiogram referral is warranted, help you understand what the report says, and coordinate follow-up care.

What does the test feel like, and do I need to prepare?

A standard transthoracic echocardiogram is painless. You lie on an exam table while the sonographer applies a small amount of gel to your chest and presses the probe gently against the skin. You may be asked to breathe in, hold your breath briefly, or roll onto your left side to improve image quality. The test takes 30–60 minutes.

For a standard TTE, no special preparation is needed. For a transesophageal echo or stress echo, your cardiology team will give you specific instructions about fasting, medications, and arriving with a driver.

After the test, a cardiologist reviews the images and sends a structured report to the ordering clinician. If you have questions about what your echo results mean, a Gale primary care clinician can help you review them in context.