Echo image quality – Does size really matter??

There is no doubt that over the past 10 years the average size of our patients has increased noticeably. It is well recognized that body habitus plays a role in echo image quality, with both unusually small and large patients potentially being difficult to image. There is however considerable variability between individuals and it is near impossible to predict image quality just by “sizing” the patient up.

The following clips are 2D images of the aortic valve taken from the PSAX view. Both patients are male and 5ft 11in (180cm) tall. Patient A however weighs 165lbs (75kg) and Patient B weighs 330lbs (150kg). There is not a lot of difference in image quality between the 2 patients. and in fact, when you look closely, the much larger patient B has some exceptional detail in his images!

Echo image quality in 75kg male

Patient A: PSAX view at AoV level – Male. 5ft 11in (180cm) tall, 165 lbs (75 kg)

Reasonable echo image quality in 150 kg male

Patient B: PSAX view at AoV level – Male. 5ft 11in (180cm) tall, 330 lbs (150 kg)









So, what is the moral of the story??

Every story has to have a point… and the point today is that you can’t judge a patients images by their size. It may be a physical strain to image some patients because of their size, but it does not automatically mean we are going to obtain poor images. I have heard some Drs suggest that a patient should automatically go on to have an MRI (without even trying an echo first) just because of body habitus, pre-judging the patient as having poor images without even looking. Often these are for clinical questions that would easily be sorted out with a cheaper and more accessible echocardiogram. It is ALWAYS worth a look with the echo first and additional imaging modalities can be arranged later if needed.

And sonographers… don’t pre-determine your image quality before you even start the test. Optimize the image as best you can and more often than not you will obtain diagnostic data. If you are convinced that you are going to obtain poor images, then you probably will…. Have a positive outlook and you might even image some echo gold like this view of the coronary arteries (yes, it is in the 330lbs/150kg man!!!).

CorArt_dynamic CorArt_label_2

Special thanks to Dr Justin Morze, Hearts 1st – Brisbane for the fantastic images….



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  • Reply Doug Wuebben April 17, 2015 at 12:32 am

    Great education, advice and food for thought!

    • Reply echoguru April 17, 2015 at 1:10 am

      Thanks Doug! The increasing size of our patients makes your advice on stretching and injury prevention even more valuable!

  • Reply Elton Aguilar, BS RDCS April 17, 2015 at 1:02 am

    You are absolutely right!! I always tell sonographers, the new and the seasoned, that you never know what you’re going to get until you place that probe on their chest. I still get surpised sometimes on some of those 300+ pounders how well they can image. Even then… though they may not have the prettiest pictures, you can still attempt to make the study diagnostic. I can say comfortably that in 97% of the technically challenging patients you can at least estimate global left ventricular function. And that would be without the use of LV opacifying agents.

    But, hallelujia for LV opacifying agents and new probe technology! I love it! I’ve been a sonographer for over 25 years and remember the pre-harmonic imaging and pre-contrast days of scanning. That’s all we had. That’s all we knew. But, we learned the tricks and techniques to make an echo diagnostic. I hate to say it… but, I think contrast has made the newer sonographers lesser scanners because they bail out too quickly for the Definity injection. They fail to learn how to tweek the ultrasound machine to get a great image.

    Thanks again, Echo Guru, for another great topic!


    • Reply echoguru April 17, 2015 at 1:09 am

      Thanks Elton. We refer to pre-contrast imaging as the “dark ages”. 10,000 contrast injections later and I am still constantly blown away at how little we actually saw…
      Thanks for your support!

  • Reply Anele April 17, 2015 at 9:29 am

    As a Sonograher I can safely agree with not pre judging patient size…. There is a lot to consider: the window you scanning from, the Physics of U/S e.g. Gains, TGC, DR. someone can get the worst images from the thinnest patints because of bone from the ribs. So put the probe on and try to optimise your Image.

  • Reply Karen Farrar April 18, 2015 at 12:39 am

    In terms of image quality, I often find body shape more relevant than body size. Some body shapes are just harder to image and I agree with the comment about ribs in thin patients. I have been able to obtain great images in morbidly obese patients (especially from the parasternal window) but then struggled to get anything on cachectic patients. Thanks for the great imaging of the coronary arteries, by the way. It’s not often you get to see them like this on TTE.

  • Reply LITFL Review 179 | LITFL April 26, 2015 at 9:01 pm

    […] from echo.guru that our larger patients can still make good transthoracic echo images. I guess size doesn’t matter so much? […]

  • Reply Emma Halton June 1, 2015 at 1:19 am

    For me it’s about reassessing where the heart will lie in the chest in these more “spherical” guys and gals. For example I’ll always begin looking for an apical window from a higher up and more medial position.

    • Reply echoguru June 1, 2015 at 5:09 pm

      Great point Emma. Also don’t be scared to try rolling the patient differently. Sometimes you will get better images with the patient laying supine then when they are on the side.

  • Reply LITFL Review 179 March 27, 2017 at 7:35 am

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  • Reply LITFL Review 179 • LITFL Medical Blog • FOAMed Review January 4, 2019 at 3:22 am

    […] from echo.guru that our larger patients can still make good transthoracic echo images. I guess size doesn’t matter so much? […]

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