Every week in my imaging lab, I sit with patients who are holding a report full of abbreviations they have never seen before — EF, LVEDD, TAPSE, moderate MR — and they have no idea whether they should be worried or relieved. Most were told they need surgery. Some were told they don't. And in both cases, the echocardiogram was the single most important test driving that recommendation.
I am Kunal U. Gurav, MD, a fellowship-trained specialist in echocardiography and nuclear cardiology. My work centers on acquiring and interpreting the cardiac images that surgeons and interventional cardiologists rely on to make life-altering decisions. When I say that echocardiogram interpretation is not a commodity — that the same images, read by different eyes, can lead to fundamentally different surgical plans — I mean it. I have seen it happen far too many times.
This article is written for you: the patient or family member who has been told an echo shows something concerning, or who is trying to understand what the numbers on that report really mean. I want you to walk away understanding what kind of echo you had (or should have), what the critical measurements are, and why a second look at your cardiac imaging can sometimes change everything.
What Is an Echocardiogram and Why Does It Matter So Much?
An echocardiogram is an ultrasound of the heart. It uses sound waves — not radiation — to create real-time, moving images of your heart's chambers, valves, and blood flow. It is the most commonly performed cardiac imaging test in the world, and for good reason: it is safe, repeatable, widely available, and extraordinarily informative when performed and interpreted correctly.
Here is what a comprehensive echocardiogram can tell us:
- How well your heart pumps. The ejection fraction (EF) is the headline number — the percentage of blood your left ventricle ejects with each beat. Normal is generally 55-70%. Below 40%, we start having serious conversations about heart failure management and potentially surgical intervention.
- Whether your valves open and close properly. Stenosis means a valve does not open fully. Regurgitation means it leaks. The difference between "moderate" and "severe" regurgitation on an echo can be the difference between watchful waiting and an operating room date.
- The size and thickness of your heart chambers. An enlarged left ventricle or left atrium tells a story about how long your heart has been under stress — and how urgently it needs relief.
- How blood flows through your heart. Doppler imaging lets us measure pressures and flow velocities that were once only available through invasive cardiac catheterization.
- Structural abnormalities. Holes between chambers, abnormal muscle thickening, fluid around the heart, blood clots — all visible on a well-performed echo.
According to the ACC/AHA guidelines, echocardiography is a Class I recommendation (meaning it is considered essential) for evaluating patients with suspected valve disease, heart failure, and many other cardiac conditions. It is usually the first test ordered and often the most important test in your surgical decision-making process.
TTE vs TEE: Two Types of Echocardiogram and When Each One Matters
Not all echocardiograms are the same. The two you are most likely to encounter are TTE (transthoracic echocardiogram) and TEE (transesophageal echocardiogram). Understanding the difference between TTE vs TEE is essential because each has strengths, limitations, and specific clinical indications.
Transthoracic Echocardiogram (TTE)
This is the standard echo — the one most patients have had. A sonographer places an ultrasound probe on the surface of your chest wall and acquires images through the ribs and lung tissue. It is noninvasive, requires no sedation, takes 30-60 minutes, and provides an excellent overview of cardiac structure and function.
A TTE is usually the right first test. It gives us ejection fraction, valve assessments, chamber sizes, and basic hemodynamic data. For many patients, it is sufficient to guide clinical decisions.
Limitations: Because the sound waves must travel through skin, fat, muscle, ribs, and lung, image quality can be suboptimal in patients with obesity, chronic lung disease (COPD or emphysema), or certain body habitus. Certain structures — particularly the left atrial appendage, the mitral valve from behind, and prosthetic (replacement) valve details — are simply harder to see from the chest surface.
Transesophageal Echocardiogram (TEE)
A TEE involves passing a specialized ultrasound probe into the esophagus — the swallowing tube that sits directly behind the heart. Because there is no lung or bone between the probe and the heart, the images are dramatically sharper and more detailed.
A TEE requires mild sedation (similar to what you would receive for an upper endoscopy), takes about 20-30 minutes, and is considered a semi-invasive procedure. It is extremely safe, but it is not performed casually — there needs to be a specific clinical reason.
Common reasons a TEE is ordered:
- Evaluating the mitral valve in detail before repair surgery — this is critical, because a surgeon needs to know the exact mechanism of the leak to plan the repair
- Looking for blood clots in the left atrial appendage, especially in patients with atrial fibrillation
- Assessing prosthetic (artificial) heart valves, where a TTE often cannot see clearly due to shadowing from the metal or tissue components
- Diagnosing endocarditis (infection on a valve) when TTE images are inconclusive
- Evaluating the aorta for dissection or aneurysm in emergency settings
- Guiding the surgeon in the operating room during valve repair or replacement
Here is what I tell patients: a TTE is like looking at your house from the street. A TEE is like walking inside. Both are valuable. But if someone is planning to renovate your kitchen, they need to be inside.
If you have been told you need mitral valve surgery based on a TTE alone and no TEE has been performed, that is worth questioning. ACC/AHA guidelines recommend TEE for preoperative assessment of mitral valve disease being considered for surgical intervention. The mechanism of the leak — which leaflet is involved, whether chords are ruptured, whether there is calcification — directly determines whether the valve can be repaired rather than replaced. And repair, when feasible, carries significantly better long-term outcomes.
Echocardiogram Interpretation: Why the Reader Matters as Much as the Machine
Here is something most patients do not realize: the same echocardiogram images can be graded differently by different readers. A regurgitant jet that one cardiologist calls "moderate" might be called "moderate-to-severe" or even "severe" by another. And that single-word difference can determine whether you are sent to surgery or told to come back in six months.
This is not because anyone is being careless. Echocardiogram interpretation involves integrating multiple data points — jet area, vena contracta width, regurgitant volume, EROA (effective regurgitant orifice area), chamber sizes, and the clinical context — into a final assessment. There is inherent subjectivity in this process. Studies have shown that inter-observer variability in grading valve regurgitation severity can be significant, even among experienced readers.
A 2013 study published in the Journal of the American Society of Echocardiography demonstrated that agreement on mitral regurgitation severity between independent readers was approximately 65-75%, meaning that in roughly one-quarter to one-third of cases, two qualified cardiologists would grade the same echo differently.
This is precisely why cardiac imaging for patients facing surgical decisions deserves a second set of expert eyes. Not because the first reader was wrong, but because the stakes are high enough that confirmation matters. If you are told your aortic stenosis is "severe" and you need a valve replacement, it is entirely reasonable to ask: was the aortic valve area measured by continuity equation? Was a dimensionless index calculated? Were the findings consistent across multiple parameters, or was it borderline by some measures?
These are the kinds of questions an independent imaging review answers. At WhiteGloveMD, our team reviews the actual imaging data — not just the report summary — to ensure the interpretation aligns with guideline-based criteria and supports the recommended plan.
Practical Advice: What to Ask and What to Bring to a Second Opinion
If you are considering a second opinion about a recommended cardiac surgery, here is what I would advise from an imaging standpoint:
- Request a copy of your echo images, not just the report. The written report is a summary. The actual images (usually stored as DICOM files on a CD or available through a patient portal) contain far more information. Any meaningful echocardiogram interpretation review requires seeing the images themselves.
- Ask what type of echo was performed. Was it a TTE or TEE? Was a stress echo done? If you are being recommended for valve surgery and only a resting TTE has been performed, ask whether additional imaging is warranted.
- Understand the key numbers on your report. You do not need a medical degree to know your ejection fraction, the grade of any valve disease (mild, moderate, or severe), and your basic chamber dimensions. These are your numbers — own them.
- Ask about the grading criteria. If your aortic stenosis is called severe, ask: what was the valve area? What was the mean gradient? What was the peak velocity? ACC/AHA defines severe aortic stenosis as a valve area less than 1.0 cm², a mean gradient greater than 40 mmHg, or a peak velocity greater than 4.0 m/s. If not all criteria are met, the picture may be more nuanced than a single-word grade suggests.
- Use the WhiteGloveMD free cardiac surgery risk calculator to understand how your imaging findings fit into your overall surgical risk profile. Imaging does not exist in a vacuum — it must be interpreted alongside your age, other medical conditions, and the specific procedure being recommended.
When Cardiac Imaging Changes the Surgical Plan
I want to share why this matters in real, practical terms. In my experience, there are several common scenarios where a closer look at cardiac imaging for patients changes the trajectory of care:
Scenario 1: Mitral regurgitation regraded from severe to moderate. A patient is told they need mitral valve surgery. On independent review, the regurgitation is actually moderate by quantitative criteria, and the left ventricle is normal in size and function. Guideline-based management in this case is surveillance, not surgery. The patient avoids an unnecessary operation.
Scenario 2: Aortic stenosis is severe, but the echo missed something else. A patient is being scheduled for aortic valve replacement. On careful review of the echo images, there is also moderate mitral regurgitation and a dilated ascending aorta measuring 4.6 cm. This changes the surgical plan significantly — perhaps a concomitant mitral repair and aortic graft should be discussed, or perhaps the aorta needs a CT angiogram for better characterization before the surgeon commits to an approach.
Scenario 3: The echo quality was poor, and a TEE or cardiac MRI is needed. Sometimes the honest answer is that the TTE images were suboptimal and a definitive assessment cannot be made from what is available. Rather than proceeding to surgery based on uncertain data, the right move is to obtain better imaging. A structured second opinion review can identify this gap before you are on the operating table.
These are not hypothetical scenarios. They happen routinely. And in every case, the patient benefits from having their imaging examined with fresh, expert eyes.
The Bottom Line: Your Echo Is the Foundation of Your Surgical Decision
If you take one thing away from this article, let it be this: the echocardiogram is not just a test you check off a list. It is the foundation upon which your entire cardiac surgical recommendation is built. The accuracy of its interpretation directly affects whether you are offered the right procedure, at the right time, for the right reasons.
As a fellowship-trained cardiac imaging specialist, I believe every patient facing a major surgical decision deserves to know that their echo was read carefully, graded accurately, and interpreted in context. You would not buy a house based on a single home inspection without reading the full report. Your heart deserves at least the same diligence.
If you are facing a recommendation for cardiac surgery — whether it involves your aortic valve, mitral valve, coronary arteries, or aorta — and you want to ensure that your echocardiogram interpretation and overall imaging workup support that plan, a WhiteGloveMD second opinion can help. Our team reviews your actual imaging studies, operative reports, and clinical data to provide an independent, evidence-based assessment. You owe it to yourself to be certain before you consent.