What is the reason for and aim of the publication?
This guideline was developed to address a persistent and clinically important problem in echocardiography: cardiac ultrasound artifacts are common, often unavoidable, and can significantly affect diagnostic accuracy. Ultrasound artifacts occur across all echocardiographic modalities, including 2D imaging, spectral Doppler, color Doppler, 3D echocardiography, and imaging with ultrasound-enhancing agents.
The aim of the document is to provide a uniform, structured framework for identifying and mitigating these artifacts in clinical practice. The writing group systematically reviewed how each artifact appears, the physical mechanism behind it, its potential clinical impact, and the practical strategies that can be used to avoid or reduce misinterpretation. Moreover, the guideline addresses artifact-like phenomena related to machine settings or normal device-related findings, which are often confused with true artifacts.
This guidelines document is intended to improve interpretive accuracy, reduce preventable diagnostic error, and strengthen patient safety in daily echocardiographic practice.
What are the most important take-home messages?
- Cardiac ultrasound artifacts are not rare exceptions; they are inherent to ultrasound physics and therefore an expected part of routine imaging. Ultrasound image formation depends on a set of assumptions made by every ultrasound system and violation of these assumptions predictably generates artifacts.
- Artifacts can have major clinical consequences when they mimic serious pathology or obscure true disease. The guideline highlights several high-risk examples, including reverberation or side-lobe artifacts simulating type A aortic dissection, left atrial appendage reverberation mimicking thrombus, color Doppler mirror artifacts simulating prosthetic mitral regurgitation, and shadowing artifacts concealing vegetations, paravalvular leaks, thrombi, or intracardiac masses.
- Recognition of artifacts depends on a systematic interpretive approach. Features such as lack of respect for anatomic boundaries, identical motion to neighboring structures, absence of physiologic Doppler correlation, and disappearance with alternative imaging planes are often critical clues that a finding is artifactual rather than pathologic.
- The guidelines document suggests mitigation strategies include changing probe position or insonation angle, adjusting gain and wall filters, optimizing focal zone and frequency, narrowing the color sector, using harmonic imaging, and escalating when needed to TEE, 3D echocardiography, ultrasound-enhancing agents, cardiac CT, or CMR.
What are challenges in practical implementation – and possible solutions?
A major challenge in implementation is that artifact recognition is highly dependent on the expertise and experience of a diagnostician interpreting echo studies. Knowledge of image appearance as well as understanding of ultrasound physics, machine behavior, Doppler principles, and modality-specific limitations are needed. In practice, many artifacts are difficult because they closely resemble clinically important pathology and may arise in urgent or high-stakes scenarios, such as suspected aortic dissection, prosthetic valve dysfunction, endocarditis, intracardiac thrombus, or structural heart intervention.
A second challenge is the breadth of artifacts across imaging modes. The diagnostician must distinguish axial artifacts such as reverberation, mirror image, shadowing, enhancement, and speed displacement; lateral artifacts such as refraction, beam width, slice thickness, and side lobes; Doppler-specific artifacts such as aliasing, spectral broadening, mirror artifacts, and double envelopes; and modality-specific artifacts in 3D imaging, contrast imaging, and device-related imaging.
A third challenge is that some artifacts cannot be avoided. In many situations, the appropriate goal is not elimination, but recognition and mitigation. For example, prosthetic valves, intracardiac catheters, ventricular assist devices, calcification, and closure devices inherently generate reverberation, shadowing, and blooming artifacts that must be interpreted around rather than entirely eliminated.
Potential solutions are well outlined in the guidelines. These include structured training in artifact physics and image interpretation; use of standardized troubleshooting approaches; routine use of alternative windows and orthogonal planes; optimization of gain, wall filter, baseline, velocity scale, sample volume depth, and focal zone; and early use of complementary imaging modalities when findings remain equivocal. The document also points to simulation-based training and closer collaboration with engineers and physicists as important future enablers of better implementation.
Which issues still need to be tackled, that are not yet addressed by the paper?
Although the guidelines are comprehensive, several important issues remain for future work. One is the need for more formal implementation science: how best to translate artifact recognition into reproducible quality improvement across laboratories, vendors, training environments, and levels of operator experience.
Another important issue is the expanding impact of devices and interventions. As structural heart procedures, intracardiac implants, ventricular assist devices, and extracardiac support systems become more common, the range of artifact patterns will continue to evolve. Some newer device-related artifacts are recognized clinically, but their exact mechanisms and optimal mitigation strategies may not be fully characterized.
The document establishes the framework, but further work is needed in validation, education, competency assessment, and real-world outcome measurement.
What further developments on the topic are emerging?
Several important developments are emerging. One is the increasing use of artificial intelligence and software-based image support tools. The guideline notes that deep-learning systems may eventually help identify common artifacts automatically and guide users in real time to adjust imaging planes, angles, or settings to reduce artifact generation.
A second area is continued hardware and software innovation. Advances in beam forming, signal processing, harmonic imaging, 3D acquisition, and contrast-specific imaging may improve artifact discrimination and reduce some artifact burden, even though artifacts can never be completely eliminated because they arise from fundamental ultrasound physics.
A third development is the increasing relevance of artifacts in the era of structural and device-based cardiovascular care. As more intracardiac and extracardiac devices are implanted, imagers will encounter new artifact signatures, making ongoing adaptation of imaging techniques essential.
Finally, the guideline points toward simulation-based education and stronger interdisciplinary collaboration with engineers and medical physicists. That combination is likely to be central to the next phase of progress: not only recognizing artifacts more reliably, but preventing misdiagnosis through smarter systems, better training, and more integrated multimodality imaging workflows.
