Position statement: Adult congenital echocardiography in hospitals without congenital heart disease surgery

Published 03/11/2025

Background and rationale

The British Society of Echocardiography (BSE) recognises that the adult congenital heart disease (ACHD) population within the UK is growing rapidly, and that the skilled workforce is not growing at the same rate. Many ACHD patients are seen outside of specialist congenital surgical centres by non ACHD-trained echocardiographers. This diverse patient population, including those with complex anatomy, physiology and/or additional needs, are often seen infrequently, thereby presenting a challenge for these echocardiographers.

The diversity of this patient population makes a one-size-fits-all service model impractical. The importance of complete segmental, sequential imaging must not be overlooked, and is considered the gold standard for new presentations, however it is acknowledged that these are rare in an outreach clinic setting. Serial ACHD echocardiographic assessments are typically less protocol-driven than the traditional adult minimum dataset, allowing for a more clinically bespoke study, the nuances of which are often less understood by non-ACHD specialists and must therefore be supported by appropriate clinical guidance (see Appendix 2).

This position statement aims to support echocardiographers performing ACHD studies in non-specialist and non-surgical congenital centres where robust clinical support is not readily available by ensuring that the timeslot available for each echocardiogram is of a suitable duration for appropriate diagnostic assessment, without compromising patient access and flow in the clinic setting.

Adult congenital echocardiography timeslots

The BSE recognise that staff performing echocardiography in ACHD patients need time to review the clinical and surgical history, and previous echocardiographic images before beginning the scan. Additionally, it is noted that non-ACHD specialist echocardiographers may be unfamiliar with some of the interventions used and the views required to assess them. Therefore, they may be less able to plan a suitably bespoke approach to the echocardiogram. Thus, in the absence of widespread structured and standardised clinical support and training:

We recommend a timeslot of 1 hour for performing transthoracic echocardiography in adult patients with congenital heart disease by non-ACHD specialist echocardiographers in the UK.

In centres where CHD Cardiologists or senior CHD echocardiographers proactively screen and triage lists (see Appendix 2), provide robust clinical support and work closely with non-specialist echocardiographers to guide studies.

and/or

The patient has a mild CHD lesion, as defined in “2020 ESC Guidelines for the Management of Adult Congenital Heart Disease1” (see Appendix 1 for details).

and/or

The patient does not have complex additional needs:

This timeslot may be reduced to 45 minutes, in line with the standard BSE transthoracic echocardiogram timeslot.

There are situations where a shorter, more bespoke study is appropriate, these should be specifically directed, requested and clearly documented by the specialist ACHD cardiologist, who will be responsible for reviewing these studies.

Further advice and considerations

The BSE and British Congenital Cardiac Association (BCCA) have committed to working together, alongside the congenital heart disease networks to address the wider issues relating to appropriate levels of clinical support and training.

The BSE and BCCA expect that non ACHD-specialist echocardiographers will be supported to work alongside their specialist colleagues, both within their own clinics but also via attendance at their specialist ACHD cardiology centre to increase exposure to build confidence and skill. Echocardiography leads and departmental managers should also consider supporting attendance at network-wide education sessions and congenital heart disease MDT meetings, which are often virtual, to further build relationships, knowledge and confidence.

It is acknowledged that there are some patients with complex anatomy, physiology and/or additional needs in whom a clinically useful echocardiogram will not be achieved in a non-specialist centre. These patients must be referred to a specialist cardiology centre with the appropriately skilled echocardiography team.

In cases where an ACHD patient unexpectedly presents to a non-specialist centre, communication with their specialist congenital cardiology team is essential to inform their optimal management pathway and recommendations relating to a local echocardiogram if one is required.

Appendix 1: Mild congenital heart disease lesions

  • Isolated congenital aortic valve disease
  • Isolated bicuspid aortic valve disease, i.e. in the absence of aortopathy
  • Isolated congenital mitral valve disease, excluding parachute valves or cleft leaflets
  • Mild isolated pulmonary stenosis, this may be infundibular, valvular or supravalvular
  • Isolated small atrial septal defect (ASD)
  • Isolated small ventricular septal defect (VSD)
  • Isolated small patent ductus arteriosus (PDA)
  • Repaired secundum ASD or sinus venosus defect, repaired VSD, repaired PDA in the absence of residuae or sequellae, for example ventricular dysfunction, chamber enlargement or elevated pulmonary artery pressures.

Adapted from the Table 4 Classification of Congenital Heart Disease Complexity, in the 2020 ESC Guidelines for the Management of Adult Congenital Heart Disease1.

Appendix 2: Suggested framework for clinical support of ACHD clinics in non-surgical centres

Purpose
  • Intended to support echocardiographers outside of specialist ACHD surgical centres who are not trained or accredited in congenital heart disease echocardiography.
General notes
  • Most ACHD echocardiograms are follow up cases (new cases < 10% per clinic)
  • CHD diagnosis, including cardiac position, connections, structure are often well-defined in previous studies (Paediatric or ACHD settings)
  • Whilst acknowledging the above, echocardiographers undertaking ACHD studies should develop the skillset to perform a sequential segmental analysis2,3 and adopt this protocol where appropriate and possible.
Main principle: Clinical “stewardship” of the ACHD echo list
  • Robust leadership, supervision and support of non-ACHD specialist echocardiographers is essential.
  • This could be provided by a CHD cardiologist or an experienced CHD echocardiographer.
  • This may be based in-house or remotely, e.g. within CHD network, at regional specialist ACHD centre.
  • Stewardship will provide guidance on conducting the ACHD echo list, by offering advice prior to, and during, the clinic/list.

For each case, the CHD cardiologist or specialist CHD echocardiographer should review and summarise the patient clinical information:

  1. Original diagnosis
  2. Procedures/operations
  3. Review previous echo
  4. Summarise currentphysiology
  5. Key anatomical/structural features
  6. Key clinical/echocardiography questions
  7. What the report should include
  8. Be available for advice / support / feedback

(Level of detail should be appropriate to clinic/setting and echocardiographer experience)

Example:
  1. Diagnosis - double outlet right ventricle (DORV), transposition of the great arteries (TGA), ventricular septal defect (VSD), pulmonary stenosis (PS)
  2. Procedures/operations -
    1. Waterston procedure
    2. Blalock-Taussig procedure
    3. Rastelli repair with insertion of RV to PA conduit
    4. Replacement of RV to PA conduit
    5. Percutaneous pulmonary valve implantation (Melody valve) 
  3. Summarise current physiology
    1. Disregard a and b as they have been tied off and/or divided
    2. “Normal” cardiac position and connections
    3. Essentially: RV to PA conduit with implanted transcatheter pulmonary valve
  4. Key anatomical/structural features
    1. LV to aorta connection is through a large VSD which has an unusual appearance but should demonstrate a laminar blood flow pattern
    2. RV to PA conduit can be difficult to visualise, often very anterior, sometimes seen best in a high parasternal view - guided by colour Doppler
  5. Key clinical/echocardiography questions
    1. RV size and function
    2. RV pressure (TR velocity) and/or PA pressure (PR velocity)
    3. Function of implanted valve, severity of PS, PR
    4. Assessment of branch pulmonary arteries
  6. What the report should include - 3 and 5, plus any new findings

BSE Advisory Council and Trustees, November 2025

References

  1. Baumgartner, H; et al; ESC Scientific Document Group. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J. 2021 Feb 11;42(6):563-645. https://doi.org/10.1093/eurheartj/ehaa554
  2. Corbett, L., Forster, J., Gamlin, W. et al.A practical guideline for performing a comprehensive transthoracic echocardiogram in the congenital heart disease patient: consensus recommendations from the British Society of Echocardiography. Echo Res Pract 9, 10 (2022). https://doi.org/10.1186/s44156-022-00006-5
  3. Bellsham-Revell, H., Masani, N. Educational Series in Congenital Heart Disease: The sequential segmental approach to assessment. Echo Res Pract6, R1–R9 (2019). https://doi.org/10.1530/ERP-17-0039
  4. IAC Standards and Guidelines for Pediatric and Congenital Echocardiography Accreditation (Published April 2025). IAC Standards & Guidelines for Pediatric and Congenital Echocardiography Accreditation