Identifying Factors that Influence Pediatric Echo Lab Image Quality: Development and Validation of a New Assessment Tool.

No method of evaluating transthoracic echocardiograms (TTE) image quality (IQ) has been validated. Furthermore, structural echo lab elements impacting IQ are unknown. We sought to develop and validate a TTE IQ grading tool and determine patient and echo lab features associated with IQ. Ten pediatric echo labs each submitted 50 consecutive new patient TTEs without complex heart disease. For each study, 3 sonographers independently rated IQ and performed routine measurements. IQ scoring used the American College of Cardiology Quality Network (ACC QNet) tool plus a novel Likert scale component. IQ scores were validated against the ability to make measurements and, when all measurements were made, variation between sonographers. After validation, patient and lab factors, from a previously published survey, associated with improved TTE IQ were determined by linear regression. Total IQ score (R = 0.64), ACC QNet (R = 0.29) and the Likert component (R = 0.52) correlated with the total number of measurements made (p < 0.001). For the 236 (52%) TTEs with all measurements, the Likert scale component (OR 0.9, 95% CI 0.82-0.99, p = 0.037) was associated with lower measurement variability. Factors significantly associated with worse IQ scores were higher patient weight, performance by a traveling sonographer, lower annual and inpatient TTE volume, less dedicated teaching/administrative sonographer time, and full-day sessions for reading physicians. A novel TTE IQ scoring tool was created and validated for pediatric TTE. Modifiable structural components of echo labs associated with TTE IQ were identified. This novel IQ tool should guide IQ beyond the ACC QNet score.