First-ever guideline dedicated to cardiac ultrasound artifacts aims at reducing diagnostic error
The American Society of Echocardiography (ASE) released on May 4, 2026 the first guideline dedicated exclusively to identifying and mitigating artifacts in cardiac ultrasound. The document, titled "Recommendations for the Identification and Mitigation of Cardiac Ultrasound Artifacts," covers all current echocardiographic modes — two-dimensional, spectral Doppler, color Doppler and three-dimensional echo — and addresses an uncomfortable observation: despite hardware and software advances over the last few years, artifacts remain prevalent across all modes and can lead to serious diagnostic mistakes.
The sensitive point is that artifacts are not random errors: they arise from the inherent physical properties of ultrasound — reverberation, acoustic shadowing, mirror image, side-lobe, among others — and can be amplified by interference from external equipment emitting ultrasound waves. Without specific training, it is easy to interpret a reverberation as aortic dissection or a near-field artifact as a ventricular thrombus, with serious clinical consequences.
What the guideline brings
The publication organizes knowledge in three blocks. First, it describes the visual characteristics of the most common artifacts in each mode — from reverberation and shadowing to comet tails, beam-width artifacts and refraction artifacts. Second, it explains the physical mechanisms generating each artifact, helping the operator understand when to expect them. Third, it presents practical mitigation strategies: gain, focus, frequency, depth, tissue harmonic and acoustic-window adjustments.
For Guideline Chair Dr. Muhamed Saric, director of echocardiography at NYU Langone, the initiative "is the first document published by an imaging society focused exclusively on cardiac ultrasound artifacts." Saric stresses that sonographers and clinicians must recognize these "Achilles’ heels" of ultrasound to reduce the risk of misdiagnosing critical conditions such as aortic dissection and ventricular thrombus. Another differentiator is the extensive figure and video case collection, which becomes a reference for training and clinical review.
Why this matters for clinical practice
Echocardiography is the most performed cardiac imaging exam in many health systems, with broad penetration across public and private hospitals. The technical training of cardiac sonographers is heterogeneous — it varies with residency, specialization and hands-on experience. In lower-volume centers, artifact recognition can be exposed to individual gaps, with direct impact on surgical decision-making, anticoagulation and decisions to escalate to CT aortography.
The ASE guideline offers international standardization that can be absorbed by national cardiology societies into continuing education programs. For services adopting double reads or structured peer review, the document serves as objective reference to discuss borderline cases in interpretation efficiency programs and in joint actions with clinical cardiology and cardiothoracic surgery.
Hardware helps, but operator education is still essential
Recent innovations in transducers, beamforming algorithms, tissue harmonic and AI image processing promise to reduce artifact frequency. Modern echo systems already include adaptive reverberation filters and dynamic speckle correction. But the guideline is unambiguous: operator education remains essential. Every new equipment must be revalidated for presets, local adjustments and acquisition protocols. Skipping that step costs image quality.
There is also the AI angle. AI has shown superiority on some radiology tasks and automated chamber-detection, color-flow and wall-segmentation algorithms are increasingly embedded in echo systems. The guideline acknowledges that movement but reinforces that AI remains assistive — it does not replace the sonographer’s clinical judgment in the face of an obvious artifact. The ideal combination involves modern hardware, supportive AI and an operator trained on guidelines such as the ASE’s.
How to adapt the routine
Echo services can leverage the publication on four fronts. First, update institutional acquisition protocols with mode-specific (2D, spectral, color, 3D) artifact-mitigation checklists. Second, integrate the ASE video collection into internal training for sonographers and residents. Third, review retrospective reports for potential discrepancies attributable to artifacts, especially in surgically discordant cases. Fourth, build second-opinion workflows for ambiguous images in high-risk conditions — dissection, thrombus, vegetation, tamponade-grade effusion.
The ASE move also dialogues with parallel cardiac-imaging trends: distribution of Philips cardiac ultrasound systems by Heart Medical and the expansion of installed base put pressure on more explicit quality standards. Operational guidelines like this provide exactly the educational backstop missing from many services.
Expected next steps
Regional societies are expected to publish translations and adapted versions, and hospital quality committees are likely to embed items from the guideline into audit metrics. In parallel, equipment manufacturers will likely refresh training materials and on-console tutorials — a path already seen after previous ASE guidelines on fetal and stress echo. For the cardiac sonographer, the recommendation is straightforward: read the document, review the video collection and include artifact checks as an explicit step in the acquisition protocol.
Quality programs that already use peer review platforms — such as RADPEER for radiologists or institutional echocardiography review committees — should consider adding artifact-related categories so that recurrent operator-level patterns are captured and addressed through targeted training rather than left as anecdotal feedback.
Source: Imaging Technology News — New Guideline for Cardiac Ultrasound Artifacts Released by ASE.
