Referral Notes:

  • In May 2026, the ASE released new clinical practice guidelines for the identification and mitigation of cardiac ultrasound artifacts.
  • Key recommendations focus on awareness, clinical consequences, systematic interpretive approaches to recognition, and mitigation strategies.
  • To review the comprehensive list of recommendations, readers should refer to the full guideline document, published in the Journal of the American Society of Echocardiography.

The American Society of Echocardiography (ASE) recently issued new guidelines for the identification and mitigation of cardiac ultrasound artifacts. Developed by an international team of ultrasound experts, this guideline is the first report published by an imaging society focused exclusively on cardiac ultrasound artifacts.

Muhamed Saric, MD, PhD, professor of medicine and clinical director of noninvasive cardiology at NYU Langone Health, led this effort as the chair of the guideline writing committee. The guideline, published in the Journal of the American Society of Echocardiography, integrates the latest evidence and recommendations to better detect, understand, and manage cardiac ultrasound artifacts.

“Ultrasound artifacts—which are misleading or false image features—contribute to misdiagnoses and have potentially severe clinical consequences.”

Muhamed Saric, MD, PhD

“Ultrasound artifacts—which are misleading or false image features—contribute to misdiagnoses and have potentially severe clinical consequences,” says Dr. Saric. “These guidelines may help cardiac sonographers and clinicians to recognize common pitfalls while enhancing diagnostic accuracy and patient safety.”

Key Takeaways

Broadly, the group of experts reviewed how each artifact appears, the physical mechanism behind it, its potential clinical consequences, and the practical strategies that can be used to avoid or minimize misinterpretation.

Awareness

Cardiac ultrasound artifacts are common—and should be considered a routine part of imaging practice—originating from the physical properties of ultrasound itself. Clinicians involved in performing or interpreting cardiac ultrasound should be familiar with artifacts and their potential for misdiagnosis.

The guidelines note that artifacts may arise due to interference from external equipment and devices that generate ultrasound waves.

“Even with the progress in ultrasound imaging technologies, artifacts are still widely seen across all echocardiographic modes,” explains Dr. Saric.

Clinical Consequences

According to the authors, if artifacts mimic serious pathology or obscure true disease, they may have severe clinical consequences.

The guideline document includes several high-risk case examples: left atrial appendage reverberation mimicking thrombus; reverberation or side-lobe artifacts simulating type A aortic dissection; shadowing artifacts concealing vegetations, paravalvular leaks, thrombi, or intracardiac masses; and color Doppler mirror artifacts simulating prosthetic mitral regurgitation.

“These guidelines may help cardiac sonographers and clinicians to recognize common pitfalls while enhancing diagnostic accuracy and patient safety.”

Systematic Interpretive Approach to Recognition

Ultimately, recognition of artifacts requires a systematic interpretive approach.

The guidelines highlight distinct features—such as the absence of physiologic Doppler correlation, lack of respect for anatomic boundaries, disappearance with alternative imaging planes, and identical motion to neighboring structures—as important clues that a finding is artifactual as opposed to pathologic.

Mitigation Strategies

Other recommendations pertain to mitigation strategies, including adjusting gain and wall filters, optimizing focal zone and frequency, adjusting probe position or insonation angle, using harmonic imaging, and narrowing the color sector. When needed, clinicians may also escalate to three-dimensional (3D) echocardiography, transesophageal echocardiogram, ultrasound-enhancing agents, cardiovascular magnetic resonance, or cardiac CT.

Importantly, optimal mitigation strategies for some newer device-related artifacts have not been fully characterized.

Emerging Areas for Nuanced Guidance

While the guidelines do not directly offer guidance on several emerging developments, Dr. Saric acknowledges the recent rise of artificial intelligence (AI) and software-based image support tools.

“AI 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,” says Dr. Saric.

Additionally, the guidelines discuss the growing relevance of structured training in artifact physics and image interpretation—including simulation-based training with engineers and medical physicists. “These areas are likely to become more crucial in the coming years,” Dr. Saric adds.