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In Module 4, we covered the fundamental artifacts you must know. However, as ultrasound technology advances, new highly specific artifacts tend to emerge.
The American Society of Echocardiography (ASE) recently released its 2026 "Recommendations for the Identification and Mitigation of Cardiac Ultrasound Artifacts". While basic artifacts such as acoustic shadowing and standard reverberation are thoroughly covered in our Burwin modules, in this document, the ASE highlights several specialized artifacts that every cardiac sonographer should be aware of. (full article at right ➡️)
Below is a summary of these new additions categorized by imaging mode.
Recommendations for the Identification and Mitigation of Cardiac Ultrasound Artifacts: A Guideline from the American Society of Echocardiography1. Specialized Spectral Doppler Artifacts
While we have covered standard spectral aliasing and mirroring, the ASE describes some unique spectral artifacts you may encounter in cardiac ultrasound.
Tiger Stripes Artifact: This unique artifact appears as a pattern of alternating stripes on the spectral display. It results from the rapid oscillations of structures within the Doppler beam path, such as flail valve leaflets. Significance: Unlike most artifacts that we want to eliminate, tiger stripes can actually be helpful diagnostically to alert you to look for the oscillating structure that is producing them.
Double Envelope Artifact: This is a specific duplication artifact seen in the spectral envelope. Significance: It is important to recognize this, as it may cause you to erroneously overestimate pressure gradients when assessing native or prosthetic mitral valves, especially during a TEE (transesophageal echocardiogram).
Spectral Doppler Clicks: When performing a Doppler study of a mechanical prosthetic valve, you may see prominent vertical white lines on the spectrum right before and after the flow. These are the opening and closing clicks of the mechanical valve. Significance: We want to see these! The absence of these prominent clicks may suggest prosthetic valve dysfunction.
2. 3D Echocardiography Artifacts
With the rise of 3D and 4D volumetric imaging (which we introduced in Module 3), we now have to deal with some artifacts unique to 3D ultrasound:
3D Stitching (Reconstruction) Artifact: When the machine builds a 3D image over multiple heartbeats (a multibeat 3D image), patient or operator motion can cause the final image to look divided or "stitched" together. Significance: Interestingly, stitching artifacts can sometimes be used as a tool for determining the exact anatomic orientation of cardiac structures or even detecting pathologies, such as a prolapsing mitral valve segment.
3D Dropout Artifact: This artifact creates "false holes" in tissues, such as the aortic valve or the interatrial septum, which typically occurs when the anatomical structure is nearly parallel (coaxial) to the ultrasound beam. Significance: This artifact may lead to the misdiagnosis of a septal defect. We should suspect a 3D dropout artifact when the "defect" has ill-defined borders and completely lacks physiologic flow when evaluated with Color Doppler.
3D Blurring and Blooming Artifacts: These artifacts cause cardiac tissues or metallic structures to appear artificially thicker than their actual anatomy in 3D space. Significance: Recognizing these artifacts is important to avoid overestimating the thickness of structures. The 3D blurring artifact can often be avoided by acquiring the 3D image from a different view that emphasizes axial resolution.
3. Advanced Device & Clutter Artifacts
Nearfield Clutter Mimicking Thrombus: From time to time, acoustic clutter in the near field of the beam can mimic a blood clot (thrombus) inside the heart. Significance: The ASE suggests that ultrasound contrast can be used to prove that there is no thrombus present.
Acoustic Shadowing from Mitral Clips: We know from Module 4 that highly attenuating structures cast an acoustic shadow. The ASE specifically warns that newer interventional devices, such as Mitral Clips, can cast an acoustic shadow that may completely obscure a mitral regurgitation (MR) color jet.
Intentional Color Doppler Aliasing (PISA): We have seen how color aliasing can be useful in carotids to identify regions of high flow velocity. The same process can be useful in PISA measurements. The ASE reminds us that we can intentionally induce Color Doppler aliasing by lowering the Nyquist limit and shifting the baseline. Significance: This helps clearly define the Proximal Isovelocity Surface Area (PISA) shell, allowing us to quantify the severity of regurgitant flows through an orifice.
IMPORTANT: While you are unlikely to see "Tiger Stripes" or "3D Stitching" tested on the SPI exam, recognizing these artifacts in cardiac ultrasound is an important skill.
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