Echocardiography Artifacts: Reverberations, Side Lobes, and Mirror Artifacts — How to Recognize
Reverberation Artifacts
Reverberations occur as multiple equidistant reflections. According to ASE (Saric M. et al., 2026), they can be mistakenly identified as real anatomical structures — thrombi in the left atrial appendage (LAA) or membranes in aortic dissection, leading to misdiagnosis, unwarranted interventions, anticoagulant therapy, or even surgery.
Key features of reverberation:
- movement along the same axis as the target tissue;
- disregard for anatomical boundaries;
- lack of clinical correlation.
Clinical example (ASE, Taub C.C., Stainback R.F. et al., 2025): pronounced reverberation from an electrode in the right ventricle in the subcostal four-chamber view complicates the exclusion of RV thrombus.
Side Lobes
A side lobe is formed by a strong reflector located outside the central beam. According to ASE (2025), side lobe artifacts should be suspected in association with calcium of the sinotubular junction of the aortic root, and less likely, aortic root dissection.
Refraction Artifacts
Refraction appears as a side-by-side duplicate image. According to ASE (2025), an unusual appearance of the aortic valve in the short axis is most likely a refraction artifact rather than an aortic dissection.
Summary Table
| Artifact | Manifestation | What it Mimics |
|---|---|---|
| Reverberation | Multiple equidistant reflections | Thrombus (including RV, LAA), dissection membrane |
| Side Lobes | Strong reflector outside the central beam | Aortic root dissection (calcium of the sinotubular junction) |
| Refraction | Side-by-side duplicate image | Aortic dissection (unusual appearance of AV in short axis) |
Practical Tips
In the presence of intracardiac devices, the report should describe the type of device, entry and exit locations, velocities, and settings (ASE, 2025) — this helps associate reverberations with electrodes. A differential indicator is the lack of clinical correlation: a suspicious structure without movement synchronous with anatomy and not fitting within anatomical boundaries is more likely an artifact [clarify].
Frequently asked questions
How to distinguish reverberation from a true thrombus?
Reverberation moves along the same axis as the target tissue, disregards anatomical boundaries, and lacks clinical correlation (ASE, 2026).
What does a side lobe most commonly mimic in the aortic root area?
Calcium of the sinotubular junction of the aortic root gives a side lobe artifact, which should be suspected first; aortic root dissection is less likely (ASE, 2025).
Is an unusual appearance of the aortic valve in the short axis a dissection?
According to ASE (2025), it is most likely a refraction artifact (side-by-side duplicate image) rather than an aortic dissection.
Why is reverberation from an RV electrode clinically important?
Pronounced reverberation from an electrode in the subcostal four-chamber view complicates the exclusion of right ventricular thrombus (ASE, 2025).
What should be specified in the report when devices are present?
Type of device(s), entry and exit locations, velocities, and settings (ASE, 2025).