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Specifically, this is what the ACVIM states about ultrasounding cavaliers once a mitral valve murmur is detected: "In small breed dogs with typical murmurs, echocardiography is recommended to answer specific questions regarding either cardiac chamber enlargement or the cause of the murmur if those questions are not answered adequately by auscultation and thoracic radiography." In other words, if the vet heard something unexpected, like a muffled heart sound, or if the dog had something like a suspicion of pulmonary thromboembolism, then an echo after the x-ray would be appropriate.But otherwise, no echo would be needed