This paper proposes an Echocardiogram Transmission Protocol (ETP) for real-time end-to-end transmission of echocardiograms over IP networks. The ETP has been designed taking into account the echocardiogram characteristics of each visualized region, encoding each region according to its data type, visualization characteristics and diagnostic importance in order to improve the coding and thus the transmission efficiency. Furthermore, each region is sent separately and different error protection techniques can be used for each region. This leads to an efficient use of resources and provides greater protection for those regions with more clinical information. Synchronization is implemented for regions that change over time. The echocardiogram composition is different for each device. The protocol is valid for all echocardiogram devices thanks to the incorporation of configuration information which includes the composition of the echocardiogram. The efficiency of the ETP has been proved in terms of the number of bits sent with the proposed protocol. The codec and transmission rates used for the regions of interest have been set according to previous recommendations. Although the saving in the codified bits depends on the video composition, a coding gain higher than 7% with respect to without using ETP has been achieved.