Hand-held Echocardiography Research Articles

Early Detection of Subclinical Rheumatic Heart Disease Through Echocardiographic Screening: A Study in North Sumatra, Indonesia

Background: Given the urgent need to address the significant morbidity and mortality associated with Rheumatic Heart Disease (RHD) in Indonesia, there is a growing interest in exploring cost-effective screening approaches, such as handheld echocardiography. Objective: The purpose of this study was to ascertain the prevalence of RHD in North Sumatra, Indonesia. Material and Methods: This descriptive observational study was conducted within the population of North Sumatra from 2022 to 2023. Junior high school students aged 12 to 15 years were included from randomly selected schools in Langkat, Tebing Tinggi, and Labuhan Batu. Data collection encompassed various parameters, including social demographic information, parental characteristics, environmental factors, household details, anthropometric measurements, physical assessments, auscultation findings, and echocardiographic data. The data were analyzed descriptively. Result: In our study, a total of 692 children were examined, with an average age of 12.9 years and a standard deviation of 1.1 years, among whom 42.5% were male. Utilizing echocardiographic evaluations, we identified RHD in four children, yielding a prevalence rate of 0.6%. Further examination of these cases revealed that the majority, accounting for three individuals (75%), exhibited borderline RHD, while one child (25%) presented with definite RHD. Conclusion: In our study population, the prevalence of RHD was 0.6%. A broader echocardiographic screening program is necessary to determine the overall prevalence of RHD, assess the disease burden, and identify individuals earlier to prevent adverse outcomes. Keyword: Echocardiography, Prevalence, Rheumatic Heart Disease, Screening.

Comparison between Handheld Echocardiography and Cardiac Magnetic Resonance for Stroke Volume and Left Ventricular Ejection Fraction Quantification.

Reliable quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is essential for point-of-care assessment in hemodynamically compromised patients. Handheld echocardiography (HHE) equipment has entered the market a few years ago and is now available for clinical use. However, the performance of HHE for SV and LVEF quantification in comparison to cardiac magnetic resonance (CMR) imaging as golden standard is yet unknown. Twenty volunteers were scanned with HHE, standard echocardiography (SE), and CMR. LVEF and SV were measured with each modality, and their accuracy and precision were evaluated. Bias and limits of agreement (LOA) between HHE and CMR were -0.21% (-2.89: 2.48) and 11.24% (-15.79: 15.59) for LVEF and 29.85 ml (22.13: 37.57) and 32.34 ml (-15.01: 44.86) for SV, respectively. Bias and LOA between SE and CMR were -0.60% (-3.74:2.55) and 13.16% (-18.85:18.26) for LVEF and 32.08 ml (24.61:39.54) and 31.34 ml (-11.29:43.37) for SV, respectively. HHE versus CMR showed comparable accuracy and precision compared to SE versus CMR.

Systematic hand-held echocardiography in patients hospitalized with acute coronary syndrome.

Transthoracic echocardiography is recommended in all patients with acute coronary syndrome but is time-consuming and lacks an evidence base. We aimed to assess the feasibility, diagnostic accuracy, and time efficiency of hand-held echocardiography in patients with acute coronary syndrome and describe the impact of echocardiography on clinical management in this setting. Patients with acute coronary syndrome underwent both hand-held and transthoracic echocardiographies with agreement between key imaging parameters assessed using kappa statistics. The immediate clinical impact of hand-held echocardiography in this population was systematically evaluated. Overall, 262 patients (65 ± 12 years, 71% male) participated. Agreement between hand-held and transthoracic echocardiographies was good-to-excellent (kappa 0.60-1.00) with hand-held echocardiography having an overall negative predictive value of 95%. Hand-held echocardiography was performed rapidly (7.7 ± 1.6 min) and completed a median of 5 (interquartile range 3-20) h earlier than transthoracic echocardiography. Systematic hand-held echocardiography in all patients with acute coronary syndrome identified an important cardiac abnormality in 50%, and the clinical management plan was changed by echocardiography in 42%. In 85% of cases, hand-held echocardiography was sufficient for patient decision-making, and transthoracic echocardiography was no longer deemed necessary. In patients with acute coronary syndrome, hand-held echocardiography provides comparable results to transthoracic echocardiography, can be more rapidly applied, and gives sufficient imaging information for decision-making in the vast majority of patients. Systematic echocardiography has clinical impact in half of patients, supporting the clinical utility of echocardiography in this population and providing an evidence base for current guidelines.

Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines

Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. World Health Organization. For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.

Advancing health-care access with handheld echocardiography for rheumatic heart disease

Advancing health-care access with handheld echocardiography for rheumatic heart disease

Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD).

Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.

Silent Acute Rheumatic Fever Unmasked by Using Handheld Echocardiography for Febrile Children Presenting in a Rheumatic Heart Disease–Endemic Area

ObjectiveTo understand the burden of acute rheumatic fever (ARF) among children living in low-income countries who presenting to the hospital with febrile illness and to determine the role of handheld echocardiography (HHE) in uncovering sub-clinical carditis as a major manifestation of ARF. Study designA cross-sectional study carried at the Pediatric Hospital in Al Obeid, North Kordofan, Sudan, from September 2022 to January 2023 and including febrile children 3 through 18 years of age with or without clinical features of ARF and without another cause for their fever (not excluding malaria). History, examination, blood investigations and HHE were done. ARF was diagnosed according to the Jones Criteria (JC). Clinical ARF was diagnosed if there is a major clinical JC and silent ARF if the only major JR is subclinical carditis. ResultsThe study cohort included 400 children with a mean age of 9 years. Clinical ARF was diagnosed in 95 patients (95/400, 24%), most of whom presented with a joint major manifestation (88/95, 93%). Among the 281 children who did not present with a clinical manifestation of ARF, HHE revealed RHD in 44 patients (44/281, 16%); 31 of them fulfilled criteria for silent ARF (31/281, 11%). HHE increased the detection of ARF by 24%. HHE revealed mild RHD in 41/66 (62%) and moderate or severe RHD in 25/66 (38%) patients. Both sensitivity and specificity of HHE compared with standard echocardiography were 88%. ConclusionsThere is a significant burden of ARF among febrile children in Sudan. HHE increased the sensitivity of diagnosis, with 11% of children having sub-clinical carditis as their only major manifestation (ie, silent ARF). RHD prevention policies need to prioritize decentralization of echocardiography to improve ARF detection.

Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure.

The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings. Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment. Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE. A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001). Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.

Spatiotemporal Deep Learning-Based Cine Loop Quality Filter for Handheld Point-of-Care Echocardiography.

The reliability of automated image interpretation of point-of-care (POC) echocardiography scans depends on the quality of the acquired ultrasound data. This work reports on the development and validation of spatiotemporal deep learning models to assess the suitability of input ultrasound cine loops collected using a handheld echocardiography device for processing by an automated quantification algorithm (e.g. ejection fraction estimation). POC echocardiograms (n=885 DICOM cine loops from 175 patients) from two sites were collected using a handheld ultrasound device and annotated for image quality at the frame-level. Attributes of high-quality frames for left ventricular (LV) quantification included a temporally-stable LV, reasonable coverage of LV borders, and good contrast between the borders and chamber. Attributes of low-quality frames included temporal instability of the LV and/or imaging artifacts (e.g., lack of contrast, haze, reverberation, acoustic shadowing). Three different neural network architectures were investigated - (a) frame-level convolutional neural network (CNN) which operates on individual echo frames (VectorCNN), (b) single-stream sequence-level CNN which operates on a sequence of echo frames (VectorCNN+LSTM) and (c) two-stream sequence-level CNNs which operate on a sequence of echo and optical flow frames (VectorCNN+LSTM+Average, VectorCNN+LSTM+MinMax, and VectorCNN+LSTM+ConvPool). Evaluation on a sequestered test dataset containing 76 DICOM cine loops with 16,914 frames showed that VectorCNN+LSTM can effectively utilize both spatial and temporal information to regress the quality of an input frame (accuracy: 0.925, sensitivity = 0.860, specificity = 0.952), compared to the frame-level VectorCNN that only utilizes spatial information in that frame (accuracy: 0.903, sensitivity = 0.791, specificity = 0.949). Furthermore, an independent sample t-test indicated that the cine loops classified to be of adequate quality by the VectorCNN+LSTM model had a statistically significant lower bias in the automatically estimated EF (mean bias = - 3.73 ± 7.46 %, versus a clinically obtained reference EF) compared to the loops classified as inadequate (mean bias = -15.92 ± 12.17 %) (p = 0.007). Thus, cine loop stratification using the proposed spatiotemporal CNN model improves the reliability of automated point-of-care echocardiography image interpretation.

Detection and management of latent rheumatic heart disease: a narrative review

Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, ʻdefiniteʼ RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.

Hand-held echocardiography-based heart failure screening in hypertensive or diabetic patients in community: a pilot study

Abstract Background There is lack of solid data on screening methods for preclinical heart failure (HF) in primary care settings. Standard echocardiography is not regarded as a routine test due to high cost and need of operation by specialists. Hand-held echocardiography (HHE) has been used in various clinical settings with easier access and lower price but has never been integrated into HF screening programme. Purpose This study aimed to explore the feasibility and cost-effectiveness of hand HHE-based HF screening strategies in patients with risk factors in community. Methods The registered patients with hypertension or diabetes at two Chinese community health service centres (CHSCs) who had not been diagnosed previously as HF were recruited. Every patient received symptom assessment (dyspnea and/or lower limb edema), blood test for N-terminal-probrain natriuretic peptide (NT-proBNP ≥ 125 pg/ml regarded as positive), and HHE for any indexed abnormality in the dedicated protocol with focused and semiquantitative scanning [i.e. left ventricular (LV) dilation, left atrial (LA) dilation, interventricular septum (IVS) thickening, LV systolic dysfunction by calipers, as well as region wall motion abnormality, valvular stenosis, ≥moderate valvular regurgitation, significant pericardial effusion by eyeballing). By using the results of all the three modalities for screening compared to the concurrent guidelines, the patients were categorized into HF stages A, B, or C as the "gold standard". Three screening strategies were proposed (Figure 1), of which Strategy I was designed as a single test, Strategy II as a combined test, and Strategy III as a stratified stepwise test. Diagnostic accuracy and cost-effectiveness of each strategy was calculated in comparison with the "gold standard". Results A total of 423 patients (70 ± 9 years; 46.6% males) were enrolled. There were 166 (39.2%) symptomatic patients, while 106 (25.1%) patients had elevated NT-proBNP. HHE abnormalities were found in 286 (67.0%) patients, of which IVS thickening was the most common finding (47.0%), followed by LA enlargement (30.0%). LV systolic dysfunction was identified in 18 (4.3%) patients. 232 (54.8%) and 59 (13.9%) patients were reclassified as HF stage B and C, respectively. As shown in Figure 2, the stepwise Strategy III of using symptoms for the first stratification, followed by choosing HHE or NT-proBNP test led to a 100% accuracy and a 35.6% reduction in cost. Conclusions HHE-based focused screening detects HF earlier in high-risk populations. The screening strategy combined with symptoms, NT-proBNP, and HHE is feasible for identifying underdiagnosed HF stage B or C that may be considered in primary care.Scheme of HF stage screening strategiesHF Screening and cost-effectiveness

Abstract 15237: Feasibility and Diagnostic Accuracy of Handheld Echocardiography in Patients Hospitalized With Acute Coronary Syndrome

Introduction: Transthoracic echocardiography (TTE) is recommended in every acute coronary syndrome (ACS) patient, but is time-consuming and not always deliverable. Development of handheld echocardiography (HHE) devices provide a fast, low-cost method to facilitate rapid bedside clinical assessment of those patients. Hypothesis: We hypothesized that evaluation of hospitalized ACS patients using HHE is feasible and provide similar information to standard TTE in detecting important cardiac pathology. Methods: Patients admitted with ACS were prospectively enrolled, and underwent both bedside HHE (Philips Lumify) and clinical TTE evaluation. Independent analysis of HHE and TTE images was performed by a blinded expert team to determine key predetermined imaging findings that might alter management of ACS patients (Table 1). The TTE analysis was repeated for these variables after 1 month. Agreement of HHE vs TTE was assessed with kappa statistics and compared to agreement of TTE vs TTE as reference standard. Results: The analysis included 108 patients (mean age 65y, 78% male). Duration of HHE was a third faster than targeted clinical TTE (8.2±1.8min vs 12.1±5.0min; p&lt;0.001). Agreement in detecting the following variables was good (&gt;0.60) and similar for HHE vs TTE compared to TTE vs TTE: left ventricle (LV) dilatation, LV hypertrophy, LV ejection fraction &lt;40%, anterior and inferior wall motion abnormalities, right ventricle (RV) dilatation, pericardial effusion, aortic stenosis, ventricle septum defect, and takotsubo cardiomyopathy. Agreement between HHE vs TTE was less good than TTE vs TTE for detection of lateral wall motion abnormalities, RV dysfunction, and LV thrombus. Conclusions: In ACS patients, bedside HHE is faster and provides similar diagnostic information to TTE for the majority of key echo findings. However, important exceptions exist, in particular HHE is less good at detecting lateral wall motion abnormalities, RV dysfunction and LV thrombus.

Abstract 14701: Agreement Between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren From High-Prevalence Settings

Background: Handheld echocardiography (echo) is the tool of choice for Rheumatic Heart Disease (RHD) screening, based on the 2012 World Heart Federation (WHF) Criteria. We aimed to assess the agreement between screening and standard echo for diagnosis of latent RHD in schoolchildren from an endemic setting. Methods: Over 14 months, 3 non-physicians used handheld machines (GE, VSCAN) and the 2012 WHF Criteria to determine RHD prevalence in low-income public schools in Minas Gerais, Southeast Brazil. Consented children were eligible for participation. Studies were interpreted remotely using a telemedicine cloud-server by 2 experts in Brazil and the US. RHD-positive children (borderline and definite) and those with congenital heart disease (CHD) were referred for standard echo with portable devices (GE, Vivid IQ), with acquisition and interpretation by an expert cardiologist. Agreement between screening and standard echo, by category and according to the WHD criteria, was assessed, and the kappa statistic was applied. Results: A total of 1,390 students were screened in 6 schools and, among these, 110 (7.9%, 95% CI 6.5 - 9.5) were screen-positive and referred for standard echo, with mean age of 14±2 years, 80 (72%) women. Among the 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline and 1 to normal. Among the 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) to definite RHD and 2 had mild CHD. Among 11 children with CHD in screening, 4 were confirmed, 5 were reclassified to normal and 2 to RHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criteria was B (isolated mitral regurgitation): 64%, followed by A (2 morphological features of the mitral valve): 31%. In the only patient with definite RHD reclassified to normal, WHF criteria was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3 - 4.2). Conclusions: Although practical, RHD screening with handheld devices tend to overestimate prevalence. Even in endemic settings, continuous education for detection, and application of risk stratification for management are crucial.

Abstract 14599: A Pilot Rheumatic Heart Disease Screening Program Using Portable, Handheld Echocardiography in Rivas, Nicaragua

Introduction: Portable, handheld echocardiography offers several advantages for rheumatic heart disease (RHD) screening in low-resource settings. Analyses of focused protocols using handheld echocardiography have yielded acceptable sensitivity and specificity for diagnosis of RHD, including in those performed by non-expert sonographers. Previous studies estimate high burden of RHD in Nicaragua. We conducted a pilot community-based RHD screening program using handheld echocardiography in Rivas, Nicaragua using contemporary RHD diagnostic criteria. Methods: Non-expert sonographers were trained using the GE Vscan Extend TM device and a simplified version of the 2012 World Heart Federation criteria for diagnosis of RHD. Referral criteria for complete echocardiogram included the presence of a mitral regurgitant jet of &gt; 2.0 cm, aortic regurgitant jet &gt; 1.0 cm, or any morphologic abnormality of the mitral or aortic valve, as well as left ventricular dysfunction or significant congenital heart disease. Participants were recruited by convenience-based sampling in communities throughout Rivas, Nicaragua. Participants were notified at the point-of-care of need for complete echocardiogram. All studies were overread asynchronously by expert readers for diagnostic accuracy. Results: Between March 2022 and April 2023, 494 screening echocardiographic studies were performed and evaluated for diagnostic accuracy. The median age was 36.3 years (IQR 19.2, 56.2), 22% of participants were &lt;18 years of age, and 60% of participants were female. There were 17.6% of participants referred for complete echocardiogram at the point-of-care compared with 13.0% meeting referral criteria on expert review. Negative and positive predictive values for non-expert vs. expert assessment were 92.4% and 62.1%, respectively. Cohen’s kappa for inter-rater reliability was 0.338, suggesting fair agreement. Conclusions: This pilot program demonstrated the feasibility of a screening program for RHD in rural Nicaragua with non-expert sonographers. Lessons from this program are intended to inform future epidemiological studies to determine the population prevalence and longitudinal outcomes of RHD in this region.

Evaluation of the image quality and validity of handheld echocardiography for stroke volume and left ventricular ejection fraction quantification: a method comparison study.

Bedside quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is valuable in hemodynamically compromised patients. Miniaturized handheld ultrasound (HAND) devices are now available for clinical use. However, the performance level of HAND devices for quantified cardiac assessment is yet unknown. The aim of this study was to compare the validity of HAND measurements with standard echocardiography (SE) and three-dimensional echocardiography (3DE). Thirty-six patients were scanned with HAND, SE and 3DE. LVEF and SV quantification was done with automated software for the HAND, SE and 3DE dataset. The image quality of HAND and SE was evaluated by scoring segmental endocardial border delineation (2 = good, 1 = poor, 0 = invisible). LVEF and SV of HAND was evaluated against SE and 3DE using correlation and Bland-Altman analysis. The correlation, bias, and limits of agreement (LOA) between HAND and SE were 0.68 [0.46:0.83], 1.60% [-2.18:5.38], and 8.84% [-9.79:12.99] for LVEF, and 0.91 [0.84:0.96], 1.32ml [-0.36:4.01], 15.54ml [-18.70:21.35] for SV, respectively. Correlation, bias, and LOA between HAND and 3DE were 0.55 [0.6:0.74], -0.56% [-2.27:1.1], and 9.88% [-13.29:12.17] for LVEF, and 0.79 [0.62:0.89], 6.78ml [2.34:11.21], 12.14ml [-26.32:39.87] for SV, respectively. The image quality scores were 9.42 ± 2.0 for the apical four chamber views of the HAND dataset and 10.49 ± 1.7 for the SE dataset and (P < 0.001). Clinically acceptable accuracy, precision, and image quality was demonstrated for HAND measurements compared to SE. In comparison to 3DE, HAND showed a clinically acceptable accuracy and precision for LVEF quantification.

Handheld Echocardiography Measurements Concordance and Findings Agreement: An Exploratory Study

The professional association has already developed guidelines on the appropriate use of handheld ultrasound devices, especially in an emergency setting. Handheld ultrasound devices are seen as the 'stethoscope of the future' to assist in physical examination. Our exploratory study evaluated whether the measurements of cardiovascular structures and the agreement in identifying aortic, mitral, and tricuspid valve pathology made by a resident with a handheld device (HH, Kosmos Torso-One) reach the results reported by an experienced examiner who used a high-end device (STD). Patients referred for cardiology examination in a single center from June to August 2022 were eligible for the study. Patients who agreed to participate underwent two heart ultrasound examinations scanned by the same two operators. A cardiology resident performed the first examination with a HH ultrasound device, and an experienced examiner performed the second examination with an STD device. Forty-three consecutive patients were eligible, and forty-two were included in the study. One obese patient was excluded because none of the examiners succeeded in performing the heart examination. The measurements obtained with HH were generally higher than those obtained with STD, with the highest mean difference of 0.4 mm, but without significant differences (all 95% confidence intervals of the differences contain the value of 0). For valvular disease, the lowest agreement was observed for mitral valve regurgitation (26/42, with a Kappa concordance coefficient of 0.5321), which was missed in almost half of the patients with mild regurgitation and underestimated in half of the patients with moderate mitral regurgitation. The measurements performed by the resident with the handheld Kosmos Torso-One device showed high concordance with those conducted by the experienced examiner with a larger high-end ultrasound device. The learning curve of the resident could explain the limited performance in identifying valvular pathologies between examiners.

Cardiac imaging in rheumatic heart disease and future developments.

Rheumatic heart disease (RHD) is the most common cause of valvular heart disease worldwide, affecting millions, especially in low- and middle-income countries. Multiple imaging modalities such as cardiac CT, cardiac MRI, and three-dimensional echocardiography may be utilized in diagnosing, screening, and managing RHD. However, two-dimensional transthoracic echocardiography remains the cornerstone of imaging in RHD. Criteria developed by the World Heart Foundation in 2012 sought to unify the diagnostic imaging criteria for RHD, but concerns remain regarding their complexity and reproducibility. In the intervening years, further measures have been developed to find a balance between simplicity and accuracy. Nonetheless, there remain significant unresolved problems within imaging in RHD, including the development of a practical and sensitive screening tool to identify patients with RHD. The emergence of handheld echocardiography has the potential to revolutionize RHD management in resource-poor settings, but its role as a screening or diagnostic tool is yet to be fully established. The dramatic evolution of imaging modalities over the last few decades has not addressed RHD compared to other forms of structural heart disease. In this review, we examine the current and latest developments concerning cardiac imaging and RHD.

Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease

BackgroundRheumatic heart disease (RHD) is a major and preventable cause of cardiac morbidity in Sudan. It can be detected early with a handheld echocardiography (HHE) machine. Our study aimed to screen for RHD in rural South Kordofan and to investigate the ability of non-experts to obtain good quality HHE records. MethodsA cross-sectional study was conducted in South Kordofan, Sudan. A team of non-experts was trained for two weeks on handheld echocardiographic screening for RHD using a simplified protocol. Cases were recorded and reviewed by a pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Descriptive statistics were presented as “number (%)” or “mean ± SD”. RHD frequency was expressed as cases per 1000, and the Chi-Square test/Fisher's Exact test was used to compare RHD findings between different groups. ResultsA total of 467 subjects were screened. Echocardiographic quality was acceptable in 93% of recorded studies, hence 452 cases were included in the analysis. The disease frequency was found to be 50 per 1000. Out of 452 screened subjects (age 10–25 years), 23 were found to have RHD. The disease was mild in 70% and moderate or involving two valves in 30% of patients. Risk factors for the disease included the father's occupation and the village of residence. ConclusionShortly trained non-expert medicals can assist in RHD surveillance in remote areas using HHE for early detection and management. South Kordofan state is highly endemic to RHD and a control program needs to be implemented.

A deep learning framework assisted echocardiography with diagnosis, lesion localization, phenogrouping heterogeneous disease, and anomaly detection

Echocardiography is the first-line diagnostic technique for heart diseases. Although artificial intelligence techniques have made great improvements in the analysis of echocardiography, the major limitations remain to be the built neural networks are normally adapted to a few diseases and specific equipment. Here, we present an end-to-end deep learning framework named AIEchoDx that differentiates four common cardiovascular diseases (Atrial Septal Defect, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, prior Myocardial Infarction) from normal subjects with performance comparable to that of consensus of three senior cardiologists in AUCs (99.50% vs 99.26%, 98.75% vs 92.75%, 99.57% vs 97.21%, 98.52% vs 84.20%, and 98.70% vs 89.41%), respectively. Meanwhile, AIEchoDx accurately recognizes critical lesion regions of interest along with each disease by visualizing the decision-making process. Furthermore, our analysis indicates that heterogeneous diseases, like dilated cardiomyopathy, could be classified into two phenogroups with distinct clinical characteristics. Finally, AIEchoDx performs efficiently as an anomaly detection tool when applying handheld device-produced videos. Together, AIEchoDx provides a potential diagnostic assistant tool in either cart-based echocardiography equipment or handheld echocardiography device for primary and point-of-care medical personnel with high diagnostic performance, and the application of lesion region identification and heterogeneous disease phenogrouping, which may broaden the application of artificial intelligence in echocardiography.

Hand-held echocardiography during complex electrophysiologic procedures.

Complex electrophysiologic (EP) procedures are time consuming and open to complications. Accurate and rapid recognition of cardiac pathologies is essential before, during, and immediately after such procedures. In this study, we aimed to compare hand-held echocardiography (HHE) with standard echocardiography (SE) to determine whether HHE can be used as a practical and reliable diagnostic tool during such procedures. One hundred consecutive patients undergoing complex EP procedures and catheter ablation were included in the study. All patients were evaluated with SE or HHE in terms of main cardiac pathologies at the beginning and immediately after the procedure. The diagnostic accuracy and evaluation time of both methods were compared at the beginning and after the procedure. The agreement between both methods was calculated. At the beginning and after the procedure, opening and evaluation times with HHE were significantly shorter than with SE (P<0.001 for all). There was significant agreement between the two methods in the diagnosis of cardiac pathologies (Agreement was 95% for minimal mild aortic regurgitation (AR), 99% for moderate/ severe AR, 93% for minimal/ mild mitral regurgitation (MR), 95% for moderate/ severe MR, 100% for pericardial effusion, and 100% for left ventricular thrombus at the beginning of the procedure). With the use of HHE during complex EP procedures, cardiac pathologies can be diagnosed with similar accuracy as SE. In addition, HHE has a significant advantage over SE in terms of time to diagnosis.