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

OBJECTIVE: To understand the burden of acute rheumatic fever (ARF) among children living in low-income countries who present to the hospital with febrile illness and to determine the role of handheld echocardiography (HHE) in uncovering subclinical carditis as a major manifestation of ARF. STUDY DESIGN: This was a 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. Clinical ARF was diagnosed if there was a major clinical Jones criterion and silent ARF if the only major Jones criteria was subclinical carditis. RESULTS: The 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 rheumatic heart disease (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 of 66 (62%) and moderate or severe RHD in 25 of 66 (38%) patients. Both sensitivity and specificity of HHE compared with standard echocardiography were 88%. CONCLUSIONS: There is a significant burden of ARF among febrile children in Sudan. HHE increased the sensitivity of diagnosis, with 11% of children having subclinical carditis as their only major manifestation (ie, silent ARF). RHD-prevention policies need to prioritize decentralization of echocardiography to improve ARF detection.

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], 1.32 ml [- 0.36:4.01], 15.54 ml [- 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], 6.78 ml [2.34:11.21], 12.14 ml [- 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 in patients with cardiovascular disease: to use or not to use, that is the question.

The physical examination is one of the most important diagnostic tools for physicians. Traditionally, a physical examination consists of inspection (looking), palpation (feeling), percussion (reflection of sound) and auscultation (listening). Handheld echography devices could become the new fifth element of a physical examination. The use of handheld echocardiography has recently increased because the devices have become smaller, easier to handle and more affordable. Handheld echocardiography is used by many specialists involved in acute cardiovascular care. In this narrative review we give a summary of the diagnostic accuracy and limitations of cardiovascular physical examination combined with handheld echocardiography. In patients with cardiovascular disease, adding handheld echocardiography to physical examination increases the sensitivity for detecting valvular heart disease (71% vs 46%) and left ventricular dysfunction with an ejection fraction < 50% (84% vs 43%). Handheld echocardiography might be better for ruling out diseases with a low pre-test probability than in confirming diseases with a high pre-test probability.

A Novel Handheld Echocardiography Device with Continuous-Wave Doppler Capability: Implications for the Evaluation of Aortic Stenosis Severity.

BACKGROUND: The aim of this study was to evaluate the ability of a novel handheld echocardiography (HHE) device with continuous-wave Doppler (CWD) capability to measure aortic valve peak jet velocity (Vmax) and facilitate aortic stenosis (AS) severity grading. METHODS: One hundred twenty-one consecutive patients with known or suspected AS were prospectively included. All patients were scanned with the HHE device and a high-end echocardiography system (the reference standard) to obtain CWD signal across the aortic valve. Aortic Vmax measurements were acquired from the apical five-chamber view using both methods and were compared to assess method agreement using the intraclass correlation coefficient, linear regression analysis, and Bland-Altman analysis. Diagnostic accuracy for the detection of at least moderate AS (Vmax ≥ 3 m/sec) was calculated. Also, the utility of HHE with CWD to reclassify patients compared with the visual estimation of AS severity was assessed. RESULTS: The acquisition of CWD signal using HHE was feasible in 118 of 121 patients (mean age, 68 ± 17 years; 57% men). There was excellent agreement between the HHE CWD and the cart-based measurements (intraclass correlation coefficient = 0.97 [95% CI: 0.83-0.99] and r = 0.98 [95% CI: 0.91-0.99], P < .001 for both). The Bland-Altman plot showed a small underestimation bias of -0.2 m/sec (P < .001), with limits of agreement ±0.44 m/sec for Vmax. Detection of at least moderate AS using HHE with CWD was feasible with sensitivity of 93% (95% CI: 83%-98%), specificity of 98% (95% CI: 91%-100%), positive predictive value of 98% (95% CI: 88%-100%), negative predictive value of 94% (95% CI: 85%-97%), and total diagnostic accuracy of 96%. Patients visually assessed as having mild AS were reclassified as having no stenosis (17%), mild AS (72%), or moderate AS (11%) with the addition of CWD imaging. CONCLUSIONS: Use of a novel HHE device with CWD spectral analysis by experienced operators can reliably detect clinically significant AS and facilitate AS grading. This technology may improve screening and diagnostic workup of AS compared with current practice.

Adapting the role of handheld echocardiography during the COVID-19 pandemic: A practical guide.

The COVID-19 pandemic has altered our approach to inpatient echocardiography delivery. There is now a greater focus to address key clinical questions likely to make an immediate impact in management, particularly during the period of widespread infection. Handheld echocardiography (HHE) can be used as a first-line assessment tool, limiting scanning time and exposure to high viral load. This article describes a potential role for HHE during a pandemic. We propose a protocol with a reporting template for a focused core dataset necessary in delivering an acute echocardiography service in the setting of a highly contagious disease, minimising risk to the operator. We cover the scenarios typically encountered in the acute cardiology setting and how an expert trained echocardiography team can identify such pathologies using a limited imaging format and include cardiac presentations encountered in those patients acutely unwell with COVID-19.

A tricky case of cardiogenic shock: Diagnostic challenges in the COVID-19 era.

Myocardial wall rupture should be considered in patients presenting with hypotension and STEMI especially of delayed onset. Diagnosing this entity in the COVID-19 era can be challenging-handheld echocardiography may aid toward this end.

Tablet-Based Limited Echocardiography to Reduce Sonographer Scan and Decontamination Time during the COVID-19 Pandemic.

BACKGROUND: Limited assessments with handheld ultrasound have found meaningful clinical use in the care of acutely ill patients. However, there are limited data on incorporating handheld-based limited echocardiography into the echocardiography laboratory. The purpose of this study was to assess the efficacy of limited handheld tablet echocardiography as an alternative to traditional echocardiography during the coronavirus disease 2019 (COVID-19) pandemic as a means to limit exposure while providing essential clinical information. METHODS: Ninety consecutive inpatients with known or suspected COVID-19 were scanned according to laboratory COVID-19 guidelines using a limited 11- to 20-clip protocol on a tablet sonograph. The primary assessment was length of study time. Comparison data were drawn from comprehensive echocardiographic examinations ordered on intensive care patients not under COVID-19 precautions. RESULTS: Over a 36-day time period, a total of 91 requests were deemed to be appropriate for echocardiography on patients with suspected or confirmed COVID-19 (average age, 67 years; 64% men; mean body mass index, 32 kg/m2). Of these, 90 (99%) examinations were performed using a handheld device, and all were deemed diagnostic and provided sufficient information for the clinical care team. Sonographer scan time decreased from an average of 24 ± 6.8 min on a traditional platform to 5.4 ± 1.9 min on a tablet. CONCLUSIONS: Limited handheld echocardiography can be successfully implemented in the echocardiography laboratory for screening of COVID-19-related cardiac conditions. The protocol performed with handheld tablet ultrasound provides adequate diagnostic information of major cardiac complications of COVID-19 while decreasing sonographer contact and simplifying decontamination.

Point-of-care echocardiography - A road to future or a step backwards.

Echocardiography (Echo) has a myriad of clinical applications. Traditionally, it was performed and interpreted by cardiologist but the scope of its applications has lead physicians of other specialities to learn this useful skill. One of the newer and expanding scope of echocardiography is point-of-care (POC) echocardiography. In this review article, we aim to discuss the clinical applications of POC echo, common protocols and its limitations. Despite its widespread use, there is paucity of data describing its clinical efficacy and there is lack of guidelines regarding credentialing and quality control of POC echo.

Validation of the accuracy of handheld echocardiography for diagnosis of congenital heart disease.

BACKGROUND: Handheld echocardiography (HHE) has been increasingly used for rheumatic heart disease screening and in adult emergency room settings. AIMS: This study aimed to validate the accuracy of HHE in the diagnosis of congenital heart disease (CHD). SETTINGS AND DESIGN METHODOLOGY: This is a prospective study carried out at three pediatric cardiology outpatient clinics in Khartoum, Sudan.All patients with suspected CHD were evaluated by clinical examination followed by HHE, performed using a modified segmental approach. Then, a complete study was performed using a standard echocardiography machine. The results were then compared using appropriate statistical tools. RESULTS: A total of eighty cases were included with the following diagnoses either in isolation or combination: ventricular septal defect (n = 23), atrial septal defect (n = 10), pulmonary stenosis (n = 7), tetralogy of Fallot (n = 7), patent ductus arteriosus (n = 6), atrioventricular septal defect (n = 6), transposition of the great arteries (n = 6), and other diagnoses (n = 15). Agreement between HHE and SE was excellent both for visualizing heart segments (κ =77%-100% with a mean of 92.9%) and for diagnosis of CHD (κ =66%-100% with a mean of 91.7%). The sensitivity of HHE was 69.2%-100% (mean = 90.2%) and specificity was 98.5%-100% (mean = 99.3%). CONCLUSION: This study supports extending the utility of HHE in children for screening of CHD in addition to its current role in rheumatic heart disease screening.

Handheld echocardiography versus auscultation for detection of rheumatic heart disease.

BACKGROUND: Rheumatic heart disease (RHD) remains a major public health concern in developing countries, and routine screening has the potential to improve outcomes. Standard portable echocardiography (STAND) is far more sensitive than auscultation for the detection of RHD but remains cost-prohibitive in resource-limited settings. Handheld echocardiography (HAND) is a lower-cost alternative. The purpose of this study was to assess the incremental value of HAND over auscultation to identify RHD. METHODS: RHD screening was completed for schoolchildren in Gulu, Uganda, by using STAND performed by experienced echocardiographers. Any child with mitral or aortic regurgitation or stenosis plus a randomly selected group of children with normal STAND findings underwent HAND and auscultation. STAND and HAND studies were interpreted by 6 experienced cardiologists using the 2012 World Heart Federation criteria. Sensitivity and specificity of HAND and auscultation for the detection of RHD and pathologic mitral or aortic regurgitation were calculated by using STAND as the gold standard. RESULTS: Of 4773 children who underwent screening with STAND, a subgroup of 1317 children underwent HAND and auscultation. Auscultation had uniformly poor sensitivity for the detection of RHD or valve disease. Sensitivity was significantly improved by using HAND compared with auscultation for the detection of definite RHD (97.8% vs 22.2%), borderline or definite RHD (78.4% vs 16.4%), and pathologic aortic insufficiency (81.8% vs 13.6%). CONCLUSIONS: Auscultation alone is a poor screening test for RHD. HAND significantly improves detection of RHD and may be a cost-effective screening strategy for RHD in resource-limited settings.

Simplified rheumatic heart disease screening criteria for handheld echocardiography.

BACKGROUND: Using 2012 World Heart Federation criteria, standard portable echocardiography (STAND) reveals a high burden of rheumatic heart disease (RHD) in resource-poor settings, but widespread screening is limited by cost and physician availability. Handheld echocardiography (HAND) may decrease costs, but World Heart Federation criteria are complicated for rapid field screening, particularly for nonphysician screeners. The aim of this study was to determine the best simplified screening strategy for RHD detection using HAND. METHODS: In this prospective study, STAND (GE Vivid q or i or Philips CX-50) was performed in five schools in Gulu, Uganda; a random subset plus all children with detectable mitral regurgitation or aortic insufficiency also underwent HAND (GE Vscan). Borderline or definite RHD cases were defined by 2012 World Heart Federation criteria on STAND images, by two experienced readers. HAND studies were reviewed by cardiologists blinded to STAND results. Single and combined HAND parameters were evaluated to determine the simplified screening strategy that maximized sensitivity and specificity for case detection. RESULTS: In 1,439 children (mean age, 10.8 ± 2.6 years; 47% male) with HAND and STAND studies, morphologic criteria and the presence of any mitral regurgitation by HAND had poor specificity. The presence of aortic insufficiency was specific but not sensitive. Combined criteria of mitral regurgitation jet length ≥ 1.5 cm or any aortic insufficiency best balanced sensitivity (73.3%) and specificity (82.4%), with excellent sensitivity for definite RHD (97.9%). With a prevalence of 4% and subsequent STAND screening of positive HAND studies, this would reduce STAND studies by 80% from a STAND-based screening strategy. CONCLUSIONS: In resource-limited settings, HAND with simplified criteria can detect RHD with good sensitivity and specificity and decrease the need for standard echocardiography. Further study is needed to validate screening by local practitioners and long-term outcomes.

The utility of handheld echocardiography for early rheumatic heart disease diagnosis: a field study.

AIMS: The World Heart Federation (WHF) guidelines for rheumatic heart disease (RHD) are designed for a standard portable echocardiography (STAND) machine. A recent study in a tertiary care centre demonstrated that they also had good sensitivity and specificity when modified for use with handheld echocardiography (HAND). Our study aimed to evaluate the performance of HAND for early RHD diagnosis in the setting of a large-scale field screening. METHODS AND RESULTS: STAND was performed in 4773 children in Gulu, Uganda, with 10% randomly assigned to also undergo HAND. Additionally, any child with mitral or aortic regurgitation also underwent HAND. Studies were performed by experienced echocardiographers and blindly reviewed by cardiologists using 2012 WHF criteria, which were modified slightly for HAND--due to the lack of spectral Doppler capability. Paired echocardiograms were performed in 1420 children (mean age 10.8 and 53% female), resulting in 1234 children who were normal, 133 who met criteria for borderline RHD, 47 who met criteria for definite RHD, and 6 who had other diagnoses. HAND had good sensitivity and specificity for RHD detection (78.9 and 87.2%, respectively), but was most sensitive for definite RHD (97.9%). Inter- and intra-reviewer agreement ranged between 66-83 and 71.4-94.1%, respectively. CONCLUSIONS: HAND has good sensitivity and specificity for diagnosis of early RHD, performing best for definite RHD. Protocols for RHD detection utilizing HAND will need to include confirmation by STAND to avoid over-diagnosis. Strategies that evaluate simplified screening protocols and training of non-physicians hold promise for more wide spread deployment of HAND-based protocols.

Handheld Echocardiography Saves the Brain: A Serendipitously Found Left Ventricular Thrombus.

Handheld echocardiography (HHE) is an emerging technology with potential to alter routine clinical practice. Our institution has adopted the use of HHE devices for both teaching and patient care. However, the appropriate clinical scope of HHE continues to be controversial, and the literature is largely devoid of prognosis-altering applications. We report the diagnosis of left ventricular (LV) thrombus with HHE. A 75-year-old man presented with a large anteroapical ST-elevation myocardial infarction (MI). Initial transthoracic echocardiography (TTE) after percutaneous intervention showed no LV thrombus. Before his hospital discharge, HHE was performed and showed LV thrombus. The finding substantially changed the patient's treatment and prognosis; he was discharged with warfarin. This observation will help guide further inquiry into the proper clinical role of HHE.

Can hospital rounds with pocket ultrasound by cardiologists reduce standard echocardiography?

BACKGROUND: Frequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative. METHODS: This was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities. RESULTS: A total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10(-7)). All outcomes remain significant after correcting for multiple testing using the false discovery rate. CONCLUSIONS: The results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.

The utility of handheld echocardiography for early diagnosis of rheumatic heart disease.

BACKGROUND: Rheumatic heart disease (RHD) remains endemic in most of the developing world. Echocardiography has proved highly sensitive for early detection of RHD, but it remains too costly for most low-income settings. Handheld ultrasound machines used to perform handheld echocardiography (HAND) are both less expensive and more portable, possibly making them ideal screening tools. HAND has never been tested for the early diagnosis of RHD. The aim of this study was to evaluate the performance of focused HAND compared with focused standard portable echocardiography for the diagnosis of subclinical RHD. METHODS: HAND and standard portable echocardiography were performed on 125 Ugandan children, 41 with borderline or definite RHD, and 84 healthy controls. Images were blindly reviewed according to the 2012 World Heart Federation guidelines. RESULTS: HAND was highly sensitive (90.2%) and specific (92.9%) for distinguishing between normal patients and those with RHD, but it performed best with definite RHD. HAND overestimated mitral valve morphologic valve abnormalities, being only 66.7% specific for anterior leaflet thickness > 3 mm and 79.0% specific for restricted leaflet motion. False-negative results (n = 4) were due primarily to underestimation of mitral regurgitation length. CONCLUSIONS: In this population, HAND was highly sensitive and specific for early detection of RHD. HAND functions best as a screening tool with confirmation of positive screening results by fully functional echocardiography machines. Technical advances may enable one-step RHD screening using HAND. The performance of HAND should be studied across diverse populations and in field tests before recommending it for widespread screening.