Real-Time Artificial Intelligence-Based Guidance of Echocardiographic Imaging by Novices: Image Quality and Suitability for Diagnostic Interpretation and Quantitative Analysis.

BACKGROUND: We aimed to assess in a prospective multicenter study the quality of echocardiographic exams performed by inexperienced users guided by a new artificial intelligence software and evaluate their suitability for diagnostic interpretation of basic cardiac pathology and quantitative analysis of cardiac chamber and function. METHODS: The software (UltraSight, Ltd) was embedded into a handheld imaging device (Lumify; Philips). Six nurses and 3 medical residents, who underwent minimal training, scanned 240 patients (61±16 years; 63% with cardiac pathology) in 10 standard views. All patients were also scanned by expert sonographers using the same device without artificial intelligence guidance. Studies were reviewed by 5 certified echocardiographers blinded to the imager's identity, who evaluated the ability to assess left and right ventricular size and function, pericardial effusion, valve morphology, and left atrial and inferior vena cava sizes. Finally, apical 4-chamber images of adequate quality, acquired by novices and sonographers in 100 patients, were analyzed to measure left ventricular volumes, ejection fraction, and global longitudinal strain by an expert reader using conventional methodology. Measurements were compared between novices' and experts' images. RESULTS: Of the 240 studies acquired by novices, 99.2%, 99.6%, 92.9%, and 100% had sufficient quality to assess left ventricular size and function, right ventricular size, and pericardial effusion, respectively. Valve morphology, right ventricular function, and left atrial and inferior vena cava size were visualized in 67% to 98% exams. Images obtained by novices and sonographers yielded concordant diagnostic interpretation in 83% to 96% studies. Quantitative analysis was feasible in 83% images acquired by novices and resulted in high correlations (r≥0.74) and small biases, compared with those obtained by sonographers. CONCLUSIONS: After minimal training with the real-time guidance software, novice users can acquire images of diagnostic quality approaching that of expert sonographers in most patients. This technology may increase adoption and improve accuracy of point-of-care cardiac ultrasound.

Myocardial Work in Echocardiography.

Myocardial work is an emerging tool in echocardiography that incorporates left ventricular afterload into global longitudinal strain analysis. Myocardial work correlates with myocardial oxygen consumption, and work efficiency can also be assessed. Myocardial work has been evaluated in a variety of clinical conditions to assess the added value of myocardial work compared to left ventricular ejection fraction and global longitudinal strain. This review showcases the current use of myocardial work in adult echocardiography and its possible role in cardiac pathologies.

The association between tree planting and mortality: A natural experiment and cost-benefit analysis.

Several recent longitudinal studies have found that exposure to the natural environment is associated with lower non-accidental mortality. However, most of these studies used the normalized difference vegetation index (NDVI) as an exposure metric; and because NDVI might not be sensitive enough to adequately capture changes in urban vegetation, these studies might lack true longitudinal variation in exposure. Therefore, we used a natural experiment to assess the impact of 30 years of tree planting by the nonprofit Friends of Trees on non-accidental, cardiovascular, lower-respiratory, and accidental mortality in Portland, Oregon (mortality data were provided by the Oregon Health Authority). We estimated autoregressive mixed models of Census-tract level mortality rate (deaths per 100,000 population) associated with trees planted, including a tract-level random effect. All models used data from the American Community Survey to control for year, race, education, income, and age. Each tree planted in the preceding 15 years was associated with significant reductions in non-accidental (-0.21, 95 % CI: -0.30, -0.12) and cardiovascular mortality (-0.066, 95 % CI: -0.11, -0.027). Furthermore, the dose-response association between tree planting and non-accidental mortality increased in magnitude as trees aged and grew. Each tree planted in the preceding 1-5 years was associated with a reduction in mortality rate of -0.154 (95 % CI: -0.323, 0.0146), whereas each tree planted in the last 6-10 and 11-15 years was associated with a reduction in mortality rate of -0.262 (95 % CI: -0.413, -0.110) and -0.306 (95 % CI: -0.527, -0.0841) respectively. Using US EPA estimates of a value of a statistical life, we estimated that planting a tree in each of Portland's 140 Census tracts would generate $14.2 million in annual benefits (95 % CI: $8.0 million to $20.4 million). In contrast, the annual cost of maintaining 140 trees would be $2,716-$13,720.

The politics of urban trees: Tree planting is associated with gentrification in Portland, Oregon.

This study evaluated the hypothesis that urban-tree planting increases neighborhood gentrification in Portland, Oregon. We defined gentrification as an increase in the median sales price of single-family homes in a Census tract compared to other tracts in the city after accounting for differences in the housing stock such as house size and number of bathrooms. We used tree-planting data from the non-profit Friends of Trees, who have planted 57,985 yard and street trees in Portland (1990-2019). We estimated a mixed model of gentrification (30 years and 141 tracts) including random intercepts at the tract level and a first-order auto-regressive residual structure. Tract-level house prices and tree planting may be codetermined. Therefore, to address potential endogeneity of tree planting in statistical modeling, we lagged the number of trees planted by at least one year. We found that the number of trees planted in a tract was significantly associated with a higher tract-level median sales price, although it took at least six years for this relationship to emerge. Specifically, each tree was associated with a $131 (95% CI: $53-$210; p-value=0.001) increase in tract-level median sales price six years after planting. The magnitude of the association between the number of trees planted and median sales price generally increased as the time lag lengthened. After twelve years, each tree was associated with a $265 (95% CI: $151-$379; p-value<0.001) increase in tract-level median sales price. Tree planting was not merely a proxy for existing tree cover, as the percent of tract covered in tree canopy was independently associated with an increase in median sales price. Specifically, each 1-percentage point increase in tree-canopy cover was associated with a $882 (95% CI: $226-$1,538; p-value=0.008) increase in median sales price. In conclusion, tree planting is associated with neighborhood-level gentrification, although the magnitude of the association is modest.

Rare and Complex Case Mimics Acute Myocardial Infarction: The Importance of Multimodality Imaging.

We report a rare and complex case of cardiac sarcoidosis in a patient presenting with ventricular tachycardia. Multimodality imaging, along with clinical and histological examination, was essential in establishing the diagnosis of cardiac sarcoidosis. (Level of Difficulty: Beginner.).

Comprehensive Echocardiographic Findings in Critically Ill COVID-19 Patients With or Without Prior Cardiac Disease.

PURPOSE: Coronavirus disease 2019 (COVID-19) presents with a spectrum of disease severity, the most serious cases requiring intensive care. Echocardiography is a front-line tool in evaluating cardiovascular complications of COVID-19 in the intensive care unit (ICU); we analyzed transthoracic echocardiograms obtained from this patient population with state-of-the-art ultrasound technology. METHODS: All patients with COVID-19 requiring ICU admission on whom a transthoracic echocardiogram was obtained were included in the study. Focused transthoracic protocols were performed by experienced sonographers. Echocardiographic variables, including speckle-tracking echocardiography, were collected and analyzed. Clinical information was obtained from the electronic medical record. Patients were followed until discharge. RESULTS: Of 52 total patients (mean age: 59.9 ± 11.6 years), 59.6% were male and 15 (29%) had known prior cardiac disease. Cardiac complications identified on echocardiography were prevalent, occurring in 55.7% of patients. Patients with known prior cardiac disease were more likely to have new or worsening left ventricular dysfunction. Right ventricular dysfunction was the most common abnormality (assessed qualitatively in 18 cases and with advanced echocardiographic methods in 34 cases). Known prior cardiac disease, right ventricular enlargement, and pulmonary hypertension were significantly associated with morbidity and mortality. CONCLUSIONS: Patients requiring intensive care for COVID-19 face significant morbidity and mortality, and cardiac complications occur in the majority of patients admitted to the ICU with COVID-19. Those with known prior cardiac disease fare worse, and other echocardiographic findings (right ventricular enlargement, pulmonary hypertension) are also associated with worse outcomes. State-of-the-art echocardiography performed by experienced sonographers can be critical to identifying cardiac complications and guiding ICU strategy.