In early February, cardiologists at Robert Wood Johnson University Hospital and Rutgers Robert Wood Johnson Medical School in New Jersey performed cardiac ultrasound on a patient in France. Using MELODY, the first FDA-approved clinical robotic tele-cardiac ultrasound solution, designed by AdEchoTech, they were able to assess the patient in real time for several hours, despite an ocean between them.

“What MELODY can do is increase access to ultrasound in remote communities, close to their homes. Patients don't have to travel long ways for appointments. Instead, they and the expert can be present in completely different locations,” Dr. Partho Sengupta, chief of cardiology at Robert Wood Johnson Medical University Hospital, an RWJBarnabas Health Facility, told HCB News.

Telemedicine is just one of many innovations creating new possibilities for cardiac ultrasound, with artificial intelligence and point-of-care solutions paving the way for speedier exams, higher quality care and new types of procedures. Nevertheless, cardiac ultrasound still faces a number of challenges that limit its promise and impede access for patients in need.

Providing care at a distance
Two years ago, Dr. Stephen Little, president-elect of the American Society of Echocardiography and a cardiologist at Houston Methodist Hospital, was prohibited by law from assessing patients outside of Texas remotely. But following the COVID-19 pandemic, regulations were relaxed, and long-distance telehealth became a possibility — almost overnight, he said. “Now, as a healthcare system, we're starting to evaluate post-COVID. Should we be allowed to see a patient via FaceTime or some equivalent software? Should I be permitted to read the echocardiogram that's performed in Wyoming from my office in Texas?”

Hospitals short on staff or who lack specialists can use ultrasound to scan, diagnose and treat cardiac patients faster. This would be especially in rural communities, and also possible outside hospitals and outpatient practices. “Instead of the patients queuing up for a procedure done at an outpatient facility or in hospital, we can provide ultrasound exams in community primary care centers or pharmacies. They can just go to their nearest pharmacy, get their ultrasound exams and will only be required to come to hospital if a more personal procedure is required,” said Sengupta.

He adds that remote ultrasound spares radiologists and cardiologists from radiation exposure in procedures that pair ultrasound with modalities such as X-ray and CT, and helps reduce exposure to COVID-19, which has been linked to heart problems.

While a growing field, Dr. Martin Goldman, Dr. Arthur Master Professor of Medicine/cardiology and vice chair of cardiology at Mount Sinai Heart in New York, says the value of the information is directly related to quality of images, which is directly correlated to level of training for personnel performing the imaging. “The ability to share the images via telehealth for doctor consultations is very good. But the key thing with the echo is garbage in garbage out. You can really distort the image if your acquisition is very poor, and as a result, distort the interpretation.”

Expanding reach
Historically used in cath labs and medical imaging suites, cardiac ultrasound can be found today in a range of places, from emergency rooms to intensive care units to even primary care physicians offices. This is thanks in part to the rise of point-of-care ultrasound (POCUS), which has also made it accessible in ambulances, paramedic units, helicopter medical flight programs and even on battlefields by non-cardiology personnel.

Ranging from carts to handheld devices, the technology can scan patients right at their bedside for faster exams and assessments of individuals who are challenging to move to imaging suites. “Because you can do it bedside, you don’t have to move the patient to another room. You can quickly move from patient to patient and disinfect in between patients. It really assists in how we diagnose and assess patients to improve care,” said Krys Lee, clinical analyst for symplr and registered ultrasound technologist.

In critical care units and emergency rooms, providers are also starting to perform transesophageal echo (TEE) where a miniature echo probe is attached to a long thin tubing unit that is inserted down the patient’s throat to visualize heart function, valves and potential effusion. This provides a closer and precise view compared to transthoracic echo (TTE), where the probe is placed on a person’s chest. “They actually make small, thin, long probes now, that can be put into the esophagus during chest compressions if the patient has a cardiac arrest, to help better understand the etiology of the low blood pressure of EKG abnormalities and expedite appropriate therapeutic intervention,” said Goldman.

Another new use is Focused Assessment with Sonography in Trauma (FAST) exams to look for blood around the heart, assess the heart and look for blood around other organs at the bedside. These allow for cardiac ultrasound to assess a wider range of conditions and spares patients more often from costly imaging.

But while POCUS has changed the landscape of cardiac ultrasound over the last 10 years, the technology still has drawbacks, according to Michael Blaivas, vice chair of AIUM Artificial Intelligence Community of Practices and a professor of medicine, affiliate at the University of South Carolina School of Medicine. “Training is typically required to acquire and interpret images. Even if you’re going to save them for somebody else to review, you still need to know what you’re doing to get quality images. The other challenge is having handheld or portable imaging devices that deliver images that are of adequate quality to be interpreted. We’ve only started to see that in the last few years.”

Automating speed and accuracy
In medical imaging, the development of AI is geared toward faster acquisition and more accurate interpretation of scans. One area in echocardiography where AI has helped is the interpretation of left ventricle size and function. In addition, there are now discussions about using pattern recognition to assess heart valves, according to Goldman.

He adds, however, that while exciting, AI for heart assessment is still a work-in-progress. “I think that artificial intelligence in echocardiography has a lot of promise and may be ready for prime time in certain settings. There are so many aspects of an echocardiogram. It's a dynamic study with potentially many views and potentially 50 or more 2-3 heartbeat-long loops of moving heart within a breathing patient, which makes it very challenging.”

Many companies are working to address this by designing applications that can select appropriate loops on which to perform AI and provide quantitative information on left and right heart function, size and even strain. “That's very exciting, but it still has to be vetted and proved to be working well,” said Goldman.

AI is also used to improve the quality of scans in various ways, says Lee. “There are a lot of different technologies to smooth the image out, offer better spatial resolution that create clear and crisper images. We’re also seeing a big increase in 3D and 4D rendering and 3D and 4D usage in evaluating the heart and other organs in the body. You can take a rendered image and evaluate that image in different planes, the ability to rotate the image aids in diagnosis and improved patient care.”

AI also can be used for auto calculation and offer doppler capabilities for examining heart function. But producing and interpreting quality images accurately still comes down to how well the sonographer performs a scan. “We are seeing applications that guide the user on how to scan, that say ‘rotate the probe this way, angle the probe that way. Now you have a good view. Nope, now you have a bad view, change the following.’ This is how you lower the skill level required for the cardiac ultrasound operator and you only have to look down the horizon so far before you see that eventually patients will be able to do this at home themselves because the device will be able to instruct the patients themselves,” said Blaivas.

Modern-day uses
In addition to imaging patients in real time, the miniaturization of cardiac ultrasound, plus its ability to complete scans fast makes it cost-efficient and less time-consuming compared to MR. It is also nonionizing, unlike CT, and is noninvasive, compared to open heart surgery. “It is on the scale of cardiac imaging. It's still relatively cheap to perform. It's portable. There's no radiation. There are very few clinical contraindications to get a cardiac ultrasound study,” said Little.

Little expects the technology to “merge” with other modalities in the future. “We have trans thoracic imaging. We have trans esophageal imaging. And more recently, we have intracardiac imaging with ultrasound, crystals on the end of an intravascular catheter. And at some point, those different modalities will start to talk to each other, and perhaps a single user will be able to pick and choose between modalities to create a different kind of image.”

But the solution is highly operator-dependent and needs experienced and skilled users who can acquire images at the right angles and personalize exams for individual patients. Blaivas says that automation is the key here. “What we need to do is take someone fresh out of medical school who has very little training in ultrasound but the same capability to diagnose things in the heart that I have after practicing with ultrasound for 28 years. The only way to do that is with AI. It isn’t happening as fast as we would like it to and can’t seem to happen as fast as we need it.”

Sengupta says AI will speed up image acquisition and reading in cardiac ultrasound but also help extract more unused information about the heart from images. He says that advances like MELODY and telemedicine can improve day-to-day operations and help compensate for the lack of available personnel. “Technical and sonographer shortage is a big problem. Now, sonographers can be brought into the picture from a remote location to help the workforce. In the middle of the night, they will not have to travel.”

Experts like Goldman say that greater investment in training and compensating skilled expertise is also essential for expanding access to echocardiography and for ensuring AI and telemedicine are used properly to make accurate diagnoses. “Salaries need to reflect skill and experience. A skilled sonographer or physician doing imaging recognizes that their acquisition may vary depending on their real-time interpretation as they are acquiring the images. With COVID, there were many referrals coming in every day. Sonographers were exposed and jeopardized their own and their family’s health to provide care and yet, they didn't get hazard pay.”

According to Lee, more research and development is needed to overcome certain limitations with new techniques in Intracardiac echocardiography (ICE). But she adds that innovations like these and the pandemic are changing the role and scale of echocardiography. “We are looking at the use of technology more universally. Not just isolating advances in imaging to use on one organ or system but expanding how we use technology to image the heart and the body's systems. The use of emerging technology has improved patient care and outcomes.”