Skip Navigation


European Journal of Echocardiography Advance Access originally published online on June 20, 2008
European Journal of Echocardiography 2008 9(6):721-725; doi:10.1093/ejechocard/jen177
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Supplementary Data
Right arrow All Versions of this Article:
9/6/721    most recent
jen177v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Egan, M.
Right arrow Articles by Ionescu, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Egan, M.
Right arrow Articles by Ionescu, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

The pocket echocardiograph: a useful new tool?

Margaret Egan and A. Ionescu*

Morriston Cardiac Centre, Morriston, Swansea SA6 6NL, UK

Received 21 February 2008; accepted after revision 18 May 2008; online publish-ahead-of-print 20 June 2008.

* Corresponding author. Tel: +44 1792 703195; fax: +44 1792 703544.E-mail address: adrian.ionescu{at}swansea-tr.wales.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
Aims: Hand-carried ultrasound scanners are getting smaller. The Acuson P10 is the latest and smallest portable echocardiograph available on the market.

Methods and results: We tested the ability of this scanner to allow qualitative assessment of LV size and function in an unselected group of 30 patients [19 male, 11 female; mean age (SD) 64.7 (10.3) years] seen by a consultant cardiologist (accredited for advanced echocardiography) during a week on call in a regional cardiac tertiary facility. Patients had focused scans (parasternal long-axis and apical four chamber views) for a maximum of 4 min, and an assessment of LVEF (normal/abnormal) and LV dimension (LVD) (dilated/non-dilated) was recorded. Where available, this was compared with results of alternative imaging modalities. In 23 (77%) patients, it was possible to assess LVEF and LVD; of these, 19 (83%) had alternative imaging techniques, which confirmed the findings. It was possible to obtain a parasternal long-axis image in 28 (93%) patients and apical four-chamber views in 23 (77%). Clinical management was altered by the findings of the portable scan in two patients.

Conclusion: The ‘pocket scanner’ allows accurate qualitative assessment of left ventricular dimensions and function in a substantial proportion of patients seen in tertiary cardiology practice.

Keywords: Hand-carried ultrasound scanner; Clinical use


   Introduction
Top
 Abstract
 Introduction
Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
Manufacturers are bringing out smaller scanners, for new applications such as ‘triage’ or ‘focused’ scans. There are little data on the integration of ‘1st generation’ hand-carried ultrasound scanners (HCUS)1–4 into various models of health care delivery, and no data on the clinical usefulness of the latest arrival on the scene, the recently launched ‘pocket scanner’ Siemens ACUSON P10 (Siemens Medical Solutions Mountain View, CA 94 039-7393, USA).5 We set out to assess the ability of this scanner to deliver what the manufacturers claim it can do, by testing it in a ‘real world’ clinical environment.


   Setting
Top
 Abstract
 Introduction
 Setting
Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
Morriston Cardiac Centre is a tertiary regional facility, which serves a population of 1 million in South West Wales, UK. The echocardiographic laboratory performs more than 5800 scans each year using Vivid7 scanners. In a typical on-call week, each of the tertiary cardiologists sees between 20 and 50 new patients, the majority admitted with acute coronary syndromes with a view to undergoing angiography and revascularization, but also a whole spectrum of other cardiac conditions.


   Methods
Top
 Abstract
 Introduction
 Setting
 Methods
Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
During one on-call week (17–24 December 2007) and one outpatient clinic (27 December 2007), a British Society of Echocardiography-accredited consultant cardiologist (AI) performed rapid echocardiograms using an ACUSON P10 ultrasound system (Figure 1) in all new patients referred to the cardiac centre. The scanner is destined for ‘screening’ echocardiograms, e.g. for the assessment of global left ventricular function or the exclusion of pericardial effusion causing tamponade; it is not a substitute for a conventional system. We set out to test the hypothesis that an echo-accredited cardiologist using the ACUSON P10 could provide rapid, qualitative, clinically meaningful assessment of the dimension and systolic function of the left ventricle, strictly as an adjunct to physical examination, and without significantly prolonging the duration of the consult.


Figure 1
View larger version (55K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 The ‘pocket scanner’. Clockwise from top left corner: the scanner on its docking station, with probe (left) and spare rechargeable battery (right); side view; front view.

 
The P10 measures 5.4 cm x 9.7 cm x 14.2 cm and weighs 700 g, fitting well in a white coat pocket, and has a simple and user-friendly mode of operation. Lifting the screen (in a manner similar to that of a laptop) switches the device on, and it is ready to acquire 2D echocardiograms within 13 s. Patient identification details can be entered and stored. It uses a 2 MHz probe with grey-scale imaging capabilities only. Depth and gain controls are available, and simple linear and area measurements are feasible. Both still frames and video loops can be stored digitally and downloaded to a PC or laptop using dedicated software. The device is powered by a rechargeable battery and functions for ~1 h on a single recharge.

The echocardiograms were performed according to the following protocol: patients were placed in the left lateral decubitus position after obtaining a full cardiovascular history and clinical examination. The parasternal or apical long-axis view (Figure 2 and Supplementary data online, Movie Clip) was obtained and a qualitative ‘verdict’ recorded about whether the left atrium, left ventricle, aortic and mitral valves could be imaged clearly enough for making a judgement regarding whether they were ‘grossly normal’ or ‘grossly abnormal’.


Figure 2
View larger version (58K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Long-axis parasternal freeze-frame (in systole) transferred from the hard drive of the P10 scanner. LV, left ventricle; LA, left atrium; RV, right ventricle; Ao, aortic root.

 
An apical four-chamber view was then obtained and the same type of assessment was applied to the same structures and also to the right ventricle, right atrium, and tricuspid valve. We decided the scan had to be completed within 4 min because this is a time span comparable to that needed for a cardiovascular examination; at the end, an assessment of left ventricular size (dilated/non-dilated) and ejection fraction (normal/ abnormal) was recorded. The assessment was qualitative only and no formal linear measurements were made (to reduce the duration of examination) although the device has this facility. All patients who had their heart imaged with alternative modalities during the same hospital stay (i.e. formal, BSE-compliant echocardiograms, or LV angiography) had the findings of these modalities reviewed and compared to the assessment based on the targeted bedside scan; concordance or discordance was documented accordingly. We also documented whether any immediate change in clinical management was initiated as a result of the portable scan.


   Results
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
We included 30 patients in the study [19 male, 11 female; mean age (SD) 64.7 (10.3) years). Nineteen patients (60%) had a primary diagnosis of acute coronary syndrome; 4 (13%) had complete heart block (paced rhythm in 2). Small numbers had other diagnoses (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1 Summary of patient characteristics and results

 
Scans were judged to answer the questions set in the protocol (i.e. normality/abnormality of the cardiac chambers dimensions and valve appearance, and qualitative assessment of left ventricular systolic function) in 23 (77%) patients. Of these patients with interpretable scans, 19 (83%) had the findings confirmed through an alternative imaging modality, mainly by formal departmental scans with a Vivid7 scanner. There were no instances of the bedside scan missing a significant finding that was subsequently detected with alternative methods of imaging.

Parasternal long-axis images were available in 28 (93%) of those scanned; apical four-chamber views in 23 (77%). The numbers and proportions of patients falling into the dilated/non-dilated and normal/abnormal categories regarding the left ventricle are illustrated in Table 2.


View this table:
[in this window]
[in a new window]

  		Table 2 Left ventricular ejection fraction and internal dimension: distribution of results

 

   Clinical vignettes
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 
In two cases, the limited scan had an immediate impact on the clinical management.

Patient no. 5, a 77-year-old female, developed chest pain and haemodynamic collapse 45 min after uneventful pacing via the left subclavian vein. An immediate echo using the Acuson P10 was obtained from the subcostal window with the patient in the Trendelenburg position. It showed that there was no tamponade, and hence pericardial drainage was not attempted. This finding was confirmed within 5 min with a formal bedside echo using a Vivid7.

Patient no. 11, a 56-year-old male, was admitted after an unheralded collapse and was in complete heart block. He received a temporary pacing wire and then a permanent DDD pacemaker. The bedside scan with the Acuson P10 showed multiple wall motion abnormalities, which prompted a coronary angiogram. This demonstrated extensive coronary artery disease (of which he was totally asymptomatic).


   Discussion
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
Limitations
 Conclusions
 Supplementary data
 References
 
HCUS have been available for more than a decade, and there have been attempts at formalizing their role in the delivery of cardiac care. Their successful use has been reported in settings such as community screening for left ventricular hypertrophy,6 cardiology outpatient clinic,7 cardiology consultations in a British district general hospital,8 and outpatient screening for left ventricular dysfunction.9,10 Cost effectiveness has been demonstrated in both UK and European settings.8,11

Nevertheless, the exact role of this technology is still being defined, a process made more demanding and urgent by its continued development. The pocket scanner is the latest addition to an already crowded field. It is exceptionally easy to use, and provides immediate grey-scale 2D images in a ‘no frills’ manner. Uncertainties surround the level of training required to operate such a scanner safely and meaningfully, as well as the best way in which it can be integrated within systems of health-care delivery.

The American Society of Echocardiography has produced a position paper on HCUS devices.12 HCUS are to be used for ‘brief (<15 min), focused exams’, as an ‘extension of the physical examination’. The level of accreditation required is set at a lower level than for a full-blown formal echo; an argument could be made that with a less ‘subtle’ and accurate technology more acumen is needed for using it safely. However, individuals not formally trained in echocardiography can be taught, within a relatively brief period of time, to perform limited scans with HCUS to an acceptable level of accuracy and reliability.13–16 We think it is necessary to continue to evaluate new devices in a wide variety of settings in order to circumscribe their usefulness.

In an un-selected population of ‘all-comers’ in a tertiary cardiac centre, and with its use deliberately restricted to 4 min per patient, the device allowed the assessment of LV size and function in almost four out of every five patients scanned. In a substantial proportion, these findings were confirmed with formal scanning using a high-end scanner.


   Limitations
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
Conclusions
 Supplementary data
 References
 
This is a single centre, single operator study, with small numbers. Not all patients had their findings confirmed with formal, complete echocardiograms or ventriculography. Nevertheless, we used the scanner exactly as we would use it in our clinical practice, which makes our findings relevant to the real world of acute tertiary cardiology.


   Conclusions
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
Supplementary data
 References
 
Using a recently launched ‘pocket’ ultrasound scanner, an echo-trained cardiologist can estimate global left ventricular size and ejection fraction in more than three quarters of an unselected population of cardiac patients presenting to a tertiary centre.


   Supplementary data
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
References
 
Supplementary data are available at European Journal of Echocardiography online.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Setting
 Methods
 Results
 Clinical vignettes
 Discussion
 Limitations
 Conclusions
 Supplementary data
 References
 

  1. Osranek M, Bursi F, O’Leary PW, Bruce CJ, Sinak LJ, Chandrasekaran K, et al. Hand-carried ultrasound-guided pericardiocentesis and thoracentesis. J Am Soc Echocardiogr (2003) 16:480–4.[CrossRef][Web of Science][Medline]
  2. Kirkpatrick JN, Davis A, DeCara JM, Hong AE, Kurtz PL, Balasia B, et al. Hand-carried cardiac ultrasound as a tool to screen for important cardiovascular disease in an underserved minority health care clinic. J Am Soc Echocardiogr (2004) 17:399–403.[CrossRef][Web of Science][Medline]
  3. Vourvouri EC, Poldermans D, Deckers JW, Parharidis GE, Roelandt JRTC. Evaluation of a hand carried cardiac ultrasound device in an outpatient cardiology clinic. Heart (2005) 91:171–6.[Abstract/Free Full Text]
  4. Gorcsan J, Pandey P, Sade LE. Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology. J Am Soc Echocardiogr (2004) 17:50–5.[CrossRef][Web of Science][Medline]
  5. www.pocketultrasound.com (05 January 2008).
  6. Senior R, Galasko G, Hickman M, Jeetly P, Lahiri A. Community screening for left ventricular hypertrophy in patients with hypertension using hand-held echocardiography. J Am Soc Echocardiogr (2004) 17:56–61.[CrossRef][Web of Science][Medline]
  7. Vourvouri EC, Poldermans D, de Sutter J, Sozzi B, Roelandt JRTC. Experience with an ultrasound stethoscope. J Am Soc Echocardiogr (2002) 15:80–5.[CrossRef][Web of Science][Medline]
  8. Greaves K, Jeetley P, Hickman M, Dwivedi G, Sabharwal N, Lim T, et al. The use of hand-carried ultrasound in the hospital setting—A cost-effectiveness analysis. J Am Soc Echocardiogr (2005) 18:620–5.[CrossRef][Web of Science][Medline]
  9. Kirkpatrick JN, Ghani SN, Spencer KT. Hand carried echocardiography screening for LV systolic dysfunction in a pulmonary function laboratory. Eur J Echocardiogr (2007) 11. [Epub ahead of print].
  10. Vourvouri EC, Schinkel AF, Roelandt JRTC, Boomsma F, Sianos G, Bountioukos M, et al. Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device. Eur J Heart Fail (2003) 5:767–74.[Abstract/Free Full Text]
  11. Vourvouri EC, Koroleva LY, Ten Cate FJ, Poldermans D, Schinkel AF, van Domburg RT, et al. Clinical utility and cost effectiveness of a personal ultrasound imager for cardiac evaluation during consultation rounds in patients with suspected cardiac disease. Heart (2003) 89:727–30.[Abstract/Free Full Text]
  12. Seward JB, Douglas PS, Erbel R, Kerber RE, Kronzon I, Rakowski H, et al. Hand-carried cardiac ultrasound (HCU) device: recommendations regarding new technology. A Report from the Echocardiography Task Force on New Technology of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr (2002) 15:369–73.[CrossRef][Web of Science][Medline]
  13. Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R, et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by non-cardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothor Vasc Anes (2005) 19:155–9.[CrossRef]
  14. Hellmann DB, Whiting-O’Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC. The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med (2005) 118:1010–8.[CrossRef][Web of Science][Medline]
  15. DeCara JM, Kirkpatrick JN, Spencer KT, Ward RP, Kasza K, Furlong K, et al. Use of hand-carried ultrasound devices to augment the accuracy of medical student bedside cardiac diagnoses. J Am Soc Echocardiogr (2005) 18:257–63.[CrossRef][Web of Science][Medline]
  16. Duvall LW, Croft LB, Goldman ME. Can hand-carried ultrasound devices be extended for use by the non-cardiology medical community? Echocardiogr (2003) 20:471–6.[CrossRef]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Journal of Diagnostic Medical SonographyHome page
S. C. Roll and K. Evans
Feasibility of Using a Hand-Carried Sonographic Unit for Investigating Median Nerve Pathology
Journal of Diagnostic Medical Sonography, September 1, 2009; 25(5): 241 - 249.
[Abstract] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Supplementary Data
Right arrow All Versions of this Article:
9/6/721    most recent
jen177v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Egan, M.
Right arrow Articles by Ionescu, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Egan, M.
Right arrow Articles by Ionescu, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?