IN DEPTH

Handheld Echocardiography
Current State and Future Perspectives

ABSTRACT: Echocardiography is the primary imaging modality for Mohammed A.

diagnosing cardiac conditions. Over the past 2 decades, technological Chamsi-Pasha, MD
advancements have resulted in the emergence of miniaturized handheld Partho P. Sengupta, MD,
ultrasound equipment that is compact and battery operated, and handheld DM
echocardiography can be readily performed at the point of care with William A. Zoghbi, MD,
reasonable image quality. The simplicity of use, availability at the patient’s MACC
bedside, easy transportability, and relatively low cost have encouraged
physicians to use these devices for prompt medical decision making. As a
consequence, the use of handheld echocardiography is on the rise even
among nonechocardiographers (intensivists, emergency care physicians,
internists, and medical students). One of the real utilities of ultrasound-
augmented clinical diagnosis is in evaluating patients efficiently and
selecting patients for appropriate downstream diagnostic testing including
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comprehensive echocardiography. Although clinical evidence supports

the use of handheld devices in various clinical settings and by different
users, proficiency in point-of-care ultrasound requires dedicated training in
both performance and interpretation. This review summarizes the existing
literature on the use of handheld echocardiography in conducting focused
cardiac examinations: its training requirements, challenges, opportunities,
and future perspectives in the care of the cardiovascular patient.

I have no doubt whatever, from my own experience of its value, that it will
be acknowledged to be one of the greatest discoveries in medicine ... That
it will ever come into general use, notwithstanding its value, I am extremely Correspondence to: William A.
doubtful; because its beneficial application requires much time, and gives a Zoghbi, MD, MACC, Professor
good deal of trouble both to the patient and the practitioner. and Chairman, Department
of Cardiology, Elkins Family
—1821, on stethoscopes (Mehta and Kaul1) Distinguished Chair in Cardiac
Health, Houston Methodist

F
DeBakey Heart & Vascular Center,
or the past 2 centuries, stethoscopes have been the principal tools used for
Houston Methodist Hospital, 6550
bedside diagnosis of cardiac conditions. However, physical examination alone Fannin Street, SM1901, Houston,
may not provide adequate confidence or accuracy for driving medical decision TX 77030. E-mail wzoghbi@
making. Among imaging modalities, echocardiography is the only one amenable houstonmethodist.org
to miniaturization and has thus emerged over the past 2 decades as a useful tool Key Words: computers,
to aid healthcare professionals at the point of care, addressing specific cardiac- handheld ◼ diagnostic imaging
focused questions. With the rapid emergence of miniaturized portable devices, ◼ echocardiography ◼ point-of-
studies can be performed nowadays with reasonable image quality, relatively low care testing ◼ ultrasonography
cost, and high portability.2 © 2017 American Heart
Association, Inc.

2178 November 28, 2017 Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622

 Handheld Echocardiography

HANDHELD ECHOCARDIOGRAPHY: Doppler capabilities. Figures  2 and 3 give examples

of images obtained by handheld echocardiography
EQUIPMENT AND INSTRUMENTATION

STATE OF THE ART

The concept of the ultrasonic stethoscope appeared in
the literature as early as the 1970s.3 The subsequent
increase in computing power and miniaturization of
transistor technologies resulted in the emergence of
compact ultrasound devices.4 The first-generation
mobile instruments included laptop-based equip-
ment weighing between 4 and 6 kg, which could
be brought to a patient’s bedside. The second-gen-
eration devices were hand-carried systems, weighing
between 2 and 3 kg. The recently introduced third-
generation devices include handheld or pocket-sized
systems that are battery operated and weigh less
than half a kilogram (Figure  1). The capabilities of
each device, however, vary substantially. Although
the laptop-based equipment can house almost every
state-of-the-art 2-dimensional echocardiographic ap-
plication, not all currently available pocket-sized de-
vices have full-scale color-flow and none have spectral
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(HHE) in various clinical scenarios.
The design of pocket-sized equipment continues to
evolve. Recently, mobile application–based ultrasound
systems have emerged wherein a smartphone or tablet
can turn into a handheld ultrasound simply by plug-
ging in a transducer or connecting wirelessly (Figure 4).
The transducer performs most of the beam forming,
image acquisition, and reconstruction processing, and
the smartphone serves as the display screen connected
to a cloud-based application. Some of the devices have
touchscreen displays and users can tap to start func-
tions, pinch and drag to zoom in and out, and swipe
to expand the images that can also be transferred to a
picture-archiving and communication system wirelessly.
Although HHE has a limited-spectrum functionality, it is
expected to continue to evolve technologically (further
miniaturization, incorporation of spectral Doppler) as a
cost-effective tool to provide a focused cardiac exami-
nation at the point of care.

Figure 1. All-in-one handheld echocardiogram devices with electronic transducers.

Vscan with dual probe (A) and Vscan Extend (B) (Image courtesy of GE Healthcare, Wauwatosa, WI). C, Acuson P10, © Siemens
Healthineers 2017 (used with permission), Siemens Medical Solutions Inc, Malvern, PA. D, Iviz. E, 180 Plus. F, iLook. G, Nano-
Maxx (D-G Images courtesy of FUJIFILM SonoSite Inc, Bothell, WA). H, uSmart 3200T (Image courtesy of Terason Division, Terat-
ech Corporation, Burlington, MA). I, Sonimage P3 (used with permission), Konica Minolta Healthcare Americas, Inc, Wayne, NJ.

Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622 November 28, 2017 2179

 Chamsi-Pasha et al
WHAT IS FOCUSED CARDIAC
ULTRASOUND?
Differences in ultrasound device design and the variabil-
ity in terminology and clinical use prompted the Ameri-
can Society of Echocardiography (ASE) to provide rec-
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ommendations for the use of portable and pocket-sized
equipment for performing echocardiograms.5 The 2013
ASE guidelines differentiate a focused from a limited ex-
amination. Focused cardiac ultrasound refers to a point-
of-care ultrasound examination that is goal oriented
in a specific clinical setting to supplement the physical
examination, whereas a limited echocardiogram refers
to the performance of a limited number of views with
otherwise full echocardiographic capabilities.5
Because handheld devices and pocket ultrasound
systems may not have the full functionality of larger
machines, they are best used for focused examinations
at the point of care. A parasternal view of the cardiac
Figure 3. An example of color Doppler acquisition from
a handheld device demonstrating mitral regurgitation.
2180 November 28, 2017
Figure 2. Examples of echocar-
diographic images obtained with
a handheld device in a healthy
individual (A and B), in a patient
with pericardial effusion (C), and
another with large atria (D).
EPSS indicates E-point septal separa-
tion; LA, left atrium; and LV, left
ventricle.
structures is the easiest to acquire and is correctly ob-
tained even by briefly trained healthcare professionals.
In contrast, the apical approach requires much more
expertise because the correct position of the probe
on the thorax varies widely; the 2-chamber view is the
most difficult. In the critical or unconscious patient, the
subcostal approach may be the only accessible window
and it allows simultaneous evaluation of the heart and
inferior vena cava (IVC); however, it may be limited in
its information because of quality and lower image
resolution in the far field. Last, while using a pocket
ultrasound for qualitative cardiac assessment, a system-
atic approach is useful, as validated in ASE international
programs.6,7
HHE: THE SCOPE OF PRACTICE
Although cardiologists trained in standard echocardiog-
raphy (SE) can readily use ultrasound for a variety of
indications and types of ultrasound studies, nonecho-
cardiographers can perform focused examinations after
training, without the need for long experience in SE. The
findings on these goal-directed examinations aid in early
cardiac triage and management with great utility when
used in intensive care units and emergency department
settings where comprehensive echocardiography may
not be readily available. Other additive values are short
time acquisition (<5 minutes), rapid diagnosis in symp-
tomatic patients, and detection of clinically significant
pathologies in asymptomatic individuals.5,8
To date, several guidelines addressing handheld car-
diac ultrasound have been published from major orga-
nizations including the ASE,5,9 the American College of
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622

Emergency Physicians,10 and the European Association
of Cardiovascular Imaging.11 With a wealth of data
supporting the use of this technology and the enthu-
siasm surrounding it, dedicated training in acquisition
and interpretation of images is needed to acquire and
maintain competency, especially when the handheld
echocardiographic examination is performed by non-
echocardiographers.12
HHE Versus Standard Echocardiography
Several studies have demonstrated a good correlation
of echocardiographic findings by HHE with SE.2,13 This
included morphological, valvular, and functional as-
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sessment of cardiac chambers. In addition, it allows for
early detection of previously unknown cardiac diseases
in emergency units, during inpatient rounds, and in
ambulances.14,15 A consensus statement published by
the ASE found that left ventricular (LV) dilation, LV hy-
pertrophy, LV systolic function, left atrial enlargement,
right ventricular (RV) enlargement and systolic func-
tion, pericardial effusion, and IVC size have all been ac-
curately detected.5 Table  1 summarizes the diagnostic
performance of most relevant evidence-based targets
in HHE studies.
Table 1.  Sensitivity and Specificity of Handheld
Echocardiography for Evaluating Cardiac Structures
and Function
Cardiac Targets
Left ventricular dilation13,16–19
Left ventricular systolic function 13,14,16,20–23
Left ventricular hypertrophy24
Inferior vena cava dilation 16,20
Left atrial dilation25
Pericardial effusion16,17,22
Valvular heart disease13,17,22,26,27
Right ventricle dilation and function 14,20,22
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622
Handheld Echocardiography
STATE OF THE ART
Figure 4. Wireless and USB-probe
handheld echocardiogram devices.
A, Lumify (Image courtesy of Philips, Am-
sterdam, the Netherlands). B, Clarius C3
(Image courtesy of Clarius Mobile Health,
British Columbia, Canada). USB indicates
Universal Serial Bus.
HHE can be a gatekeeper to SE, especially in the
setting of rarely appropriate indications. Pathan et al28
demonstrated that an HHE strategy has led to a 59%
reduction in the need for SE, and has reduced signifi-
cantly the total cost and time to decision making. It is
important to remember that, although the major ad-
vantage of HHE over SE is its portability in a laboratory
coat pocket, it still lags in image resolution, complex
image enhancement, and image quality, particularly in
technically difficult patients (instrumented, lung dis-
ease, etc). Furthermore, the fact that images are dis-
played on a small screen may have its own inherent
limitation.
Clinical Applications of HHE
• LV size and function: One major advantage of
HHE examinations is the rapid assessment of the
LV. Many studies have examined the diagnostic
accuracy of this approach in comparison with SE
with good sensitivity and specificity.12 Although
the interpretation of wall motion abnormalities
by using HHE is feasible, it is the most demanding
aspect of interpretation especially when the extent
of the abnormality is small; a SE is commonly
needed in this situation.9
• Right ventricle: Technical and interpretative chal-
lenges exist in assessing RV size and function. HHE
has been used in a few studies for detection of the
Diagnostic Accuracy
(%)
signs of RV pressure overload in acute pulmonary
embolism. Determining RV size is critical: a ratio
Sensitivity Specificity
of RV:LV >1 is suggestive of RV strain,29 carries an
73–100 64–93
adverse prognosis, and may affect management.30
>90 >90 • Right atrial pressure estimation: The size and col-
70 >90 lapsibility of the IVC provide compelling and accu-
≈70 >80 rate correlation to estimating right atrial filling
53–75 72–94 pressures,20 which is commonly needed to assess
89–91 ≈96
volume status in critically ill patients and patients
with heart failure. The ASE suggested the cutoff
≈80 ≈80
value of 2.1 cm with >50% IVC collapsibility with
Variable among studies
inspiration to denote normal right atrial pressures.5
November 28, 2017 2181
 Chamsi-Pasha et al
Several studies have shown the utility of IVC size
in changing management and predicting rehospi-
talization for decompensated heart failure.23,31,32 In
the intensive care setting, fluid responsiveness in
mechanically ventilated patients can be predicted
by using the IVC distensibility index (maximal –
minimal diameter / minimal diameter) with a cut-
off of >18% to predict response to fluid therapy.33
• Valvular heart disease: In patients with significant
valvular pathologies, studies have shown good
diagnostic accuracy with HHE in comparison with
SE.12,26 However, it is best used to simply corrob-
orate or clarify auscultatory findings. Adequate
evaluation of valvular disease requires time, high-
resolution imaging, and spectral Doppler for
hemodynamic assessment. Thus, valvular lesions
suspected to be beyond mild in severity should be
referred to SE.
• Rheumatic heart disease screening: Rheumatic
fever is still the leading cause of valvular heart dis-
ease in developing countries. There is accumulat-
ing evidence that HHE used for screening in rural,
less developed areas has high diagnostic accu-
racy for detecting rheumatic heart disease with
reduced costs, eliminating long wait times in pub-
lic facilities.34,35
• Aortic diseases: The availability of HHE has allowed
emergency department physicians to assess for
aortic root dilation as a sign of possible aortic dis-
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section. These devices have demonstrated good
agreements in comparison with computed tomog-
raphy and allowed timely diagnosis.36 Evaluation
of the aorta, however, beyond the aortic root is
limited with HHE and even SE.
• Pericardial effusion: HHE is well suited for the
assessment of pericardial effusion initially or seri-
ally after pericardiocentesis. The use of HHE for
suspected tamponade has been incorporated
in the FAST protocol (Focused Assessment with
Sonography in Trauma) for >25 years with good
accuracy.29,37 In the setting of invasive cardiac
procedures, rapid assessment of postprocedural
pericardial effusion is most effective and timely to
guide management.
• Heart failure: Accumulating evidence has shown
the superiority of HHE in helping manage patients
with heart failure (HF). In 1 study, HHE allowed
directed therapy to start 18 hours (on average)
before a SE was performed.23 Another trial dem-
onstrated reduced length of stay when an internist
used a focused examination to guide HF care.38
Serial follow-up addressing specific questions (LV
function, volume status) is easily obtained with
HHE and strongly predicts readmission for HF.9,39
• Intensive care unit: In critically ill patients, the
need for evaluating cardiac function and volume
2182 November 28, 2017
status is crucial in patient management. Among
patients with septic shock, myocardial dysfunction
is observed in one-third of cases, which compli-
cates fluid resuscitation management. Currently,
most of the educational curriculum of intensive
care trainees has incorporated focused ultrasound
for cardiopulmonary assessment.
When comparing HHE with SE, one has to balance the
advantages of portability and availability of echocar-
diography at the bedside with its current technological
limitations. Although a significant number of cardiac
parameters can be assessed with HHE, LV wall motion,
cardiac masses, RV function, LV thrombus, valvular veg-
etations, and aortic dissection are difficult to accurately
detect.21,40 Table 2 summarizes the most relevant clinical
indications where HHE can be used.
HHE and the Physical Examination
Ever since its introduction in 1816 by Laennec,41 stetho-
scopes have become symbolic tools of physical exami-
nation for assessing a patient’s cardiac status. Concep-
tually, the stethoscope is a 4-dimensional instrument
(sound travels in 3 dimensions and time), and one can
argue that this may be advantageous over echocardiog-
raphy for precise detection of certain conditions such
as significant valvular regurgitation, ventricular sep-
tal defect, patent ductus arteriosus; lesions that may
be difficult to detect by casual tomographic imaging.
However, with increasingly less emphasis on physical
examination, modern studies have observed variability
in auscultatory skills and a decrease in accuracy. HHE at
the bedside has been shown to have incremental value
over physical examination with regard to accuracy and
cost-effectiveness.15,21,42,43 In asymptomatic at-risk pa-
tients, it is practical to assess left atrial and LV size and
function. The detection of LV hypertrophy by using HHE
is more accurate than the traditional findings of an S4
or a sustained apical impulse.5 Moreover, there has been
Table 2.  Most Relevant Clinical Presentations for Use
of Handheld Echocardiography
• Heart failure (chamber size, global left ventricular function, inferior vena
cava size and collapsibility)
• Shock (left ventricular function and volume status)
•  Cardiac tamponade (pericardial effusion, chamber collapse)
•  Cardiac arrest, pulseless electric activity (cardiac function, effusion)
•  Respiratory distress (right ventricular size and function, volume status)
• Chest trauma (left ventricular/right ventricular function, effusion, volume
status)
• Acute chest pain (left ventricular and right ventricular size and global
function, regional wall motion abnormalities, aortic root, pericardial
disease)
•  Basic localization and evaluation of murmurs/valvular pathology
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622

increasing utility of HHE in evaluating patients with HF
to help in triaging and assessing volume status.32
Despite the existing debate in the value of cardiac
auscultation, the physical examination and HHE (when
available) can be viewed as providing complementary
sets of information, which mitigates the risks of over-
reliance on 1 technique over the other. For example, in
the presence of a murmur, HHE examination is targeted
to identify its etiology among other findings; in its ab-
sence, HHE will emphasize cardiac structure and func-
tion and less time spent on valves, improving overall
efficiency and accuracy.
HHE FOR CLINICAL DECISION MAKING
Focused cardiac ultrasound examinations using HHE are
performed at the point of care, aimed to clarify a clini-
cal problem in a time-sensitive fashion. Over the years,
efforts to expand the use of HHE among noncardiac
medical specialists have continued. Several studies have
shown promise in training medical students,16 resi-
dents,23,44,45 and internists.46,47 This has broadened the
application of such technology, provided that adequate
technical and interpretative training is achieved.
Internists’ Utilization of HHE
With the increased use of SE, challenges exist in a busy
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tertiary care hospital echocardiography laboratory to
accommodate patients in a timely fashion. Avoidance
of long waiting times and hospital stay has made HHE
an attractive alternative as a point-of-care examination.
The number of noncardiologists performing such ex-
aminations is expected to increase.12 Early studies have
evaluated the feasibility and diagnostic accuracy of HHE
performed by internists and have shown promise with re-
gard to LV function assessment, but poor performance in
evaluating valvular pathologies.47 More recently, HHE ex-
aminations performed by family physicians with remote
expert support have shown reasonable image quality and
a significant reduction in the need for referral to SE.48
The Use of HHE in Emergency
Care Settings
HHE examinations have gained popularity in the emer-
gency care setting, and are currently considered a core
application by the American College of Emergency Phy-
sicians.10 In patients presenting with acute chest pain
syndrome, a quick assessment of chamber size and func-
tion, ascending aorta, and pericardium can help triage
patients and alter management. In unstable patients, a
rapid evaluation for the presence of a large pericardial
effusion, LV failure, or RV strain in massive pulmonary
embolism is effective in delivering expedited care49; de-
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622
Handheld Echocardiography
termining volume status is crucial, and size of IVC has
been validated for assessing right atrial pressures.5
STATE OF THE ART
The Use of HHE by Nurses
More specialized nurses are following patients with HF
after discharge to identify volume overload before re-
current decompensation. Studies have shown that, af-
ter training, nurses can perform high-quality ultrasound
with good agreement to SE. Gundersen et al32 studied
the use of HHE performed by 2 specialized nurses to as-
sess volume status (IVC size and collapsibility, the pres-
ence of pleural effusion) in an outpatient HF clinic. Only
volume status led to the dose adjustment of diuretics at
the first visit and follow-up.
The Use of HHE by Medical Students/
Residents in Training
In a recent survey of US medical schools, 62% reported
that ultrasound was fundamental in their training cur-
riculum.50 Previous studies have shown that, with ade-
quate training, medical students can acquire and inter-
pret diagnostic imaging.51,52 After 3 months of training,
students could acquire diagnostic images using HHE
in <6 minutes.14 However, as with any new skill, not
performing these examinations regularly impacts per-
formance negatively.5 In a recent study, well-trained
residents were noted to lose their ultrasound skills after
2 years of no scanning.53
TRAINING TO PERFORM
HANDHELD ECHOCARDIOGRAPHIC
EXAMINATIONS
HHE has been incorporated in cardiology practice and
other specialties and has been endorsed by various soci-
eties.5,10,54 Several training protocols and standards have
been proposed.5,10,55–57 Although there is no universal
agreement for training, in particular, for the noncardi-
ologists, all agree on the need for didactic education
(ultrasound principles, cardiac anatomy and function,
image acquisition), hands-on training, and interpreta-
tion experience.5,10,55–57 The background in imaging of
the users is variable (emergency care, intensivists, and
anesthesiologists may have some ultrasound training,
whereas internists and residents do not); hence, it is
important for noncardiologists to undergo dedicated
training to avoid over- or underdiagnosis of cardiac
diseases.54 Because an HHE examination has important
implications in the management of patients, it is essen-
tial to define training parameters, image acquisition cri-
teria, and reporting requirements, and to evaluate the
overall competence of professionals performing such
examinations.
November 28, 2017 2183
 Chamsi-Pasha et al
One of the early experiences of incorporating a didac-
tic curriculum for residents to use HHE came from Kimura
et al58 and was first implemented in 2005. This involved
12 lectures (1-hour each) on a monthly basis. Once-week-
ly 1 hour of bedside teaching was given during rounds;
the expectation of residents was to perform 10 to 30 ex-
aminations under the supervision of sonographers. Other
programs and modules have been proposed for basic
didactics.5,10,55–57 After acquiring the basic knowledge
about cardiac anatomy in relation to ultrasound, a great
emphasis lies on applying this core knowledge, preferably
on patients and volunteers rather than simulators only,
so that the user is familiar with probe orientation, image
acquisition from the different views, and image optimi-
zation. The last step is an interpretation of the studies
performed: an accurate description of the findings, as-
sessment of overall study quality, and acknowledgment
of relevant structures that could not be assessed.
Technical difficulties go along with miniaturized
devices with regard to image resolution, limited pro-
cessing, a small screen, and lack of spectral Doppler.
Challenges exist in training novice learners on how to
obtain good echocardiographic windows.59 Parasternal
long- and short-axis views are typically easier to master,
need less positioning of the patient, and are more reli-
able landmarks for less experienced users. One study by
Hellman et al44 showed that, for a novice user, 20 to 30
studies are needed to acquire the basic acceptable skill
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necessary to perform and interpret images. Most pro-
fessional societies have proposed a minimum number
of ≈30 scans for basic training (range between 20 and
100).5,10,55–57 In our experience, although this is a bare
minimum for image acquisition, it would fall short for
accurate interpretation: there are a multitude of pathol-
ogies that interpreters need to be exposed to despite a
focused cardiac scope; this limited exposure would not
be adequate for assessing critically ill patients, where
images are more difficult to obtain and the diagnos-
tic implications are the highest. This experience would
need to be supplemented with case studies of other
pathologies. In fact, short-duration training has been
associated with an increased false-positive rate among
medicine residents: hence, the critical need for specific
training recommendations and maintenance of com-
petency.45 Last, frequent reviews of the stored data,
comparing interpretations with other modalities and
pathology data, are useful for quality assurance and
improvement.9
ROLE IN TELEHEALTH AND MHEALTH
Pocket echocardiography now forms a part of mobile
health (mHealth) devices enabled by the convergence
of 4 technologies: telemedicine with wearable devic-
es, smartphone apps, unobtrusive sensing with in vivo
2184 November 28, 2017
nanosensors, and ubiquitous computing with miniatur-
ized laboratory-on-a-chip devices. A major step in this
direction was first investigated in the ASE-REWARD
study (American Society of Echocardiography: Remote
Echocardiography with Web-Based Assessments for
Referrals at a Distance) where >10 000 patients with
symptoms of cardiac disease were screened in a remote
part of India and >1000 were imaged with handheld ul-
trasound.6 Performed within a 2-day period, the studies
were uploaded to a cloud-based server and distributed
to 75 cardiologists scattered over 60 medical centers in
4 countries. Scans were uploaded within 4 minutes and
interpreted within 12 hours. Results identifying struc-
tural and congenital heart disease were delivered back
to the local clinicians, effectively creating a digital plat-
form for providing specialty cardiac services where they
may be needed the most.7 Among the various design
properties of mHealth devices, the portability, ease of
use, and lower cost are among the features ideally suit-
ed for use in resource-constrained areas. To assess the
benefit of multiple mHealth devices, the ASE-VALUES
trial (A Randomized Trial of Pocket-Echocardiography
Integrated Mobile Health Device Assessments in Mod-
ern Structural Heart Disease Clinics) randomly assigned
253 consecutive patients with symptomatic rheumat-
ic and structural heart disease to an initial diagnostic
strategy with mHealth including HHE, smartphone-
connected ECG, blood pressure and oxygen measure-
ments, activity monitoring, and point-of-care laborato-
ry testing in wireless mHealth clinics or to standard-care
medical clinics.60 During follow-up, 34% of the study
population underwent treatment with valvuloplasty or
valve replacement. The mean duration from the time
of enrollment to the primary outcome was significantly
shorter in the mHealth arm, and the occurrence of a
hospitalization and death was lower in the mHealth
than in the standard-care arm.60
IS HHE COST-EFFECTIVE?
Multiple studies have evaluated the cost-effective-
ness of HHE versus SE strategy. On average, the total
charges of an HHE study including the cost of device
and operator charge ranged between $11 and $116,
in comparison with $170 to $1500 for an SE.28,43,61 In
the era of appropriate use and testing costs, Mehta et
al43 compared the diagnostic accuracy of HHE versus
physical examination and whether its use reduced over-
all costs in patients referred for a transthoracic echo-
cardiogram. HHE correctly identified abnormal findings
(significant valvular pathologies) in 82% of the patients
in comparison with 47% identified by physical exami-
nation. HHE was associated with the reduced charge
of $63 per patient (average of $644.43 versus $707.4).
In another study, a strategy of HHE in comparison with
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622
 Handheld Echocardiography

SE resulted in savings up to $72 per study.28 Greaves Table 3.  Advantages and Limitations of Handheld
et al61 demonstrated that if HHE was performed on all Echocardiography and Its Use in Clinical Practice

STATE OF THE ART

inpatients for LV function assessment (based of 2000 Advantages Limitations
standard echocardiograms performed per annum), this Lightweight, pocket size, portable Lower resolution, limited
would result in savings up to $23 000 and 29% reduc- at the bedside ultrasound frequencies, and image
tion in departmental workload. optimization in comparison with
larger systems
Time and cost-effective Limited to 2-dimensional (some

CHALLENGES AND BARRIERS TO with color Doppler); no spectral

Doppler
IMPLEMENTATION Adjunct to clinical examination Small screen size
For HHE to be successful at the point of care, devices Allows early diagnosis and triaging
Incidental or equivocal findings
must provide reliable imaging, be easy to use, and be in emergency settings, when
need confirmation by conventional
comprehensive echocardiography
affordable. The examination should be short enough may not be available
echocardiography
in duration so as not to prevent physicians from seeing
Daily use as needed during rounds Lack of hemodynamic
their patients in an expeditious manner. Although it is or clinics measurements and limited valve
relatively easy for physicians already trained in echocar- assessment
diography to acquire and interpret images, nonechocar- Use in frequent serial
diographers would need to be trained in acquisition and echocardiographic examinations
Not reimbursed
(eg, heart failure, pericardial
interpretation to meet consistently high standards. Phy- effusion)
sicians using handheld devices must be able to discern
Allows assessing heart disease in Specific training for image
when information from a handheld device is diagnostic underserved or remote populations acquisition and interpretation is
or of suboptimal quality to merit a full echocardiograph- needed for nonechocardiographers
ic study. Education and training are therefore critically
important and need standardization. Last, among the wearable ultrasound transducers as a belt-like ultra-
major challenges for adoption is the lack of incentive to sound device for continuous ultrasonography and vas-
use HHE. In the current US healthcare model of fee for cular imaging.63,64 There has also been significant inter-
service, there is no reward for spending more time at est in the development of ultrasound-on-chip designs
the bedside to arrive at a quick diagnosis, although the with capacitive micromachined ultrasonic transducers
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immediate knowledge from imaging expedites care; the

viability and sustainability of a clinical practice or hospi-
tal institution currently depends on referrals to the more
established diagnostic modalities (comprehensive or lim-
ited echocardiography) where time and effort are ac-
counted for and built into the reimbursement scheme.
Despite these challenges, several trends in health
care will undoubtedly promote the incorporation of
HHE into patient management and improve the pa-
tient-physician encounter. Healthcare reform has stipu-
lated a more integrated healthcare system, the imple-
mentation of electronic health records and evaluation
of new payment models that reward value, quality, and
outcomes over quantity of care. Handheld devices are
poised to help facilitate the delivery of cost-effective,
quality care. The more empowered and informed a
healthcare professional is at the point of care, the more
effective is the rendition of care. Table 3 lists the advan-
tages and limitations of HHE technology and its use in
the clinical setting.
NEW TECHNOLOGY AND FUTURE
APPLICATIONS
Newer designs of miniaturized cardiac ultrasound sys-
tems that are currently being evaluated include wire-
less transducers62 (Figure 4), fingertip probes, and other
as an effective alternative to piezoelectric transducers
for ultrasound-imaging applications.65 These develop-
ments soon will have potential not only for B-mode and
Doppler processing, but also as an area- and power-
efficient solution for 3-dimensional real-time volumetric
imaging on a portable scale for point-of-care diagnostic
applications.
Application of artificial intelligence techniques to
point-of-care ultrasound in the development of ma-
chine-learning systems may aid in the optimization of
acquisition and interpretation of a high volume of im-
ages, reduce variability, and improve diagnostic accura-
cy, in particular, for novice users.66 Such algorithms may
be delivered to the care provider in real time by using
cloud computing–based solutions for avoiding delays in
clinical diagnosis and therapeutic interventions. More-
over, the combination of digital imaging and telero-
botics may expand the use of ultrasound even further,
allowing an expert to perform an examination from a
distance, virtualizing both ultrasound image acquisition
and interpretation.67,68 These applications will help lend
expertise to remote and dangerous locations, expand
the applicability of community screening procedures,
and expedite point-of-care remote examinations for
patients who are hospitalized or waiting in emergency
triage locations.

Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622 November 28, 2017 2185

 Chamsi-Pasha et al
As point-of-care cardiac ultrasound evolves, it may
become impossible for an expert to review every ultra-
sound examination, which exacerbates the potential for
harm with inadequately trained providers. The training
requirements and standardization of protocols could
potentially be performed using universally available on-
line-training platforms and simulation environments.69
Development of such point-of-care simulation at a low
cost will enable cardiac ultrasound training and simula-
tion to be broadly affordable for developing countries.
Furthermore, the emergence of machine vision (like au-
tomated security cameras) may enhance the develop-
ment of an infrastructure and algorithm that provide
quality assurance while minimizing patient risk.
As ultrasound technology continues the impressive
trend toward miniaturization, we foresee that handheld
devices of the future will incorporate additional diag-
nostic tools, beyond those of ultrasound of the heart or
vessels such as auscultation and electrocardiography to
help physicians obtain the maximum diagnostic quest
at the bedside and thus allow them to initiate timely
and cost-effective care.70 Such information including
other vital signs would be uploaded wirelessly into the
electronic health record under the cardiac section of
the physical examination, thus keeping a record of the
totality of the patient encounter for serial follow-up.
Healthcare professionals will embrace handheld devices
if they see that the extra time spent at the bedside is
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enhancing care. This time is valuable and needs to be
accounted for in a new sustainable, integrated, and
value-based healthcare system.
DISCLOSURES
Dr Sengupta received a research grant and is an advisor for
Heart Test Labs Inc and Hitachi Aloka Ltd. Dr Zoghbi is an
advisor for Siemens Medical Solutions USA, Inc, and has a
licensing agreement with GE Healthcare.
AFFILIATIONS
Cardiovascular Imaging Institute, Department of Cardiology,
the Methodist DeBakey Heart and Vascular Center, Houston,
TX (M.A.C.-P., W.A.Z.). Section of Cardiology, West Virginia
University Heart and Vascular Institute, J.W. Ruby Memorial
Hospital, Morgantown (P.P.S.).
FOOTNOTES
Circulation is available at http://circ.ahajournals.org.
REFERENCES
1. Mehta M, Kaul S. Reply: handheld ultrasound is a valuable bedside tool
which can supplement the bedside cardiac exam but not replace it. JACC
Cardiovasc Imaging. 2015;8:622. doi: 10.1016/j.jcmg.2015.01.016.
2186 November 28, 2017
2. Breithardt OA. Hand-held ultrasound-the real stethoscope. Eur Heart J
Cardiovasc Imaging. 2015;16:471–472. doi: 10.1093/ehjci/jeu320.
3. Ligtvoet C, Rijsterborgh H, Kappen L, Bom N. Real time ultrasonic imaging
with a hand-held scanner. Part I–technical description. Ultrasound Med
Biol. 1978;4:91–92.
4. Bhavnani SP, Narula J, Sengupta PP. Mobile technology and the digitiza-
tion of healthcare. Eur Heart J. 2016;37:1428–1438. doi: 10.1093/eur-
heartj/ehv770.
5. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Fo-
cused cardiac ultrasound: recommendations from the American Society
of Echocardiography. J Am Soc Echocardiogr. 2013;26:567–581. doi:
10.1016/j.echo.2013.04.001.
6. Singh S, Bansal M, Maheshwari P, Adams D, Sengupta SP, Price R, Dantin
L, Smith M, Kasliwal RR, Pellikka PA, Thomas JD, Narula J, Sengupta PP;
ASE-REWARD Study Investigators. American Society of Echocardiography:
Remote Echocardiography with Web-Based Assessments for Referrals at
a Distance (ASE-REWARD) Study. J Am Soc Echocardiogr. 2013;26:221–
233. doi: 10.1016/j.echo.2012.12.012.
7. Bansal M, Singh S, Maheshwari P, Adams D, McCulloch ML, Dada T, Sengupta
SP, Kasliwal RR, Pellikka PA, Sengupta PP; VISION-in-Tele-Echo Study Investiga-
tors. Value of interactive scanning for improving the outcome of new-learners
in transcontinental tele-echocardiography (VISION-in-Tele-Echo) study. J Am
Soc Echocardiogr. 2015;28:75–87. doi: 10.1016/j.echo.2014.09.001.
8. Fuster V. The stethoscope’s prognosis: very much alive and very necessary.
J Am Coll Cardiol. 2016;67:1118–1119. doi: 10.1016/j.jacc.2016.01.005.
9. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR,
Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent
setting: a consensus statement of the American Society of Echocardiog-
raphy and American College of Emergency Physicians. J Am Soc Echocar-
diogr. 2010;23:1225–1230. doi: 10.1016/j.echo.2010.10.005.
10. American College of Emergency Physicians. Emergency ultrasound guide-
lines. Ann Emerg Med. 2009;53:550–570.
11. Neskovic AN, Edvardsen T, Galderisi M, Garbi M, Gullace G, Jurcut R,
Dalen H, Hagendorff A, Lancellotti P, Popescu BA, Sicari R, Stefanidis A;
European Association of Cardiovascular Imaging Document Reviewers:.
Focus cardiac ultrasound: the European Association of Cardiovascular Im-
aging viewpoint. Eur Heart J Cardiovasc Imaging. 2014;15:956–960. doi:
10.1093/ehjci/jeu081.
12. Mirabel M, Celermajer D, Beraud AS, Jouven X, Marijon E, Hagège AA.
Pocket-sized focused cardiac ultrasound: strengths and limitations. Arch
Cardiovasc Dis. 2015;108:197–205. doi: 10.1016/j.acvd.2015.01.002.
13. Prinz C, Voigt JU. Diagnostic accuracy of a hand-held ultrasound scanner
in routine patients referred for echocardiography. J Am Soc Echocardiogr.
2011;24:111–116. doi: 10.1016/j.echo.2010.10.017.
14. Mjolstad OC, Dalen H, Graven T, Kleinau JO, Salvesen O, Haugen BO. Rou-
tinely adding ultrasound examinations by pocket-sized ultrasound devices
improves inpatient diagnostics in a medical department. Eur J Intern Med.
2012;23:185–191. doi: 10.1016/j.ejim.2011.10.009.
15. Di Bello V, La Carrubba S, Conte L, Fabiani I, Posteraro A, Antonini-Can-
terin F, Barletta V, Nicastro I, Mariotti E, Severino S, Caso P, Benedetto F,
Savino K, Carerj S; SIEC (Italian Society of Cardiovascular Echography).
Incremental value of pocket-sized echocardiography in addition to physi-
cal examination during inpatient cardiology evaluation: a multicenter Ital-
ian study (SIEC). Echocardiography. 2015;32:1463–1470. doi: 10.1111/
echo.12910.
16. Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ. Is pocket
mobile echocardiography the next-generation stethoscope? A cross-sec-
tional comparison of rapidly acquired images with standard transthoracic
echocardiography. Ann Intern Med. 2011;155:33–38. doi: 10.7326/0003-
4819-155-1-201107050-00005.
17. Testuz A, Müller H, Keller PF, Meyer P, Stampfli T, Sekoranja L, Vuille C,
Burri H. Diagnostic accuracy of pocket-size handheld echocardiographs
used by cardiologists in the acute care setting. Eur Heart J Cardiovasc
Imaging. 2013;14:38–42. doi: 10.1093/ehjci/jes085.
18. Réant P, Dijos M, Arsac F, Mignot A, Cadenaule F, Aumiaux A, Jimenez
C, Dufau M, Prévost A, Pillois X, Fort P, Roudaut R, Lafitte S. Validation
of a new bedside echoscopic heart examination resulting in an improve-
ment in echo-lab workflow. Arch Cardiovasc Dis. 2011;104:171–177. doi:
10.1016/j.acvd.2011.01.003.
19. Giusca S, Jurcut R, Ticulescu R, Dumitru D, Vladaia A, Savu O, Voican
A, Popescu BA, Ginghina C. Accuracy of handheld echocardiography for
bedside diagnostic evaluation in a tertiary cardiology center: comparison
with standard echocardiography. Echocardiography. 2011;28:136–141.
doi: 10.1111/j.1540-8175.2010.01310.x.
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622

20. Galderisi M, Santoro A, Versiero M, Lomoriello VS, Esposito R, Raia R,
Farina F, Schiattarella PL, Bonito M, Olibet M, de Simone G. Improved
cardiovascular diagnostic accuracy by pocket size imaging device in non-
cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in
Cardiology) study. Cardiovasc Ultrasound. 2010;8:51. doi: 10.1186/1476-
7120-8-51.
21. Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D, Rahman
S, Nihoyannopoulos P. Pocket-size hand-held cardiac ultrasound as an ad-
junct to clinical examination in the hands of medical students and junior
doctors. Eur Heart J Cardiovasc Imaging. 2013;14:323–330. doi: 10.1093/
ehjci/jes140.
22. Andersen GN, Haugen BO, Graven T, Salvesen O, Mjølstad OC, Dalen
H. Feasibility and reliability of point-of-care pocket-sized echocardiog-
raphy. Eur J Echocardiogr. 2011;12:665–670. doi: 10.1093/ejechocard/
jer108.
23. Razi R, Estrada JR, Doll J, Spencer KT. Bedside hand-carried ultrasound
by internal medicine residents versus traditional clinical assessment for
the identification of systolic dysfunction in patients admitted with decom-
pensated heart failure. J Am Soc Echocardiogr. 2011;24:1319–1324. doi:
10.1016/j.echo.2011.07.013.
24. Senior R, Galasko G, Hickman M, Jeetley P, Lahiri A. Community screen-
ing for left ventricular hypertrophy in patients with hypertension using
hand-held echocardiography. J Am Soc Echocardiogr. 2004;17:56–61.
doi: 10.1016/j.echo.2003.09.013.
25. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physi-
cal examination: better at the bedside. Heart. 2017;103:987–994. doi:
10.1136/heartjnl-2016-309915.
26. Abe Y, Ito M, Tanaka C, Ito K, Naruko T, Itoh A, Haze K, Muro T, Yoshi-
yama M, Yoshikawa J. A novel and simple method using pocket-sized
echocardiography to screen for aortic stenosis. J Am Soc Echocardiogr.
2013;26:589–596. doi: 10.1016/j.echo.2013.03.008.
27. Xie T, Chamoun AJ, McCulloch M, Tsiouris N, Birnbaum Y, Ahmad M.
Rapid screening of cardiac patients with a miniaturized hand-held ultra-
sound imager–comparisons with physical examination and conventional
two-dimensional echocardiography. Clin Cardiol. 2004;27:241–245.
28. Pathan F, Fonseca R, Marwick TH. Usefulness of hand-held ultrasonog-
raphy as a gatekeeper to standard echocardiography for “rarely appro-
priate” echocardiography requests. Am J Cardiol. 2016;118:1588–1592.
Downloaded from http://ahajournals.org by on March 9, 2019
doi: 10.1016/j.amjcard.2016.08.027.
29. Kennedy Hall M, Coffey EC, Herbst M, Liu R, Pare JR, Andrew Taylor R,
Thomas S, Moore CL. The “5Es” of emergency physician-performed fo-
cused cardiac ultrasound: a protocol for rapid identification of effusion,
ejection, equality, exit, and entrance. Acad Emerg Med. 2015;22:583–
593. doi: 10.1111/acem.12652.
30. Dresden S, Mitchell P, Rahimi L, Leo M, Rubin-Smith J, Bibi S, White L,
Langlois B, Sullivan A, Carmody K. Right ventricular dilatation on bed-
side echocardiography performed by emergency physicians aids in the
diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63:16–24. doi:
10.1016/j.annemergmed.2013.08.016.
31. Goonewardena SN, Blair JE, Manuchehry A, Brennan JM, Keller M, Reeves
R, Price A, Spencer KT, Puthumana J, Gheorghiade M. Use of hand carried
ultrasound, B-type natriuretic peptide, and clinical assessment in iden-
tifying abnormal left ventricular filling pressures in patients referred for
right heart catheterization. J Card Fail. 2010;16:69–75. doi: 10.1016/j.
cardfail.2009.08.004.
32. Gundersen GH, Norekval TM, Haug HH, Skjetne K, Kleinau JO, Graven T,
Dalen H. Adding point of care ultrasound to assess volume status in heart
failure patients in a nurse-led outpatient clinic. A randomised study. Heart.
2016;102:29–34. doi: 10.1136/heartjnl-2015-307798.
33. Mok KL. Make it SIMPLE: enhanced shock management by focused car-
diac ultrasound. J Intensive Care. 2016;4:51. doi: 10.1186/s40560-016-
0176-x.
34. Beaton A, Aliku T, Okello E, Lubega S, McCarter R, Lwabi P, Sable C. The
utility of handheld echocardiography for early diagnosis of rheumatic
heart disease. J Am Soc Echocardiogr. 2014;27:42–49. doi: 10.1016/j.
echo.2013.09.013.
35. Ploutz M, Lu JC, Scheel J, Webb C, Ensing GJ, Aliku T, Lwabi P, Sable
C, Beaton A. Handheld echocardiographic screening for rheumatic
heart disease by non-experts. Heart. 2016;102:35–39. doi: 10.1136/
heartjnl-2015-308236.
36. Pare JR, Liu R, Moore CL, Sherban T, Kelleher MS Jr, Thomas S, Taylor
RA. Emergency physician focused cardiac ultrasound improves diagnosis
of ascending aortic dissection. Am J Emerg Med. 2016;34:486–492. doi:
10.1016/j.ajem.2015.12.005.
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622
Handheld Echocardiography
37. Kimura BJ, Yogo N, O’Connell CW, Phan JN, Showalter BK, Wolfson T.
Cardiopulmonary limited ultrasound examination for “quick-look” bed-
STATE OF THE ART
side application. Am J Cardiol. 2011;108:586–590. doi: 10.1016/j.amj-
card.2011.03.091.
38. Lucas BP, Candotti C, Margeta B, Mba B, Kumapley R, Asmar A, Franco-
Sadud R, Baru J, Acob C, Borkowsky S, Evans AT. Hand-carried echocar-
diography by hospitalists: a randomized trial. Am J Med. 2011;124:766–
774. doi: 10.1016/j.amjmed.2011.03.029.
39. Goonewardena SN, Gemignani A, Ronan A, Vasaiwala S, Blair J, Bren-
nan JM, Shah DP, Spencer KT. Comparison of hand-carried ultrasound
assessment of the inferior vena cava and N-terminal pro-brain natriuretic
peptide for predicting readmission after hospitalization for acute decom-
pensated heart failure. JACC Cardiovasc Imaging. 2008;1:595–601. doi:
10.1016/j.jcmg.2008.06.005.
40. Borges AC, Knebel F, Walde T, Sanad W, Baumann G. Diagnostic accuracy
of new handheld echocardiography with Doppler and harmonic imag-
ing properties. J Am Soc Echocardiogr. 2004;17:234–238. doi: 10.1016/j.
echo.2003.11.011.
41. Bank I, Vliegen HW, Bruschke AV. The 200th anniversary of the stetho-
scope: Can this low-tech device survive in the high-tech 21st century? Eur
Heart J. 2016;37:3536–3543. doi: 10.1093/eurheartj/ehw034.
42. Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, Toste J, Cobos MA,
Carmelo V, Nunes I, Oliveira AG, Zamorano J. Usefulness of a new min-
iaturized echocardiographic system in outpatient cardiology consulta-
tions as an extension of physical examination. J Am Soc Echocardiogr.
2011;24:117–124. doi: 10.1016/j.echo.2010.09.017.
43. Mehta M, Jacobson T, Peters D, Le E, Chadderdon S, Allen AJ, Caughey
AB, Kaul S. Handheld ultrasound versus physical examination in patients
referred for transthoracic echocardiography for a suspected cardiac
condition. JACC Cardiovasc Imaging. 2014;7:983–990. doi: 10.1016/j.
jcmg.2014.05.011.
44. Hellmann DB, Whiting-O’Keefe Q, Shapiro EP, Martin LD, Martire C, Zie-
gelstein RC. The rate at which residents learn to use hand-held echo-
cardiography at the bedside. Am J Med. 2005;118:1010–1018. doi:
10.1016/j.amjmed.2005.05.030.
45. Wilkinson JS, Barake W, Smith C, Thakrar A, Johri AM. Limitations of con-
densed teaching strategies to develop hand-held cardiac ultrasonography
skills in internal medicine residents. Can J Cardiol. 2016;32:1034–1037.
doi: 10.1016/j.cjca.2015.10.008.
46. Martin LD, Howell EE, Ziegelstein RC, Martire C, Shapiro EP, Hellmann
DB. Hospitalist performance of cardiac hand-carried ultrasound after
focused training. Am J Med. 2007;120:1000–1004. doi: 10.1016/j.am-
jmed.2007.07.029.
47. Martin LD, Howell EE, Ziegelstein RC, Martire C, Whiting-O’Keefe QE,
Shapiro EP, Hellmann DB. Hand-carried ultrasound performed by hos-
pitalists: does it improve the cardiac physical examination? Am J Med.
2009;122:35–41. doi: 10.1016/j.amjmed.2008.07.022.
48. Evangelista A, Galuppo V, Méndez J, Evangelista L, Arpal L, Rubio C,
Vergara M, Liceran M, López F, Sales C, Miralles V, Galinsoga A, Pérez
J, Arteaga M, Salvador B, López C, García-Dorado D. Hand-held car-
diac ultrasound screening performed by family doctors with remote ex-
pert support interpretation. Heart. 2016;102:376–382. doi: 10.1136/
heartjnl-2015-308421.
49. Gunst M, Ghaemmaghami V, Sperry J, Robinson M, O’Keeffe T, Friese
R, Frankel H. Accuracy of cardiac function and volume status estimates
using the bedside echocardiographic assessment in trauma/critical care. J
Trauma. 2008;65:509–516. doi: 10.1097/TA.0b013e3181825bc5.
50. Bahner DP, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound
education in U.S. medical schools: results of a national survey. Acad Med.
2014;89:1681–1686. doi: 10.1097/ACM.0000000000000414.
51. Andersen GN, Viset A, Mjølstad OC, Salvesen O, Dalen H, Haugen BO.
Feasibility and accuracy of point-of-care pocket-size ultrasonography
performed by medical students. BMC Med Educ. 2014;14:156. doi:
10.1186/1472-6920-14-156.
52. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, San-
filippo AJ, Johri AM. Development and evaluation of methodologies for
teaching focused cardiac ultrasound skills to medical students. J Am Soc
Echocardiogr. 2014;27:302–309. doi: 10.1016/j.echo.2013.12.006.
53. Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Reten-
tion of ultrasound skills and training in “point-of-care” cardiac ul-
trasound. J Am Soc Echocardiogr. 2016;29:992–997. doi: 10.1016/j.
echo.2016.05.013.
54. Sicari R, Galderisi M, Voigt JU, Habib G, Zamorano JL, Lancellotti P, Badano
LP. The use of pocket-size imaging devices: a position statement of the Eu-
November 28, 2017 2187
 Chamsi-Pasha et al
ropean Association of Echocardiography. Eur J Echocardiogr. 2011;12:85–
87. doi: 10.1093/ejechocard/jeq184.
55. Expert Round Table on Echocardiography in ICU. International consensus
statement on training standards for advanced critical care echocardiogra-
phy. Intensive Care Med. 2014; 40: 654–666.
56. Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D;
World Interactive Network Focused On Critical UltraSound ECHO-ICU
Group. Echocardiography practice, training and accreditation in the in-
tensive care: document for the World Interactive Network Focused on
Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008;6:49. doi:
10.1186/1476-7120-6-49.
57. Walley PE, Walley KR, Goodgame B, Punjabi V, Sirounis D. A practical ap-
proach to goal-directed echocardiography in the critical care setting. Crit
Care. 2014;18:681. doi: 10.1186/s13054-014-0681-z.
58. Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations dur-
ing development of an internal medicine residency training program in
cardiovascular limited ultrasound examination. J Hosp Med. 2012;7:537–
542. doi: 10.1002/jhm.1944.
59. Culp BC, Mock JD, Chiles CD, Culp WC Jr. The pocket echocardiograph:
validation and feasibility. Echocardiography. 2010;27:759–764. doi:
10.1111/j.1540-8175.2009.01125.x.
60. Bhavnani S, Sola S, Adams D, Venkateshvaran A, Dash PK, Sengupta PP.
A randomized trial of pocket-echocardiography integrated mobile health
device assessments in modern structural heart disease clinics (published
online ahead of print September 9, 2017). JACC Cardiovasc Imaging. doi:
10.1016/j.jcmg.2017.06.019. https://linkinghub.elsevier.com/retrieve/pii/
S1936-878X(17)30721-0.
61. Greaves K, Jeetley P, Hickman M, Dwivedi G, Sabharwal N, Lim T, Janard-
hanan R, Senior R. The use of hand-carried ultrasound in the hospital set-
ting–a cost-effective analysis. J Am Soc Echocardiogr. 2005;18:620–625.
doi: 10.1016/j.echo.2004.09.015.
Downloaded from http://ahajournals.org by on March 9, 2019
2188 November 28, 2017
62. Walsh JA III, Topol EJ, Steinhubl SR. Novel wireless devices for cardiac
monitoring. Circulation. 2014;130:573–581. doi: 10.1161/CIRCULA-
TIONAHA.114.009024.
63. Mierzwa AP, Huang SP, Nguyen KT, Culjat MO, Singh RS. Wearable ul-
trasound array for point-of-care imaging and patient monitoring. Stud
Health Technol Inform. 2016;220:241–244.
64. Steinhubl SR, Muse ED, Topol EJ. The emerging field of mobile health. Sci
Transl Med. 2015;7:283rv3.
65. Khuri-Yakub BT, Oralkan O. Capacitive micromachined ultrasonic
transducers for medical imaging and therapy. J Micromech Microeng.
2011;21:54004–54014. doi: 10.1088/0960-1317/21/5/054004.
66. Narula S, Shameer K, Salem Omar AM, Dudley JT, Sengupta PP. Machine-
learning algorithms to automate morphological and functional assess-
ments in 2D echocardiography. J Am Coll Cardiol. 2016;68:2287–2295.
doi: 10.1016/j.jacc.2016.08.062.
67. Sengupta PP, Narula N, Modesto K, Doukky R, Doherty S, Soble J, Narula
J. Feasibility of intercity and trans-Atlantic telerobotic remote ultrasound:
assessment facilitated by a nondedicated bandwidth connection. JACC
Cardiovasc Imaging. 2014;7:804–809. doi: 10.1016/j.jcmg.2014.03.014.
68. Boman K, Olofsson M, Berggren P, Sengupta PP, Narula J. Robot-assisted
remote echocardiographic examination and teleconsultation: a random-
ized comparison of time to diagnosis with standard of care referral ap-
proach. JACC Cardiovasc Imaging. 2014;7:799–803. doi: 10.1016/j.
jcmg.2014.05.006.
69. Damjanovic D, Goebel U, Fischer B, Huth M, Breger H, Buerkle H, Schmutz
A. An easy-to-build, low-budget point-of-care ultrasound simulator: from
Linux to a web-based solution. Crit Ultrasound J. 2017;9:4. doi: 10.1186/
s13089-017-0061-4.
70. Zoghbi WA. Echocardiography at the point of care: an ultra sound
future. J Am Soc Echocardiogr. 2011;24:132–134. doi: 10.1016/j.
echo.2010.12.014.
Circulation. 2017;136:2178–2188. DOI: 10.1161/CIRCULATIONAHA.117.026622