Back in the spotlight: Exploring echocardiography's revival

AI is one of top discussions in echo

"The reality is AI is already in clinical practice today. Most echo labs use software that already implements elements of AI. There is some concern because it is new, but I would say the optimism outweighs the concerns," Little explained. 

He added that there are a multitude of AI applications in cardiac ultrasound, including some that help improve image acquisition and others more focused on image interpretation. With the number of patients growing and reimbursements shrinking, Little said AI holds the potential to speed or automate echo workflows, which would allow clinicians to see more patients. 

"Easier things need to be faster and hard things have to be easier," Little said. 

Interventional echocardiography continues to expand

The subspecialty of interventional echocardiography grew out of the need for transesophageal echo (TEE) image guidance during transcatheter aortic valve replacements (TAVR) procedures a decade ago. TEE is now also used to guide transcatheter left atrial appendage occlusion (LAAO), transcatheter mitral and tricuspid valve leaflet clip repair procedures, transcatheter mitral valve replacement (TMVR), transcatheter pulmonary valve replacement, and to seal holes in the heart such as perivalular leaks, atrial septal defects (ASD), patent foramen ovale (PFO) and ventricular spatula defects (VSD). Echo is also used to guide alcohol septal ablation procedures to treat hypertrophic cardiomyopathy (HCM). 

Several new transcatheter device technologies are also working their way through clinical trials. Little said the first tricuspid devices will likely see FDA clearance in the next year or so, which will to lead to increased procedural volumes in this largely undertreated patient population. 

Recent imaging technology advances in the structural heart space include fusion imaging with echo, computed tomography (CT) and magnetic resonance imaging (MRI) to use in both pre-planning procedures and periprocedural guidance. 

In pediatric imaging, several imaging advancements to visualize blood flow and the very small anatomical structures of of the fetal heart have come onto the scene in the past couple years, making diagnosis and surgical planning for congenital heart cases easier. 

ASE partnering with industry to move echo technology forward

While there are many potentially groundbreaking new technologies that have been developed for cardiac ultrasound, reimbursement for this new tech is often lacking. It may take years to attain revenue from adopting a new technology through insurance or Medicare. And that often happens after a long and costly series of clinical trials to build clinical evidence for its use. This can lead to start up companies going out of business long before reimbursement is available, or hospitals and clinics not purchasing the technology because of the lack of return on investment from the added expense, or the lack of clinical evidence the technology can improve care based. 

For these reasons, Little said ASE has take a more active roll in recent years to partner with vendors to better connect them with cardiologists and institutions. This can help move the needle forward and speed the development and data collection process. Little outlined this program during his State of Echo speech at the opening session of the ASE annual meeting. 

ASE now partners with at least 14 vendors. It also hosts an annual industry roundtable meeting so that vendors and ASE representatives can discuss the modality's future.  

"One of the goals is to make sure a new tool is not just a tool looking for a problem, and that it is a tool for a problem. The goal of the clinical groups is to say, 'here is the problem, and here is a tool that might work, but let's see if we can have a conversation on adapting it,'" Little explained. 

He also noted that the number of vendors interested in echo has expanded in the past decade to include several new players on the ASE expo floor. Years ago, Little said it was just echo machine vendors. Then PACS vendors started coming in because you need a way to report, manage and archive these digital format studies. Today, he said, the show floor now includes structural heart vendors that rely on echo to guide their device procedures. It also includes point-of-care ultrasound vendors who are marketing their devices to clinicians outside of echocardiography, but need the support of ASE members because of the key role of performing POCUS echo exams. Most importantly, there has been the appearance of pharmaceutical vendors of the ASE expo floor. 

New drugs to treat amyloid and HCM increased pharma involvement with echo

"One of the big trends that has just happened is the advancement of pharmacotherapies for specific cardiomyopathies, such as hypertrophic cardiomyopathy and amyloidosis. Well, they need echo to diagnose these diseases and to follow serially these patients to evaluate treatment success or nonresponse," Little explained. 

Bristol Myers Squibb (BMS) and Pfizer have both taken on active roles and had a large presence at ASE to raise awareness about their new HCM and amyloid treatments. Little said both of these treatments were approved in just the last year or two and have revolutionized patient care for these conditions. Since echo plays a key role, Little said training is needed to image these diseases. Information also needs to be shared with referring physicians so they know more about the symptoms and that something can be done for these patients so they send them on for echo evaluations. 

Find more cardiac amyloidosis news and video.

Find more HCM news and video.

Echo is undergoing a renaissance with new roles and technology 

Combined, these areas have come to a head and are re-energizing echo after years of cardiac imaging being largely focused on new advances in CT and MRI. Little said AI is also driving this renaissance because it promises to make this sonographer-dependent modality faster, more reproducible and less prone to intraoperator variability. 

"We have all these things happening at the same time. Putting all that together, my sense of the meeting and also the field right now is that echo is truly undergoing a renaissance. There has been a lot of focus on CT and MRI as new tools and what those advanced imaging modalities can help us identify. But echo is kind of coming back in, specially when you see the new uses of point-of-care echo, pediatric echo, interventional echo, and now new disease identification for pharmacotherapy that we did not have just two years ago. It is really putting a lot of spotlight back on the echocardiogram," Little said.

In addition, he aded, the image quality of echo has greatly improved in recent years.

"But, the cloud over this sunny day is the funding. That is always the problem where the innovation precedes the funding. To insure patient access, we ultimately need to figure out the funding," Little explained. 

Lack of medical reimbursement requires advocacy in Washington 

The issue of funding for adoption of new echo technology from reimbursements is closely connected with ASE's lobby and government advocacy efforts in Washington. Little said advocacy is one of the somewhat invisible, but most important parts of ASE membership benefits. This includes ASE's involvement with the American Medical Association (AMA) and its resource-based relative value scale (RVS) Update Committee, or RUC. This is the process that forms the basis for how services are reimbursed by Medicare via CPT codes. 

"This is the group that decides once a technology is approved by the FDA, is there a payment for it. Because approval without a payment isn't a solution for anybody, so the ASE is very involved in that process," Little stressed.