Key takeaways in cardiac ultrasound from ASE 2023

AI is front and center in cardiac ultrasound

Ultrasound is the largest cardiac imaging modality that serves as both a workhorse diagnostic tool and gatekeeper to more advanced imaging like CT and MRI. However, echo has known issues, including its variability in exam quality and reproducibility from one sonographer to another. Different sonographers will provide different measurements for the same patient. Also, with increasing workloads and pressure to see more patients each day, some quantifications are estimated by eyeballing images, including ejection fractions. 

These issues have brought AI algorithms for echocardiography to the forefront of U.S. Food and Drug Administration (FDA) clearances in recent years. AI has now moved from being the subject of academic discussions in sessions to being the center of serious discussions on the expo floor. This was evident of the ASE 2023, where more than a dozen vendors demonstrated FDA-cleared clinical algorithms. 

These commercialized algorithms include automated time-saving tools to contour and identify the anatomy of the heart, automated measurements, automated ejection fractions and strain, and automated slicing of optimal views from 3D echo datasets. In cardiac PACS, AI can now fetch relevant prior exams and patient information from the EMR. Two vendors on the expo floor have developed AI to help novice sonographers position the ultrasound probe to obtain higher quality cardiac exams. Other AI vendors now offer diagnostic algorithms to help better risk assess patients and automatically detect certain cardiac diseases earlier. 

"There is obviously a lot of concern about AI replacing jobs, but the reality is, we are seeing AI as a tool," Kirkpatrick explained. 

He also said sonographers and cardiologists should expect to see more about AI as a way to increase efficiency as it continues to see wider adoption in hospitals and clinics.

"AI was also front and center in a lot of our award ceremonies, where a lot of the research award abstracts were along the lines of applying AI in the echo space," Kirkpatrick added. 

There is a growing amount of AI research in echo and discussion in sessions at ASE. And it was not just talks on testing experimental algorithms, but in terms of real-world application of AI. There were also numerous speakers that shared expectations that AI will be used to aid detection and classification for amyloid, hypertrophic cardiomyopathy and other cardiac diseases.

NIH key note speaker asked ASE to help change the standard of care with new technology

George Mensah, MD, delivered the Gardin Lecture on echocardiography and the global burden of cardiac care. He is the director of the Center for Translation Research and Implementation Science  at the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.  

Kirkpatrick said Mensah has worked for years to address cardiovascular disparities and implementation of new technologies. 

"In his lecture, he brought those two things together and he gave us a charge as a society to take another step to not only develop all these wonderful tools and products, but also to implement them," Kirkpatrick explained. "I heard several people quote back to be after the lecture that it takes on average 17 years on average for the development of some crucial technology to actually get to the service of patients. That too long."

In his presentation, Mensah outlined disparities in underserved areas and developing countries. He said new technologies like AI might be able to help address these disparities, but champions are needed to move the needle forward as global burden of heart disease continues to increase.

Many startups struggle to exist for more than a decade without being able to commercialized a product or the ability to be profitable. Some fail as a result. 

Mensah noted that the developing world is seeing rapidly increasing rates cardiovascular diseases and new ways are needed to detect these diseases earlier and to increase efficiency to enable more patients to be imaged by limited imaging resources. 

"Our society really has an opportunity to really implement all the great things we saw here at this meeting, and that really was his charge to us," Kirkpatrick said. 

The ASE Foundation may be able to help with that implementation through its global outreach efforts, funding research and dissemination of information and guidelines to developing countries, Kirkpatrick said. 

Hypertrophic cardiomyopathy and amyloid take center stage in numerous sessions

New drugs were introduced in recent years to treat cardiac amyloid and in 2022 for hypertrophic cardiomyopathy (HCM). With these new treatments available, there have been growing efforts to train imagers about these diseases and how to image them. There were several new sessions this year on HCM and amyloid at ASE, which is part of a larger trend also seen at other cardiology conferences as well.

"Echo is of course the frontline for finding patients with hypertrophic cardiomyopathy. We are learning a lot more about the disease and how to image it and understanding the different forms. That was a pretty major part of our scientific sessions. We also now have treatments now for amyloid, and echo is the frontline imaging modality, so we had sessions on how to identify it and how echo fits into multimodality imaging for amyloid," Kirkpatrick explained.

Hands-on training highlighted at ASE meeting

Following the isolation of the COVID-19 pandemic, there was a renewed focus on in-person, hands-on training at ASE. There were several do-it-yourself sessions this year on how to perform cardiac strain exams, what to look for in congenital heart patients, and 3D cropping for echo for valve interventions. 

"Much of the content from scientific sessions can be [obtained] online, so you really have to justify why people should come in person. We were very conscientious about that, so we had hands-on sessions, and I think that has been amazingly successful," Kirkpatrick said. 

Getting sonographers more involved

The ASE has more than 16,500 members. While 80% are U.S. based, 20% are international, representing 111 countries. About 45% of the ASE members are sonographers. 

The society also has made efforts to get sonographers up on the podium in ASE sessions so they feel like they are an integral part of the society, Kirkpatrick said. He likes the collaborative nature between sonographers and physicians working together in ASE.

Addressing the sonographer shortage

There was a growing shortage of sonographers prior to COVID that was exacerbated as clinicians became more burned out during the pandemic. This has led to the clinical version of the Great Resignation with clinicians and physicians leaving their jobs, and sometimes clinical practice altogether, in record numbers.

One thing ASE did at the annual meeting was shoot video clips that will be edited into a recruiting video for sonographers. The final product will be shown in high schools in underserved communities in an effort to get more people into the profession.  

The ASE Cares program, implemented just before the pandemic, was set up to try and address several factors that lead to clinician burnout. Kirkpatrick said there was a session on the ASE Cares program at this year's meeting to try to get the word out about what ASE is doing, what health systems can do, and ideas for self-help to deal with stressful situations in healthcare and dealing with patients.  

ASE hosted a career day at the annual meeting where numerous hospitals and health systems set up tables to recruit sonographers and tell them, about the jobs they have open. These booths were packed a good part of the day. 

ASE also used an app for its annual meeting this year that included a sizable number of postings for jobs. ASE sent a message to attendees that indicated it will work to make these postings easier to understand in future meetings. 

In addition, ASE offered sonographers an opportunity to get free professional head shots taken at the meeting. Multiple meetings sessions also focused on different things job applicants can do to be noticed.