The European Association of Echocardiography (EAE) released a position statement on the use of pocket-size imaging devices in January 2011. Cardiovascular News spoke to Rosa Sicari, CNR, Institute of Clinical Physiology, Italy, one of the authors of the paper published in the European Journal of Echocardiography.
What are the EAE’s concerns with regard to pocket-size imaging devices?
In general, none. Miniaturisation is one of the many advantages that technology development has offered to echocardiography. However, we felt as a professional and scientific organisation that the cardiology community as well as manufacturers were asking for indications and profiles of potential users. Indeed, pocket-size devices are powerful tools, at low cost, and abuse and misuse is the real danger when given outside the echo community and the conventional pathways of training and certification. If you buy a Ferrari no one will ask for your driving license but it is your duty to respect speed limits. The document is designed to reduce these potential dangers: anybody can use such devices but indications and limitations should be acknowledged. This is the reason why in the document we spelled out the need for an appropriate training for those who are not fully conversant in ultrasounds. At the same time, due to the limited capacity of these devices, the exam should be performed only as a complement to the physical examination. In other words, these devices do not allow performing a complete echo exam but helping physicians in the clinical evaluation of patients.
What are the main recommendations of the position statement?
The document is focused on four main aspects: classification of echo machines and indications, reporting, training and certification, information to patients. We clearly state that these devices do not provide a complete diagnostic echo examination. Pocket-size devices should complement the physical examination in outreach clinics, coronary and intensive care units. They may serve as a tool for fast initial cardiac assessment in emergency units, during cardiologic counseling inside or outside health-care facilities and hospitals, for first cardiac evaluation in ambulances and for screening programmes in schools, industries and other community activities. Moreover, pocket-size imaging devices may be used for the triage of patient in need of a complete echocardiographic examination. Pocket-size imaging devices may further become a valuable teaching tool in medical schools. We also indicated the use for thoracic echography with the assessment of B-lines as a sign of extravascular lung water. This is a novel application highly informative in the differential diagnosis of dyspnoea. Reporting, then, becomes part of the physical examination. We focused on training, because this is the only way to limit potential misuse, with a technology such as ultrasounds that suffers of operator-dependence and high inter and intra-observer variability. With the exception of cardiologists who are certified for transthoracic echocardiography according to national legislation, specific training and certification is recommended for all users. However, certification should be limited to the clinical questions that can potentially be answered by pocket-size devices. The patient should be informed that such an exam does not replace a complete echocardiogram.
What about non-cardiologists and other medical professionals, what do they need to bear in mind when using pocket-size imaging devices?
As recommended, non-cardiologists need to become fully acquainted with ultrasounds. For non-cardiologists and/or other medical professionals, a dedicated training and revision of basic cardiac physiology and pathology knowledge should be mandatory. This appears to be the only way to avoid abuse and potential harm to patients due to both over- and under-diagnosis of serious heart diseases. The EAE promotes the idea of a pocket size training specifically tailored to the information that can be obtained from this new class of devices as mandatory part of a certification process. This would ensure a widespread use of this new technology with certified competence, avoiding abuse and potential misuse.
The EAE says that no reimbursement should be warranted for the use of these devices. What are the reasons for this recommendation?
This recommendation has raised some criticism inside the medical community. Some have seen this position as the usual approach to echocardiography: low cost, extra burden for cardiologists and no potential economic advantage. However, this specific recommendation stems from the obvious consideration that these tools do not allow the performance of a complete exam and it would not be fair both for the healthcare system and the patient to make it reimbursable. Moreover, partial examination is not encouraged by the EAE.
