Single-View Echocardiography by Nonexpert Practitioners to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy

Abstract

Background: Echocardiographic screening can detect asymptomatic cases of rheumatic heart disease (RHD), facilitating access to treatment. Barriers to implementation of echocardiographic screening include the requirement for expensive equipment and expert practitioners. We aimed to evaluate the diagnostic accuracy of an abbreviated echocardiographic screening protocol (single parasternal-long-axis view with a sweep of the heart) performed by briefly trained, nonexpert practitioners using handheld ultrasound devices. Methods: Participants aged 5 to 20 years in Timor-Leste and the Northern Territory of Australia had 2 echocardiograms: one performed by an expert echocardiographer using a GE Vivid I or Vivid Q portable ultrasound device (reference test), and one performed by a nonexpert practitioner using a GE Vscan handheld ultrasound device (index test). The accuracy of the index test, compared with the reference test, for identifying cases with definite or borderline RHD was determined. Results: There were 3111 enrolled participants; 2573 had both an index test and reference test. Median age was 12 years (interquartile range, 10–15); 58.2% were female. Proportion with definite or borderline RHD was 5.52% (95% CI, 4.70–6.47); proportion with definite RHD was 3.23% (95% CI, 2.61–3.98). Compared with the reference test, sensitivity of the index test for definite or borderline RHD was 70.4% (95% CI, 62.2–77.8), specificity was 78.1% (95% CI, 76.4–79.8). Conclusions: Nonexpert practitioners can be trained to perform single parasternal-long-axis view with a sweep of the heart echocardiography. However, the specificity and sensitivity are inadequate for echocardiographic screening. Improved training for nonexpert practitioners should be investigated.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

“…Another essential part in the prevention efforts will be continuous education, and task-shifting to use cardiac non-expert practitioners for time detection, treatment, and referral of ARF and RHD. These have been reported to be effective LMICs with limited cardiac expertise [ 22 , 42 , 43 ].…”

Challenges in Management of Pediatric Rheumatic Heart Disease in Indonesia: A Narrative Review

“…In Timor-Leste, non-specialist health practitioners were briefly trained and supervised by cardiac sonographers and cardiologists which expertise is in the RHD diagnosis. When compared with the assessments from the experts, the accuracy of the non-experts tests employing single parasternal-long-axis view with a sweep of the heart (SPLASH) echocardiography in the detection of any MR and/or AR were 70.4% for sensitivity, 78.1% for specificity, and 78.2% for kappa agreement [13]. It is also comparable to those discovered by [14,15], which presented good agreement between non-experts' assessment and cardiologists for any RHD, and notably higher sensitivity for definite RHD or when conducted by two views.…”

“…These findings corroborate a promising opportunity to train non-expert operators in facilitating RHD screening in limited-resources areas. However, the extensive variability of scans resulted among non-expert operators, and fact that trainees conducting more scans demonstrate better accuracy suggest improvement of training system with the needs of longer and more under supervision scans [13]. Therefore, regular monitoring, continuing training program, building facilities for confirmatory diagnosis and management, is also crucial to ensure the screening program quality.…”

Acute Rheumatic Fever: Recent Advances

“…In settings like Timor-Leste where nonexpert practitioners have been trained, and handheld devices and remote support are available, echocardiographic confirmation of the presence of carditis has enabled diagnoses of ARF and RHD even in extremely remote locations. 6…”