Harald Becher

Ultrasound enhancing agents (UEAs, formerly called contrast agents) have enhanced echocardiographic diagnostics of myocardial disease and masses as well as myocardial perfusion abnormalities. This review provides up-to-date guidance on the procedures and interpretations according to current recommendations of imaging societies and considering the results of recent major studies. For the different indications, a standardized approach has been created including technical aspects, pre-assessment and primary scan planes, contrast-enhanced ultrasound (CEUS) procedure, interpretation and reporting. In a previous publication (part 1) the UEAs, imaging methods, preparation of the patients and assessment of global and regional LV function with UEAs were included. The two parts represent a comprehensive state-of-the-art compendium on how to perform CEUS examinations in clinical echocardiography and provide advice on education, qualification and quality control.

Ultrasound enhancing agents (UEAs, formerly called contrast agents) for assessments of the left heart have improved the applicability of echocardiography and the accuracy of echocardiographic measurements. UEAs have been recommended for several diagnostic echocardiographic procedures by national and supernational agencies. The increased use of UEAs during the last years provided more evidence and experience in clinical practice data which is helpful for optimizing the UEA procedures and which will be useful for both newcomers to UEA in echocardiography and sonographers/physicians with experience in echocardiography with UEAs. In two parts, this review focuses on the “how to do” for the approved UEA applications. This is part 1, covering the available UEAs and providing specific guidance on the assessment of global and regional LV function. Part 2 covers the imaging of myocardial disease and masses as well as myocardial perfusion. Recommendations include the application of UEAs in two-dimensional echocardiography as there is limited data on three-dimensional echocardiography. A step-by-step approach is proposed for each of the procedures as well as guidance on how to interpret recordings and how to report them.

This review investigates recent advancements in autonomous, semi-autonomous, and teleoperated robotic ultrasound systems.Traditional ultrasound imaging depends on manual probe manipulation, which introduces operator variability, physical strain, and limitations in accessibility. To address these challenges, this review investigates recent advancements in autonomous, semi-autonomous, and teleoperated robotic ultrasound systems by analyzing over 60 publications, including key developments from 2022 to 2025. Our survey reveals a growing adoption of cobot-based solutions equipped with 6-DOF force/torque sensors and RGB-D vision systems for precise probe positioning [34], [58], [60]. Notably, several systems now integrate reinforcement learning, image-guided visual servoing, and real-time feedback loops to enable intelligent trajectory planning and adaptive force control [46]–[48]. However, we identify critical gaps in the literature: surface-parallel force and torque components are often ignored in control models, limiting the accuracy of probe orientation and tissue coupling [39], [40]. Furthermore, real-time ultrasound image feedback is rarely used for path optimization, despite its importance in enhancing image quality and diagnostic reliability [38], [50]. This review emphasizes the need for future systems to integrate multi-modal sensing, adaptive control, and real-time image quality assessment to achieve robust, generalizable robotic ultrasound workflows.

Background: Echocardiography is crucial to understanding cardiac function in the Intensive Care Unit (ICU), often by measuring the left ventricular ejection fraction (LVEF). Traditionally, measures of LVEF are completed as part of a comprehensive examination by an expert sonographer or cardiologist, but front-line practitioners increasingly perform focused point-of-care estimates of LVEF while managing life-threatening illness. The two main echocardiographic windows used to grossly estimate LVEF are parasternal and apical windows. Artificial intelligence (AI) algorithms have recently been developed to assist non-experts in obtaining and interpreting point-of-care ultrasound (POCUS) echo images. We tested the feasibility, accuracy and reliability of novice users estimating LVEF using POCUS-AI echo. Methods: A total of 30 novice users (most never holding an ultrasound probe before) received 2 h of instruction, then scanned ICU patients (10 patients, 80 scans) using the Exo Iris POCUS probe with AI guidance tool. They were permitted up to 5 min to attempt parasternal long axis (PLAX) and apical 4 chamber (A4C) views. AI-reported LVEF results from these scans were compared to gold-standard LVEF obtained by an expert echo sonographer. To further assess accuracy, this sonographer also scanned another 65 patients using Exo Iris POCUS-AI vs. conventional protocol. Results: Novices obtained images sufficient to estimate LVEF in 96% of patients in <5 min. Novices obtained PLAX views significantly faster than A4C (1.5 min vs. 2.3 min). Inter-rater reliability of LVEF estimation was very high (ICC 0.88–0.94) whether images were obtained by novices or experts. In n = 65 patients, POCUS-AI LVEF was highly specific for a decreased LVEF ≤ 40% (SP = 90% for PLAX) but only moderately sensitive (SN = 56–70%). Conclusions: Estimating cardiac LVEF from AI-enhanced POCUS is highly feasible even for novices in ICU settings, particularly using the PLAX view. POCUS-AI LVEF results were highly consistent whether performed by novice or expert. When AI detected a decreased LVEF, it was highly accurate, although a normal LVEF reported by POCUS-AI was not necessarily reassuring. This POCUS-AI tool could be clinically useful to rapidly confirm a suspected low LVEF in an ICU patient. Further improvements to sensitivity for low LVEF are needed.

Background: Echocardiography is crucial to understanding cardiac function in the In-tensive Care Unit (ICU), often by measuring the left ventricular ejection fraction (LVEF). Traditionally measures of LVEF are completed as part of comprehensive ex-amination by an expert sonographer or cardiologist, but front-line practitioners in-creasingly perform focused point-of-care estimates of LVEF while managing life-threatening illness. The two main echocardiographic windows used to grossly es-timate LVEF are parasternal and apical windows. Artificial intelligence (AI) algo-rithms have recently been developed to assist non-experts in obtaining and interpret-ing point-of-care ultrasound (POCUS) echo images. We tested the feasibility, accuracy and reliability of novice users estimating LVEF using POCUS-AI echo. Methods: A total of 30 novice users (most never holding an ultrasound probe before) received 2 hours of instruction, then scanned ICU patients (10 patients, 80 scans) using the Exo Iris POCUS probe with AI guidance tool. They were permitted up to 5 minutes at-tempting parasternal long axis (PLAX) and apical 4 chamber (A4C) views. AI-reported LVEF results from these scans were compared to gold-standard LVEF obtained by an expert echo sonographer. To further assess accuracy, this so-nographer also scanned another 65 patients using Exo Iris POCUS-AI vs. conventional protocol. Results: Novices obtained images sufficient to estimate LVEF in 96% of pa-tients in < 5 minutes. Novices obtained PLAX views significantly faster than A4C (1.5 min vs. 2.3 min). Inter-rater reliability of LVEF estimation was very high (ICC 0.88-0.94) whether images were obtained by novices or experts. In n=65 patients, POCUS-AI LVEF was highly specific for a decreased LVEF< 40% (SP=90% for PLAX) but only moderately sensitive (SN=56-70%). Conclusion: Estimating cardiac LVEF from AI-enhanced POCUS is highly feasible even for novices in ICU settings, particu-larly using the PLAX view. POCUS-AI LVEF results were highly consistent whether performed by novice or expert. When AI detected a decreased LVEF, it was highly accurate, although a normal LVEF reported by POCUS-AI was not necessarily reas-suring. This POCUS-AI tool could be clinically useful to rapidly confirm a suspected low LVEF in an ICU patient. Further improvements to sensitivity for low LVEF are needed.

Echocardiography or ultrasound imaging of the heart is an invaluable tool for non-invasive cardiac evaluation. It is inexpensive, portable, and safe due to its lack of ionizing radiation. However, prolonged manual operation introduces musculoskeletal strain to sonographers, which requires innovative solutions. Collaborative robots or cobots offer an excellent option to reduce strain during cardiac scans. However, precise force control is vital to ensure patient comfort and optimal image quality. This study evaluates the application of force during robotic echocardiography scans in 30 healthy volunteers, demonstrating significantly reduced force compared to manual scans. Importantly, image quality remains uncompromised despite the minimal force exerted. These findings underscore the potential for robotic systems to be introduced into clinical practice by improving patient care and alleviating the stress of the sonographer. Future research could explore the application of robotic echocardiography in diverse patient populations, including those with various cardiac pathologies, to further validate its efficacy and safety. Overall, this study marks a significant step towards improving cardiac imaging practices and improving healthcare outcomes through the implementation of advanced robotic technologies.

The precise alignment of 3D echocardiographic images taken from different views has been shown to enhance image quality and increase the field of view. This study proposes a novel sequential Monte Carlo (SMC) algorithm for the 3D-3D rigid registration of echocardiographic images with significant overlap that is robust to the noise present in ultrasound images. The algorithm estimates the translational and rotational components of the rigid transform through an iterative process and requires an initial approximation of the rotation and translation limits that depend on the dimension of the image and the initial overlap between images. The registration is performed in two ways that the same transform approach applies the transform computed for the end diastolic frame to all frames of the cardiac cycle, whereas the unique transform approach registers each frame independently. The proposed SMC and exhaustive search algorithms were evaluated for 3D echocardiographic volumes recorded from 3 patients and 3 volunteers who participated in two different research studies conducted at the Mazankowski Alberta Heart Institute. The evaluations demonstrate that the same transform approach yielded a Dice score value of 0.716 ± 0.041 for the left ventricle and required less computational time than the unique transform approach or exhaustive search. It was found that the SMC performs better than the exhaustive search at 0.05 significance level using the paired t test. The accuracy was improved further using the Simple Elastix non-rigid registration algorithm to fix misalignments due to deformations, with an overall Dice score value of 0.787 ± 0.038.

Purpose of Review The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018. Recent Findings The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Summary Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.