Recognizing the limitations of handheld ECHO for patients with COVID-19

7th Jan 2021

Although handheld echocardiography (HHE) has a unique role in the current clinical era, it is not without limitations. 


Handheld echocardiography has limited modalities

The majority of HHE devices are limited to two-dimensional (2D) and color Doppler modalities. Therefore, they do not have the full functionality of a standard echocardiography machine, such as M-mode and spectral Doppler modalities. 

Multi-component illustration of a handheld echocardiography (HHE) device displaying a 2D color modality beside a standard echocardiography machine displaying M-mode and spectral doppler functions.

Figure 1. Handheld echocardiography (HHE) devices are limited to 2D and color Doppler modalities. They do not have M-mode and spectral Doppler functions, which are found in standard echocardiography machines.  


Interpretation challenges 

Due to these limited functionalities, the common interpretation challenges of echocardiography may be more difficult to overcome. In COVID-positive patients with changing hemodynamics, lung consolidation, rhythm disturbances, patient positioning, and artifacts from indwelling lines all pose challenges to interpretation of images. 

Illustration of ventilated patient with COVID-19 in an intensive care unit.

Figure 2. In COVID-positive patients with changing hemodynamics, lung consolidation, rhythm disturbances, patient positioning, and artifacts from indwelling lines all pose challenges to the interpretation of images from a handheld echocardiography machine.


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Valvular disease assessment

The restricted functionalities of HHE also pose a particular challenge in the assessment of valvular heart disease. Handheld echocardiography can clarify auscultatory findings but determining the severity of valve lesions is complex and requires high-resolution imaging with spectral Doppler for hemodynamic assessment. Therefore, valvular lesions suspected to be beyond mild in severity should be referred for standard transthoracic echocardiography at a suitable time.

Multi-component illustration of caution sign and heart with valves highlighted.

Figure 3. The restricted functionalities of handheld echocardiography (HHE) devices pose a challenge for the assessment of valvular heart disease. Valvular lesions suspected to be beyond mild in severity should be referred for standard transthoracic echocardiography. 


Heart rhythm assessment

Another limitation is that HHE devices do not usually come with electrocardiogram (ECG) capability. Although in the intensive care unit (ICU) setting the heart rhythm can be appreciated from the heart monitor, in other situations it can become a challenge if the rhythm was not noted during the scan. 

Illustration of crossed-out heartbeat.

Figure 4. Handheld echocardiography (HHE) devices do not have electrocardiogram (ECG) capacity. 


Operator proficiency

Since the aim when performing HHE in the COVID-19 era is to limit scanning time, it is necessary that these focused studies are performed by suitably qualified individuals. The operator should understand the fundamentals of cardiac ultrasound image acquisition and optimization and have the necessary in-depth knowledge of cardiac anatomy and physiology, in order to quickly obtain high-quality images at the bedside. 

Illustration of a male operator with a medal on lapel holding a handheld echocardiography (HHE) device.

Figure 5. The handheld echocardiography (HHE) device operator should understand the fundamentals of cardiac ultrasound image acquisition and optimization, and have the necessary in-depth knowledge of cardiac anatomy and physiology in order to obtain high-quality images. 

Regardless of the limitations, to ensure high clinical standards, education and training are key considerations for HHE. Therefore, a guided protocol is essential to ensure clinical governance in the evolving role of handheld echocardiography. 


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Recommended reading

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