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Abstract

Background—

Rheumatic heart disease (RHD) remains a major public health problem worldwide. Although early diagnosis by echocardiography may potentially play a key role in developing active surveillance, systematic evaluation of simple approaches in resource poor settings are needed.

Methods and Results—

We prospectively compared focused cardiac ultrasound (FCU) to a reference approach for RHD screening in a school children population. FCU included (1) the use of a pocket-sized echocardiography machine, (2) nonexpert staff (2 nurses with specific training), and (3) a simplified set of echocardiographic criteria. The reference approach used standardized echocardiographic examination, reviewed by an expert cardiologist, according to 2012 World Heart Federation criteria. Among the 6 different echocardiographic criteria, first tested in a preliminary phase, mitral regurgitation jet length ≥2 cm or any aortic regurgitation was considered best suited to be FCU criteria. Of the 1217 subjects enrolled (mean, 9.6±1 years; 49.6% male), 49 (4%) were diagnosed with RHD by the reference approach. The sensitivity of FCU for the detection of RHD was 83.7% (95% confidence interval, 73.3–94.0) for nurse A and 77.6% (95% confidence interval, 65.9–89.2) for nurse B. FCU yielded a specificity of 90.9% (95% confidence interval, 89.3–92.6) and 92.0% (95% confidence interval, 90.4–93.5) according to users. Percentage of agreement among nurses was 91.4%.

Conclusions—

FCU by nonexperts using pocket devices seems feasible and yields acceptable sensitivity and specificity for RHD detection when compared with the state-of-the-art approach, thereby opening new perspectives for mass screening for RHD in low-resource settings.
Rheumatic heart disease (RHD) has been eradicated in many areas, but remains a major public health problem in the developing world with >345 000 related deaths each year.14 RHD is the consequence of valvular damage caused by an exaggerated immune response to group A streptococcal infections, usually during infancy and childhood. Disease control is based on the administration of penicillin for primary prevention (ie, the treatment of group A streptococcal sore throat) and for secondary prevention (ie, at regular intervals to avoid further exposure to group A streptococcal infections that trigger the autoimmune response).
Because penicillin prevents RHD progression when initiated in a timely fashion (ie, secondary prevention), early detection has been emphasized to be of particular interest.1 The World Health Organization had recommended active surveillance in the past. There are, however, no guidelines as how screening should be undertaken. A 2-step approach involving clinical examination followed by echocardiography has proven to be of low sensitivity and specificity when compared with echocardiography alone.5 Indeed, echocardiography detects 3 to 25 times more cases than auscultation alone in endemic regions.610 The World Heart Federation (WHF) has, therefore, provided guidelines to optimize echocardiographic RHD diagnosis.11,12 There are certain issues that may prevent implementation of active surveillance by echocardiography in regions where RHD prevalence is highest.13 Cost-effectiveness and ethical issues arise when considering echocardiography-based screening as a public health policy in deprived regions. Concerns also include the cost of comprehensive portable equipment, the complexity of echocardiographic criteria, and the need for highly trained health workers in countries where access to specialist care remains limited. All these factors represent significant barriers to mass screening in low-income countries.14 Echocardiography may, however, emerge as the method of choice for active surveillance in highly endemic regions in this rapidly moving field.15
We, therefore, prospectively assessed a new approach for RHD screening based on focused cardiac ultrasound (FCU) combining the use of a pocket-sized echo system, performed by nurses after a standardized training program, and using a simplified diagnostic algorithm.

Methods

Settings, Study Populations, and Screening Methodology

New Caledonia is a special collectivity of France located in the southwest Pacific Ocean. The prevalence of RHD in this region remains high, especially among indigenous populations.16 The country’s social security, however, provide access to secondary prophylaxis, specialist care, and cardiac interventions overseas free of charge.
The study comprises 2 parts. We first tested the most appropriate simplified set of echocardiographic criteria for RHD to be used for FCU among 189 selected children with and without RHD in March 2013 (part 1 of the study). These children had previously participated in the yearly echo-screening campaigns conducted in New Caledonia since 2008 (then aged 9–10 years). Participants in part 1 included children with subclinical RHD and children with previously normal echocardiograms.16 We then prospectively evaluated the feasibility and performance of an FCU approach among a population of school children (fourth graders aged 9–10 years in Nouméa, the capital city, and its suburbs) from April to August 2013 (part 2).
Participants were enrolled after parental written consent. Ethical clearance was granted from the Committee for the Protection of Persons of Overseas Territories and from the French Institute of Medical Research and Health (IRB00003888-FWA00005831).
The FCU approach used (1) a pocket-sized echo machine (V-scan; General Electric, Milwaukee, WI), (2) nonexpert staff (2 nurses after a standardized 60-hour training program) for performance and interpretation, and (3) a simplified set of echocardiographic criteria. The FCU approach was compared with the reference state-of-the-art approach. Each participant underwent 3 echocardiograms the same day in a randomly allocated order, blinded to the child’s diagnosis and to the other sonographer’s findings: 2 independent examinations by nurses using FCU and 1 examination by a cardiologist on-site (Figure 1). Each participant was assigned a unique research identification number, which could be used to link the imaging studies to the research participant. All studies were systematically reviewed in part 1 of the study, including the on-site cardiologist (reference echocardiogram) and nurses’ (FCU) recordings. The time for each scan was also systematically recorded in part 1.
Figure 1. Methodology of the focused cardiac ultrasound (FCU) and of the reference approach. RHD indicates rheumatic heart disease; and WHF, World Heart Federation.
The different echocardiographic criteria tested in part 1 were (1) any mitral regurgitation (MR); (2) MR jet length ≥1.5 cm; (3) MR jet length ≥2.0 cm; (4) morphological changes of the mitral valve defined as any irregular/focal thickening of the mitral leaflet, chordal thickening, restricted leaflet motion, excessive leaflet motion, or flail; (5) any aortic regurgitation; and (6) MR jet length ≥2.0 cm or any aortic regurgitation.
After determination of the optimal simplified set of echocardiographic criteria for FCU, we applied the FCU to a broader population of children (part 2 of the study) from April to August 2013 in local primary schools. All children attending these schools in fourth grade (aged 9–10 years) were offered to take part in the study. During this second part of the study, all suspected abnormal reference echocardiograms, identified either by the nurses or the on-site cardiologist, were independently reviewed.

Focused Cardiac Ultrasound Approach

The FCU approach was defined by the evaluation of on-site screening using a pocket echocardiography device, performed by 2 nurses trained specifically for the purpose of the study, according to simplified echocardiographic criteria. The ability to detect RHD was evaluated in comparing the on-site diagnosis made by the nurses by FCU to the reference approach.
The pocket-echo machine used was the V-scan (GE Medical Systems, version 1.2), with a 1.7- to 3.4-MHz transducer. The V-scan offers regular grayscale imaging and color blood flow mode with a 75° imaging sector. Grayscale and color Doppler parasternal long axis and parasternal short axis, apical 4-, 2-, and 3-chamber views were acquired, saved on the device’s microSD card and transferred to a computer. Distance measurements were performed during the examination using a caliper.
Two nurses with no previous experience in echocardiography underwent focused training for the recognition of left-sided valve abnormalities. The aim and stepwise methodology used for training the nurses are reported in the Data Supplement (Supplemental Methods). Briefly, the training included first theoretical lectures for 3 days, followed by 30 hours of hands-on sessions (with normal volunteers followed by sessions with RHD patients at the echocardiography laboratory, Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia) in February 2013. Additional tailored tutorship was undertaken between parts 1 and 2 of the study, including a review of the nurses’ scans and hands-on sessions addressing pitfalls in their practice.

Reference Approach

An experienced cardiologist performed standard echocardiograms with a portable machine (Vivid I, GE) on site after a predefined acquisition protocol with a 1.5- to 3.6-MHz probe. Frame rates ranged from 25 to 35 Hz for black-and-white imaging and from 12 to 18 Hz for color Doppler. Parasternal long axis and parasternal short axis, apical 4-, 2-, and 3-chamber views were acquired and settings optimized: grayscale without harmonics were recorded in the parasternal long-axis view for subsequent measurements of the anterior mitral leaflet, color Doppler was used in all views, continuous wave Doppler was applied to systematically measure the mean transmitral gradient and if a mitral or aortic regurgitant jet was seen on color Doppler. An experienced reader (M.M.) reviewed all studies using WHF criteria.

Statistical Analysis

Participant characteristics were described as mean (SD) or proportions, as appropriate. Categorical variables were compared using χ2 test. Sensitivity and specificity were calculated for the detection of any RHD (including borderline and definite RHD), with 95% confidence intervals (CIs). CIs for sensitivity and specificity were computed using the log-odds scale. Additional sensitivity analysis was performed for definite RHD cases. A predefined analysis was performed for part 1 of the study, including (1) sample size calculations based on the hypothesis that the FCU approach would yield a sensitivity of 80% with 95% CI of 70% to 90% if 61 definite RHD and 61 controls were included in the study; (2) the sensitivity and specificity to detect RHD for both nurses, with predefined cutoff values of 70%, to implement a simplified algorithm in part 2 prospectively. To evaluate agreement between investigators, we used κ coefficient with 95% CIs or percentage of agreement, as appropriate. Perceived differences in image quality (qualified as poor, moderate, and good) according to users were compared between the 2 users using Bowker test of symmetry. All data were analyzed at the Cardiovascular Epidemiology Unit of the Paris Cardiovascular Research Center, INSERM 970, Paris, France, with the use of Statistical Analysis System software (version 9.3).

Results

Evaluation of the Optimal Simplified Set of Echocardiographic Criteria for FCU Approach: Part 1

One hundred eighty-nine children were enrolled in this preliminary study. Mean age was 12.2 years (SD, 2.0) and 84 (44.4%) were male. One hundred six (56.1%) children had findings of RHD (63 definite and 43 borderline RHD), whereas 83 (43.9%) had normal echocardiograms.
Sensitivity and specificity of the 6 criteria interpreted by the nurses, when compared with the reference approach, are reported in Table 1 and Figure 2. Overall, there was an important heterogeneity with sensitivity varying from 26.4 (95% CI, 18.9–35.6) to 97.2 (95% CI, 91.7–99.1), specificity from 13.5 (95% CI, 7.6–22.7) to 91.6 (95% CI, 83.4–95.6), with also a wide range for interobserver agreement (κ varying from 0.09 to 0.57). The breakdown of echocardiographic findings according to WHF criteria is presented in the Data Supplement (Table).
Table 1. Sensitivity, Specificity, and Interobserver Variability of the Simplified Approach Per Criterion in Part 1 Including 189 Selected Children
Criteria TestedSensitivity Nurse ASensitivity Nurse BSpecificity Nurse ASpecificity Nurse Bκ
MR87.7 (80 to 92.7)97.2 (91.7 to 99.1)55.4 (44.6 to 65.7)13.5 (7.6 to 22.7)0.27 (0.14 to 0.40)
MR ≥15 mm81.1 (72.5 to 87.5)84 (75.8 to 89.8)69.9 (59.2 to 78.8)57.8 (47 to 67.9)0.47 (0.35 to 0.60)
MR ≥20 mm67 (57.5 to 75.3)66 (56.5 to 74.4)83.1 (73.5 to 89.7)74.7 (64.3 to 82.9)0.51 (0.39 to 0.63)
Morphological changes of the MV*61.3 (51.7 to 70.1)54.7 (45.2 to 63.9)57.8 (47 to 67.9)74.7 (64.3 to 82.9)0.09 (−0.05 to 0.23)
AR33 (24.7 to 42.5)26.4 (18.9 to 35.6)89.2 (80.5 to 94.3)91.6 (83.4 to 95.9)0.57 (0.43 to 0.71)
MR ≥20 mm or AR76.4 (67.4 to 83.5)70.7 (61.4 to 78.6)73.5 (63 to 81.9)69.9 (59.2 to 78.8)0.48 (0.35 to 0.60)
AR indicates aortic regurgitation; MR, mitral regurgitation; and MV, mitral valve.
*
Defined by ≥2 morphological changes of the MV, as per World Heart Federation criteria.11
Figure 2. Sensitivity and specificity (with upper 95% confidence interval) of the simplified approach for all 6 criteria tested in 189 selected children with high prevalence of rheumatic heart disease (RHD) to diagnose overall RHD for nurses A and B (part 1 of the study). Criteria 1, any mitral regurgitation; criteria 2, mitral regurgitation jet length ≥1.5 cm; criteria 3, mitral regurgitation jet length ≥2.0 cm; criteria 4, any morphological changes of the mitral valve defined as coaptation defect, restricted leaflet motion, prolapse, anterior mitral leaflet thickening ≥3 mm, restricted leaflet motion, chordal thickening, excessive leaflet motion or flail for mitral valve; criteria 5, any aortic regurgitation; and criteria 6 (in red), mitral regurgitation jet length ≥2.0 cm or any aortic regurgitation (combined criteria).
Among the 6 criteria tested, the combined criteria of MR jet length ≥2.0 cm or any aortic regurgitation (regardless the length) seemed to achieve the best combination of sensitivity and specificity. Compared with the reference approach, sensitivity of the combined criteria to detect any RHD was 76.4% (95% CI, 67.4–83.5) and 70.7% (95% CI, 61.4–78.6) for nurses A and B, respectively. The specificity to detect any RHD was of 73.5% (95% CI, 63.0–81.9) and 69.9% (95% CI, 59.2–78.8) according to nurses A and B, respectively. The agreement between nurses was moderate for the detection of all RHD cases when using the combined criteria (κ=0.48; 95% CI, 0.35–0.60; Figure 3).
Figure 3. Examples of images acquired with a pocket-sized echocardiographic device (V-scan; GE) during the study. A, Maximum mitral regurgitant jet length measurement ≥2.0 cm by one of the nurses on a still frame of an apical 2-chamber view. B, Maximum mitral regurgitant jet length measurement <2.0 cm by one of the nurses on a still frame of a parasternal long-axis view. C, Physiological aortic regurgitation. D, Pathological aortic regurgitation.

Assessment of Image Quality and On-Site Diagnosis: Part 1

Image quality of the FCU recordings was evaluated as good in 68 (36.8%) and 79 (42.7%), fair in 109 (58.9%) and 104 (56.2%), and poor in 8 (4.3%) and 2 (1.1%) cases, for nurses A and B, respectively (missing data in 4 cases), without significant difference between the 2 nurses (P=0.07).
When an experienced cardiologist reviewed FCU recorded by nurses in the field, the sensitivity and specificity of the diagnoses made by the nurses were not statistically significantly different from the corresponding values obtained from the experienced cardiologist (Figure 4). Mean scanning time per FCU scan was 5.9 minutes (1.7) for nurse A and 7.0 minutes (1.9) for nurse B.
Figure 4. Ability to diagnose any rheumatic heart disease (RHD; ie, definite and borderline RHD), using the focused cardiac ultrasound approach, according to the reader’s experience. Light blue, nurse’s on-site interpretation; dark blue, cardiologist’s interpretation after review of the nurses’ recordings (nurse A, pocket-sized echo recording A and nurse B, pocket-sized echo recording B).

Focused Cardiac Ultrasound in the Population (School-Based Screening): Part 2

Among the 1217 children included at school (mean age, 9.6±0.5 years; 603 male; 49.6%), 49 (4.0%) were diagnosed with findings of RHD according to the reference approach, including 15 definite and 34 borderline RHD cases (Figure 5).
Figure 5. Flow chart of the school-based study (part 2). RHD indicates rheumatic heart disease.
The sensitivity, specificity, and interobserver agreement between the 2 nurses are shown in Tables 2 and 3. The sensitivity of FCU to detect any RHD cases was 83.7% (95% CI, 70.7–91.6) for nurse A and 77.6% (95% CI, 63.9–87.1) for nurse B. FCU yielded a specificity of 90.9% (95% CI, 89.1–92.4) and 92.0% (95% CI, 90.3–93.4) according to nurses A and B, respectively. The percentage of agreement between nurses was 91.4%.
Table 2. Sensitivity and Specificity According to Users for the Focused Cardiac Ultrasound Using the Combined Criteria (Mitral Regurgitation Jet ≥2.0 cm or Any Aortic Regurgitation) in 1217 School Children to Diagnose Either Any RHD or Definite RHD
Combined CriteriaNurse ANurse B
Sensitivity of any RHD (definite and borderline), n=4983.7 (70.7–91.6)77.6 (63.9–87.1)
Sensitivity of definite RHD only, n=1593.3 (64.7–99.1)86.7 (59.5–96.7)
Specificity n=116890.9 (89.1–92.4)92.0 (90.3–93.4)
RHD indicates rheumatic heart disease.
Table 3. Inter-observer Variability and Percentage of Agreement Among Users for the Focused Cardiac Ultrasound Approach Using the Combined Criteria (Mitral Regurgitation Jet ≥2.0cm or Any Aortic Regurgitation) in 1217 Schoolchildren to Diagnose Either Any RHD or Definite RHD.
Combined CriteriaκConcordance, %
Any RHD (definite and borderline), n=12170.57 (0.50–0.65)91.4
Definite RHD only, n=11830.53 (0.44–0.61)91.8
RHD indicates rheumatic heart disease.
When restricted to definite RHD, the performance of the FCU approach was better. FCU yielded a sensitivity of 93.3% (95% CI, 64.7–99.1) and 86.7% (95% CI, 59.5–96.7) according to nurses A and B, respectively. The percentage of agreement between nurses was 91.8%. All RHD valve lesions detected in schools were graded as mild with no case of mitral stenosis.

Discussion

We report here, to the best of our knowledge, the first evaluation of an FCU approach for RHD screening by nonexperts with pocket devices using simple echocardiographic criteria. Such an approach may be potentially applicable in many poorly resourced settings. We first established an optimal simplified diagnostic algorithm for nonexperts, and then tested it in the field. Our findings suggest that this approach, although imperfect, yields acceptable sensitivity and specificity (≈80% and ~90%) to detect RHD within minutes with no further readings when compared with the state-of-the-art approach.11 These findings open new possibilities for the implementation of active surveillance of RHD in developing countries.
Overall, our study tested a combination of 3 factors, such as (1) the adequacy of the pocket-echo machine in detecting RHD, (2) the proficiency of the nurses after brief training, and (3) the performance of simplified criteria combining MR jet ≥2.0 cm or any aortic regurgitation (regardless of jet length). This global strategy incorporates affordable equipment by nonexperienced users with the aim to be translated into public health policies with widespread applicability.
In our study, the image quality of the pocket-echocardiograms was good or fair in the majority (≈90%) of cases by 2 operators, as in other settings including adults with larger body habitus.17,18 Beaton et al19 have recently shown that pocket-echo (V-scan; GE) was highly sensitive and specific (>90%) to diagnose RHD in a set of previously screened schoolchildren when operated by an experienced cardiologist with off-line interpretation by another experienced cardiologist on a dedicated software. Their findings are of the outmost importance because they demonstrate the technical capabilities of pocket-echo for RHD screening. However, the extent to which their methods could be translated into public health policies, in the light of a scarcity of specialized health workers in many low-income countries, remains questionable.14 Not surprisingly, the performance of pocket-echo in our study was slightly lower, even when an experienced reader interpreted the nurses’ echocardiograms, suggesting that operators’ skills in acquiring the images may affect the performance of an FCU strategy.
We deliberately chose to test nonexperienced users because it would be the most probable scenario in low-income countries. Sensitivity and specificity of the FCU approach were higher in part 2 than in part 1. Proficiency may have improved after additional tailored training between the 2 parts of the study, which would suggest the effect of longer training schemes on the accuracy of an FCU approach by nonexperts. Several studies have tested FCU by nonexperts with variable results. This may be because of high expectancies of FCU and to different training schemes.20,21 Echocardiography requires skilled users in image acquisition and during interpretation. Galderisi et al22 showed that trainees yield lower performance when compared with experienced cardiologists, in spite of 15 hours of lectures and ≈150 supervised echocardiograms for the purpose of FCU with a V-scan. We based our training scheme on a previous experience in neighboring Fiji with a total of ≈60 hours of training (combining lectures and supervised hands-on sessions).23 Consistently, our results are similar to this pilot study that assessed the feasibility of echo screening by nurses using standard nonportable equipment.23 As outlined by the American Society of Echocardiography and the European Society of Cardiology, standardization of training programs and proficiency are of outmost need before the widespread use of pocket-echo for FCU, especially for screening purposes by nonexperts.24,25 In the absence of such standardization, varying results may be obtained according to the skills and motivation of different health workers. There may be room for improvement in the proficiency of RHD screening by nonexperts, possibly through the experience acquired in the field.
Finally, we used simplified echocardiographic criteria for the diagnosis of RHD on site. Diagnostic criteria directly affect the case-detection rates, which may partly explain the performance of our strategy in the detection of RHD.7 The increasing interest in exploring echocardiographic detection of silent or subclinical RHD has led to the publication of standardized echocardiographic criteria.6,8,9,11,13 In the lack of a gold standard for RHD diagnosis, the WHF criteria are of the outmost importance as a surrogate marker of the disease. Although based on the best level of evidence, the WHF criteria require experienced operators and readers because it includes the use of continuous Doppler and the analysis of morphological changes of the mitral and aortic valves.11 Morphological criteria seem to be of additional value in experienced hands with high-end equipment.7 However, preliminary data suggest that more simple criteria may carry acceptable sensitivity and specificity when it comes to RHD detection.26 Our prospective evaluation demonstrates that complex diagnostic criteria is not applicable to pocket-echo, such as the analysis of morphological changes of the mitral valve, in line with a previous report.19
To date, studies have systematically used a 2-step diagnostic approach using high-quality nonportable equipment and qualified cardiologists.6,810,13,27,28 Although imperfect, our methods explore ways of providing a diagnosis on site with no need for further testing or readings. Remoteness is a major barrier to healthcare delivery, especially in rural areas in developing countries. Therefore, a rapid diagnosis in school or in the community (without the need for further testing in hospital) seems most appropriate in the planning of active surveillance for RHD.
In addition, the performance of this FCU approach improves in the detection of definite RHD, with a sensitivity of ≈90%. Definite RHD requires secondary prophylaxis by penicillin for ≥10 years, whereas borderline RHD should be offered regular follow-up.12 Indeed, some authors question the pathogenicity of borderline RHD although significantly more prevalent among children at risk of RHD.27 High sensitivity for the detection of definite RHD is, therefore, crucial for the management of screened populations, whereas the interest of screening borderline RHD remains unclear.29

Strengths and Limitations

In considering all issues together, this is the first pragmatic global approach to RHD echocardiography-based screening. We carried out a preliminary step to assess the feasibility of FCU with pocket-echo by nurses in a selected population, and then translated it into the real conditions of school-based screening. Although the performance of the test is imperfect, it yields acceptable sensitivity and specificity, especially in the case of definite RHD.
However, we acknowledge some limitations. First of all, echocardiography-based screening for RHD cannot be recommended at this stage.30 Active surveillance should be advocated only in places where secondary prophylaxis can be effectively administered, ideally within the frame of a disease control program including a register. Although there are some data that support the cost-effectiveness of echocardiography-based screening, this needs to be more thoroughly addressed.31 There are still significant unanswered questions about the significance of borderline cases. In addition, a simplified approach does not discriminate definite from borderline RHD leading to potentially unnecessary treatment in some children. This, however, needs to be appreciated in the context of poor-resourced settings where a more complex approach would be prohibitive. We tested FCU using echocardiographic criteria based on the results of a preliminary study that included older selected children (part 1). The age difference may have an effect on our results.
We assessed in this study a combination of factors that affect the accuracy of our methods and render interpretations challenging. FCUs using pocket-echo by nonexperienced users are still the subject of research and need further evaluation before being recommended in daily practice.24,25 Longer training schemes may improve users’ skills in both the image acquisition and interpretation. Our population-based study may have lacked power, especially to address improvement of the performance overtime. We screened relatively young children aged 9 to 10 years. This may explain why all lesions were mild. Although we cannot generalize our results to other settings, RHD lesions usually become more severe later in adolescence, thereby more probably be detected by FCU.32
Further studies are needed to validate this strategy before being translated into public health policies. Cost-effectiveness analysis should, however, consider simplified strategies for active surveillance as the one described in this work.

Conclusions

FCU with pocket-sized devices, operated by nonexperts, through simple echocardiographic criteria, seems feasible and yields acceptable sensitivity and specificity for RHD detection when compared with the state-of-art approach. FCU has the potential to provide a diagnosis on site within minutes. However, echocardiography-based screening cannot be advocated for at this stage, and further evaluation is needed before implementation in countries where RHD remains endemic.

Acknowledgments

We thank Victoria Desmarets and Juliette Gili who participated in the study. We are grateful to Dr Corinne Braunstein, Cardiology Department at the Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia for giving permission to scan patients at the Echocardiography Unit during the training sessions. We thank Drs Daniel Engleman and Andrew Steer, Melbourne, Australia, for giving access to the preliminary versions of the echo-standardization training modules launched under the auspices of the World Heart Federation. We are indebted toward all the children who took part in the study and their parents, as well as all the staff of the Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia, especially Weena Penehata, Dick Forest, Loïc Broquart, and Nancy Kuggler.

CLINICAL PERSPECTIVE

Rheumatic heart disease (RHD), a preventable condition, remains the leading cause of acquired cardiac disease in the young worldwide. Early detection has the potential to prevent progression of the disease. Echocardiography may be of value in the design of active surveillance. Methods used to date, have, however, involved high-end equipment and experienced cardiologists using complex diagnostic criteria. This study explored ways of making echo-based screening for RHD feasible and affordable in low- and middle-income countries. We tested a focused cardiac ultrasound approach compared with the current gold standard for the diagnosis of RHD (including definite and borderline cases). The focused cardiac ultrasound approach used included (1) a pocket-sized echo machine, (2) nonexpert staff (2 nurses after a standardized 60-hour training program) for performance and interpretation, and (3) a simplified set of echocardiographic criteria. We first tested different echocardiographic criteria in a pilot study including selected children with high prevalence of RHD. Our initial findings suggested that a mitral regurgitation jet length ≥2.0 cm or aortic regurgitation (regardless its jet length) yielded acceptable sensitivity and specificity. We then prospectively used these criteria in a school-based survey including 1217 children. Using this approach, the sensitivity and specificity to detect all RHD were of ≈80% and ≈90%, respectively. Our findings suggest that focused cardiac ultrasound by nonexperts using pocket-echocardiograms may be an attractive solution to implement echo-based active surveillance in resource-constrained regions.

Supplemental Material

File (circcvim_circcvim-2014-002324-t_supp1_.pdf)

References

1.
Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet. 2012;379:953–964. doi: 10.1016/S0140-6736(11)61171-9.
2.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Barker-Collo S, Bartels DH, Bell ML, Benjamin EJ, Bennett D, Bhalla K, Bikbov B, Bin Abdulhak A, Birbeck G, Blyth F, Bolliger I, Boufous S, Bucello C, Burch M, Burney P, Carapetis J, Chen H, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahodwala N, De Leo D, Degenhardt L, Delossantos A, Denenberg J, Des Jarlais DC, Dharmaratne SD, Dorsey ER, Driscoll T, Duber H, Ebel B, Erwin PJ, Espindola P, Ezzati M, Feigin V, Flaxman AD, Forouzanfar MH, Fowkes FG, Franklin R, Fransen M, Freeman MK, Gabriel SE, Gakidou E, Gaspari F, Gillum RF, Gonzalez-Medina D, Halasa YA, Haring D, Harrison JE, Havmoeller R, Hay RJ, Hoen B, Hotez PJ, Hoy D, Jacobsen KH, James SL, Jasrasaria R, Jayaraman S, Johns N, Karthikeyan G, Kassebaum N, Keren A, Khoo JP, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lipnick M, Lipshultz SE, Ohno SL, Mabweijano J, MacIntyre MF, Mallinger L, March L, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGrath J, Mensah GA, Merriman TR, Michaud C, Miller M, Miller TR, Mock C, Mocumbi AO, Mokdad AA, Moran A, Mulholland K, Nair MN, Naldi L, Narayan KM, Nasseri K, Norman P, O’Donnell M, Omer SB, Ortblad K, Osborne R, Ozgediz D, Pahari B, Pandian JD, Rivero AP, Padilla RP, Perez-Ruiz F, Perico N, Phillips D, Pierce K, Pope CA, Porrini E, Pourmalek F, Raju M, Ranganathan D, Rehm JT, Rein DB, Remuzzi G, Rivara FP, Roberts T, De León FR, Rosenfeld LC, Rushton L, Sacco RL, Salomon JA, Sampson U, Sanman E, Schwebel DC, Segui-Gomez M, Shepard DS, Singh D, Singleton J, Sliwa K, Smith E, Steer A, Taylor JA, Thomas B, Tleyjeh IM, Towbin JA, Truelsen T, Undurraga EA, Venketasubramanian N, Vijayakumar L, Vos T, Wagner GR, Wang M, Wang W, Watt K, Weinstock MA, Weintraub R, Wilkinson JD, Woolf AD, Wulf S, Yeh PH, Yip P, Zabetian A, Zheng ZJ, Lopez AD, Murray CJ, AlMazroa MA, Memish ZA. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–2128. doi: 10.1016/S0140-6736(12)61728-0.
3.
Kaplan EL. T. Duckett Jones Memorial Lecture. Global assessment of rheumatic fever and rheumatic heart disease at the close of the century. Influences and dynamics of populations and pathogens: a failure to realize prevention? Circulation. 1993;88(4 pt 1):1964–1972.
4.
Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5:685–694. doi: 10.1016/S1473-3099(05)70267-X.
5.
Carapetis JR, Hardy M, Fakakovikaetau T, Taib R, Wilkinson L, Penny DJ, Steer AC. Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren. Nat Clin Pract Cardiovasc Med. 2008;5:411–417. doi: 10.1038/ncpcardio1185.
6.
Beaton A, Okello E, Lwabi P, Mondo C, McCarter R, Sable C. Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren. Circulation. 2012;125:3127–3132. doi: 10.1161/CIRCULATIONAHA.112.092312.
7.
Marijon E, Celermajer DS, Tafflet M, El-Haou S, Jani DN, Ferreira B, Mocumbi AO, Paquet C, Sidi D, Jouven X. Rheumatic heart disease screening by echocardiography: the inadequacy of World Health Organization criteria for optimizing the diagnosis of subclinical disease. Circulation. 2009;120:663–668. doi: 10.1161/CIRCULATIONAHA.109.849190.
8.
Carapetis JR. Pediatric rheumatic heart disease in the developing world: echocardiographic versus clinical screening. Nat Clin Pract Cardiovasc Med. 2008;5:74–75. doi: 10.1038/ncpcardio1065.
9.
Paar JA, Berrios NM, Rose JD, Cáceres M, Peña R, Pérez W, Chen-Mok M, Jolles E, Dale JB. Prevalence of rheumatic heart disease in children and young adults in Nicaragua. Am J Cardiol. 2010;105:1809–1814. doi: 10.1016/j.amjcard.2010.01.364.
10.
Saxena A, Ramakrishnan S, Roy A, Seth S, Krishnan A, Misra P, Kalaivani M, Bhargava B, Flather MD, Poole-Wilson PP. Prevalence and outcome of subclinical rheumatic heart disease in India: the RHEUMATIC (Rheumatic Heart Echo Utilisation and Monitoring Actuarial Trends in Indian Children) study. Heart. 2011;97:2018–2022. doi: 10.1136/heartjnl-2011-300792.
11.
Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, Lawrenson J, Maguire G, Marijon E, Mirabel M, Mocumbi AO, Mota C, Paar J, Saxena A, Scheel J, Stirling J, Viali S, Balekundri VI, Wheaton G, Zühlke L, Carapetis J. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease–an evidence-based guideline. Nat Rev Cardiol. 2012;9:297–309. doi: 10.1038/nrcardio.2012.7.
12.
Reményi B, Carapetis J, Wyber R, Taubert K, Mayosi BM; World Heart Federation. Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease. Nat Rev Cardiol. 2013;10:284–292. doi: 10.1038/nrcardio.2013.34.
13.
Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, Paquet C, Jacob S, Sidi D, Jouven X. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. 2007;357:470–476. doi: 10.1056/NEJMoa065085.
14.
Zühlke L, Mirabel M, Marijon E. Congenital heart disease and rheumatic heart disease in Africa: recent advances and current priorities. Heart. 2013;99:1554–1561. doi: 10.1136/heartjnl-2013-303896.
15.
Marijon E, Tafflet M, Jouven X. Time to use ultrasound and not stethoscopes for rheumatic heart disease screening. Nat Clin Pract Cardiovasc Med. 2008;5:E1–E3. doi: 10.1038/ncpcardio1300.
16.
Baroux N, Rouchon B, Huon B, Germain A, Meunier JM, D’Ortenzio E. High prevalence of rheumatic heart disease in schoolchildren detected by echocardiography screening in New Caledonia. J Paediatr Child Health. 2013;49:109–114. doi: 10.1111/jpc.12087.
17.
Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ. Is pocket mobile echocardiography the next-generation stethoscope? A cross-sectional comparison of rapidly acquired images with standard transthoracic echocardiography. Ann Intern Med. 2011;155:33–38. doi: 10.7326/0003-4819-155-1-201107050-00005.
18.
Frederiksen CA, Juhl-Olsen P, Larsen UT, Nielsen DG, Eika B, Sloth E. New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners. Acta Anaesthesiol Scand. 2010;54:1217–1223. doi: 10.1111/j.1399-6576.2010.02320.x.
19.
Beaton A, Aliku T, Okello E, Lubega S, McCarter R, Lwabi P, Sable C. The utility of handheld echocardiography for early diagnosis of rheumatic heart disease. J Am Soc Echocardiogr. 2014;27:42–49. doi: 10.1016/j.echo.2013.09.013.
20.
Mjølstad OC, Andersen GN, Dalen H, Graven T, Skjetne K, Kleinau JO, Haugen BO. Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents. Eur Heart J Cardiovasc Imaging. 2013;14:1195–1202. doi: 10.1093/ehjci/jet062.
21.
Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D, Rahman S, Nihoyannopoulos P. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. 2013;14:323–330. doi: 10.1093/ehjci/jes140.
22.
Galderisi M, Santoro A, Versiero M, Lomoriello VS, Esposito R, Raia R, Farina F, Schiattarella PL, Bonito M, Olibet M, de Simone G. Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study. Cardiovasc Ultrasound. 2010;8:51. doi: 10.1186/1476-7120-8-51.
23.
Colquhoun SM, Carapetis JR, Kado JH, Reeves BM, Remenyi B, May W, Wilson NJ, Steer AC. Pilot study of nurse-led rheumatic heart disease echocardiography screening in Fiji–a novel approach in a resource-poor setting. Cardiol Young. 2013;23:546–552. doi: 10.1017/S1047951112001321.
24.
Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567–581. doi: 10.1016/j.echo.2013.04.001.
25.
Sicari R, Galderisi M, Voigt JU, Habib G, Zamorano JL, Lancellotti P, Badano LP. The use of pocket-size imaging devices: a position statement of the European Association of Echocardiography. Eur J Echocardiogr. 2011;12:85–87. doi: 10.1093/ejechocard/jeq184.
26.
Mirabel M, Celermajer DS, Ferreira B, Tafflet M, Perier MC, Karam N, Mocumbi AO, Jani DN, Sidi D, Jouven X, Marijon E. Screening for rheumatic heart disease: evaluation of a simplified echocardiography-based approach. Eur Heart J Cardiovasc Imaging. 2012;13:1024–1029. doi: 10.1093/ehjci/jes077.
27.
Roberts K, Maguire G, Brown A, Atkinson D, Reményi B, Wheaton G, Kelly A, Kumar RK, Su JY, Carapetis JR. Echocardiographic screening for rheumatic heart disease in high and low risk Australian children. Circulation. 2014;129:1953–1961. doi: 10.1161/CIRCULATIONAHA.113.003495.
28.
Bhaya M, Panwar S, Beniwal R, Panwar RB. High prevalence of rheumatic heart disease detected by echocardiography in school children. Echocardiography. 2010;27:448–453. doi: 10.1111/j.1540-8175.2009.01055.x.
29.
Colquhoun SM, Kado JH, Remenyi B, Wilson NJ, Carapetis JR, Steer AC. Echocardiographic screening in a resource poor setting: borderline rheumatic heart disease could be a normal variant. Int J Cardiol. 2014;173:284–289. doi: 10.1016/j.ijcard.2014.03.004.
30.
Roberts K, Colquhoun S, Steer A, Reményi B, Carapetis J. Screening for rheumatic heart disease: current approaches and controversies. Nat Rev Cardiol. 2013;10:49–58. doi: 10.1038/nrcardio.2012.157.
31.
Manji RA, Witt J, Tappia PS, Jung Y, Menkis AH, Ramjiawan B. Cost-effectiveness analysis of rheumatic heart disease prevention strategies. Expert Rev Pharmacoecon Outcomes Res. 2013;13:715–724. doi: 10.1586/14737167.2013.852470.
32.
Kane A, Mirabel M, Touré K, Périer MC, Fazaa S, Tafflet M, Karam N, Zourak I, Diagne D, Mbaye A, Kane M, Diack B, Jouven X, Marijon E. Echocardiographic screening for rheumatic heart disease: age matters. Int J Cardiol. 2013;168:888–891. doi: 10.1016/j.ijcard.2012.10.090.

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Go to Circulation: Cardiovascular Imaging
Go to Circulation: Cardiovascular Imaging
Circulation: Cardiovascular Imaging
PubMed: 25567654

History

Received: 21 March 2014
Accepted: 4 December 2014
Published online: 1 January 2015
Published in print: January 2015

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Keywords

  1. acute rheumatic fever
  2. developing countries
  3. epidemiology
  4. heart valve diseases
  5. rheumatic heart disease
  6. ultrasound

Subjects

Authors

Affiliations

Mariana Mirabel, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Raoul Bacquelin, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Muriel Tafflet, PhD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Corinne Robillard, RN
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Bertrand Huon, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Philippe Corsenac, MPH
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Isabelle de Frémicourt, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Kumar Narayanan, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Jean-Michel Meunier, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Baptiste Noël, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Albert Alain Hagège, MD, PhD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Bernard Rouchon, MD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Xavier Jouven, MD, PhD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).
Eloi Marijon, MD, PhD
From the Paris Cardiovascular Research Center, INSERM U970, Paris, France (M.M., R.B., M.T., K.N., X.J., E.M.); Université Paris Descartes, Sorbonne Paris Cité, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology Department, European Georges Pompidou Hospital, Paris, France (M.M., A.A.H., X.J., E.M.); Cardiology and Development, Paris, France (M.M., X.J., E.M.); Agence Sanitaire et Sociale de Nouvelle Calédonie, Nouméa, New Caledonia (C.R., B.H., P.C., J.-M.M., B.R.); Département de l’Action Sanitaire de Sociale des Iles Loyaté, Wé, Lifou, New Caledonia (I.d.F.); Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA (K.N.); and Centre Hospitalier Territorial de Nouvelle Calédonie, Nouméa, New Caledonia (B.N.).

Notes

Correspondence to Mariana Mirabel, MD, Paris Cardiovascular Research Center, Inserm U970, Hôpital Européen Georges Pompidou, 56 rue Leblanc, 75737 Paris Cedex 15, France. E-mail [email protected]

Disclosures

None.

Sources of Funding

This work was supported by a grant from the French Federation of Cardiology that allowed the purchase of echocardiographic equipment (V-scan; GE) with no involvement of the constructor. The Agence Sanitaire et Sociale de Nouvelle Calédonie partly promoted the study.

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  1. Advanced Cardiac Point-of-Care Ultrasound, Medical Clinics of North America, 109, 1, (81-103), (2025).https://doi.org/10.1016/j.mcna.2024.08.009
    Crossref
  2. Impact of point-of-care ultrasound use on patient referral decisions in rural Kenya: a mixed methods study, BMC Health Services Research, 24, 1, (2024).https://doi.org/10.1186/s12913-024-10673-1
    Crossref
  3. NEARER SCAN (LENO BESIK) evaluation of a task-sharing echocardiographic active case finding programme for rheumatic heart disease in Australia and Timor-Leste: protocol for a hybrid type II effectiveness-implementation study, BMJ Open, 14, 10, (e083467), (2024).https://doi.org/10.1136/bmjopen-2023-083467
    Crossref
  4. The roles of immuno-modulator treatment and echocardiographic screening in rheumatic fever and rheumatic heart disease control: research from Aotearoa, New Zealand, Journal of the Royal Society of New Zealand, 55, 2, (241-266), (2024).https://doi.org/10.1080/03036758.2024.2306981
    Crossref
  5. Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines, The Lancet Global Health, 12, 6, (e983-e994), (2024).https://doi.org/10.1016/S2214-109X(24)00127-X
    Crossref
  6. Rheumatic Heart Disease—A Neglected Tragedy in Young Patients, JAMA Cardiology, 9, 7, (597), (2024).https://doi.org/10.1001/jamacardio.2024.1852
    Crossref
  7. Analysis of Mitral Regurgitation Jet for Rheumatic Heart Disease Detection in Doppler Echocardiography, 2023 IEEE 20th International Symposium on Biomedical Imaging (ISBI), (1-5), (2023).https://doi.org/10.1109/ISBI53787.2023.10230680
    Crossref
  8. Screening for Rheumatic Heart Disease in the Community: Can non-experts do the task?, International Journal of Cardiology, 379, (102-103), (2023).https://doi.org/10.1016/j.ijcard.2023.03.006
    Crossref
  9. Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease, International Journal of Cardiology, 377, (99-103), (2023).https://doi.org/10.1016/j.ijcard.2023.01.024
    Crossref
  10. Abbreviated Echocardiographic Screening for Rheumatic Heart Disease by Nonexperts with and without Offsite Expert Review: A Diagnostic Accuracy Study, Journal of the American Society of Echocardiography, 36, 7, (733-745), (2023).https://doi.org/10.1016/j.echo.2023.02.007
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