TOPLINE:

A new framework for assessing transthoracic echocardiography (TTE) image quality revealed that only 30% of studies achieved clear inner-edge-to-outer-edge delineation of at least five segmental borders, and higher BMI, risk factors for heart failure (HF), and cardiac abnormalities were linked to reduced image quality.

METHODOLOGY:

• Researchers conducted a cross-sectional analysis of 268 TTE examinations from 230 patients qualified for cardiac resynchronisation therapy defibrillator implantation or implantable cardioverter defibrillator.
• Demographic, electrocardiographic, echocardiographic, and clinical characteristics were evaluated to identify risk factors for poor image quality.
• A fine-grained framework was used to manually assess endocardial and epicardial border delineation at the segmental level in apical two-, three-, and four-chamber views for the evaluation of image quality.
• The framework was validated for intraobserver and interobserver reliability against two parameters each (total border and total image quality scores) using an intraclass correlation coefficient (ICC) > 0.9.

TAKEAWAY:

• Anterior and anterolateral walls consistently demonstrated the poorest visualisation quality, whereas inferior segments were most frequently well visualised.
• Clear inner-edge-to-outer-edge delineation of at least five segmental borders was achieved in only 30% of studies; however, at least five endocardial border segments were visualised in 65% of HF cases.
• Reduced image quality was associated with higher BMI and body surface area; the presence of risk factors for HF, including diabetes, prior myocardial infarction, and atrial fibrillation; and increased left ventricular end-diastolic volume; no single determinant of image quality was identified.
• The framework demonstrated excellent reliability, with the ICC exceeded 0.9 in all four comparisons (P < .001 for all).

IN PRACTICE:

"The prevalence of imaging challenges in TTE examinations performed in patients qualified for CRT-D [cardiac resynchronisation therapy defibrillator]/ICD [implantable cardioverter defibrillator] implantation is high. These findings underscore the need for thorough training of echocardiographers and for sustained attention to technical details affecting image quality in order to achieve consistently high-quality images in routine practice," the authors wrote.

"Although the [proposed] framework is time-consuming and requires trained readers, it provides a robust foundation for future automation using artificial intelligence-based tools, for example, total image score prediction," they added.

SOURCE:

This study was led by Wojciech Nazar, Medical University of Gdańsk, Gdańsk, Poland. It was published online on January 28, 2026, in the Journal of Clinical Medicine.

LIMITATIONS:

The cross-sectional design of the study was a limitation. Applying the stringent predefined inclusion criteria potentially introduced selection bias. The study used an exclusive platform for imaging acquisition and analysis, limiting the generalisability of the findings to other vendor systems. Additionally, as the study population consisted solely of patients with HF, extrapolation to non-HF populations may not be effective. The proposed framework required significant time and specialised reader training, which may have limited its application in routine clinical settings.

DISCLOSURES:

This study received funding from the Polish Ministry of Science and Higher Education in Warsaw, Poland. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.