Improved Visualization in Difficult-to-Image Stress Echocardiography Patients Using Real-Time Harmonic Spatial Coherence Imaging

Stress echocardiography is used to detect myocardial ischemia by evaluating cardiovascular function both at rest and at elevated heart rates. Stress echocardiography requires excellent visualization of the left ventricle (LV) throughout the cardiac cycle. However, LV endocardial border visualization is often negatively impacted by high levels of clutter associated with patient obesity, which has risen dramatically worldwide in recent decades. Short-lag spatial coherence (SLSC) imaging has demonstrated reduced clutter in several applications. In this work, a computationally efficient formulation of SLSC was implemented into an object-oriented graphics processing unit-based software beamformer, enabling real-time (>30 frames per second) SLSC echocardiography on a research ultrasound scanner. The system was then used to image 15 difficult-to-image stress echocardiography patients in a comparison study of tissue harmonic imaging (THI) and harmonic spatial coherence imaging (HSCI). Video clips of four standard stress echocardiography views acquired with either THI or HSCI were provided in random shuffled order to three experienced readers. Each reader rated the visibility of 17 LV segments as "invisible," "suboptimally visualized," or "well visualized," with the first two categories indicating a need for contrast agent. In a symmetry test unadjusted for patientwise clustering, HSCI demonstrated a clear superiority over THI (p <; 0.0001). When measured on a per-patient basis, the median total score significantly favored HSCI with p <; 0.001. When collapsing the ratings to a two-level scale ("needs contrast" versus "well visualized"), HSCI once again showed an overall superiority over THI, with p <; 0.0001 by McNemar test adjusted for clustering.