# Development of a Framework for Echocardiographic Image Quality Assessment and Its Application in CRT-D/ICD Patients

## TL;DR

This study creates a framework to assess echocardiogram image quality and finds that certain heart segments are often poorly visualized in patients with heart failure.

## Contribution

A novel framework for echocardiographic image quality assessment in CRT-D/ICD patients is developed and validated.

## Key findings

- Anterior and anterolateral walls showed the poorest image quality, while inferior segments had the best.
- Only 30% of studies had ≥5 segmental borders clearly delineated, and 65% had ≥5 endocardial borders visualized.
- Higher BMI, BSA, and heart failure risk factors were linked to reduced image quality.

## Abstract

Background/Objectives: Low image quality reduces diagnostic accuracy. We wanted to develop a framework for assessing transthoracic echocardiography (TTE) image quality in apical 2-, 3-, and 4-chamber views, and to use this framework to characterise segment-level visualisation patterns in patients with heart failure (HF). Methods: In this cross-sectional study, 268 TTE examinations from 230 patients qualified for ICD/CRT implantation in primary prevention of sudden cardiac death were analysed. Patient demographic, electrocardiographic, echocardiographic, and clinical characteristics were collected, and apical 2-, 3-, and 4-chamber views were extracted for image quality evaluation. Mean scores for each segment were calculated. The proportion of well-visualised segments per view was also evaluated. Risk factors for poor image quality were assessed. Results: We internally assessed the reliability of the framework (intra-class correlation coefficient > 0.9). The anterior and anterolateral walls consistently demonstrated the poorest quality, and the inferior segments the best. Clear inner-edge-to-outer-edge delineation of ≥5 segmental borders was achieved in only 30% of studies, while ≥5 endocardial border segments were visualised in 65% of cases. Reduced quality was frequently observed in patients with higher BMI and BSA, presence of HF risk factors (diabetes, prior myocardial infarction, and atrial fibrillation), and heart abnormalities (increased left ventricular end-diastolic value and hypokinesis). Conclusions: The prevalence of imaging challenges in TTE examinations performed in patients qualified for CRT-D/ICD implantation is high. These findings underscore the need for thorough training of echocardiographers and for sustained attention to technical details affecting image quality to achieve consistently high-quality images in routine practice.