Short Title
: Application of “Leapfrog” Technologies
Keywords : Echocardiography, Rural Healthcare, Cardiac Disease
Authors : Hayte Samo MD 1,5,6 , Naftal Naman AMO 1,5,6 , Jan Vargas MD 3,5 Peter Zwerner
MD
3,5,
, Eric R Powers MD
3
, Jeffrey Hall MD
4
, Dilantha B. Ellegala MD
5,6
, Doyle B.
Word BS
5,6
, Joyce S. Nicholas PhD
3,5,6
, Mohamed Janabi MD
2,5,6
Affiliations : Haydom Hospital Tanzania
1
, Muhimbili National Hospital, Tanzania
2
,
Department of Medicine, and Department of Neurosciences, Medical University of South
Carolina
3
, Department of Family and Preventatitve Medicine, University of South
Carolina
4
, Centra Neurosciences Institute
5
, and Madaktari Africa
6
Disclosure : The authors would like to affirm that there is no conflict of interest to report.
Address Correspondence :
Joyce Nicholas, PhD , Medical University of South Carolina
135 Cannon St. Room 302M
Charleston, SC 29403 USA

Abstract
Background : Cardiac disease is a growing problem in the developing world, and is an important cause of death and disability. Part of the difficulty in combating these diseases is a lack of diagnostic tools. One solution is to utilize “leapfrog” technologies, such as portable echocardiography, to provide care to poorly accessible areas.
Methods : 15 patients were evaluated and included in this report by consulting physicians. Evaluation included chart review, history, physical examination, and portable echocardiography.
Results : Of the 15 patients seen, definitive cardiac diagnosis was established for all and in 11 patients the final diagnosis was different than the diagnosis made prior to consultation. In seven patients there was an immediate recommendation for more appropriate therapy.
Conclusion : Portable devices can be extremely valuable in the diagnosis and management of cardiac disease. There should be a greater role for “leapfrog” technology in providing health care to the developing world.

Background
Cardiac disease is a burgeoning problem in the developing world. While responsible for approximately 30% of deaths world wide, 80% of those deaths occur in the developing world.
1
In Sub Sahara Africa, ischemic heart disease ranks 8 th
among the leading causes of death in men and women, accounting for 10% of all deaths.
2,3
The increasing prevalence of ischemic heart disease has been attributed lifestyle changes stemming from the adoption of western diets and habits, the increasing burden of diabetes, obesity, and tobacco use. These changes suggest that ischemic cardiac disease as a health problem will continue to grow.
Rheumatic heart disease is a substantial health problem that can result in irreversible heart damage and death. Rheumatic heart disease will continue to be a global problem unless current prevention initiatives are expanded and sustained. This disease, now rare in the developed world, remains an important cause of morbidity and mortality in developing nations, in both adults and school-aged children. Previous estimates state that more than 15 million people have rheumatic heart disease and that 350,000 people die each year while many more are left disabled.
3 However, a recent study from Nicaragua has suggested that these data may underestimate the number of people with the disease by a factor of four to five. This means that between 62 million and 78 million individuals worldwide may currently have rheumatic heart disease, which could potentially result in
1.4 million deaths per year from rheumatic heart disease and its complications.
4
There are over 1 million estimated cases of rheumatic heart disease in children of ages 5-14.
5 In the developing world, rheumatic heart disease accounts for approximately 60% of

cardiovascular disease in children.
6
Accurate diagnosis and effective treatment of rheumatic heart disease has the potential to have a major impact on health in these countries. Thus, the management of cardiovascular disease is increasingly important in countries like Tanzania. In an area of the world where the ratio of doctors to patients is 1 to 25,000 the lack of diagnostic skills can be due to lack of trained personnel but also due to the lack of diagnostic equipment.
7
Echocardiography is an accurate, non-invasive and indispensable tool for the diagnosis and management of patients with cardiovascular disease. Echocardiography is known to be more sensitive than auscultation for the detection of pathologic valve disease.
According to Marijon et al. systematic screening with echocardiography, as compared with clinical screening, reveals a much higher prevalence of rheumatic heart disease.
5
However large echocardiographic machines are expensive and not easily portable. This is particularly problematic in regions with underdeveloped or nonexistent transportation systems or roadways. Additionally, the equipment is complex and subject to malfunction, requiring highly technical support for maintenance. Even in regions where the equipment may be available there are often long delays in servicing these devices which limit their utility. Portable echocardiography has recently been developed and may allow doctors and practitioners the ability to gather information and make decisions for patients in areas where current machines are impractical. The use of portable echocardiography may result in a change in workflow for doctors by allowing for more information in the initial physical examination.

“Leapfrog” technology may allow the developing world to skip a generation of equipment to allow for better diagnosis and treatment of cardiac disease while alleviating some of the limitations of older equipment stated above. These technologies may thereby improve patient care in this underserved area. We describe the preliminary results of the use of a small, PDA sized portable ultrasound in a remote large rural hospital in North-
Central Tanzania as an example of the application of a “leapfrog” technology.
The device used was a VscanTM (GE Healthcare) pocket size visualization tool providing black and white anatomic images in realtime. Additional features of the device include color-coded overlay for real-time blood flow imaging, field-of-view for black and white imaging (up to 75 degrees with maximum depth of 25 cm), a color flow sector representing blood flow within an angle of 30 degrees, and a broad-bandwidth phased array probe (from 1.7 to 3.8 MHz).
Location
Haydom Hospital is a 420 bed hospital in North Central Tanzania serving a referral base of approximately 2 million persons. The nearest main urban center is Arusha, an 8 hour drive on rough and sometimes impassable roads. Patients are seen in the hospital as well as in remote outreach clinics accessed by four wheel drive landcruisers. In many instances, technicians to service existing ultrasound machines need to be imported from
Europe or South Africa and diagnostic equipment often remains unused and nonfunctioning for long periods of time.
Patient Population

15 patients were evaluated and included in this report by consulting physicians.
Evaluation included chart review, history, physical examination, and portable echocardiography. We assessed the effect of this evaluation in establishing a diagnosis and affecting therapy.
Case Summaries
Patient #1
45 year-old female presented with chest pain, vomiting, cough, and edema for 4 months.
The initial physical examination demonstrated a pulse of 68 beats per minute, blood pressure of 100/80 mmHg and the patient was afebrile. There were physical signs of a right-sided pleural effusion and some rales at the left lung base. The diagnosis was congestive cardiac failure. The patient was treated with Captopril and Furosemide. This resulted in improvement in symptoms and edema.
Physical examination by the consulting cardiologists confirmed the right pleural effusion, cardiomegaly, and a third heart sound. Portable echocardiography demonstrated biventricular enlargement, diminished contraction with an ejection fraction of the left ventricle of approximately 25%. Therapeutic recommendations were to continue
Furosemide, Captopril, and to consider adding Digoxin.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Congestive heart failure due to left ventricular systolic dysfunction.
Impact: Medication recommendation

Patient #2
A 69 year-old man presented with unexplained edema. The preliminary diagnosis of cirrhosis and possible heart failure was made.
Consulting physical examination showed no signs of heart failure. Portable echocardiography demonstrated normal cardiac function and no cardiac abnormalities.
Initial Diagnosis: Cirrhosis and possible heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined Diagnosis
Patient #3
A 70 year-old man presented with dyspnea and palpitations. A chest x-ray was obtained and demonstrated a right-sided pleural effusion and possible right lower lobe pneumonia or atelectasis. The heart appeared large on x-ray. The initial impression was of possible cardiomegaly and congestive heart failure.
Consulting physical examination demonstrated no definite cardiac abnormality. Portable echocardiography was entirely normal without cardiac abnormality. Therapeutic recommendation was to treat for pneumonia with appropriate diagnostic testing.

Initial Diagnosis: Possible cardiomegaly and congestive heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined Diagnosis
Patient #4
A 90 year-old man presented with recent onset of dyspnea, cough, and peripheral edema.
The patient’s history included fatigue and peripheral edema as well as shortness of breath and generalized body weakness. Physical examination on admission demonstrated a pulse of 92 beats per minute and blood pressure of 110/70 mmHg and a soft systolic murmur. Chest X-ray demonstrated cardiomegaly and pulmonary congestion. The diagnosis of congestive heart failure was made. Treatment with Furosemide resulted in no improvement in symptoms or peripheral edema.
Consulting physical examination demonstrated elevated right atrial pressure, clear lungs, cardiomegaly, a paradoxically split-second heart sound, a soft apical systolic murmur, and a third heart sound. Portable echocardiography showed biventricular enlargement and decreased right and left ventricular systolic function with elevated right-ventricular pressure based on straightening of the interventricular septum, confirming the initial diagnosis of congestive cardiac failure. Our therapeutic recommendation was to consider
Furosemide, Captopril, and Digoxin, the standard treatment for congestive heart failure in this clinic.
Initial Diagnosis: Congestive heart failure.

Final Diagnosis: Confirmed congestive heart failure due to right ventricular systolic dysfunction.
Impact: Medication recommendations
Patient #5
An 18 year-old boy presented with severe dyspnea. Physical exam demonstrated normal right atrial pressure, cardiac enlargement, and systolic and diastolic heart murmurs. A diagnosis of congestive heart failure was made.
Consulting physical examination confirmed the presence of systolic and diastolic murmurs. Portable echocardiography demonstrated severe mitral regurgitation and mild aortic insufficiency consistent with rheumatic heart disease. The patient had been treated with ACE inhibitors and Digoxin. Our recommendation was to treat primarily with diuretics since ventricular function was normal.
Initial Diagnosis: Congestive cardiac failure.
Final diagnosis: Rheumatic valve disease.
Impact: Altered Diagnosis and medication recommendations.
Patient #6
An 80 year-old man presented with chest pain, cough, and chronic edema. Physical examination demonstrated hypertension, increased venous pressure and a murmur

suggesting mitral regurgitation. The lungs were clear. A diagnosis of congestive heart failure was made. Therapy with Furosemide, Captopril, and Digoxin was begun.
Consulting physical examination demonstrated a clear chest, possible cardiomegaly, but no gallop or murmur. Portable echocardiography demonstrated left ventricular dysfunction with an ejection fraction of appropriately 40% and no other abnormality.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Confirmed congestive heart failure due to left ventricular systolic dysfunction.
Impact: No changes.
Patient #7
A 75 year-old man presented with dyspnea, fatigue, abdominal distention, and diarrhea.
Cardiac examination on admission was reported as unremarkable. He was treated for typhoid fever at an outside hospital with no improvement. Chest x-ray demonstrated pleural effusion and possible cardiomegaly
.
The diagnosis was congestive heart failure.
He was treated with diuretics with some reduction of his peripheral edema but with persistent abdominal distention.
Consulting physical examination showed no cardiac abnormality. Portable ultrasound was entirely normal without evidence for cardiac disease. Thus, diuretics were stopped.

Initial Diagnosis: Congestive heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Changed diagnosis and medication recommendations.
Patient #8
A 13 year-old boy presented with cough, diarrhea, vomiting, fever, and loss of appetite.
Initial diagnosis was malaria and typhoid fever for which he received Chloramphenicol and ALU, an antimalarial medication. Chest x-ray one week after admission suggested the possibility of cardiac disease and he was put on Captopril and Digoxin. Symptoms were improved.
Consulting physical examination suggested severe mitral regurgitation and moderate aortic insufficiency. Portable echocardiography demonstrated severe mitral regurgitation and mild to moderate aortic insufficiency, consistent with rheumatic heart disease. The therapeutic suggestion was diuresis with less of a role for Captopril or Digoxin because of normal left ventricular function.
Initial Diagnosis: Malaria and typhoid fever.
Final Diagnosis: Rheumatic heart disease.
Impact: Changed diagnosis and medication recommendations.
Patient #9

A middle-aged man presented with dyspnea. There was a history of uncontrolled hypertension. Physical examination was largely unremarkable.
Consulting physical examination was essentially unrevealing. Portable echocardiography demonstrated good ventricular function without significant cardiac abnormality.
Therapeutic recommendation was control of hypertension.
Initial Diagnosis: None.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined diagnosis.
Patient #10
A 53 year-old man presented with dyspnea and edema. No diagnosis had been established.
Consulting physical examination, revealed a pericardial friction rub. Portable echocardiography demonstrated a pericardial effusion and enlarged right atrium with no other abnormality. As a result of the effusion, a work up for tuberculosis, including drainage of the pericardial fluid, was begun.
Initial Diagnosis: None.
Final Diagnosis: Pericardial effusion, probable tuberculosis.
Impact: Refined diagnosis

Patient #11
A 65 year-old woman presented with dyspnea and fatigue.
Consulting physical examination demonstrated an enlargement of the left breast, elevated right venous pressure and no other apparent abnormality. Portable echocardiography demonstrated a pericardial effusion of moderate size and no other abnormality.
Initial Diagnosis: None.
Final Diagnosis: Inflammatory versus malignant left breast disease with pericardial effusion.
Impact: Refined diagnosis.
Patient #12
A 33 year-old woman presented with vaginal bleeding. She was being worked up for possible complicated pregnancy. Physical examination by her primary care provider revealed a heart murmur.
Consulting physical examination demonstrated no abnormality except for a pulmonic flow murmur. Portable echocardiography was completely normal. The diagnosis provided was normal cardiac function with a pulmonic flow murmur due to possible pregnancy and anemia.

Initial diagnosis: Possible cardiac disease complicating pregnancy.
Final diagnosis: Normal cardiac function with pulmonic flow murmur.
Impact: Changed diagnosis.
Patient #13
A 25 year-old man presented with a history of remote pericardial effusion and possible tuberculosis in 1996. Since 2005, there was a history of fatigue, tachycardia, and palpitations. No diagnosis had been established.
Consulting physical examination revealed no abnormality except for an early to mid systolic click and late systolic murmur. Portable echocardiography demonstrated prolapse of both mitral leaflets without significant regurgitation and no other significant abnormality.
Initial Diagnosis: None.
Final Diagnosis: Mitral valve prolapse.
Impact: Refined diagnosis.
Patient #14
A young woman (approximately 20 years old) presented with dyspnea and heart murmurs. The diagnosis was congestive heart failure.

Consulting physical examination demonstrated murmurs of mitral stenosis, mitral regurgitation, and aortic regurgitation. Portable echocardiography revealed a severely enlarged left atrium, severe rheumatic mitral stenosis, mild mitral regurgitation, and moderate aortic regurgitation. There was good left ventricular function, and a significantly enlarged right ventricle and right atrium with an interventricular septum which suggested significant elevation of right ventricular pressures. Our diagnosis was rheumatic mitral and aortic valve disease with pulmonary hypertension. Our therapeutic recommendation was to manage the patient with diuretics and mitral valve surgery if surgery could be made available.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Rheumatic heart disease.
Impact: Changed diagnosis and medication recommendations.
Patient #15
A 12 year-old girl was admitted to the pediatric ward with fever, dyspnea, and chest pain. Admission physical exam reported an uncomfortable girl with dyspnea and a “heart murmur”. Chest radiography demonstrated an enlarged heart and pulmonary congestion.
Her initial diagnosis was congestive heart failure due to acute rheumatic fever, and she began therapy with diuretics. She responded poorly to this therapy.
Consulting physical exam revealed a pericardial friction rub rather than a valvular heart murmur. Bedside echocardiography confirmed a significant pericardial effusion.

Pericardiocentesis was performed under ultrasound guidance and revealed a bloody, purulent fluid. The patient had a significant clinical improvement following the aspiration. Diuretics were stopped, and intravenous fluids and antibiotics were started for presumed acute bacterial pericarditis
Initial Diagnosis: Congestive Heart Failure/Rheumatic heart disease
Final Diagnosis: Acute bacterial pericarditis with pericardial tamponade
Impact: Changed diagnosis and medication recommendations.
Thus, of the 15 patients seen, definitive cardiac diagnosis was established for all and in
11 patients the final diagnosis was different than the diagnosis made prior to consultation and echocardiographic study. In seven patients there was an immediate recommendation for more appropriate therapy.
Discussion
In this study, we demonstrate the value of portable echocardiography combined with clinical consultation for the management of cardiac disease in rural Tanzania. Cardiac disease is a burgeoning problem in the developing world including Sub-Saharan Africa.
Rheumatic valvular disease and infectious cardiomyopathy remain significant causes of cardiac pathology and as lifestyle and diet change, coronary disease is becoming more prevalent. Difficulties in patient management can be attributed to difficulties in initial diagnosis and treatment which are hindered by a lack of trained personnel and a lack of diagnostic tools. The latter issue can be addressed with careful planning and the use of
“leapfrog technology.”

Leapfrog technology refers to skipping over a generation of equipment and taking advantage of new technologies including the growing trend in technology towards smaller, more portable devices. The most obvious example in the developing world is the use of cellular telephones and internet access provided by cell phone service providers.
With the advent of wireless communications, the developing world has been able to obviate (“leapfrog”) the need for expensive placement of telephone or fiber optic lines.
This has allowed remote areas to become more accessible. Given the success of leapfrog technologies in telecommunications, it seems reasonable to apply similar strategies to the arena of medical devices.
Donation of unused medical equipment has been a major aspect of traditional mission trips. Devices such as ventilator, anesthesia, or advanced imagine machines are often donated by Western hospitals once they have become obsolete or replaced by newer versions. While well intentioned, the problem with such an approach is that if (and more often when) these devices break, a technician is required to travel in from the west or from the regional urban centers far from remote hospitals to first diagnose and then fix the problem. In the intervening weeks and months the machine is left unused. Thus, the donation of these devices has little long term impact on the health of these populations.
Portable devices such as the hand held echocardiographic machines used in the present report avoid the economic burden of calling in technicians and are relatively inexpensive to purchase and service. If such a device breaks, it can be easily shipped to repair centers with minimal cost. The portability of the device used in this report is suited to remote

areas often encountered in developing nations, which results in the ability to offer care to more patients, including those seen in outreach clinics.
This case series supports the premise that portable echocardiography can be effectively utilized to provide meaningful care.
Conclusion
“Leapfrog” technologies, such as portable echocardiography, are valuable tools for providing care to remote, poorly accessible regions of the world. We present our case series of cardiac patients from a rural hospital in Tanzania where portable echocardiography was critical in providing cardiac care to 15 patients. We believe this is just one example of the many possible applications of leapfrog technologies in the developing world.

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