Prenatal Diagnosis of an Apically Located Congenital Left Ventricular Aneurysm: A Rare Case

Congenital ventricular aneurysm is a very rare cardiac anomaly.A diagnosis can be made during the prenatal period using fetal echocardiography.This study presents a very rare apically located left ventricular aneurysm case,and the relevant literature was reviewed and discussed.In this case,a 35-year-old,gravida 2,parity 1 preg-nant woman at 24 weeks of gestation,displayed a wide aneurysmal image in the left ventricular apical wall on fetal echocardiography.There was a 1.79 mm muscular ventricular septal defect at the apical region of the interven-tricular septum.In the course of the color Doppler ultrasonography examination,an aberrantfibrous band within the left ventricle and consequent turbulentflow during systole were observed.The baby,born via cesarean section at 37 weeks of gestation,is now in its postnatal seventh month.However,during echocardiographic follow-ups,changes have been observed,including mild to moderate mitral insufficiency and a decrease in systolic function.Despite thesefindings,the clinical condition remains asymptomatic.It is of great importance to use a multidis-ciplinary approach in managing these rare cases that could lead to potential adverse outcomes during the antena-tal or postnatal periods.

Effects of sevoflurane on left ventricular function by speckletracking echocardiography in coronary bypass patients: A randomized trial

The present study aimed to dynamically observe the segmental and global myocardial movements of the left ventricle during coronary artery bypass grafting by transesophageal speckle-tracking echocardiography,and to assess the effect of sevoflurane on cardiac function.Sixty-four patients scheduled for the off-pump coronary artery bypass grafting were randomly divided into a sevoflurane-based anesthesia(AS)group and a propofolbased total intravenous anesthesia(AA)group.The AS group demonstrated a higher absolute value of left ventricular global longitudinal strain than that of the AA group at both T1(after harvesting all grafts and before coronary anastomosis)and T_(2)(30 min after completing all coronary anastomoses)(P<0.05).Moreover,strain improvement in the segment with the highest preoperative strain was significantly reduced in the AS group,compared with the AA group at both T1 and T_(2)(P<0.01).The flow of the left internal mammary artery-left anterior descending artery graft was superior,and the postoperative concentration of troponin T decreased rapidly in the AS group,compared with the AA group(P<0.05).Compared with total intravenous anesthesia,sevoflurane resulted in a significantly higher global longitudinal strain,stroke volume,and cardiac output.Sevoflurane also led to an amelioration in the condition of the arterial graft.Furthermore,sevoflurane significantly reduced strain improvement in the segmental myocardium with a high preoperative strain value.The findings need to be replicated in larger studies.

Relationship Between Gene-Phenotype and Clinical Manifestations of Chromosomal Copy Number Variations Indicated by Non-Invasive Prenatal Testing

Objective:To analyze the clinical value of non-invasive prenatal testing(NIPT)in detecting chromosomal copy number variations(CNVs)and to explore the relationship between gene expression and clinical manifestations of chromosomal copy number variations.Methods:3551 naturally conceived singleton pregnant women who underwent NIPT were included in this study.The NIPT revealed abnormalities other than sex chromosome abnormalities and trisomy 13,18,and 21.Pregnant women with chromosome copy number variations underwent genetic counseling and prenatal ultrasound examination.Interventional prenatal diagnosis and chromosome microarray analysis(CMA)were performed.The clinical phenotypes and pregnancy outcomes of different prenatal diagnoses were analyzed.Additionally,a follow-up was conducted by telephone to track fetal development after birth,at six months,and one year post-birth.Results:A total of 53 cases among 3551 cases showed chromosomal copy number variation.Interventional prenatal diagnosis was performed in 36 cases:27 cases were negative and 8 were consistent with the NIPT test results.This indicates that NIPT’s positive predictive value(PPV)in CNVs is 22.22%.Conclusion:NIPT has certain clinical significance in screening chromosome copy number variations and is expected to become a routine screening for chromosomal microdeletions and microduplications.However,further interventional prenatal diagnosis is still needed to identify fetal CNVs.

Prenatal ultrasonic characteristics and diagnosis of fetal Currarino syndrome:Report of 2 cases and review of literature

Objective To explore prenatal ultrasonic characteristics of fetal Currarino syndrome(CS)and methods for prenatal diagnosis of CS.Methods Two fetuses with CS confirmed by genetic examination were retrospectively analyzed,while 6 CS fetuses with complete prenatal ultrasonic data in literature were reviewed.Prenatal ultrasonic characteristics of CS fetuses and the method for prenatal diagnosis of CS were discussed.Results Among 8 CS fetuses diagnosed with prenatal ultrasound,4 were female singletons with a clear family history of CS,and MNX 1 gene mutation was found in 1 fetus.The other 4 fetuses were 2 pairs of male monochorionic twins,all with MNX 1 gene mutation.Among 8 CS fetuses,complete triad(sacral agenesis abnormalities,anorectal malformation and presacral mass)were displayed only in 2 fetuses,while all 8 had sacral agenesis abnormalities and 6(6/8,75.00%)were detected with prenatal ultrasound,6 had low location of conus medullaris and 2(2/6,33.33%)detected with prenatal ultrasound.Conclusion Prenatal ultrasound was the first choice for non-invasive diagnosis of fetal CS.When one of sacral agenesis abnormalities,anorectal malformation and presacral mass was found with prenatal ultrasound,the possibility of CS should be considered,and fetal MRI,genetic examination and prenatal genetic counselling should be recommended if necessary.

Deep learning models semi-automatic training system for quality control of transthoracic echocardiography

Objective To explore the value of deep learning(DL)models semi-automatic training system for automatic optimization of clinical image quality control of transthoracic echocardiography(TTE).Methods Totally 1250 TTE videos from 402 patients were retrospectively collected,including 490 apical four chamber(A4C),310 parasternal long axis view of left ventricle(PLAX)and 450 parasternal short axis view of great vessel(PSAX GV).The videos were divided into development set(245 A4C,155 PLAX,225 PSAX GV),semi-automated training set(98 A4C,62 PLAX,90 PSAX GV)and test set(147 A4C,93 PLAX,135 PSAX GV)at the ratio of 5∶2∶3.Based on development set and semi-automatic training set,DL model of quality control was semi-automatically iteratively optimized,and a semi-automatic training system was constructed,then the efficacy of DL models for recognizing TTE views and assessing imaging quality of TTE were verified in test set.Results After optimization,the overall accuracy,precision,recall,and F1 score of DL models for recognizing TTE views in test set improved from 97.33%,97.26%,97.26%and 97.26%to 99.73%,99.65%,99.77%and 99.71%,respectively,while the overall accuracy for assessing A4C,PLAX and PSAX GV TTE as standard views in test set improved from 89.12%,83.87%and 90.37%to 93.20%,90.32%and 93.33%,respectively.Conclusion The developed DL models semi-automatic training system could improve the efficiency of clinical imaging quality control of TTE and increase iteration speed.

BILL Strategy:Points to Consider During the Performance and Interpretation of Critical Care Echocardiography

The growing utilization of critical care echocardiography(CCE)by clinicians necessitates a meticulous review of clinical conditions in critically ill patients,both before and during the examination.The reviewing process of clinical conditions minimizes the risk of overlooking or misinterpreting crucial findings.This article proposes a comprehensive strategy,namely BILL strategy to integrated into the CCE protocol,where“B”represents baseline respiratory and hemodynamic support,“I”signifies information gleaned from invasive monitoring,including central venous pressure and thermodilution-derived cardiac output,the first“L”denotes laboratory results such as central venous oxygen saturation,troponin,and brain natriuretic peptide,and the second“L”refers to lung ultrasound data.xx Combining the BILL strategy with CCE enhances a more comprehensive understanding of critical illness,potentially leading to improved diagnostic accuracy and patient outcomes.

Z-Score in Fetal Echocardiography–Is there Still Room for New Studies?

Congenital heart disease(CHD)is the most common type of birth defect,representing a significant cause of peri-natal morbidity and mortality.Early diagnosis of such anomalies is crucial for improving outcomes.Current pro-tocols recommend a qualitative assessment of cardiac structures using two-dimensional ultrasound(2DUS)and color Doppler imaging.In cases of suspected abnormalities,quantitative assessments through cardiac structure measurements and reference curves can aid in accurate diagnosis.Similar to centiles widely employed in obste-trics,Z-scores provide more precise quantification of various cardiac structures,particularly at the extremes of the curve.While the development of reference curves and Z-scores has progressed over the past two decades,a lack of standardization in measurements and statistical methodology for their determination is evident.Establishing reference curves requires adherence to specific recommendations to improve their accuracy.The purpose of this study is to provide a narrative review of the major studies that have generated reference values for cardiac struc-tures using 2DUS and Z-scores,to evaluate their methodology,and to provide a summary of the results.

Status of clinical applications of artificial intelligence in echocardiography

Artificial intelligence(AI)technology has been increasingly used in medical field with its rapid developments.Echocardiography is one of the best imaging methods for clinical diagnosis of heart diseases,and combining with AI could further improve its diagnostic efficiency.Though the applications of AI in echocardiography remained at a relatively early stage,a variety of automated quantitative and analytical techniques were rapidly emerging and initially entered clinical practice.The status of clinical applications of AI in echocardiography were reviewed in this article.

Invasive Procedures for Prenatal Diagnosis in Salmaniya Medical Complex in Bahrain: A Retrospective Cross-Sectional Descriptive Study

Background: Prenatal diagnosis is the process of evaluating the presence of disease or potential disease in the fetus, this enables families to be better prepared before the birth of the baby. There are non-invasive prenatal diagnosis procedures and invasive prenatal diagnosis procedures. The invasive prenatal diagnosis procedures are CVS (chorionic villus sampling) and amniocentesis. The American College of Obstetricians and Gynecologists states that invasive diagnostic testing should be available to all women, regardless of age or risk. Objective: To determine the indications, outcome and results of diagnostic invasive prenatal procedures. Study setting: The obstetrics and Gynecology Department in Salmaniya Medical Complex in Kingdom of Bahrain. Study design: Retrospective descriptive study. Study subjects and Methods: This retrospective descriptive study was conducted on 175 pregnant women who underwent invasive prenatal procedures (CVS and amniocentesis) between January 2013 and December 2018 at SMC in Kingdom of Bahrain. All medical records of the participants were reviewed and entered the study. According to the implemented procedures, medical records were categorized into two chorionic villus sampling (CVS) and amniocentesis groups. The study subject will include indications of the procedures which are advanced maternal age, hematological disorders, genetic disorders, metabolic disorders, abnormal structural findings in fetal ultrasound and previous child with aneuploidy. In addition, the study will address the complications, outcome and results of procedures. Results: About half of our indications of the procedures were due to hematological disorders (47.6%) followed by abnormal structural findings in fetal ultrasound (30.1%) then genetic disorders (15.7%), metabolic disorders (4.8%) and advanced maternal age (1.8%). Regarding complications of the procedure;threatened miscarriage or loss of pregnancy within 3 weeks was (2.3%), amniotic fluid leakage (0.7%), abdominal cramps (0.7%) and Insufficient or contaminated sample (6.2%). Regarding outcome of the pregnancy, our results showed that the loss of pregnancy was (4.8%), intrauterine fetal death or still birth was (13.9%), live birth was (63.9%), preterm delivery was (7.8%), preterm premature rupture of membrane (PPROM) was (1.8%), limbs reduction was (0.0%). Termination of pregnancy outside the country was (7.8%) of chorionic villus sampling and amniocentesis. Conclusion: CVS and amniocentesis are useful outpatient procedures to detect diagnosis or to assess whether a patient is at increased risk of having an affected fetus and that will minimize the psychological impact on the patient and to provide a proper antenatal care to the pregnant women by her obstetrician and follow up to the baby by pediatrician. In this study it was observed that most of the patients who underwent the procedure were couples either carrier or affected to sickle cell disease or Beta thalassemia.

Intelligent diagnosis of atrial septal defect in children using echocardiography with deep learning

Background Atrial septal defect(ASD)is one of the most common congenital heart diseases.The diagnosis of ASD via transthoracic echocardiography is subjective and time-consuming.Methods The objective of this study was to evaluate the feasibility and accuracy of automatic detection of ASD in children based on color Doppler echocardiographic static images using end-to-end convolutional neural networks.The proposed depthwise separable convolution model identifies ASDs with static color Doppler images in a standard view.Among the standard views,we selected two echocardiographic views,i.e.,the subcostal sagittal view of the atrium septum and the low parasternal four-chamber view.The developed ASD detection system was validated using a training set consisting of 396 echocardiographic images corresponding to 198 cases.Additionally,an independent test dataset of 112 images corresponding to 56 cases was used,including 101 cases with ASDs and 153 cases with normal hearts.Results The average area under the receiver operating characteristic curve,recall,precision,specificity,F1-score,and accuracy of the proposed ASD detection model were 91.99,80.00,82.22,87.50,79.57,and 83.04,respectively.Conclusions The proposed model can accurately and automatically identify ASD,providing a strong foundation for the intelligent diagnosis of congenital heart diseases.

“Keyboard sign”and“coffee bean sign”in the prenatal diagnosis of ileal atresia:A case report

BACKGROUND Ileal atresia is a congenital abnormality where there is significant stenosis or complete absence of a portion of the ileum.The overall diagnostic accuracy of prenatal ultrasound in detecting jejunal and ileal atresia is low.We report a case of ileal atresia diagnosed prenatally by ultrasound examination with the“keyboard sign”and“coffee bean sign”.CASE SUMMARY We report a case of ileal atresia diagnosed in utero at 31 weeks'of gestation.Prenatal ultrasound examination revealed two rows of intestines arranged in an‘S’shape in the middle abdomen.The inner diameters were 1.7 cm and 1.6 cm,respectively.A typical“keyboard sign”was observed.The intestine canal behind the“keyboard sign”showed an irregular strong echo.There was no normal intestinal wall structure,showing a typical“coffee bean sign”.Termination of the pregnancy and autopsy findings confirmed the diagnosis.CONCLUSION The prenatal diagnosis of ileal atresia is difficult.The sonographic features of the“keyboard sign”and“coffee bean sign”are helpful in diagnosing the location of congenital jejunal and ileal atresia.

Prenatal ultrasound diagnosis of fetal maxillofacial teratoma:Two case reports

BACKGROUND Facial teratoma is a rare benign tumor that accounts for about 1.6%of all teratomas and can be diagnosed by prenatal ultrasound(US).The purpose of this report was to describe our experience with the diagnosis of fetal facial teratoma by prenatal US at second trimester to provide a reference for clinical diagnosis of fetal maxillofacial teratoma.CASE SUMMARY We present two cases of patients with abnormal fetal facial findings on US at second trimester of pregnancy in our department.Case 1 was a 31-year-old G3 P1+1 female,with US revealing a heterogeneous echogenicity of 32 mm×20 mm×31 mm on the fetal face,most of it located outside the oral cavity and filling the root of the oral cavity.Case 2 was a 29-year-old G1P0 female,with fetal head and neck US revealing a cystic-solid echo mass measuring 42 mm×33 mm×44 mm,the upper edge of the lesion reaching the palate and filling the oral cavity.The contours of the lesions were visualized using three-dimensional(3D)US imaging.Both patients decided to give up treatment.Biopsies of the lesions were performed after induction of labor,and diagnosed as maxillofacial teratoma.CONCLUSION Fetal maxillofacial teratomas can be diagnosed by US in early pregnancy,allowing parents to expedite treatment decisions.

Clinical manifestations and the prenatal diagnosis of trisomy 7 mosaicism:Two case reports

BACKGROUND The clinical manifestations of trisomy 7 mosaicism are diverse and nonspecific,so prenatal diagnosis is very difficult.CASE SUMMARY Two pregnant women with abnormal prenatal screening results were included.One was a 22-year-old woman(G1P0).At 31st week of gestation,ultrasound revealed that the posterior horn of the left lateral ventricle was 10 mm and the right renal pelvis had a separation of 7 mm.The other pregnant woman was 33 years old(G2P1L1A0),and her fetus was found to have a cardiac malformation at the 24th week of gestation.Copy number variation sequencing,whole-exome sequencing and karyotype analysis were carried out after amniocentesis,and both fetuses were diagnosed with trisomy 7 mosaicism.After parental counseling,one woman continued the pregnancy,and the other woman terminated the pregnancy.CONCLUSION In trisomy 7 mosaicism,the low proportion of trisomy does not lead to abortion,but can result in abnormal fetal development,which can be detected via ultrasound.Therefore,clinicians need to pay more attention to various aspects of fetal growth and development,combining with imaging,cellular,molecular genetics and other methods to perform comprehensive evaluations of fetuses to provide more reliable genetic counseling for pregnant women.

Analysis of the Efficacy of Prenatal B-Ultrasound in Diagnosing Fetal Abnormalities

Objective:To explore the positive significance of using prenatal B-ultrasound in diagnosing fetal abnormalities.Methods:A total of 200 pregnant women who visited Shaanxi Provincial People’s Hospital between January 2023 and January 2024 were recruited as the research subjects.All pregnant women received prenatal examinations.A retrospective analysis was carried out to analyze the positive significance of prenatal B-ultrasound examination in the diagnosis of fetal abnormalities.Results:Prenatal B-ultrasound examination detected 10 cases of fetal abnormalities,with a detection rate of 5.00%.When compared with the postnatal examination results of 5.50%,the difference was insignificant(P>0.05).Moreover,comparing the fetal limb abnormalities and cardiovascular abnormalities in prenatal B-ultrasound examination and postnatal examination,one case of congenital heart disease was missed in the prenatal B-ultrasound examination,and the others were consistent with the postnatal examination results,with a coincidence rate of 90.91%,indicating a high compliance rate.Conclusion:Fetal abnormalities have a great impact on mothers,babies,and families,and it is particularly important to strengthen diagnosis during this process.Prenatal B-ultrasound examination can improve the accuracy of diagnosis of fetal abnormalities and can be promoted in clinical practice as a basis for screening fetal abnormalities.

Self-Appraisal of Clinical Competence in Echocardiography of Chinese Intensivists Post Basic Echocardiography Training

Objectives To learn the echocardiography skills of intensivists after receiving a basic critical care echocardiography training course,and investigate factors that may influence their performance.Methods We completed a web-based questionnaire that assessed the skills in ultrasound scanning techniques of intensivists who took a training course on basic critical care echocardiography held in 2019 and 2020.MannWhitney test was used to analyze the factors which might affect their performance on image acquisition,recognizing clinical syndrome,and measuring the diameter of inferior vena cava,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral.Results We enrolled 554 physicians from 412 intensive care units across China.Among them,185(33.4%)reported that they had 10%-30%chance of being misled by critical care echocardiography when making therapeutic decision,and 34(6.1%)reported that the chance was greater than 30%.Intensivists who performed echocardiography under the guidance of a mentor and finished ultrasound scanning more than 10 times per week reported significant higher scores in image acquisition,clinical syndrome recognition,and quantitative measurement of inferior vena cava diameter,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral than those without mentor and performing echocardiography 10 times or less per week respectively(all P 0.05).Conclusion The skills in diagnostic medical echocardiography of Chinese intensivists after a basic echocardiographic training course remain low,and further quality assurance training program is clearly warranted.

Quantitative Parameters Analysis for Prenatally Echocardiographic Diagnosis of Atrioventricular Septal Defects

Background:Atrioventricular septal defects(AVSDs)are screened and diagnosed usually rely on the imaging characteristics of fetal echocardiography(FE).However,diagnosis on images is heavily depended on sonographers’experience and the quantitative data are rarely studied.Objective:This study aimed to realize the prenatal diagnosis of AVSDs by analyzing the quantitative data on FE.Methods:One hundred and thirteen cardiac quantitative data was analyzed in 370 normal and 49 AVSDs fetuses retrospectively.The top six with the highest diagnostic accuracy rate were acquired according to the area under the curve(AUC),and the diagnostic value of six variables was analyzed.Results:Six parameters obtained on the four-chamber view(4CHV),including the atrial to ventricular length ratio in end-diastole(AVLR-ED),AVLR-ED combined with the atrial to ventricular length ratio in end-systole(AVLR-ES),quantile score(Q score)of AVLR-ED,Q score of AVLR-ES,Q score of ventricle length in end-diastole(VL-ED),and AVLR-ES,were the top six with the highest diagnostic value,and the AUC was 0.99(95%CI 0.99–1.00),0.99(95%CI 0.99–1.00),0.99(95%CI 0.98–1.00),0.95(95%CI 0.91–0.99),0.93(95%CI 0.87–0.99),and 0.91(95%CI 0.83–1.00),respectively.And within the 20%false positive rate,the diagnostic sensitivity was greater than 100%,100%,100%,90%,90%,and 88%,respectively.Conclusions:Six variables could be used for prenatal diagnosis of AVSDs.Among them,AVLR-ED and Q score of AVLR-ED,obtained on the 4CHV,were more convenient to acquire and had higher diagnostic accuracy.

Real-Time Remote-Mentored Echocardiography in Management of Newborns with Critical Congenital Heart Defects

Background:The management of suspected critical congenital heart defects(CCHD)relies on timely echocardiographic diagnosis.The availability of experienced echocardiographers is limited or even non-existent in many hospitals with obstetric units.This study evaluates remote-mentored echocardiography performed by physicians without experience in imaging of congenital heart defects(CHD).Methods:The setup included a pediatric cardiologist in a separate room,guiding a physician without experience in echocardiographic imaging of CHD in the examination of a symptomatic newborn.This remote-mentoring pair was blinded to the diagnosis of the newborn and presented with a simplified patient history.The echocardiographic images were streamed to the laptop of the mentor,along with a webcam feed showing the probe position.The task was to identify CCHD in need of immediate transfer to a pediatric cardiac surgical center.The result was compared to the previously completed echocardiographic report and the clinical decision of the patient-responsible pediatric cardiologist.Results:During 17 months,15 newborns were recruited.All six newborns with CCHD were correctly labeled by the remotementoring pair.One newborn with Tetralogy of Fallot was erroneously labeled as needing immediate transfer.Eight newborns without CCHD were correctly labeled.Conclusions:Remote-mentored echocardiography performed by examiners without experience in imaging CHD identified all newborns with CCHD in need of immediate transfer for specialist care.The setup shows promising results for improving the management of CCHD in hospitals without continuous pediatric cardiology service.

Determinants of the Frequency of Prenatal Consultations among Women Giving Birth in the Maternity Wards of the Commune of Agbangnizoun (Zou), Benin

Antenatal care is a safe way to prevent pregnancy-related health problems, difficult deliveries and even further to anticipate low birth weight [1]. But pregnant women, especially in Africa, do not attend antenatal clinics as recommended by the WHO. The general objective of this study was to study the norm in terms of Antenatal Consultation (ANC) frequency as well as the determinants of the frequency among women who gave birth in the maternity hospitals of Agbangnizoun. Our research was a cross-sectional, descriptive, retrospective and quantitative type, which was carried out among 335 women in Agbangnizoun, Benin from 1 February to 3 April 2020 (3 months), in order to find out the general or specific characteristics of women that we associate with the frequency of prenatal consultation. At the end of the study, we found that 60%, 68% and 15% of the surveyed population had received ANC in the first, second and third trimesters, respectively. Ethnicity, income level of spouses over the three trimesters as well as the level of their knowledge and overall practice of ANC are determinants of the frequency of prenatal consultation.

Prenatal programing of motivated behaviors:can innate immunity prime behavior?

Prenatal programming during pregnancy sets physiological outcomes in the offspring by integrating external or internal stimuli.Accordingly,pregnancy is an important stage of physiological adaptations to the environment where the fetus becomes exposed and adapted to the maternal milieu.Maternal exposure to high-energy dense diets can affect motivated behavior in the offs p ring leading to addiction and impaired sociability.A high-energy dense exposure also increases the pro-inflammatory cytokines profile in plasma and brain and favors microglia activation in the offspring.While still under investigation,prenatal exposure to high-energy dense diets promotes structural abnormalities in selective brain regions regulating motivation and social behavior in the offspring.The current review addresses the role of energy-dense foods programming central and peripheral inflammatory profiles during embryonic development and its effect on motivated behavior in the offspring.We provide preclinical and clinical evidence that supports the contribution of prenatal programming in shaping immune profiles that favor structural and brain circuit disruption leading to aberrant motivated behaviors after birth.We hope this minireview encourages future research on novel insights into the mechanisms underlying maternal programming of motivated behavior by central immune networks.

Current role and future perspectives of artificial intelligence in echocardiography

Echocardiography is an essential tool in diagnostic cardiology and is fundamental to clinical care.Artificial intelligence(AI)can help health care providers serving as a valuable diagnostic tool for physicians in the field of echocardiography specially on the automation of measurements and interpretation of results.In addition,it can help expand the capabilities of research and discover alternative pathways in medical management specially on prognostication.In this review article,we describe the current role and future perspectives of AI in echocardiography.