A buzzword of the past century was “bigger is better.”Carswere built to be large and luxurious, even if they were “gas-guzzlers.” The Titanic was the largest ship ever built andtherefore thought to be unsinkable. Movies competed to bemore spectacular and expensive with ever more dramaticand daring special effects.Cities outdid each other to createthe tallest skyscrapers. Sports arenas were built with greatercapacity and more luxury. Airlines competed to build largerand more profitable planes that could fly longer distances.

Initial attempts to design modern ultrasonographic equip-ment followed a similar pattern, focusing on technologicinnovation, which required large equipment.The prototypephased-array echocardiography machine, which was devel-oped at Duke University and used clinically by Joe Kisslo,occupied a space about the size of a small garage. RandyMartin and I worked in Richard Popp’s laboratory almost 25years ago with the prototype of the first commercially suc-cessful Varian phased-array 2-dimensional ultrasonoscope.There was no on-line calculation package,and to trace mitralvalve areas, we had to use a massive and very expensivecomputer that took more than 30 minutes to load and occu-pied a space larger than most rooms used for scanning today.Over the years, high-end ultrasound systems became moresophisticated, complex, and powerful. System size remainedrelatively constant or increased as a larger number of small-er, more powerful processors were used to fill the space inthe box and to provide major advances in features and qual-ity. Tremendous engineering efforts have been made toimprove image quality and to enable machines to providemore quantitative information that can be used for clinicaldecision making. Early-generation systems capable of real-time 3-dimensional imaging required an even larger size.

An evolving trend countered “bigger is better” with “goodthings come in small packages.”While there is no limit on thelength of these president’s messages, those familiar with thebook The Elements of Style by Strunk and White know thatbrief and concise writing is highly desirable and effective. Iam still learning.Minimalist haiku poems describe events andphilosophy in a simple way, yet with very powerful imagery.A small but delicious meal is much more enjoyable than onethat is large but unappetizing. A small diamond is much morevaluable than a larger semiprecious stone.

The computer revolution has demonstrated how devicescan become smaller and less expensive and, at the sametime, more powerful and available to a greater number ofusers. Initial computers were very expensive and weredesigned for use by large businesses. Laptops continue toshrink in size and weight, yet they have greater capabilitythan the largest medical computers of 10 years ago.

AMERICAN SOCIETY OF ECHOCARDIOGRAPHY NEWS

President’s MessageGOOD THINGS AND SMALL PACKAGES

Databases no longer reside on large servers, viewable onlywith great difficulty. Patient records and management algo-rithms can be downloaded via wireless communication tosmall,handheld computers. The cardiologist of the not-too-distant future may use a handheld device the size of a PalmPilot to store a complete patient record. Medical decisionswill be validated by wireless access to a decision analysisdatabase. New drug therapy could automatically bereviewed electronically for adverse effects and negativeinteractions with other patient medication, with a directlink to the dispensary.The same device, when connectedto a special probe, could become an ultrasound stetho-scope and an invaluable aid to bedside diagnosis. It couldprovide real-time 2-dimensional images of the heart toenable the practitioner to evaluate cardiac structure andfunction and to determine whether enough pathology ispresent to warrant a complete echocardiographic study. Inaddition, we could use the device to determine the pres-ence of pleural effusions and ascites, accurately measureabdominal organ size, and evaluate vascular flow. Drugdelivery could be targeted to organs by using ultrasounddisruption of drug-carrying microbubbles. Many of usremember Dr Bones on Star Trek using a small, handhelddevice to scan a patient for vital signs and diagnose andtreat a host of ailments, all without the laying on of hands.Is this an unrealistic dream or a destined reality?

It is therefore not surprising that recently we have seengreat interest in the creation of smaller, less expensive

20A Journal of the American Society of Echocardiography Volume 13 Number 10

for a sonographer or for a physician performing studies tolearn how to obtain and interpret images for the evalua-tion of left ventricular function. There is no shortcut forthe training required to accurately perform and interpretsuch studies. The very nature of these instruments willcreate a broader use for ultrasonographic studies and willlikely be performed by a more varied range of users.

Lord Beaverbrook said that “If we attempt to hold the pre-sent chained to the past, we shall find we have lost thefuture.”As buggy whip manufacturers learned too late, bothevolutionary and revolutionary changes in the marketplaceare ignored at great peril. Small, portable devices capable ofacting as ultrasonic stethoscopes are very exciting, and theywill find a place in the decision making of cardiologists andother physicians. The marketplace will decide their valueand utility.However, there is also great risk in using this newtechnology on a very large scale without careful educationand training. Echocardiography has become so dominantbecause, when performed properly, it provides extremelyvaluable information for patient care. Limited studies per-formed inaccurately by inadequately trained physicians willgreatly harm the value of echocardiography and our confi-dence in the information provided.The ASE will do every-thing that it can to ensure high-quality standards for any car-diac ultrasound examination. Our approach will be to workwith others who share our goals of quality. The risk ofimproper use can be summarized in this haiku poem.

Fragile silver threads support greatnessFalling on deaf ears.

Haiku poems teach us to relate ideas precisely and mean-ingfully. They demonstrate that good things indeed comein small packages but that some of those packages need tobe opened carefully.

Harry Rakowski, MDPresident

American Society of Echocardiography

echocardiographic machines that are capable of eithercomplete or limited studies. It is important to distinguish acomplete study performed on a smaller but highly featuredmachine from a limited study,with or without a permanentrecord, performed on a very small system.The former sys-tem can provide all the information required to diagnoseand quantitate the full range of cardiac abnormalities.Whilesuch systems represent an important advance, they will notradically alter the way ultrasonic imaging is performed.Thelatter system has been designed as an ultrasonic stetho-scope to be used at the bedside or for limited studies in atriage situation. In patients with cardiac pathology, follow-up with a complete diagnostic study is usually required.

I recently evaluated such a very small ultrasounddevice, using it for bedside evaluations in the intensivecare unit and for triage decisions in the emergencydepartment.The image quality obviously was not nearly asgood as could be obtained with a high-quality, fully fea-tured ultrasonoscope. However, it was very helpful inrapidly defining left ventricular function and excludingpericardial effusions in most patients.The residents whoevaluated the patients with me were extremely impressedthat such important information could be obtained so eas-ily and quickly. I was unable to quantitate valvular steno-sis and regurgitation because the quality of color imagingwas poor and quantitative Doppler studies could not beperformed. In the future, significant enhancements andadded features may overcome many of these limitations,but to date, such systems lack major capabilities andtherefore provide a study limited to anatomic definition inpatients with adequate fundamental images. I was struckby the simplicity of the system: it had a limited number ofsetup choices, which made the limited examination easyto perform rapidly. However, the evaluation of left ven-tricular function is both the most basic and often the mostdifficult part of the echocardiographic study. In NorthAmerica, we depend on expert sonographers to provideus with high-quality images to review. It takes a long time

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