The Visual, Real-Time Stethoscope Design Team 5 Team Leader: Haoxin Sun John Downey Nicholas Kucher Ami Kumordzie Marina Pedisich Raghav Ramachandran Sponsored By: Angelo All, MD The Visual, Real-Time Stethoscope

Problem: Can You Hear It? Answer Is it a split S2, possibly indicating right ventricular failure… Let’s spend some time on this slide, we want to sell our device. Split S2 and S3: Split S2 is a fairly common condition. A split S2 is really always occurring to some degree, as the closing of the pulmonic and aortic valves don't both occur at the same millisecond. When the pulmonic valve closes a little later than the aortic valve, split S2 occurs S3 can be present in childrem and athletes; however, in other people, it can indicate a non-specific impairment of ventricular function, which needs further testing. Market Target: physicians who are cardiologists and medical trainees, this data is awesome because the subjects are our target customers!!!! What does the table show: A group of 20 physicians, none are cardiologists, participated in this study. They first went through a training course on identifying the key sounds produced by the heart, and then were tested on real patients. They listened to 33 events, and the percentage indicates correct identification. Audio file, get it Look up frequency display of these …or an S3 indicating left ventricular failure? Lack of training, sounds overlap, limited hearing, selective hearing Favrat B, Pecoud A, Jaussi, A. Teaching cardiac auscultation to trainees in internal medicine and family practice: Does it work? BMC Medical Education 2004, 4:1-7 http://www.blaufuss.org/tutorial/index1c.html

Answer: Now you can see it!!! Normal Mitral Stenosis Aortic Regurgitation Ventricular Septal Defect (VSD) Let’s spend some time on this slide, we want to sell our device. Split S2 and S3: Split S2 is a fairly common condition. A split S2 is really always occurring to some degree, as the closing of the pulmonic and aortic valves don't both occur at the same millisecond. When the pulmonic valve closes a little later than the aortic valve, split S2 occurs S3 can be present in childrem and athletes; however, in other people, it can indicate a non-specific impairment of ventricular function, which needs further testing. Market Target: physicians who are cardiologists and medical trainees, this data is awesome because the subjects are our target customers!!!! What does the table show: A group of 20 physicians, none are cardiologists, participated in this study. They first went through a training course on identifying the key sounds produced by the heart, and then were tested on real patients. They listened to 33 events, and the percentage indicates correct identification. Audio file, get it Look up frequency display of these http://www.bsignetics.com/new_page_4.htm 3

Mission To develop a visual stethoscope that enables viewing of a real-time visual representation of a patient’s heart sounds GOALS Integrated spectrogram display screen that is large without being cumbersome Visual display can be disabled, and device must be able to be used as a traditional stethoscope By using this device, healthcare workers should be able to increase their accuracy in cardiac abnormalities Stress that this is not for cardiologists, and it is NOT a diagnostic tool but an visual aid.

Current State of the Art Current Technologies Compatibilities On-Site Littman Electronic Stethoscope 3200 (3M) Amplification Noise filtering Data transfer via Bluetooth Elite Electronic Stethoscope (Welch Allyn) Dual position filter Data recording Patents for signal processing algorithms Sound processing Cardiac sound detection Data recording and storage Visual stethoscope patents Visual display of sounds Don’t spend too much time on this: 1 sentence: these are some of the current technologies Emphasize: All of these do not provide on-site display of the data, and the visual stethoscopes are bulky and inconvenient.

Display Options Frequency Spectrogram Phonocardiogram What do we display? Look up phonocardiogram Split S2 – left or right Bundle Branch Block – cardiac dyssynchrony Sounds from mechanical valve prostheses may largely exceed the upper limit** increase device bandwidth 6

Packaging Constraint: Keep acoustic stethoscope functionality untouched Constraint: Build on the stethoscope as little as possible “Fill the bell” Enclose the unit Bigger compartment -as long as we leave the red box untouched! Fill the bell – use the empty space that is there and preserve the entire original shape Seal it off – leave it concave around to preserve the way the doctor holds it – how much depends on how much we need to put in there Gives more packing space, but is the furthest from the original shape; can get bigger screen Nick’s button idea Use the rest of the steth to help enclose components Fetal heart sound using the bell Find evi. Why we don’t use a bell Talk about

Four Components Microphone Filtering Battery Visual Display 8

1) Microphone Small microphone implanted in head of stethoscope Divide signal into cycles by identifying S1 http://www.intricontibbets.com/151.html

Waveform Processing Two options: 1. Show sequentially: 2. Average: These are 2. Average:

2) Filtering – Algorithm 1 Sources. * Make sure we stress this is one option, not what we are going to do

2) Filtering – Algorithm 2 Using the ECG-trace to pick up where a heart beat start. We understand that ECG trace and PCG trace do not line up exactly; however, we need a reliable cue that can indicate the start of a cardiac cycle, and ECG is one method that we can use. Abbas K. Abbas and Rasha Bassam, Phonocardiography Signal Processing, Morgan & Claypool 2009

3) Power Options Power Requirements: 5 Volts for the screen 1 1.2 Volts for the microphone 50 mA for the necessary size 2 Battery Decisions: Rechargeable is better than disposable Needs at least an hour of use per charge Must be small enough to fit in head Best Option: 2 Rechargeable Lithium-Ion CR2450 coin batteries in series 3: 24.5 mm Diameter 200 mAh capacity 3.7 V 2 hour charge time 1. http://en.wikipedia.org/wiki/Liquid_crystal_display 2. http://www.sparkfun.com/commerce/product_info.php?products_id=257 3. http://www.sparkfun.com/commerce/product_info.php?products_id=8818

4) Visual Display LCD OLED Pros Cons Power saving Motion blur Portable Inherent viewing angle Slim Dead Pixels OLED Pros Cons Large Field of View, 170 o Expensive More power efficient Color decay Light and flexible Water damage Don’t dismiss LCD, making it as a concept

Putting the Pieces Together 1. ttp://www.liquidware.com/shop/show/OLED/1-5+OLED+Screen 2.http://www.directindustry.com/prod/intel/microprocessor-33710-194227.html

Acknowledgements Dr. Angelo All Vikram Aggarwall Dr. Robert Allen Dr. Artin Shoukas Dr. Youseph Yazdi Dr. Pamela Ouyang Susan Vazakas Busra Dinc

Thank You! Questions?

Appendix A Question- Why would a health care providers pay for it? Pressure from insurance companies Lack of expertise (residents, nurses/EMTs, or care givers in developing countries) Increased incentive to avoid false positives (areas with no higher level care) Teaching tool Question- Why not use wireless? Simplicity is critical, especially for care providers in disadvantaged areas An important goal is to maintain traditional stethoscope shape as well as procedures for use

Appendix B: Heart Sound Frequencies Ultra-low (linear frequency band) Medium Low (60-120Hz) Medium High (120-240Hz and 240-480Hz) threshold of the audible heart murmurs has a cut-off of 57 Hz with energy level 0.98 Dyne/cm2

Appendix C: Packaging

Appendix C: Packaging

Appendix C: Packaging

Appendix D ~ costs According to Harvard Pilgrim HealthCare myocardial perfusion : $729 - $1442 echocardiogram with interpretation: $262- $561 Doppler Color Flow Velocity Mapping: $137-$252 Electrocardiogram with interpretation : $32-$56 CT scan : $297-$598 https://www.harvardpilgrim.org/portal/page?_pageid=253,192924&_dad=portal&_schema=PORTAL

Appendix E ~ market size Visual Stethoscope Market Size Years % of Growth 2006 2007 2008 2009 2010 2011 2012 Physician/Surgeons 1.4 633,000 641,862 650,848 659,960 669,199 678,568 688,068 Healthcare/Provider 2.3 2,772,000 2,835,756 2,900,978 2,967,701 3,035,958 3,105,785 3,177,218 Academia 1.5 42,000 42,630 43,269 43,918 44,577 45,246 45,925 In 2008… 3M Health Care earn $4293 million in revenue 8.2% increase since 2007. Boston Scientific Corp. earned $8,357 million in revenue 6.9 % increase since 2007.

Appendix F ~ normal vs. abnormal