Proceedings of the 2018 Design of Medical Devices Conference

DMD2018
April 9-12, 2018, Minneapolis, MN, USA

DMD2018-6905

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A smartphone stethoscope and application for automated identification of
innocent Still’s murmur
Titus John Robin W. Doroshow Raj Shekhar
Sheikh Zayed Institute for Division of Cardiology Sheikh Zayed Institute for
Pediatric Surgical Innovation Children’s National Pediatric Surgical Innovation
Children's National Health Health System Children's National Health
System Washington, DC, USA System
Washington, DC, USA AusculTech Dx Washington, DC, USA
AusculTech Dx Dayton, MD, USA AusculTech Dx
Dayton, MD, USA Dayton, MD, USA

BACKGROUND

Primary care physicians (PCPs) often lack the skills to

distinguish the common innocent Still’s murmur from far
less frequent but potentially serious pathological heart
murmurs. This leads to approximately 800,000 children
being referred to pediatric cardiologists each year for
evaluation of heart murmurs in the United States [1-2].
The murmur is ultimately diagnosed as an innocent Still’s
murmur in approximately 78% of these children
(Children’s National Health System data). These
unnecessary referrals and associated tests cost the
healthcare system over half a billion annually, and are a
source of avoidable anxiety for children and families while
waiting to see a pediatric cardiologist.
We have created a novel digital stethoscope (see
Figure 1), which connects to a smartphone, and
developed a custom mobile application that records heart
sounds, using the developed hardware, and analyzes
them for the presence of Still’s murmur [3]. We call this
application and digital stethoscope StethAid.
Our first goal was to compare our device with a
commercially available electronic stethoscope (3M
Littmann model 4100) in terms of recording quality and
demonstrate that the two devices produced comparable
sound representations in both the time and frequency
domains.
Our second goal was to demonstrate that our
automated Still’s murmur identification algorithm
produced comparable results, in terms of specificity and
sensitivity in identifying a Still’s murmur, for each of the
two stethoscopes.
Figure 1. The current StethAid prototype that includes a
novel digital stethoscope and a custom mobile
application.
METHODS
For our first goal, we evaluated the developed digital
stethoscope. Sounds (sinusoidal waves and normal heart
sounds) for the given comparison test were played
through speakers into the diaphragms of the StethAid and
Littmann stethoscopes. Sounds were played at the same
volume for the two devices.
Next, we evaluated the frequency response of the two
devices by recording the sinusoidal signals from 40 Hz to
400 Hz in 20-Hz steps, corresponding to 19 recordings for
each of the stethoscopes. Discrete 1024-point Fourier
transforms (FFTs) were performed on each of the
recorded sine waves to produce one-sided power spectra
corresponding to each of the 19 recordings. These
respective power spectra were summed in the frequency
domain and a third order polynomial was fitted to the
summed response as shown in Figure 2.
Then we compared the reception of prerecorded
normal heart sounds on the devices. The sounds were
played through speakers into the diaphragms of the

1 Copyright © 2018 ASME

stethoscopes. Raw signals were band passed filtered
from 40 Hz to 400 Hz. Five cardiac cycles from each of
the recordings were manually segmented. An example
cardiac cycle recorded on each device is presented in
Figure 3. A 1024-point FFT was then performed on each
of the five cycles of each recording, and the resulting
spectra were averaged in the frequency domain to

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produce the respective curves seen in Figure 4. The
recordings from both devices were also compared to the
prerecorded normal heart sounds, in both time and
frequency domains.
For our second goal, we compared our automated
Still’s murmur identification algorithm [3] on Still’s and
pathological murmurs recorded using StethAid
stethoscope. Utilizing the Littmann stethoscope, we built
a database of different heart murmur types and their
associated diagnoses as provided by an expert pediatric
cardiologist. The identification algorithm was trained and
tested on the database of the Littmann sounds. 70% of
the murmur library was used to train the algorithm, while
30% comprised the test set.

RESULTS

Hardware Analysis - We show a comparable

frequency response between our device and the Littmann
stethoscope as shown in Figure 2. This response is
characterized as the bell-shaped response with increased
power in the 100 Hz - 350 Hz range.

Figure 3. Prerecorded source normal heart sounds

(black, top). Recorded sounds with StethAid (red, middle)
and with Littmann (blue, bottom) stethoscopes.

Figure 2. Comparison of the frequency response of

StethAid (red) and Littmann (blue) stethoscopes.

The comparisons shown in Figure 3 are of normal

heart sounds in the time domain. Generally, the
phonocardiogram of normal heart sounds has a
frequency content varying from approximately 40 Hz up to
300 Hz [4].
Figure 4. Frequency response of normal heart sounds for
the two hardware devices.
Murmur Analysis - The analysis algorithm has been
developed and tested using an in-house murmur library
with clinically documented diagnoses. The library

2 Copyright © 2018 ASME

consisted of 119 Still’s murmurs, 84 other innocent
murmurs, and 502 pathological murmurs [3].
Our improved algorithm offers a true positive
identification rate (Still’s murmur identified correctly) of
89% with a false positive identification rate (pathological
murmur misidentified as Still’s) of 3% on Littmann
recordings. We have also evaluated our algorithm on the
heart sounds of 64 children (33 Still’s murmurs and 31
pathological murmurs) recorded utilizing StethAid
hardware. For this analysis we observed a true positive
identification rate of 85% with a false positive rate of
3.2%. These preliminary results indicate that the
diagnostic accuracy of our algorithm is similar whether
the recordings are made using the StethAid hardware or
the Littmann stethoscope.
INTERPRETATION
We compared our StethAid digital stethoscope with a
commercial electronic stethoscope. We analyzed
frequency response between the two stethoscopes and
found that the StethAid stethoscope’s frequency response
was comparable to that of a commercial electronic
stethoscope, and that our hardware reproduced heart
sounds with the same fidelity as that of the Littman
hardware.
The bell-shaped frequency response seen in Figure 3
was as expected because diaphragms of stethoscopes
are tuned for recording frequencies present in normal
heart sounds and pathologies while attenuating other
frequencies. The frequency response seen with normal
heart sounds was also shown to follow the same shape
and follows previously characterized examples [4].
Although we obtained respectable true positive and
false positive identification rates, these numbers need
refinement per the clinical needs. From a clinical
standpoint, false positives, which represent pathological
murmurs incorrectly labeled as Still’s murmurs, pose a
risk. However, if the current false positive identification
rate is deemed high, adjusting the threshold of the
classifier can reduce this rate. This would minimize the
possibility of not referring pathological murmur cases, but
would come at the expense of a slightly reduced true
positive identification rate and a smaller savings in the
number of Still’s murmur referrals. Given the current high
rate of over-referrals, the potential for decreasing them
would still exist.
The Still’s murmur identification algorithm is cloud-
based, which provides a convenient paradigm to further
3 Copyright © 2018 ASME
improve its accuracy as the murmur library grows and
introduce the improved algorithm to all users. The
algorithm can also be trained on StethAid recordings only
or on mixed recordings from different hardware types.
Once the algorithm is fully developed with clinically
acceptable sensitivity and specificity, it will be made
available for use by PCPs.
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By equipping PCPs with automated murmur
classification at the point of care, StethAid offers the
possibility of avoiding unnecessary referrals of children
with innocent heart murmurs to pediatric cardiologists or
for echocardiography. This would save costs to the
healthcare system and avoid needless anxiety and
inconvenience to affected families.
Acknowledgments
This work has been supported by National Institutes of
Health grant 1R41HL131081 and a grant (RE159-G5)
from the Atlantic Pediatric Device Consortium (funded
through Food and Drug Administration grant
5P50FD004193).
REFERENCES
1. Fogel, D. H. (1960). The innocent systolic murmur in
children: a clinical study of its incidence and
characteristics. American heart journal, 59(6), 844-
855.
2. Vukanovic-Criley, J. M., Criley, S., Warde, C. M.,
Boker, J. R., Guevara-Matheus, L., Churchill, W. H.,
... & Criley, J. M. (2006). Competency in cardiac
examination skills in medical students, trainees,
physicians and faculty. Arch Intern Med, 166(6), 610-
6.
3. Kang, S., Doroshow, R., McConnaughey, J., &
Shekhar, R. (2017). Automated Identification of
Innocent Still's Murmur in Children. IEEE
Transactions on Biomedical Engineering, 64(6),
1326-1334.
4. Debbal, S. M., & Bereksi-Reguig, F. (2008).
Computerized heart sounds analysis. Computers in
biology and medicine, 38(2), 263-280.