Evidence-Based Actor-Verifier Reasoning for Echocardiographic Agents

Reliable interpretation of echocardiography (Echo) is crucial for assessing cardiac function, which demands clinicians to synchronously orchestrate multiple capabilities, including visual observation (eyes), manual measurement (hands), and expert knowledge learning and reasoning (minds). While current task-specific deep-learning approaches and multimodal large language models have demonstrated promise in assisting Echo analysis through automated segmentation or reasoning, they remain focused on restricted skills, i.e., eyes-hands or eyes-minds, thereby limiting clinical reliability and utility. To address these issues, we propose EchoAgent, an agentic system tailored for end-to-end Echo interpretation, which achieves a fully coordinated eyes-hands-minds workflow that learns, observes, operates, and reasons like a cardiac sonographer. First, we introduce an expertise-driven cognition engine where our agent can automatically assimilate credible Echo guidelines into a structured knowledge base, thus constructing an Echo-customized mind. Second, we devise a hierarchical collaboration toolkit to endow EchoAgent with eyes-hands, which can automatically parse Echo video streams, identify cardiac views, perform anatomical segmentation, and quantitative measurement. Third, we integrate the perceived multimodal evidence with the exclusive knowledge base into an orchestrated reasoning hub to conduct explainable inferences. We evaluate EchoAgent on CAMUS and MIMIC-EchoQA datasets, which cover 48 distinct echocardiographic views spanning 14 cardiac anatomical regions. Experimental results show that EchoAgent achieves optimal performance across diverse structure analyses, yielding overall accuracy of up to 80.00%. Importantly, EchoAgent empowers a single system with abilities to learn, observe, operate and reason like an echocardiologist, which holds great promise for reliable Echo interpretation.

Echocardiography interpretation requires integrating multi-view temporal evidence with quantitative measurements and guideline-grounded reasoning, yet existing foundation-model pipelines largely solve isolated subtasks and fail when tool outputs are noisy or values fall near clinical cutoffs. We propose Echo-CoPilot, an end-to-end agentic framework that combines a multi-perspective workflow with knowledge-graph-guided measurement selection. Echo-CoPilot runs three independent ReAct-style agents, structural, pathological, and quantitative, that invoke specialized echocardiography tools to extract parameters while querying EchoKG to determine which measurements are required for the clinical question and which should be avoided. A self-contrast language model then compares the evidence-grounded perspectives, generates a discrepancy checklist, and re-queries EchoKG to apply the appropriate guideline thresholds and resolve conflicts, reducing hallucinated measurement selection and borderline flip-flops. On MIMICEchoQA, Echo-CoPilot provides higher accuracy compared to SOTA baselines and, under a stochasticity stress test, achieves higher reliability through more consistent conclusions and fewer answer changes across repeated runs. Our code is publicly available at https://github.com/moeinheidari7829/Echo-CoPilot.

Echocardiography is the most widely used non-invasive cardiac imaging modality, providing essential information for cardiovascular diagnosis. Interpreting an echocardiogram requires synthesizing complementary evidence across multiple heart views to identify abnormalities and produce structured clinical reports. While recent efforts focus on improving classification performance, most models lack explicit diagnostic reasoning and spatially grounded anatomical evidence, limiting clinician trust. We present EchoSonar-R, a multi-view reasoning-enabled vision-language model that jointly performs multi-label disease classification and report generation from echocardiography studies. EchoSonar-R combines a spatiotemporal video encoder with a structure-aware cardiac detector that provides spatially grounded anatomical cues to improve interpretability and clinician trust during cross-view reasoning. EchoSonar-R is trained in two stages: supervised fine-tuning (SFT) on reasoning-annotated targets, followed by Group Relative Policy Optimization (GRPO) with task-specific rewards that jointly align classification and report generation within a unified reinforcement-learning framework. Across a private multi-view dataset and two public benchmarks, EchoSonar-R improves macro balanced accuracy by 17.1% on the private set and 6.1% on MIMICEchoQA over the strongest baseline, achieves a GREEN clinical faithfulness score of 0.800, and produces interpretable reasoning traces grounded in multi-view visual evidence.