Artificial Intelligence in Echocardiography: Five Clinical Challenges and a Roadmap Toward Responsible Integration by 2030

Artificial intelligence (AI)-enabled echocardiography has demonstrated strong agreement with expert measurements across a broad range of cardiac functional parameters. However, the transition from technical validation to clinical impact remains incomplete. This structured narrative review employed a systematic literature search to identify the principal structural barriers to AI integration in echocardiography and to develop an expert-informed, evidence-grounded perspective on the priorities for responsible implementation by 2030. The methodological heterogeneity of the included studies, including retrospective and prospective designs, diverse outcome measures ranging from measurement agreement to workflow implementation, and multiple AI application domains, precluded quantitative pooling. Therefore, qualitative synthesis was selected as the primary prespecified analytical approach. PubMed/MEDLINE was searched for studies published between January 2015 and January 2026 addressing clinical AI applications, real-world validation, implementation science, and governance. Forty-six studies meeting predefined inclusion criteria underwent qualitative synthesis. Five interdependent domains were identified: reproducibility across clinical settings, generalizability beyond development datasets, the lack of outcome-focused evidence, regulatory and governance immaturity, and insufficient trust among clinicians and patients. Automated measurements of left ventricular function, strain, and valvular disease severity demonstrate close agreement with expert assessments. However, few studies have shown that AI-assisted echocardiography translates into improved patient outcomes. Based on the available evidence, the principal translational barrier appears to be not algorithmic capability itself, but rather the structural requirements necessary for accountable clinical integration. An expert-informed, evidence-grounded roadmap emphasizing decision-level reproducibility, rigorous external validation, outcome-linked evidence generation, continuous lifecycle governance, and human-centered design is proposed to guide the integration of AI into echocardiography and to support the development of a more durable and accountable clinical infrastructure by 2030.