Echocardiographic Contrast Agent Research Articles

First-in-human noninvasive left ventricular ultrasound pacing: A potential screening tool for cardiac resynchronization therapy.

A screening tool to predict response to cardiac resynchronization therapy (CRT) could improve patient selection and outcomes. The purpose of this study was to investigate the feasibility and safety of noninvasive CRT via transcutaneous ultrasonic left ventricular (LV) pacing applied as a screening test before CRT implants. P-wave-triggered ultrasound stimuli were delivered during bolus dosing of an echocardiographic contrast agent to simulate CRT noninvasively. Ultrasound pacing was delivered at a variety of LV locations with a range of atrioventricular delays to achieve fusion with intrinsic ventricular activation. Three-dimensional cardiac activation maps were acquired via the Medtronic CardioInsight 252-electrode mapping vest during baseline, ultrasound pacing, and after CRT implantation. A separate control group received only the CRT implants. Ultrasound pacing was achieved in 10 patients with a mean of 81.2 ± 50.8 ultrasound paced beats per patient and up to 20 consecutive beats of ultrasound pacing. QRS width at baseline (168.2 ± 17.8 ms) decreased significantly to 117.3 ± 21.5 ms (P<.001) in the best ultrasound paced beat and to 125.8 ± 13.3 ms (P <.001) in the best CRT beat. Electrical activation patterns were similar between CRT pacing and ultrasound pacing with stimulation from the same area of the LV. Troponin results were similar between the ultrasound pacing and the control groups (P = .96), confirming safety. Noninvasive ultrasound pacing before CRT is safe and feasible, and it estimates the degree of electrical resynchronization achievable with CRT. Further study of this promising technique to guide CRT patient selection is warranted.

ТРОМБОЗ ЛЕВОГО ЖЕЛУДОЧКА В КЛИНИЧЕСКОЙ ПРАКТИКЕ

Left ventricular thrombosis is a potentially life-threatening condition due to a significant risk of stroke and systemic thromboembolism. Despite the more frequent use of primary percutaneous coronary interventions and dual antiplatelet therapy in clinical practice the majority of left ventricular thrombus are diagnosed after myocardial infarction, although such a complication can occur both in ischaemic and non-ischaemic cardiomyopathies. The article provides information on left ventricular thrombosis in internal diseases according to current concepts. The authors characterize risk factors and pathophysiological mechanisms in thrombosis, the predictors of embolic events. Modern imaging methods for diagnosis of left ventricular thrombosis are described. The article outlines that cardiac magnetic resonance has the highest diagnostic accuracy, followed by echocardiography with the use of echocardiographic contrast agents. Particular attention is paid to the treatment with vitamin K antagonists and direct oral anticoagulants. There is growing evidence of the benefits of direct acting oral anticoagulants in treatment of left ventricular thrombosis. It is expected that ongoing clinical trials will help elucidate the best management strategies for these patients.

Abstract 11227: A Rare Case of Echo Contrast Anaphylaxis Complicated by Acute Coronary Syndrome

Introduction: Contrast agents in echocardiography are used frequently to enhance endocardial border visualization and assessment of structural heart disease. Sulfur hexafluoride lipid type A injectable suspension is a generally well-tolerated class of contrast. Anaphylaxis to these agents is exceedingly rare. We now report the first case of acute coronary syndrome in the setting of echo contrast anaphylactic shock. Case: A 49-year-old woman was hospitalized for an ST-elevation myocardial infarction (STEMI) for which a drug-eluting stent had been placed in the left anterior descending artery (LAD). An echocardiogram was performed to evaluate for structural heart disease. Shortly after administration of echo contrast the patient developed sudden-onset tachypnea and suffered a pulseless electrical activity cardiac arrest. She was treated for anaphylactic shock with epinephrine and high-dose steroids and achieved return of spontaneous circulation. Following the arrest an electrocardiogram revealed an anterolateral STEMI. The patient immediately underwent repeat angiography which revealed a 100% in-stent thrombosis of the LAD. The occlusion was successfully revascularized with a drug eluting stent with an Impella CP (Abiomed, Danvers MA) support. Subsequent laboratory exam demonstrated an elevated blood tryptase level consistent with an anaphylactic event. Discussion: We present a unique case of anaphylactic shock with acute coronary syndrome following administration of sulfur hexafluoride echo contrast. The incidence of anaphylaxis to echo contrast is less than one per million, and therefore it may not be immediately recognized as a mechanism of shock. Any prior reactions to polyethylene glycol should be noted before using these agents as this ingredient is thought to be the cause of anaphylaxis. In our case, diagnosis of anaphylaxis was confirmed by measuring the serum tryptase level. Tryptase is released from mast cells during allergic events, so this laboratory test with high specificity for anaphylaxis can be a useful tool in challenging cases such as this. Additionally, mast cell and platelet activation secondary to anaphylaxis may be an important mechanism of acute coronary syndrome with in-stent thrombosis.

C43 A CASE REPORT OF A GIANT RIGHT CORONARY ARTERY ANEURYSM: ROLE OF CONTRAST ECHOCARDIOGRAPHY

Abstract A giant coronary aneurysm is rare entity and it is defined if the diameter is 4–fold greater the reference vessel diameter or if it is &amp;gt; 20 mm in diameter. We report the case of a 73–years–old man without prior history of cardiac disease, admitted in Emergency Department for abdominal pain with normal ECG. Abdominal CT scan showed no pathological findings. At thoracic level it was reported a suspected pericardial cyst (75x80 mm), with partial compression of right chambers (Fig. 1). Echocardiography confirmed the presence of a giant round cystic–appearance lesion characterized by the presence of an anechoic space with internal echogenic swirling flow pattern at the level of right atrioventricular groove with mild compressive effect on right chambers. (Fig. 2). The color Doppler mode showed a faint signal, without a clear evidence of flow origin. A bubble test with agitated saline contrast medium injected through antecubital vein, shows no evidence of contrast uptake by the mass. In order to better characterize the lesion, we use echocardiographic contrast agent (SonoVue®), which showed a clear pattern of blood flow inside the mass with a probable origin at a very limited region (Fig. 2a–2b). At that level it was also possible to sample an ECG–synchronized systo–diastolic pulse–wave (PW)–Doppler pattern (peak velocity 125 cm/s), typical for a coronary artery flow. According to these echocardiographic findings, we supposed a giant right coronary aneurysm. Coronary Computed Tomography Angiography with 3D reconstruction showed a giant aneurysm of the right coronary artery at mid–level, preceded by a mild aneurysm of the proximal tract and two small aneurysms of the circumflex artery and diffuse atherosclerosis diseases with significant stenosis on mid left anterior descending artery (LAD). The coronary angiography confirmed the presence of the giant aneurysm in mild tract of right coronary artery preceded by a small one in the proximal tract andthe two small aneurysm of the circumflex artery and a critical stenosis of mid tract of LAD. The patient underwent surgical treatment of the aneurysm and coronary artery bypass graft (Fig. 3). Computed Tomography Coronary Angiography is the best method for coronary artery anatomy and coronary abnormalities. In case of giant coronary abnormalities, the use of echo contrast agent provides further important information about perfusion and/or flow assessment and it helped to clarify the diagnosis.

Safety of SF6(SonoVue®) Contrast Agent on Pharmacological Stress Echocardiogram.

ResumoFundamento Em 2007, a Food and Drug Administration (FDA) determinou revisões sobre segurança dos agentes de contraste ecocardiográfico (ACE) disponíveis no mercado após relatos de mortes. Ao longo desses anos, diversos estudos comprovaram a segurança dos ACE, porém com poucos estudos relacionados ao SonoVue®.Objetivos Avaliar a segurança do SonoVue® durante o ecocardiograma sob estresse farmacológico (EEF) por meio da análise da incidência de reações alérgicas e da comparação entre os grupos quanto ao surgimento de arritmia, efeitos colaterais menores e eventos adversos.Métodos Estudo observacional, prospectivo, no qual 2.346 pacientes foram submetidos ao EEF e divididos em dois grupos: grupo 1 com ACE (n=1.099) e grupo 2 sem ACE (n=1.247). Os pacientes foram avaliados durante o EEF – 24 horas e 30 dias. Foi definido p significativo quando <0,05.Resultados O grupo 1 apresentou efeitos colaterais mais leves, como cefaleia (5/0,5% vs. 19/1,5%, p=0,012) e hipertensão reativa (3/0,3% vs . 19/1,5%, p=0,002), menos arritmias como extrassístoles ventriculares (180/16,4% vs . 247/19,8%, p=0,032) e taquicardia paroxística supraventricular (2/0,2% vs . 15/1,2%, p=0,003), assim como nenhum evento adverso como infarto agudo do miocárdio (IAM) e óbito. No grupo 2, um paciente apresentou IAM <24h (1/01%) e dois óbitos <30 dias (2/0,1%). Urticária relacionada ao SonoVue® foi observada em 3 (0,3%) pacientes sem reação anafilática.Conclusão SonoVue® demonstrou segurança durante o EEF, não sendo observados morte, IAM ou reação anafilática. Observou-se menor incidência de efeitos colaterais mais leves e arritmias no grupo que utilizou o ACE, assim como baixa incidência de reações alérgicas leves.

Management of left ventricular thrombus: a narrative review.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

FINDING A HOLE IN THE DARK: A NOVEL USE OF ECHOCARDIOGRAPHIC CONTRAST TO IDENTIFY MYOCARDIAL PERFORATION

Myocardial perforation is a known risk of lead implantation. We present the first description of Lumason, an echocardiographic contrast agent, confirming myocardial perforation after transvenous pacemaker (TVP) removal. A 75 year old male with hypertension presented with chest pain and acute

Intermolecular Forces Model for Lipid Microbubble Shells.

Lipid-coated microbubbles are currently used clinically as ultrasound contrast agents for echocardiography and radiology and are being developed for many new diagnostic and therapeutic applications. Accordingly, there is a growing need to engineer specific formulations by employing rational design to guide lipid selection and processing. This approach requires a quantitative relationship between lipid chemistry and interfacial properties of the microbubble shell. Just such a model is proposed here on the basis of lateral Coulomb and van der Waals interactions between lipid head- and tailgroups, using previous coarse graining and force fields developed for molecular dynamics simulations. The model predicts with sufficient accuracy the monolayer permeability, the elasticity as a function of either lipid composition or temperature, and the equilibrium spreading surface tension of the lipid onto an air/water interface. In the future, the intermolecular forces model could be employed to elucidate more complex phenomena and to engineer novel microbubble formulations.

Variability of left ventricular volume and ejection fraction measurements using contrast echocardiography: The influence of the left ventricular length measurements in a large cohort of patients during monitoring cardiotoxic effects of chemotherapy.

To investigate the influence of length difference in left ventricular (LV) long axis between the apical four-chamber and two-chamber views on measurements of LV volumes and ejection fraction (EF). Seven hundred consecutive cancer patients underwent contrast echocardiography from July 2010 to May 2014. All patients received the echocardiographic contrast agent Definity. Recordings of apical views were analyzed by a sonographer and then by a cardiologist. The end-diastolic and end-systolic LV volumes (EDV and ESV), and LV lengths as well as EF, were measured using the biplane Simpson's method. Inter-observer variability was assessed using relative mean error (RME) and Bland-Altman analysis. Six hundred ninety-two patients had contrast echocardiograms with complete endocardial definition. The LV length difference of the long axis measured by the cardiologist was ≤1mm in 284 studies (41%), 2mm in 146 studies (21%), 3mm in 103 studies (15%), and ≥4mm in 159 studies (23%). The limits of agreement (LOA) and RME increase with the increasing length difference. Compared to the groups with length difference <4mm, the RME of the measurements of indexed EDV, indexed ESV, and EF was significantly greater in the group with length difference ≥4mm (P<.05). These results highlight the need for reviewing the LV long axis length measurements in order to provide reproducible LV volumes and EF measurements and may be used as benchmarks for quality control. A length difference of ≤3mm can be achieved in most of our patients and is associated with an excellent inter-observer agreement.

Safety With Echocardiographic Contrast Agents.

In October 2007, the Food and Drug Administration mandated significant revisions to product labeling for the commercially available echocardiographic contrast agents (ECA) Definity and Optison after spontaneous healthcare provider reports of 4 patient deaths and ≈190 severe cardiopulmonary reactions occurring in close temporal relationship to ECA administration. Since then, multiple large ECA safety studies have been published and have included outpatients, hospitalized patients (including the critically ill), patients undergoing stress echocardiography, and patients with pulmonary hypertension. In addition, the Food and Drug Administration has convened 2 Advisory Committee meetings and the product labels for Optison and Definity have been substantially revised with a softening of safety restrictions. In this review, we will address the safety of ECA use in patients with serious cardiopulmonary conditions, patients with intracardiac shunts, and special patient populations including pulmonary hypertension, pediatrics, and pregnancy. In addition, we will discuss the confounding role of pseudocomplication in attribution of adverse events during diagnostic testing, the current status of the ECA Black Box Warning, and recommended safety precautions during ECA administration.

Gelatin lights-agitated gelatin as an echocardiographic contrast agent for alcohol septal ablation

A good contrast echocardiographic study enhances the safety and efficacy of alcohol ablation procedures. Newer generation echocardiographic contrast agents and conventional radiographic contrast agents when used as echocardiographic contrast agents for this purpose are often unsatisfactory. We describe the use of agitated modified gelatin, a cheap and readily available agent that provides excellent echocardiographic images and identifies the myocardium supplied by the targeted septal artery.

The Use of Contrast Echocardiography to Identify Infiltrating Lymphoma in the Myocardium

Introduction Echocardiographic contrast agents are approved by the US Food and Drug Administration (FDA) for delineation of the LV endocardium however its role in the assessment of myocardial disease has not been defined [1]. Contrast echocardiography has demonstrated an ability to better differentiate myocardial tissue with respect to myocardial blood flow. Ultrasound contrast agents have been demonstrated to be useful in differentiating thrombi from benign and malignant neoplasms that are confined to the endocardium [1,2]. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions. In our patient, contrast enhanced echocardiography identified infiltrating lymphoma in the myocardium that was not seen with standard 2D imaging. Case Description 68 year-old African American man, with a past medical history of AITL and hepatitis C virus, presented with 2 weeks of weakness and fatigue. Symptoms were associated low grade fevers, but were non-exertional and not associated with chest pain, shortness of breath, dyspnea on exertion or cough. Medical history included AITL with autoimmune hemolytic anemia, initially diagnosed 3 years prior to admission. Patient completed CHOP (Cyclophospharmide/Doxorubicin/Vincristine) Chemotherapy. He was in remission until 2 months prior to this admission; at which point he was found to have recurrence in his right axillary lymph node and was started on ICE (Ifosfamide/Carboplatin/Etoposide). There was no known history of cardiovascular disease. Physical exam revealed tachycardia, positive jugular venous distention, bibasilar crackles on pulmonary exam, and +1 pitting peripheral edema. Cardiac exam displayed regular rate and rhythm, with normal S1/S2 but cardiac sounds were muffled. Labs showed a BMP within normal limits. CBC revealed a leukocytosis (Wbc=23.8 10xe3/mm3) with a left shift with a new anemia (Hgb of 8.5 g/dl) and thrombocytopenia (Plt=67 10xe3/mm3). Additionally, a BNP=442 pg/ml and Trop=0.12 ng/ml

Is bacteriostatic saline superior to normal saline as an echocardiographic contrast agent?

Objective data on the performance characteristics and physical properties of commercially available saline formulations [normal saline (NS) vs. bacteriostatic normal saline (bNS)] are sparse. This study sought to compare the in vitro physical properties and in vivo characteristics of two commonly employed echocardiographic saline contrast agents in an attempt to assess superiority. Nineteen patients undergoing transesophageal echocardiograms were each administered agitated regular NS and bNS injections in random order and in a blinded manner according to a standardized protocol. Video time-intensity (TI) curves were constructed from a representative region of interest, placed paraseptally within the right atrium, in the bicaval view. TI curves were analyzed for maximal plateau acoustic intensity (Vmax, dB) and dwell time (DT, s), defined as time duration between onset of Vmax and decay of video intensity below clinically useful levels, reflecting the duration of homogenous opacification of the right atrium. To further characterize the physical properties of the bubbles in vitro, fixed aliquots of similarly agitated saline were injected into a glass well slide-cover slip assembly and examined using an optical microscope to determine bubble diameter in microns (µm) and concentration [bubble count/high power field (hpf)]. A higher acoustic intensity (a less negative dB level), higher bubble concentration and longer DT were considered properties of a superior contrast agent. For statistical analysis, a paired t test was conducted to evaluate the differences in means of Vmax and DT. Compared to NS, bNS administration was associated with superior opacification (video intensity -8.69 ± 4.7 vs. -10.46 ± 4.1 dB, P = 0.002), longer DT (17.3 ± 6.1 vs. 10.2 ± 3.7 s) in vivo and smaller mean bubble size (43.4 vs. 58.6 μm) and higher bubble concentration (1,002 vs. 298 bubble/hpf) in vitro. bNS provides higher intensity and more sustained opacification of the right atrium compared to NS. Higher bubble concentration and stability appear to be additional desirable rheological characteristics favoring bNS as a contrast agent.

Successful surgery for lateral left ventricular wall rupture with severe mitral insufficiency resulting in cardiogenic shock

A 68-year-old female was admitted to the intensive cardiac care unit with acute (6 h from pain onset) lateral myocardial infarction (MI) with ST elevation and cardiogenic shock, treated with successful circumflex stenting. On day 5, she developed pulmonary oedema and new systolic murmur 4/6 over apex. Transthoracic echocardiography (TTE) revealed a wide rupture of the left ventricular (LV) lateral wall with pseudoaneurysm entry of 46 mm (Fig. 1). A severe mitral regurgitation due to extreme mitral leaflets restriction was the predominant haemodynamic disorder (Fig. 2). The patient was supported with an intraaortic balloon and immediately transferred by air to the cardiosurgical unit, where successful reconstruction of the left ventricle with Dor’s method and mitral annuloplasty with a 28 mm ring was performed. Control contrast TTE and magnetic resonance imaging two weeks later showed a small pericardial patch leak with residual pseudoaneurysm of 18 mm diameter with LV ejection fraction of 34% and insignificant mitral regurgitation (Figs. 3, 4). This case illustrates the successful treatment of a severe mechanical complication with unusual pathophysiology resulting in functional NYHA class II eight months after surgery. A delay in hospital admission for acute MI is often associated with higher mortality, severe complications such as heart rupture (HR) with an incidence as high as 6% in the prereperfusion era, 1–4 accounting for up to 30% of hospital mortality. A free wall HR occurs in 0.45% of patients with MI treated with percutaneous coronary intervention (PCI), although primary PCI is not independently related to HR. The main risk factors for HR are: ST-segment elevation/left bundle branch block; ST-segment deviation; female sex; previous stroke; positive initial cardiac biomarkers; and older age. TTE is the first line tool for a suspected myocardial rupture, and intravenous echocardiographic contrast agent may be useful for the evaluation of the development of an LV pseudoaneurysm (LVP). However, contrast-enhanced myocardial resonance imaging helps to delineate the location and extent of the myocardial rupture, providing valuable structural and functional information in the assessment of LVP. Prompt diagnosis and early surgical intervention is essential for patients with a large or expanding LVP due to the high propensity for fatal rupture.

ST-segment elevation associated with allergic reaction to echocardiographic contrast agent administration.

We report a case of an allergic reaction after the administration of an echocardiographic contrast agent which resulted in ST-segment elevation. Hypersensitivity and allergic reactions are known causes of acute cardiovascular events. However, only limited reports are available which suggest the exact mechanism of the occurrence of angina or myocardial infarction during severe allergic reactions. In our case, through invasive imaging (coronary angiography and IVUS) we have shown for the first time a transient coronary spasm in the absence of intra-coronary thrombus and only minimal neointimal hyperplasia.

Comparative Prediction of Cardiac Events by Wall Motion, Wall Motion Plus Coronary Flow Reserve, or Myocardial Perfusion Analysis: A Multicenter Study of Contrast Stress Echocardiography

This study sought to determine whether the increasing difficulty of assessing wall motion (WM), Doppler coronary flow reserve on the left anterior descending coronary artery (CFR-LAD), and myocardial perfusion (MP) during stress echocardiography (SE) was justified by increasing prognostic information in patients with known or suspected coronary artery disease. The use of echocardiographic contrast agents during SE permits the assessment of both CFR-LAD and MP, but their relative incremental prognostic value is undefined. This study followed a multicenter cohort of 718 patients for 16 months after high-dose dipyridamole contrast SE for evaluation of known or suspected coronary artery disease. The ability of WM, CFR-LAD, and MP to predict cardiac events was studied by multivariable models and risk reclassification. Abnormal SE was detected as a reversible WM abnormality in 18%, reversible MP defect in 27%, and CFR-LAD <2 in 38% of subjects. Fifty cardiac events occurred (annualized event rate 6.0%). A normal MP stress test had a 1-year hard event rate of 1.2%. The C-index of outcomes prediction based on clinical data was improved with MP (p < 0.001) and WM/CFR-LAD (p = 0.037), and MP (p = 0.003) added to clinical and WM data. Net risk reclassification was improved by adding MP (p < 0.001) or CFR-LAD (net reclassification improvement p = 0.001) in addition to clinical and WM data. The model including clinical data, WM/CFR-LAD, and MP performed better than that without MP did (p = 0.012). The multiparametric assessment of WM, CFR-LAD and MP during stress testing in patients with known or suspected coronary artery disease is feasible. Contrast SE allowed better prognostication, irrespective of the use of CFR-LAD or MP. The addition of either CFR-LAD or MP assessment to standard WM analysis and clinical parameters yielded progressively higher values for the prediction of cardiac events and may be required in today's intensively treated patients undergoing SE, because their average low risk of future cardiac events requires methods with higher predictive sensitivity than that available with standalone WM assessment.

Two-Dimensional Longitudinal Strain Assessment in the Presence of Myocardial Contrast Agents Is Only Feasible with Speckle-Tracking after Microbubble Destruction

Longitudinal strain (LS) imaging is an important tool for the quantification of left ventricular function and deformation, but its assessment is challenging in the presence of echocardiographic contrast agents (CAs). The aim of this study was to test the hypothesis that destruction of microbubbles using high mechanical index (MI) could allow the measurement of LS. LS was measured using speckle strain (speckle-tracking LS [STLS]) and Velocity Vector Imaging (VVI) before and after CA administration in 30 consecutive patients. Low MI was used for left ventricular opacification and three-dimensional high MI for microbubble destruction. Four different settings were tested over 60 sec: (1) baseline LS without contrast, (2) LS after CA administration with low MI (0.3), (3) LS after CA administration with high MI (0.9), and (4) LS after microbubble destruction with high MI and three-dimensional imaging. Baseline feasibility of LS assessment (99.3% and 98.2% with STLS and VVI, respectively) was reduced after CA administration using STLS at low (69%, P < .0001) and high (95.4%, P= .0002) MI as well as with VVI (93.8%, P= .004, and 84.7%, P < .0001, respectively). STLS assessment was feasible with high MI after microbubble destruction (1.7% of uninterpretable segments vs 0.7%, P= .26) but not using VVI (7.2% vs 1.8%, P < .001). Regardless of which microbubbles or image settings were used, VVI was associated with significant variability and overestimation of global LS (for low MI,+4.7%, P < .01; for high MI,+3.3%, P < .001; for high MI after microbubble destruction,+1.3%, P= .04). LS assessment is most feasible without contrast. If a CA is necessary, the calculation of LS is feasible using the speckle-tracking method, if three-dimensional imaging is used as a tool for microbubble destruction 1 min after CA administration.

Implementation of echocardiographic contrast agents into clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography

The administration of echocardiographic contrast agents has been shown to improve accuracy and be cost-effective in patients with suboptimal endocardial definition. We sought to investigate the implementation of contrast agents in clinical practice. An electronic questionnaire was devised to determine the use of contrast ultrasound agents in clinical practice and sent electronically to echocardiography departments at each national health service hospital within the UK. Out of 198, 107 departments responded (54%). Out of 673,121 echocardiograms, 25,834 (3.8%) were performed with contrast. Out of 551 echocardiography machines, 358 (65%) were suitable for contrast use. Of the sonographers, out of 711, 112 (15.8%) could perform i.v. cannulation and 42 (5.9%) could administer contrast independently. The median time for an echocardiographic examination was 30 min (inter-quartile range 30-45 min). Significant predictors of contrast use were the presence of a consultant cardiologist with subspecialty training in echocardiography (odds ratio 8.7, P = 0.004), the presence of a stress echocardiography service (odds ratio 2.3, P = 0.004), and the presence of a physician during the day (odds ratio 3.0, P = 0.04). Reasons for impediment in administering contrast were staff training (34.6%), extra time required for a contrast study (29.9%), and the expense of contrast (18.7%). The use of echocardiographic contrast agents within routine echocardiographic practice in the UK is limited to <4% of all transthoracic echocardiographic studies. Major barriers to the implementation of contrast use are the absence of cardiac imaging specialists directly supervising echocardiography departments and the training of sonographers to independently administer contrast.

Echokontrastmittelgesteuerte Alkoholablation bei hypertropher obstruktiver Kardiomyopathie mit neuem Echokontrastmittel

Myocardial contrast echocardiography guided alcohol septal ablation (PTSMA) is an established treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Most important properties of the optimal echocardiographic contrast agent are good contrast imaging and sufficient stability without fast washing out. HOCM was diagnosed in a 49-year-old female patient 4 years before first admission. Despite optimal medical treatment the patient was highly symptomatic with angina pectoris and dyspnoea NYHA II-III.Investigations, treatment and course: ECG showed signs of left ventricular hypertrophy. Echocardiography revealed asymmetric septal hypertrophy, dynamic LVOT obstruction with pronounced SAM and associated moderate mitral valve regurgitation. Coronary angiography performed in the catheterization laboratory showed coronary atherosclerosis and haemodynamic measurements verified a significant LVOT obstruction. An atypical septal branch, originating from the intermediate artery, was regarded as target branch and was occluded with a balloon catheter. For the contrast echocardiography guided septal ablation cold, agitated Gelafundin® was used. This led to a good subaortic septal contrast demarcation with confirmation of the correct choice of target branch. No arrhythmias were recorded during the administration of contrast medium. Injection of Levovist® in the same septal branch for comparison resulted in opacification of the same myocardial area without any sign of misplacement. After alcohol injection in the balloon-occluded septal branch, an effective elimination of the LVOT gradient could be haemodynamically documented. For contrast echocardiography guided PTSMA a good myocardial opacification with an appropriate contrast agent is essential, not only to recognize the obstruction dependent region but also to identify any possible misplacement. Gelafundin® seems to offer similarly sufficient contrast potential as Levovist®, so that Gelafundin® could be a possible alternative.

Meta-Analysis of Adverse Cardiovascular Events Associated With Echocardiographic Contrast Agents

In October 2007, the Federal Drug Agency issued a black box warning for contrast agents used in patients undergoing echocardiography and restricted their use in patients with acute coronary syndrome, a decompensated heart, and respiratory failure. We performed a systemic review and meta-analysis to study the adverse effects of contrast agents used with respect to myocardial infarction and all-cause mortality. MEDLINE, EMBASE, BIOSIS, and Cochrane databases from inception to October 2009 were searched for studies that reported myocardial infarction and all-cause mortality after the use of contrast agents for echocardiography. A total of 8 studies were included in the present meta-analysis. A random-effect model was used, and between-studies heterogeneity was estimated with I(2). A total of 8 studies reported death as an outcome and only 4 reported myocardial infarction. The incidence of death in the contrast group was 0.34% (726 of 211,162 patients) compared to 0.9% (45,970 of 5,078,666 patients) in the noncontrast group. The pooled odds ratio was 0.57 (95% confidence interval 0.32 to 1.01, p = 0.05). The reported incidence of myocardial infarction in the contrast group was 0.15% (86 of 57,264 patients) compared to 0.2% (92 of 44,503 patients) in the noncontrast group. The pooled odds ratio was 0.85 (95% confidence interval 0.35 to 2.05, p = 0.72). Significant heterogeneity was seen among the studies. In conclusion, the cumulative evidence has suggested that the use of contrast agents for echocardiography is safe and not associated with a greater incidence of myocardial infarction or and mortality.