Contrast Two-dimensional Echocardiography Research Articles

Targeting Alcohol Septal Ablation in Patients with Obstructive Hypertrophic Cardiomyopathy Candidates for Surgical Myectomy: Added Value of Three-Dimensional Intracoronary Myocardial Contrast Echocardiography.

Background: Myocardial contrast two-dimensional echocardiography (MC-2DE) is widely used to address alcohol septal ablation (ASA) in obstructive hypertrophic cardiomyopathy (HCM). Owing to its limited cut-planes, MC-2DE may inaccurately identify the contrast misplacement associated with an unsuccessful or complicated ASA outcome. Objective: The aim of this study was to assess the added value of myocardial contrast three-dimensional echocardiography (MC-3DE) compared with MC-2DE to identify the appropriate matching between the target septal zone (TSZ) and coronary artery branch for safe and long-term effective ASA in HCM patients. Methods: A consecutive series of 52 symptomatic obstructive HCM patients referred for isolated surgical myectomy (SM) was analyzed with MC-2DE and MC-3DE following injection of echocontrast into one or more septal branches. MC-2DE and MC-3DE patterns were categorized according to complete (Type 1) or incomplete (Type 2) TSZ covering, high-risk (Type 3) exceeding TSZ, or life-threatening outside TSZ distribution (Type 4). Results: MC-2DE per patient analysis showed a Type 1 pattern in 32 patients and Types 2–4 in the remaining 20 patients; subsequent MC-3DE analysis provided a re-phenotyping of MC-2DE findings in 22 of the 52 patients (42%), showing a high-risk Type 2 pattern in 17 of the 32 patients with Type 1, and a new life-threatening Type 4 in three patients with Type 2, respectively. All patients with MC-3DE Type 1 pattern underwent safe and effective ASA with a long-term uneventful follow-up, while the remaining patients underwent SM. Conclusions: Refining high risk or life-threatening contrast misplacement, MC-3DE is more accurate than conventional MC-2DE to target safe and long-term effective septal reduction with ASA in obstructive HCM patients referred for isolated SM.

Head-to-head comparison of real-time three-dimensional transthoracic echocardiography with transthoracic and transesophageal two-dimensional contrast echocardiography for the detection of patent foramen ovale

To assess the incremental value of real-time three-dimensional echocardiography (RT-3DTE) over contrast transthoracic echocardiography (TTE), compared with contrast transesophageal echocardiography (TEE) in the identification of patent foramen ovale (PFO). Eighty-one consecutive patients with history of migraine headache (MH) or unexplained cerebrovascular events (CE) were examined using RT-3DTE, contrast TTE, and contrast TEE in sequence. Feasibility of RT-3DE in patients with MH and CE was 98 and 91%, respectively. Mean time for 3D colour data set acquisition was 9 +/- 5 min. PFO was diagnosed using contrast TEE in 36 patients (overall prevalence = 44%). Diagnostic accuracy of RT-3DE was significantly higher than that of contrast TTE: sensitivity 83 vs. 44%, P < 0.001; specificity 100 vs. 100%, P7 = NS; positive predictive value 100 vs. 100%, P = NS; negative predictive value 88 vs. 69%, P < 0.01; accuracy 93 vs. 75%, P < 0.003. Five of the six patients in whom RT-3DTE did not identify PFOs showed a defect diameter smaller than 2 mm. RT-3DTE is a feasible, accurate, and reproducible technique to detect PFO without the need of saline contrast injection. Its accuracy is superior to contrast 2D TTE and close to that of contrast TEE.

Imaging of Ventricular Septal Tumor in an Asymptomatic Adolescent using Multiple Modalities

Primary cardiac tumors are rare at all ages, and especially so in childhood, where the most prevalent type of benign cardiac masses are rhabdomyomas followed by fibromas, both of which have a predilection for ventricular septum. We report an unusual case of a tumor involving the ventricular septum in an asymptomatic 17-year-old adolescent who has been known to have this tumor for 10 years. The use of multiple imaging included myocardial contrast two-dimensional echocardiography, real time three-dimensional echocardiography (with and without myocardial contrast), and magnetic resonance imaging supported the diagnosis of cardiac rhabdomyoma.

Contrast enhanced real-time three-dimensional echocardiography for quantification of myocardial perfusion: a step forward

Many studies have shown the feasibility of contrast two-dimensional echocardiography (2DE) for myocardial perfusion imaging.1 The technique offers several important advantages over competing techniques including its wide availability, portability, low cost, no radiation concern, and the simultaneous visualization of wall motion and perfusion. However, contrast echocardiography has not become a routine procedure both for the diagnosis and assessment of ischaemic heart disease in daily practice. There are several reasons for this: no echo contrast agent has been specially approved for myocardial perfusion imaging, there are concerns about safety and reimbursement issues. In addition, it is well recognized that 2D images of the heart do not provide accurate information on both the extent and severity of myocardial perfusion defects. Theoretically, 3D imaging allows a more accurate assessment of the myocardial perfusion defects but its use and advantages in patients could not be explored until the development of real-time three-dimensional echocardiography (RT3DE). This technique allows to capture the entire myocardial volume during a single contrast injection, thus obviating the need of repeated injections of boluses of a contrast agent during sequential consecutive acquisition of multiple 2DE planes needed for off-line …

Primary cardiac angiosarcoma evaluated with contrast two-dimensional and real-time three-dimensional echocardiography

A 63-year-old lady presented with syncope and atypical chest pain. Conventional two-dimensional (2D) contrast echocardiogram showed a highly vascular mass compressing the right atrium without direct communication. A real-time three-dimensional echocardiogram (RT3DE) revealed its outer spatial relationship with the surrounding structures and its inner heterogeneity as well. A chest computed tomography revealed a solid cardiac mass (6 x 7 cm(2)) arising from the right atrium and multiple pulmonary nodules. Histopathology of the pericardial fluid confirmed angiosarcoma. To our knowledge, this is the first report of histology-confirmed primary cardiac angiosarcoma, which was completely evaluated by conventional 2D, contrast, and RT3DE.

Borderzone Geometry After Acute Myocardial Infarction: A Three-Dimensional Contrast Enhanced Echocardiographic Study

Regional myocardial geometry, function, and perfusion status are critical variables for understanding infarction-induced left ventricle (LV) remodeling. Three-dimensional contrast echocardiography (3DCE) is uniquely suited to measure these parameters. We evaluate the ability of 3DCE to assess geometric changes in the normally perfused but hypocontractile borderzone myocardium (BZM) immediately after a myocardial infarction (MI) in an ovine model, and we compare 3DCE with two-dimensional contrast echocardiography (2DCE) in the long and short axis. Four sheep were studied with 3DCE and 4 were studied using 2DCE, before and 30 minutes after an anteroapical MI. Each 3DCE data set was acquired over 18 consecutive cardiac cycles. The LV geometry was reconstructed and perfusion data spatially correlated, thereby constituting a 3D model of ventricular geometry and perfusion. The borderzone was defined as the contrast-perfused myocardium adjacent to the infarct. The 2DCE short-axis analysis demonstrated decreased curvature and decreased wall thickness in the borderzone after MI. These findings are consistent with increased BZM wall stress. However, the long-axis 2DCE analysis demonstrated increased BZM wall thickness and a surprising change in BZM concavity acutely after infarction. The 3DCE analysis confirmed these findings and added additional information regarding regional variability in BZM geometry that was not evident in the two orthogonal 2D views. This study provides evidence that regional changes in BZM geometry are more complex than previously believed and are not necessarily indicative of increased regional stress. The superiority of 3DCE over 2DCE for assessing these changes is strongly supported.

An experimental intraoperative quantitative echocardiographic study of myocardial perfusion in dogs

Myocardial contrast echocardiography is a valuable technique for demonstration and delineation of regions of myocardial underperfusion secondary to coronary occlusion and/or significant coronary stenosis. Various contrast materials have been used. The aim of this study was to determine whether myocardial contrast echocardiography by the original contrast agent AQ-DDT (albumin based), produced in the Institute for Cardiovascular Diseases, Clinical Center of Serbia in Belgrade can be used in the detection and quantification of regions of myocardial perfusion defects. In 14 adult open chest dogs the perfusion defect was produced by selective coronary ligations (30 seconds) and was observed with epicardial contrast two-dimensional echocardiography. For administration of contrast a modified pigtail catheter was positioned in the aorta just above the aortic valves. In this way the perfusion regions of the left main and right coronary artery were included. The left anterior descending and left circumflex artery could not be selectively injected with contrast agent and their individual perfusion areas were not clearly demonstrated. In all cases contrast echocardiography images of the left ventricle were obtained in a short-axis cross-sectional view at the mid-papillary muscle level. Forty-two injections of AQ-DDT for perfusion analysis were done, and were recorded on a VHS recorder. Quantification of the quality in demonstrating myocardial perfusion was scored as good, poor or without visual echocardiographic effect, by an investigator experienced in echocardiography, immediately and one month later. There was 100% agreement in the scoring. Our results indicated that agent AQ-DDT produces a good contrast effect (echocardiography visualization) in dogs and has the potential to demonstrate regional perfusion defects of the myocardium. Its potential role in human medicine, for diagnosis and evaluation of the results of interventional therapy, especially during aortocoronary bypass graft surgery, should be evaluated.

Assessment of segmental wall motion abnormalities using contrast two-dimensional echocardiography in awake mice.

Murine models of cardiac disease are becoming an important tool for studying pathophysiological processes. Development of methods to accurately assess ventricular function are therefore important. The purpose of this study was to evaluate the feasibility of echocardiographic assessment of segmental wall motion abnormalities in a murine model of myocardial infarction. Two-dimensional contrast (C+) and noncontrast (C-) echocardiography were performed in 76 awake mice 2 days before and 2 days after left coronary ligation. The short-axis images obtained with two-dimensional echocardiography and corresponding postmortem cross-sectional histological samples stained with Evans blue dye were each divided into 16 segments, and all matched segments were examined for correlation between wall motion abnormalities and myocardial hypoperfusion. With the use of contrast enhancement, the number of visualized segments was significantly increased (base: C- 86%, C+ 98%; midpapillary: C- 57%, C+ 89%; apex: C- 30%, C+ 74%). Agreement between echocardiographically assessed regional wall motion abnormalities and pathologically determined hypoperfusion in basal, midpapillary, and apical levels were 90%, 93%, and 93%, respectively. Agreement between echocardiographically normal wall motion and pathologically normal findings in basal, midpapillary, and apical levels were 99%, 88%, and 71%, respectively. Thus echocardiographic assessment of segmental wall motion in awake mice was feasible and the accuracy was improved with the use of a contrast agent.

Assessment of left ventricular systolic function using contrast two-dimensional echocardiography with a high-frequency transducer in the awake murine model of myocardial infarction.

The estimation of global left ventricular function using M-mode echocardiography has technical limitations in the murine model of myocardial infarction (MI), but the recent improvements in 2-dimensional (2-D) echocardiography using a high-frequency transducer provide more accessible images. Furthermore, intravenous injection of contrast agent has the additional benefit of enhancing the endocardial border in the murine heart. The present study was designed to evaluate the value of 2-D echocardiography with intravenous injection of contrast agent in the assessment of global systolic function of the murine heart with MI. Two-dimensional and M-mode echocardiography without and with intravenous injection of contrast agent (Optison, 0.1-0.15 ml) were performed in 76 awake mice 2 days before and 2 days after left coronary artery ligation. Fractional shortening (FS) was calculated from the end-diastolic and end-systolic diameters on M-mode echocardiography, and fractional area change (FAC) from the end-diastolic and end-systolic areas on 2-D echocardiography. Both FS and FAC were compared with the areas of hypoperfusion observed in the pathological samples. The use of contrast agent improved the number of hearts that could be evaluated by both the M-mode and 2-D method (M-mode: non-contrast 87% vs contrast 99%, p<0.01; 2-D: non-contrast 26% vs contrast 89%, p<0.001). FAC from the 2-D method correlated better with the region of hypoperfusion in the pathological samples than did FS from the M-mode method (FAC: r=0.84 vs FS: r=0.51). In conclusion, FAC obtained from 2-D contrast echocardiography is useful for noninvasive assessment of global systolic function in infarcted murine hearts and can be used to serially assess systolic function in various models of the murine heart.

Quantitative 3-Dimensional Contrast Echocardiographic Determination of Myocardial Mass at Risk and Residual Infarct Mass After Reperfusion: Experimental Canine Studies with Intravenous Contrast Agent NC100100

Two-dimensional contrast echocardiography has been shown to enable the evaluation of myocardial perfusion abnormalities. However, its ability to quantify a regional myocardial mass is limited. The goal of this study was to examine the quantitative value of 3-dimensional echocardiography (3DE) in the estimation of myocardial mass at risk, salvaged mass, and residual infarct mass after intravenous injection of contrast. We created acute coronary occlusion, followed by reperfusion in 10 dogs. Three-dimensional echocardiographic data were acquired at the end of each stage, and the perfusion defect mass and dysfunctional mass were measured. The true mass at risk and infarct mass were determined by anatomic methods. The anatomic mass at risk (x) (27.1 ± 14.6 g or 23.8% ± 9.7% of the left ventricle [%LV]) correlated well with the 3DE–determined perfusion defect mass (y) during coronary occlusion (y = 0.5x + 8.9; r = 0.90; P <.001; mean difference –4.8 ± 8.1 g; or y = 0.7x + 6.5; r = 0.83, P <.01; mean difference –0.1 ± 5.4 %LV). Good correlation was also found between the anatomic infarct mass (x) (9.3 ± 8.1 g or 9.1 ± 8.8 %LV) and the 3DE perfusion defect mass after reperfusion (y) (y = 1.2x + 1.2; r = 0.93; P <.001; mean difference 2.3 ± 4.0 g; or y = 1.3x, r = 0.98, P <.0001; mean difference 2.7 ± 3.7 %LV). The salvaged mass was 13.6 ± 11.0 %LV from anatomic methods and 14.2 ± 13.0 %LV by 3DE. To conclude, with the use of intravenous contrast, 3DE could quantify the actual mass at risk during acute ischemia, and in the setting of reperfusion, the residual infarct mass and salvaged mass. (J Am Soc Echocardiogr 2000;13:570-81.)

Quantitation of left-to-right shunts in secundum atrial septal defect by two-dimensional contrast echocardiography with use of Albunex

Our data indicate that 2-dimensional contrast echocardiography with use of Albunex is a safe, non-invasive, and feasible method for quantitating left-to-right shunts in patients with secundum ASD.

Pericardiocentesis guided by two-dimensional contrast echocardiography.

The clinical application of two-dimensional contrast echocardiography to pericardiocentesis was investigated in 20 patients with pericardial effusion. Multiple views were obtained to determine the ideal needle entry route. During pericardiocentesis, after 5 to 10 mL of pericardial fluid was withdrawn, 3 to 5 mL of agitated saline solution was injected through the exploring needle into the pericardium and a cloud of echoes indicated the needle's position. Contrast echoes were observed in all 20 patients. The procedure was performed smoothly in all patients except two (10%): the exploring needle was inserted into the right atrium in one patient and into the right ventricle in the other patient. The former promptly underwent a surgical drainage procedure, and the latter a second pericardiocentesis successfully guided by contrast echocardiography. The pericardial fluid was simply, safely, and successfully aspirated in the other 18 patients. We conclude that two-dimensional contrast echocardiography is valuable for locating needle position, thus facilitating successful pericardiocentesis in clinical practice.

On-line intraoperative quantitation of regional myocardial perfusion during coronary artery bypass graft operations with myocardial contrast two-dimensional echocardiography

We hypothesized that the success of coronary artery bypass graft operations could be assessed by means of on-line quantitative myocardial contrast echocardiography. Accordingly, myocardial contrast echocardiography was performed at baseline and after each placement of venous graft in 21 patients undergoing coronary artery bypass graft operations. Time-intensity plots were generated on-line with the use of a dedicated computer system, and areas under the curve were assessed for each injection. Successful on-line quantitation of myocardial contrast echocardiography data was performed in 17 patients; this allowed comparison before and after coronary artery bypass graft operations for 21 grafts, with agreement between expert visual analysis and quantitative data in 91% of these cases. Three distinct perfusion patterns were noted on myocardial contrast echocardiography: (1) reduced contrast effect before coronary artery bypass graft operations with improvement after coronary artery bypass graft operations (n = 11); (2) adequate contrast effect before coronary artery bypass graft operations with no change after coronary artery bypass graft operations (n = 9) (for patients in group 2, the mean percentage of coronary stenosis was less than the mean for patients in group 1-67% +/- 25% vs. 88% +/- 20%, p = 0.05); and (3) no contrast effect either before or after coronary artery bypass graft operations in one patient with previous infarction. One third of the time (34 of 95 injections), on-line quantitation was unsuccessful. Failure was related three times more often to problems associated with myocardial contrast echocardiography, such as attenuation and inadequate quality of bubbles, than to computer failure. Despite its limitations, on-line quantitative myocardial contrast echocardiography is feasible in patients undergoing coronary artery bypass graft operations and provides important objective information regarding the success of revascularization.

Contrast Two-Dimensional Echocardiography Provides Clinical Information Not Available with Color Flow Imaging

Contrast two-dimensional (2D) echocardiography using peripheral venous injections of agitated saline provides useful clinical information not available with standard 2D Doppler and color flow imaging techniques. Intraor extracardiac right-to-left shunting in patients with atrial or ventricular septal defects and patent ductus arteriosus can be identified in this manner, and the relative degree of shunt can be assessed. Other conditions, such as left superior vena cava to the coronary sinus or pulmonary arteriovenous malformation, are accurately detected only when contrast 2D echo is incorporated during the noninvasive examination. Recent work has also demonstrated that venous injections of agitated saline can be used to enhance continuous wave Doppler recordings of tricuspid regurgitant jet envelopes when poorly defined, or with color flow imaging to characterize the jet area. Twodimensional visualization of the needle placed in the pericardial sac for drainage of pericardial effusion may be difficult. Injection of agitated saline through the needle may be used to verify proper location in the pericardial sac and not in the ventricular chambers. The role of contrast 2D echocardiography with new agents has been used to assess myocardial perfusion. All of these applications of contrast echo contribute to standard echocardiographic techniques to provide a better characterization of flow dynamics not seen with color flow imaging.

Transesophageal echocardiographic diagnosis of isolated tricuspid valve prolapse with severe tricuspid regurgitation

Prolapse of only the tricuspid valve (TVP), with or without associated cardiac disease, is a phenomenon infrequently reported.’ Weinreich et a1.2 in 1985 found just 34 cases in the world literature. Even rarer are descriptions of tricuspid regurgitation (TR) with isolated TVP. This combination of findings was implied but not well documented in two of the patients described by Weinreich et al. In a 1975 catheterization study of TVP by Maranhao et al.,s “mild or moderate degrees of tricuspid regurgitation occurred in some cases, but was caused, at least in part, by catheter impingement.“3 In 1985, Yamazaki et a1.4 found mild TR by contrast two-dimensional echocardiography and right ventriculography in a patient with isolated TVP. To our knowledge, the following is the first reported case of isolated TVP with severe TR, diagnosed by transesophageal echocardiography. A 40-year-old black man was referred by his family phy

Two-dimensional contrast echocardiography in the detection and follow-up of congenital pulmonary arteriovenous malformations

Pulmonary arteriovenous (A-V) malformation is frequently a manifestation of Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia). We identified 14 patients (9 men and 5 women) with A-V malformation by contrast echocardiography; 10 patients with atrial right-to-left shunt served as control subjects. Agitated saline solution (10 ml) was injected through a peripheral vein during echocardiographic imaging. The delay in the appearance of microcavitations in the left atrium was measured (in number of frames) after right atrial appearance. The degree of left ventricular opacification was graded 1 to 4+ (where 4+ = intense left ventricular endocardial outline, and 1+ = minimal opacification). Results indicated patients with A-V malformation had a significant delay (p < 0.001) in left atrial appearance of microcavitations compared with those with atrial right-to-left shunt (66 ± 27 vs 21 ± 7 frames, mean ± 1 standard deviation). In the group with A-V malformation, abnormal blood gases were present in only 6 of 14 patients and chest x-ray was positive in 7. Pulmonary angiography was performed in 11 of 14 patients with positive contrast echocardiography, and all 11 had A-V malformation identified. In patients with 3 to 4+ left ventricular opacification (n = 8), large (>5 mm feeding vessel) or multiple malformations were present, whereas patients with small or isolated malformation had 1 to 2+ left ventricular opacification. Balloon occlusion of malformations was performed in all 11 of these patients; repeat contrast echocardiography revealed significant diminution of right-to-left shunt in 9, and 2 required repeat embolotherapy for an additional previously undetected A-V malformation. Thus, contrast 2-dimensional echocardiography is extremely sensitive for the identification of pulmonary A-V malformation.

Assessment of Myocardial Perfusion during CABG Surgery with Two-dimensional Transesophageal Contrast Echocardiography

No reliable, quantifiable index of tissue perfusion is currently available to assess the efforts of coronary artery bypass graft (CABG) surgery. We used two-dimensional transesophageal contrast echocardiography with sonicated Renografin-76 microbubbles to determine the distribution of myocardial blood flow during coronary artery bypass graft surgery in 15 patients. Sonicated Renografin-76 contrast agent was injected into the aortic root of all patients after institution of cardiopulmonary bypass and application of the aortic occlusive clamp. Eight patients had contrast agent injected directly into the free proximal end of the vein-CABG anastomosis. All patients again received aortic root injections during reperfusion after anastomosis of the proximal aortovein and distal coronary artery. Echocardiographic images of the left ventricle short axis at the level of the papillary muscles were obtained in real time and analyzed retrospectively from videotape. Injection of contrast provided information about the magnitude and geometric distribution of coronary artery-vein bypass run-off and enabled identification of poorly perfused myocardial regions. When predicted myocardial perfusion patterns, based on preoperative evaluation of epicardial vessel distribution derived from coronary angiography, were compared to actual perfusion patterns assessed with intraoperative echocardiography, contrast regional myocardial perfusion patterns were predicted 84% of the time (71-97%, 95% confidence limit). Regional myocardial perfusion deficits detected after coronary bypass grafting were associated with regional wall motion abnormalities detected after separation from cardiopulmonary bypass. Our technique makes possible on-line visualization of changes in regional blood flow in the heart before, during, and after CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary cardiac hemangiopericytoma causing rupture of the right atrium and chronic cardiac tamponade.

A 53-year-old woman presented with symptoms of dyspnea on exertion and edema of lower extremities. Chronic cardiac tamponade caused by the rupture of the right atrial wall was diagnosed by two-dimensional contrast echocardiography. Autopsy findings revealed primary cardiac hemangiopericytoma.

Intraoperative demonstration of coronary collateral flow using myocardial contrast two-dimensional echocardiography

The extent of coronary collateral vessels and their significance are controversial issues. 1 The controversy regarding collaterals in man is related, to a large extent, to the lack of an appropriate method to assess collateral function in vivo. The most frequently used technique of assessing collateral blood vessels is coronary angiography. This technique, however, can only detect vessels >100 to 200 μ in diameter. 1 It has been shown in animals, particularly dogs, that most of the collateral vessels are <100 μ in diameter. 1 Furthermore, the angiographic assessment of collateral vessels is unrelated to the functional capacity of these channels. 1 Myocardial contrast echocardiography is a new technique capable of demonstrating myocardial perfusion in humans. 2 This technique uses the intracoronary or intraaortic injection of microbubbles of air. The size of these microbubbles is similar to that of red blood cells, as is their intravascular rheology. 3 The appearance of these microbubbles within regions of the myocardium remote from the site of injection should, therefore, reflect collateral flow. This technique has been shown to demonstrate collateral flow in dogs. 4

Method for the Quantitation of Myocardial Perfusion During Myocardial Contrast Two-Dimensional Echocardiography

This article describes the hardware and software components of two systems designed for quantitative analysis of data obtained during myocardial contrast two-dimensional echocardiography. One system is meant for off-line analysis of data, whereas the other is designed for on-line analysis, especially in the operating room. The algorithms used for data transfer, selection of appropriate frames, data alignment, derivation of time-intensity plots, and curve-fitting and parameter generation are described in some detail. It is hoped that this information will be of use to others who work in the field of myocardial perfusion imaging.