Opacification Of Left Ventricle Research Articles

Case report: Takotsubo syndrome following percutaneous coronary intervention

BackgroundTakotsubo syndrome (TTS), which is frequently secondary to severe emotional (fear, anxiety, etc.) or physical stress, is an acute reversible heart failure syndrome characterized by temporary left ventricular regional systolic dysfunction. Nevertheless, TTS after percutaneous coronary intervention (PCI) is rare, and its clinical characteristics are easily confused with complications after PCI.Case presentationThis article reports a case of TTS induced by psychological and physical pressure after successful PCI in our institution. The patient had symptoms comparable to complications after PCI, including V1-V5 ST segment elevation and T wave changes of electrocardiogram (ECG) and troponin elevation. Coronary angiogram, left ventricle opacification (LVO), and cardiac magnetic resonance (CMR) were performed to exclude postoperative complications. Diagnosis of TTS was eventually achieved.ConclusionWe cannot dismiss the risk of TTS in patients who have unexplained V1-V5 ST segment elevation and T wave changes of ECG and troponin elevation following successful PCI. Meanwhile, medical personnel should provide mental, cultural, and emotional services to patients in addition to essential diagnostic and treatment technical services during the perioperative period.

P122 CONTRAST–ENHANCED ECHOCARDIOGRAPHY IN BETTER STUDYING (OR EXCLUDING) HYPERTROPHIC CARDIOMYOPATHY. TWO CASES

Abstract Aim of this case–series report is to elucidate the potential role of contrast echocardiography (C–Echo) to optimize and improve the study of patients with Hypertrophic Cardiomyopathy (HCM). However, this report is also aimed to demonstrate the role of C–Echo in excluding a HCM diagnosis. Case 1. A young male patient, 27 y–o, presented to our Emergency Department (ED) because of chest pain and dyspnea. He referred a diagnosis of HCM without LVOT obstruction. Trans–Thoracic Echocardiogram (TTE) demonstrate a severe hypertrophy of interventricular septum with a maximum diastolic thickness of 25 mm. There was no a significant LVOT gradient. Contrast enhanced echocardiography, by left ventricle opacification (LVO) (Sonovue, Bracco Imaging, Milan, Italy), demonstrated: an interventricular septum thickness of 32 mm (7 mm more than TTE measurement); a clear touching of mid–ventricular walls with a max systolic gradient of 40 mmHg (figure 1). This aspect was no clearly detectable by TTE alone. Case 2. A young male patient, 31 y–o, presented to our ED because of palpitations. At 12–leads ECG he presented a sinus rhythm with frequent monomorphic premature ventricular complexes (PVC). A TTE was performed. It put a suspicion of left ventricle (LV) APICAL HCM, because of an apical diastolic thickness of 26 mm. A contrast enhanced echocardiography by LVO (Sonovue, Bracco Imaging, Milan, Italy) was planned. It allowed to excluding a HCM by demonstrating a LV apical false tendon mimicking endocardial border (figure 2). LV false tendons are fibromuscular bands that traverse LV cavity and are generally considered to be benign. Thay may also contain conduction tissue (Purkinje fibers) and have been identified as a source of ventricular arrhythmias. They are most commonly located near the LV apex. Conclusion It is possible to conclude that, by LV cavity opacification optimization of echocardiographic planes and views, C–Echo represents a suitable tool for: 1) a more accurate LV wall thickness (WT) measurement; 2) acquiring additional informations about intraventricular gradients in patients with HCM. In addition, C–Echo allows to exclude a HCM diagnosis in presence of LV apical false tendons.

Improved Thrombus Assessment by Transesophageal Echocardiography: The DOLOP (Detection of Left Atrial Appendage Thrombosis Utilizing Optison) Study

Transesophageal echocardiography (TEE) to assess for thrombus in the left atrial appendage (LAA) is an essential clinical tool prior to cardioversion or ablation in the setting of atrial fibrillation (AF) or flutter. While TEE is superior to transthoracic echo for LAA evaluation, noncontrast images can be limited by artifact and reverberation as well as spontaneous echo contrast (SEC).1 Use of ultrasound-enhancing agents (UEAs) can improve diagnostic accuracy;2 however, the only Food and Drug Administration–approved use of UEAs is left ventricle opacification.

Contrast Echocardiography

Ultrasound contrast agents are widely used in clinical practice for left ventricle opacification in sub-optimal echocardiograms. Recently, significant research has focused on the use of contrast echocardiography as a non invasive means to evaluate myocardial perfusion. Advances in contrast agents as well as ultrasound technology have enabled investigations into myocardial contrast echocardiography as a possible alternative to nuclear imaging studies. This review will focus on the development and current uses of contrast echocardiography, as well as future indications, including myocardial perfusion and risk stratification following myocardial infarction.

Ultrasound Contrast Materials in Cardiovascular Medicine: from Perfusion Assessment to Molecular Imaging

Ultrasound imaging is widely used in cardiovascular diagnostics. Contrast agents expand the range of tasks that ultrasound can perform. In the clinic in the USA, endocardial border delineation and left ventricle opacification have been an approved indication for more than a decade. However, myocardial perfusion contrast ultrasound studies are still at the clinical trials stage. Blood pool contrast and perfusion in other tissues might be an easier indication to achieve: general blood pool ultrasound contrast is in wider use in Europe, Canada, Japan, and China. Targeted (molecular) contrast microbubbles will be the next generation of ultrasound imaging probes, capable of specific delineation of the areas of disease by adherence to molecular targets. The shell of targeted microbubbles (currently in the preclinical research and early stage clinical trials) is decorated with the ligands (antibodies, peptides or mimetics, hormones, and carbohydrates) that ensure firm binding to the molecular markers of disease.

Safety and positive predictive value of high-dose dipyridamole stress-echocardiography with or without contrast flash-replenishment perfusion imaging in patients with suspected or known coronary artery disease

⁎ Corresponding author at: Parma University Hospital, Cardiology Department, Via Gramsci, 14-43100 PARMA, Italy. E-mail address: ngaibazzi@gmail.com (N. Gaibazzi). A growing body of literature has demonstrated the safety of ultrasound contrast agents in conjunction with low mechanical-index imaging during echocardiography, although most studies reported on contrast use during rest echocardiography for left ventricle opacification and rarely on its use during stress-echo (SE) with flash-replenishment myocardial perfusion imaging (MPI). Flash-replenishment sequences, bymeans of high-mechanical index pulses, represent a specificmodel of interaction among ultrasound, microbubbles and myocardial tissue, which could theoretically portend specific safety concerns. We retrospectivelyanalyzedour prospectively collected SEdatabase to evaluate the safetyof a contrast agent (SonoVue©Bracco Imaging Italia srl, Milan, Italy) routinely administered for flash-replenishment high-dose (0.84 mg/kg) dipyridamole echocardiography (cDipSE) and compared this cDipSE groupwith a reference cohortwho underwent standard highdose dipyridamole echocardiography without contrast administration (sDipSE) in the same time frame. According to CTCAE v3.0 standardized terminology (1), moderate (grade 2), severe (grade 3), life-threatening (grade 4) or deadly (grade 5) adverse events (AEs) were recorded during and after SE directly by the physicianperforming the test and after 24 hby contacting the patient. True and false positive figures for coronary artery disease (CAD) detectionwere also calculated in the selected patients who underwent coronary angiography. The database includes 1953 patients who presented between January 2008 and June 2011 and underwent DipSE with (n=1342) or without contrast, (n=611) for suspected or known CAD. Standard DipSE exclusion criteria were used, while pregnancy, knownallergy to sulfonamides or previous anaphylactoid reactions were considered contraindications to contrast administration (cDipSE). The decision to proceed to coronary angiography after DipSE was left to the referring physician, based on clinical judgment and hence influenced by DipSE results. The primary endpoint of the studywas the short-term safety of DipSE (any AENgrade 1 taking place b24 h after the test) and secondarily of sDipSE compared with cDipSE. ContrastDipSE:PatientswhounderwentDipSEwith contrast andflashreplenishment perfusion imaging were 1342; 771 underwent bolus contrast administration,while 571underwent continuous infusion of contrast using a dedicated rotating pump; repeated 0.5 ml boluses (4 to 5 boluses for each test) or infusion at 0.8–1 ml/minute of SonoVue© was used. Myocardial perfusion was studied activating low-MI power-modulation imaging and acquiring flash-replenishment cine-loops in the apical four, three and two-chamber views. Baseline characteristics of the entire DipSE group and of the 2 subgroups based on the use of contrast administration for flash-replenishment perfusion imaging are shown in Table 1. The demographic data and the prevalence of CAD risk factors did not differ significantly between the 2 subgroups, but there were significantly (pb0.001) more abnormal cDipSE than sDipSE—371/ 1342 (28%) vs 55/611 (9%), which was largely expected due to cDipSE taking advantage of wall motion+perfusion imaging analysis. Table 2 reports AEs in the study groups. No fatalities (AEs grade 5) were recorded during the SE study or in the next 24 h. Three lifeTable 1 Baseline clinical characteristics, stress-echocardiography results and coronary angiography data. DipSE = high-dose dipyridamole echocardiography, sDipSE = standard high-dose dipyridamole echocardiography, cDipSE = contrast flash-replenishment dipyridamole echocardiography, CAD = coronary artery disease, MI = myocardial infarction.

Adverse Bioeffects of Ultrasound Contrast Agents Used in Echocardiography: True Safety Issue or “Much Ado About Nothing”?

Ultrasound contrast agents, consisting of gas-filled microbubbles, have long been used to enhance ultrasonographic imaging of various organs and in several settings. In echocardiography, after their first use for Doppler signal enhancement, their applications have expanded and several studies, combining a range of stress modalities with myocardial contrast echocardiography have shown the clinical utility of these agents. In experimental isolated heart animal models, the interaction of ultrasound with echo-contrast microbubbles was shown to have significant biologic effects when the acoustic energy of the beam exceeded a threshold, leading them to rupture and causing cavitation phenomena; the observed consequences in the experimental setting included microvascular damage, transient decrease of contractile performance and increased lactate production. From the clinical point of view, the reporting of a number of serious adverse events - whose association with the echo-contrast agents was debated - has led to the addition of warning boxes in the prescribing documentation of these preparations. On the other hand, clinical studies including high numbers of patients have shown good safety and tolerance of contrast use during stress echocardiography, both for left ventricle opacification and myocardial perfusion imaging. The present review aims at presenting a balanced account of the existing data regarding the mechanisms and clinical implications of echo-contrast bioeffects, in order to make an informed assessment of their safety in clinical practice.