Noncontrast Echocardiography Research Articles

Incidence of left ventricular thrombus following STEMI in the modern era via multimodality imaging: A systematic review and meta-analysis

BackgroundLeft ventricular thrombus (LVT) is a significant complication in STEMI. Previous studies were conducted prior to modern timely percutaneous reperfusion networks. Current expert opinion suggests incidence in the current era has decreased. We conducted a systematic review and meta-analysis to better understand the incidence and diagnosis of LVT in patients with STEMI treated with timely percutaneous techniques as assessed by multimodality imaging. MethodsCochrane, EMBASE, LILACS, and MEDLINE were searched over the last 10 years only including studies using contemporary techniques. The primary outcome was detection of LVT in patients via echocardiogram with or without contrast or Cardiac MRI (cMRI) following STEMI (both anterior and any territory) treated with PCI. Data was pooled across studies and statistical analysis was conducted via random effects model. Results31 studies were included. 18 studies included data on any territory STEMI, totaling 14,172 patients, and an incidence of 5.6% [95% CI 4.3–7.0]. 18 studies were included in analysis for anterior STEMI, totaling 7382 patients and incidence of 12.7% [95% CI 9.8–15.6]. Relative to cMRI as a gold standard, the sensitivity of non-contrast echocardiography to detect LVT was 58.2% [95% CI 46.6–69.2] with a specificity of 97.8% [95% CI 96.3–98.8]. ConclusionsIncidence of LVT in STEMI patients treated with contemporary timely percutaneous revascularization is in keeping with historical data and remains significant, suggesting this remains an ongoing issue for further investigation. Numerically, both cMRI and contrast echo detected more LVT compared to non-contrast echo in any-territory STEMI patients.

Automatic view classification of contrast and non-contrast echocardiography.

BackgroundContrast and non-contrast echocardiography are crucial for cardiovascular diagnoses and treatments. Correct view classification is a foundational step for the analysis of cardiac structure and function. View classification from all sequences of a patient is laborious and depends heavily on the sonographer’s experience. In addition, the intra-view variability and the inter-view similarity increase the difficulty in identifying critical views in contrast and non-contrast echocardiography. This study aims to develop a deep residual convolutional neural network (CNN) to automatically identify multiple views of contrast and non-contrast echocardiography, including parasternal left ventricular short axis, apical two, three, and four-chamber views.MethodsThe study retrospectively analyzed a cohort of 855 patients who had undergone left ventricular opacification at the Department of Ultrasound Medicine, Wuhan Union Medical College Hospital from 2013 to 2021, including 70.3% men and 29.7% women aged from 41 to 62 (median age, 53). All datasets were preprocessed to remove sensitive information and 10 frames with equivalent intervals were sampled from each of the original videos. The number of frames in the training, validation, and test datasets were, respectively, 19,370, 2,370, and 2,620 from 9 views, corresponding to 688, 84, and 83 patients. We presented the CNN model to classify echocardiographic views with an initial learning rate of 0.001, and a batch size of 4 for 30 epochs. The learning rate was decayed by a factor of 0.9 per epoch.ResultsOn the test dataset, the overall classification accuracy is 99.1 and 99.5% for contrast and non-contrast echocardiographic views. The average precision, recall, specificity, and F1 score are 96.9, 96.9, 100, and 96.9% for the 9 echocardiographic views.ConclusionsThis study highlights the potential of CNN in the view classification of echocardiograms with and without contrast. It shows promise in improving the workflow of clinical analysis of echocardiography.

Association Between Patent Foramen Ovale and Overt Ischemic Stroke in Children With Sickle Cell Disease

Ischemic stroke is one of the most devastating complications of sickle cell anemia (SCA). Previous studies have shown that intracardiac shunting including patent foramen ovale (PFO) can be a potential risk factor for stroke in children with SCA. This study investigates the association between PFO and overt ischemic stroke in the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study cohort of 5,247 children with SCA of whom 1,414 had at least one clinical non-contrast transthoracic echocardiogram. Presence of PFO was taken from the clinical report. Further, we assessed the association between PFO and other clinical and hemolytic factors in children with SCA such as history of abnormal sickle stroke screen [elevated Transcranial Doppler ultrasound (TCD) velocity] and patient's baseline hemoglobin. In 642 children for whom all data were available, the adjusted odds ratio (OR) for overt stroke was higher in those with PFO but this was not statistically significant (OR: 1.49, 95% CI: 0.20–11.03, p = 0.6994). With an OR of 0.85, the study suggested less PFOs in those with abnormal TCD, but this was not statistically significant (95% CI: 0.17–4.25, p = 0.8463). Overall, the prevalence of PFO in this large sub study of non-contrast echocardiography amongst children with SCA is much lower than previous smaller studies using bubble contrast echocardiography. Overt stroke was non-statistically more common in children with SCA and PFO, but there was no evidence that PFO was more common in those with abnormal TCD, the most important pediatric sickle stroke screen.

Left Ventricular Apical Aneurysms in Hypertrophic Cardiomyopathy: Equivalent Detection by Magnetic Resonance Imaging and Contrast Echocardiography

Left ventricular (LV) apical aneurysm is a unique morphological entity and novel adverse risk marker existing within the broad phenotypic spectrum of hypertrophic cardiomyopathy (HCM). Its true prevalence in the HCM population is likely underestimated because of inherent limitations of conventional noncontrast echocardiography. The authors hypothesized that contrast echocardiography is a reliable imaging technique compared with cardiovascular magnetic resonance (CMR) for the detection of apical aneurysms. The aim of this study was to assess the effectiveness of contrast echocardiography in the detection of LV apical aneurysms in patients with HCM in comparison with the gold standard, CMR. One hundred twelve patients with HCM identified from an institutional clinical database, who underwent echocardiographic and CMR examinations within 12months and had LV apical aneurysms identified on either or both imaging modalities, were retrospectively analyzed. Discordant cases were reviewed by an expert panel, and a consensus was reached regarding the presence or absence of an apical aneurysm. The reason for any discrepancy was recorded. The mean age of the patients was 59±13years, and 73% were men. Sixty-four (57%) underwent contrast echocardiography. The median interval between echocardiography and CMR was 118days (interquartile range, 61-237days). Thirty-nine patients (35%) had discordance between echocardiographic and CMR findings, of whom 20 had aneurysms reported on echocardiography but not CMR and 19 vice versa. Upon reanalysis by the expert panel, aneurysms were initially missed on CMR in 16 patients (80%), largely because of interpretation error secondary to small aneurysms, with a mean aneurysm size of 0.82±0.38cm in these cases. Before secondary review by the expert panel, contrast echocardiography had sensitivity of 97% compared with 85% for CMR (P=.0198) and 64% for noncontrast echocardiography (P=.0001). After secondary review, contrast echocardiography had sensitivity of 98% compared with 67% for noncontrast echocardiography (P=.0001) and 97% for CMR (P=1.00). Contrast echocardiography has high sensitivity for detecting LV apical aneurysms and should beused routinely in the evaluation and risk stratification of patients with HCM.

Impact of Contrast Echocardiography on Outcomes in Critically Ill Patients

Limited data suggests ultrasound enhancing agent (UEA) use is associated with changes in clinical management and lower mortality in intensive care unit (ICU) patients. We conducted a retrospective observational study to determine if contrast echocardiography (vs non-contrast echocardiography) is associated with differences in length of stay (LOS) and subsequent resource utilization in the ICU setting. The Premier Healthcare Database (Charlotte, NC) was analyzed to identify patients receiving Definity vs. no use of contrast during the initial rest transthoracic echocardiogram (TTE) in an ICU setting. The primary outcomes of interest were subsequent TTE and transesophageal echocardiography (TEE) during the index hospitalization, and ICU LOS. Propensity scoring was used to statistically model treatment selection to minimize selection bias. A total of 1,538,864 patients from 773 hospitals were identified as undergoing resting TTE in the ICU with use of DEFINITY in 51,141 (3.3%) patients and no contrast agent use in 1,487,723 (96.7%) patients. After adjusting for patient, clinical, and hospital characteristics, patients in the Definity cohort were less likely to undergo a subsequent TTE or TEE as compared to those in the no contrast cohort (odds ratio = 0.704 for TTE, odds ratio = 0.841 for TEE; p < 0.0001 for both). Adjusted mean ICU LOS for the Definity cohort was shorter than that of the no contrast cohort (4.59 vs 4.15 days, p < 0.0001). In conclusion, Definity-enhanced echocardiography in the ICU setting (in comparison with non-contrast TTE) is associated with lower rates of subsequent TTE and TEE during the index hospitalization, and shorter ICU LOS.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Acute Mortality in Critically Ill Patients Undergoing Echocardiography With or Without an Ultrasound Contrast Agent

The objective of this observational study was to compare 48-h all-cause mortality (aswell as hospital stay mortality) among critically ill patients who underwent echocardiography either with or without an ultrasound contrast agent (UCA). The safety of perflutren-based UCAs has been questioned by the U.S. Food and Drug Administration (particularly when administered to critically ill patients) following rare reports of deaths or life-threatening adverse reactions that occurred in close temporal relationship to UCA administration. This was a retrospective observational outcome study conducted in critically ill patients to compare all-cause 48-h and hospital stay mortality subsequent to echocardiography procedures performed either with or without a UCA. The study utilized discharge data from a database maintained by Premier, Inc. (Charlotte, North Carolina). Premier's database is the largest U.S. hospital-based, service-level comparative database for quality and outcomes research, and provides detailed resource utilization data along with patients' primary and secondary diagnoses and procedure billing codes. Apropensity score-matching algorithm between UCA-enhanced echocardiography patients and non-contrast-enhanced echocardiography patients was utilized to reduce the potential for imbalance in covariates of selected patients in the comparison of mortality between groups. Patients undergoing echocardiography with a UCA had lower mortality at 48 h compared with patients undergoing non-contrast-enhanced echocardiography (1.70% vs. 2.50%), with an odds ratio= 0.66 (95% confidence interval [CI]: 0.54 to 0.80). Patients undergoing echocardiography with a UCA had lower hospital stay mortality compared with patients undergoing noncontrast echocardiography (14.85% vs. 15.66%), with an odds ratio= 0.89 (95% CI: 0.84 to 0.96). In critically ill, propensity-matched hospitalized patients undergoing echocardiography, use of a UCA is associated with a 28% lower mortality at 48 h in comparison with patients undergoing non-contrast-enhanced echocardiography. These results are reassuring, given previous reports suggesting an association between UCAs and increased mortality in critically ill patients.

Myocardial Deformation Analysis in Contrast Echocardiography: First Results Using Two-Dimensional Cardiac Performance Analysis

Contrast echocardiography (CE) provides closer agreement with magnetic resonance imaging (MRI) for left ventricular (LV) volumes and ejection fraction (EF) than noncontrast echocardiography. However, the feasibility and role of myocardial deformation analysis on contrast echocardiographic images have not been well established. The aim of this study was to assess the feasibility of deformation analysis on CE using a new software tool that provides simultaneous measurements for LV volumes and EF. Data from 52 patients who were recruited for the Alberta Heart Failure Etiology and Analysis Research Team Study (34 men; mean age, 64 ± 9 years) and underwent CE and MRI were considered. Contrast bolus injections were administered for optimal endocardial definition. Offline LV volume analysis was performed by standard manual tracing. A single frame was traced manually for two-dimensional (2D) cardiac performance analysis (CPA), which automatically calculated LV volumes, EF, and global longitudinal strain (GLS). Volumes obtained with 2D CPA were compared with those measured with standard CE and MRI. GLS from noncontrast echocardiographic recordings was also calculated with 2D CPA and compared with CE-derived and MRI-derived GLS. Tracing of contrast echocardiographic images with 2D CPA was possible in 49 out of 52 patients, and measurements correlated well with standard CE and MRI (EF: r = 0.93, P < .001, and r = 0.85, P < .001, respectively). Mean GLS from noncontrast echocardiographic and contrast echocardiographic recordings was -13.4 ± 5.8 and -15.3 ± 4.64, respectively (P = .056), and the latter correlated well with MRI-derived GLS (r = 0.78 vs 0.81, respectively). Simultaneous volumetric and deformation analysis on contrast echocardiographic recordings is feasible and reproducible. While volumes and EF obtained with the new software compare well with those obtained from standard CE and MRI, GLS from CE shows a good correlation with strain measured with MRI.

Microsphere contrast echocardiography in the critical care complex

Th e paper by Saranteas and colleagues [1] in the previous issue of Critical Care describes the use of transthoracic echocardiography (TTE) for detection of ventricular thrombus in postoperative patients in the critical care unit. While we agree that TTE is a fundamental diagnostic imaging tool that enhances detection of anatomic and physiologic abnormalities within the critical care complex, we would like to make several comments regarding its utility in this clinical setting. In up to 25% of TTE scans performed in the critical care complex, the images are nondiagnostic despite operator excellence, and this fact can have a signifi cant impact on patient diagnosis and management [2]. We agree with the authors that, owing to the suboptimal spatial orientation of the transducer in relation to the left ventricular apex, trans oesophageal echocardiography may not help in these cases. However, we would like to propose that the use of contrast echocardiography be expanded in the critical care setting in order to clarify those ‘vague results’ rather than have those same suboptimal, nondiagnostic images reinterpreted by another reader. Even experienced readers of TTE cannot make an accurate interpretation of ‘vague’ or suboptimal TTE images. In these cases, it is clearly recommended that contrast echocardiography be performed to improve diagnostic clarity [3]. Contrast echocardiography, using contrast microspheres coupled with contrast-specifi c ultrasound imaging modalities, overcomes many of the limitations that cause suboptimal echocardiograms in the critical care environment [4]. Contrast echocardiographic imaging has been assessed in the critical care setting and has been shown to be safe, feasible, and accurate [2,5]. Th e recent contrast guidelines of the American Society of Echocardiography state that ‘the availability of contrast imaging in the [intensive care unit] enhances overall effi ciency, diagnostic accuracy, and cost-eff ective patient management and has no incremental risk for death compared with non-contrast echocardiography’ [3]. For patients who are in the critical care setting and who have nondiagnostic TTE results, a contrast-enhanced TTE should now be at the forefront of a diagnostic algorithm.

APİKAL HİPERTROFİK KARDİYOMYOPATİDE MAGNETİK REZONANS GÖRÜNTÜLEMENİN ÖNEMİ

The differential diagnoses of T-wave inversions are diverse and ischemia, inflammation, electrolyte abnormalities, cocaine use, trauma, and others. Apical hypertrophic cardiomyopathy (HC) is a subtype of HC in which myocardial hypertrophy predominantly involves the apex of the left ventricle. Diagnosis is based on the presence of typical giant inverted T waves in midprecordial derivations (3) and spadelike view in ventriculography, cardiovascular magnetic resonance (MRI) and computed tomography(CT). Non-contrast echocardiography has been the usual first line investigation. However, echocardiography has limitations for visualising the apex and apical hypertrophy and may miss apical HCM. In this case report, we will present a patient with giant T wave inversion and inconclusive echocardiography which lead us to the diagnosis of apical HCM.

A Retrospective Comparison of Mortality in Critically Ill Hospitalized Patients Undergoing Echocardiography With and Without an Ultrasound Contrast Agent

To compare acute mortality in critically ill hospitalized patients undergoing echocardiography with and without an ultrasound contrast agent (UCA). Because of serious cardiopulmonary reactions reported immediately after administration of perflutren-containing UCAs, the FDA required a black box safety warning for this class of agents, including perflutren protein-type A microspheres injectable suspension. This study used the largest hospital service-level database in the U.S. All adult patients undergoing in-patient echocardiography between January 2003 and October 2005 were identified (n = 2,588,722, of which 22,499 received perflutren protein-type A microspheres injectable suspension). Of the 22,499 contrast echocardiography patients, 2,900 had diagnoses meeting criteria for critical illness (heart failure, acute myocardial infarction, arrhythmia, respiratory failure, pulmonary embolism, emphysema, and pulmonary hypertension). To control for the differences between the contrast and noncontrast patients, we used propensity score matching. Variables used in the construction of the propensity score included comorbidities, demographic factors, hospital-specific factors, level of care, and mechanical ventilation status. Patients receiving contrast echocardiography were matched to 4 control patients who received noncontrast echocardiography. Conditional logistic regression was used to estimate mortality effects. There were 167 deaths in the study among critically ill patients, 38 of 2,900 from the contrast group and 129 of 11,600 from the control group. The contrast agent was not associated with an increase in same-day mortality (odds ratio: 1.18; 95% confidence interval: 0.82 to 1.71; p = 0.37). Before matching, contrast patients showed greater morbidity than noncontrast patients (Deyo-Charlson comorbidity score 2.45 vs. 2.25, p < 0.0001). After propensity score matching, these differences were significantly reduced, showing that both groups were well balanced. There is no increase in mortality in critically ill patients undergoing echocardiography with the UCA compared with case-matched control patients.

202 Contrast-Enhanced MRI for high yield detection of left ventricular thrombus – predictors of improved thrombus detection versus echocardiography

Introduction Identification of left ventricular thrombus (LVT) affects clinical management of at risk patients. Contrastenhanced MRI (CE-MRI) identifies LVT based on tissue characteristics and has been validated as a highly sensitive technique that improves LVT detection vs non-contrast echocardiography. However, prior comparative studies were performed without echo contrast agents, which facilitate LVT detection by improving LV cavity delineation.

Current role of contrast echocardiography in the diagnosis of cardiovascular diseases.

The use of contrast echocardiography (CE) in cardiovascular medicine has grown significantly over the last 15 years. Depending on the site of injection, contrast enhancement of the right- or left-sided cardiac chambers or myocardium now can be achieved. Contrast echocardiography can improve the evaluation of patients with valvular heart disease by enhancing the Doppler signal; CE also improves detection of intracardiac or intrapulmonary shunts. In patients with coronary artery disease, enhancement of the endocardial blood-tissue boundary allows for improved visualization of endocardial wall motion, assessment of wall thickening, and calculation of ejection fraction. Contrast echocardiography promises to delineate myocardial perfusion and has the potential for quantitating coronary flow and assessing myocardial viability. These applications may add important physiologic information to the anatomic information readily available from noncontrast echocardiography. Because it can be rapidly performed at the bedside, CE may be a valuable tool for use with inpatients with acute myocardial ischemia. When CE has been used after recanalization of occluded coronary arteries, the assessment of myocardial salvage conveys information concerning reflow, stunning, and prognosis, and in the case of an angioplasty it provides immediate information regarding the success of the procedure. Contrast echocardiography can also assess myocardial areas at risk of irreversible damage and the presence or absence of collateral flow. When performed with transesophageal or epicardial echocardiography in the operating room, CE is emerging as a valuable tool in the assessment of cardioplegia distribution and graft patency as well as in the delineation of the regional supply of each graft. With the continued development of newer contrast agents and refinement of ultrasound imaging equipment, the applications of CE will continue to grow.