Abstract
Contrast echocardiography has become a valuable tool for accurate measurement of LV volumes and ejection fraction (EF) as well as for diagnosis of structural LV diseases and LV masses. This chapter is aligned to the Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017 and the 2018 American Society of Echocardiography Focused Update Regarding the Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography. Following the indications for contrast agents the appropriate imaging modalities, machine settings, imaging planes and dosages of the contrast agents are provided. Advice for image optimization and trouble shooting are included. In addition to a detailed description on how to perform measurements of the EF, all relevant EF reference values are provided. Similar comprehensive guidance is given for assessment of structural LV disease—in particular apical cardiomyopathies and LV masses.
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2.1 Electronic Supplementary Material
Four chamber view, non contrast 2D echocardiography (left), ‘very low MI contrast’-Mode (center) and following injection of 0.5 mL SonoVue® (right). No signals are obtained from myocardium and valves using the “very low MI contrast”-Mode, no artefacts ware displayed in the near field and on the right side of the sector (center). Homogeneous opacification of the LV cavity and good delineation of the myocardium without artifacts can be seen after injection of the contrast agent (AVI 70294 kb)
4-, 2- and 3-chamber views, poor acoustic windows. On non-contrast 2D echocardiography delineation of the trabeculated and compact myocardium is not possible at the apex. The poor display of the apical myocardium also impairs finding the typical apical shape which helps avoiding foreshortening. In 2D contrast all myocardial segments are well delineated—including the apex. The ‘gothic’ shape of the apex which is typical in patients with normal LV function can be seen in the 2- and 3 chamber views (AVI 71564 kb)
2D contrast echocardiography in a patient with breast cancer. This patient was referred for assessment of her LV function prior to treatment with Trastuzumab. End-diastolic frames of the 4 and 2 chamber views. The interface between the trabeculated and compact myocardium cannot be seen in several LV segments (top: mid and basal lateral, apical septal and anterior). This is an indication for contrast echocardiography, which resulted in adequate display of the entire LV cavity border (AVI 73148 kb)
Suboptimal recording of the 2 chamber view (left): both papillary muscles are visible (arrows) (AVI 8719 kb)
Clockwise rotation of the probe resulted in correct recording without display of papillary muscles (right) (AVI 8546 kb)
Rib shadow in a 2 chamber view (left): the shadow behind the rib is dark and has straight line borders—obscuring parts of the anterior walls. Rib shadows should be appreciated during recording and the probe position should be changed in order to avoid rib shadows. Recording without rib shadow (right), note the rounded anterior border of the anterior LV wall (AVI 52920 kb)
Contrast dosage too low resulting in poor opacification of the entire LV cavity (left and middle): inhomogeneous LV opacification and swirling of opacified and non opacified blood. This can also be caused by incorrect preparation of the contrast agent. In this case an additional bolus injection resulted in homogeneous LV opacification with good definition of the compact myocardium (right) (MP4 5163 kb)
Apical opacification too intense with blooming across the apical myocardium in the 4 chamber view (left and middle). The basal cavity is not opacified at all. This can be observed early after bolus injection of the contrast agent or when the infusion rate of contrast is too high. After bolus injection of a contrast agent it is just a matter of waiting to improve the image. Recording 20 s later shows homogeneous LV opacification (right). When the contrast agent is administered as an infusion, the infusion rate should be reduced (AVI 4934 kb)
Apical opacification too intense with blooming across the apical myocardium in the 4 chamber view (left and middle). The basal cavity is not opacified at all. This can be observed early after bolus injection of the contrast agent or when the infusion rate of contrast is too high. After bolus injection of a contrast agent it is just a matter of waiting to improve the image. Recording 20 s later shows homogeneous LV opacification (right). When the contrast agent is administered as an infusion, the infusion rate should be reduced (AVI 7998 kb)
Adequate contrast effect without swirling in the apical LV cavity and lack of contrast of the basal cavity (left and middle). This registration was performed too early after the injection of the contrast agent resulting in a high concentration of microbubbles in the LV cavity which attenuates the ultrasound. The registration 10 s later (right), when the concentration of the microbubbleshas decreased, shows opacification of the entire LV. When the basal attenuation during infusion of the contrast agent persists for several seconds, the MI should be increased (AVI 19390 kb)
Swirling in the apical cavity and adequate opacification in the basal cavity and the adjacent atrium (left and middle): the mechanical index is too high which results in destruction of contrast microbubbles in the nearfield of the probe. In the far field the ultrasound is attenuated causing only minor bubbles destruction. Mixing of blood coming from the far field and the blood in the nearfield results in swirling. After reduction of the transmit power (lower mechanical index adequate opacification of the entire LV cavity (right) (AVI 12765 kb)
Swirling in the apical cavity and adequate opacification in the basal cavity and the adjacent atrium (left and middle): the mechanical index is too high which results in destruction of contrast microbubbles in the nearfield of the probe. In the far field the ultrasound is attenuated causing only minor bubbles destruction. Mixing of blood coming from the far field and the blood in the nearfield results in swirling. After reduction of the transmit power (lower mechanical index) adequate opacification of the entire LV cavity (right) (AVI 11187 kb)
2-Chamber view recorded using the “low MI” (left) and “very low MI” contrast specific imaging technique (right). In the “low MI” technique, the contrast in the LV cavity appears apically inhomogeneous, and it is difficult to distinguish the myocardium from the cavity on the still frames which impairs the tracing of the LV cavity. This video also shows swirling of the contrast agent in the apical cavity. Using the “very low MI” technique (right), the myocardium can easily be distinguished from the bright myocardium (AVI 27441 kb)
The lateral papillary muscle is visible in the 4 chamber view (arrow). This should be avoided during registration, but it is not always possible. When tracing the boundaries of the LV cavity for volume measurement, the papillary muscles as well as the trabeculated myocardial layer are regarded as part of the LV cavity. In case of a papillary muscle within the scan plane, the boundary between compact and non-compact muscle layer in front of and behind the papillary muscle are interpolated (AVI 15919 kb)
Left bundle branch block and apical rocking (4-chamber view, modified according to Stankovic et al. 2016). After an early systolic septal contraction with short movement of the septal apex to the left, the apex moves laterally and the septum is stretched due to the delayed activation of the lateral LV wall. Because of the optimal display of the apical myocardial borders, contrast echocardiography can be helpful for diagnosing apical rocking. The presence of apical rocking makes it likely that the patients benefit from CRT (Ghani et al. 2016; Stankovic et al. 2016) (AVI 31326 kb)
Patient after inferior STEMI, 2 chamber after injection of the contrast agent, end-diastole (left), end-systole with end-diastolic border (middle) and assessment of regional wall motion (right) green normal, yellow hypokinetic and red akinetic (AVI 7404 kb)
4-Chamber view in a patient with chest pain. The non contrast recording was read as abnormal (top) (AVI 29343 kb)
The examination with contrast medium shows normal regional wall movement (bottom) (AVI 18338 kb)
4-Chamber view: Without contrast agent, no regional wall motion abnormality was detected (top) (AVI 31937 kb)
Mid lateral akinesis is displayed on the corresponding recording after injection of the contrast agent (bottom) (AVI 47392 kb)
Example of the ‘very low MI’ contrast setting in 3D echocardiography (Epiq, Philips): The monitor displays the machine settings. The mechanical index (MI) is displayed on the top right. On the left side you find (from top to bottom) the name of the preset (MAHI TTE), the transducer (X5-1), the volume rate (27 Hz) and the sector depth. This is followed by the gain and the contrast setting for the video signals (as a percentage for the 2D and 3D registrations) (AVI 4045 kb)
Rib shadow highlighted by the dotted green lines Rib shadows can be recognized by a straight line boundary of the LV cavity Rib shadows are more frequently found in the reconstructed plane corresponding to the 2-chamber view (bottom right). In this case, the inferior LV wall is not displayed because it is behind a rib (AVI 3928 kb)
Multiplanar reconstruction: 4-chamber view (top left), 2-chamber view (top right), mid LV short axis (bottom left). Additional short axis views can be reconstructed (bottom right). In both longitudinal views the long axes (green and red) are shown connecting the middle of the mitral annulus with the LV apex. This indicates that both planes are not foreshortened. The dotted lines shows where the reconstructed short axis planes are obtained (AVI 1955 kb)
Multiple short axis planes reconstructed from a 3D contrast dataset starting from the LV apex (top left) to the base of the LV (bottom right) (AVI 1844 kb)
Dilated cardiomyopathy on 2D echocardiography (4-chamber view): Without contrast agent the border between the cavity and the compact myocardium is hardly visible in several wall segments (left) (AVI 7473 kb)
After injection of the contrast agent the spherical LV cavity is well delineated (right) (AVI 8324 kb)
Apical hypertrophy not visualized on the non contrast 4-chamber view. Typical spindle shape displayed during contrast echocardiography (AVI 20844 kb)
Apical hypertrophy not visualized on the non contrast 4-chamber view. Typical spindle shape displayed during contrast echocardiography (AVI 12024 kb)
Apical aneurysm (arrow) in a patient with hypertrophic cardiaomyopathy. The aneurysm was not visualized without contrast agent. Courtesy to Dr. McCarty, London, Ontario (AVI 36694 kb)
Apical aneurysm (arrow) in a patient with hypertrophic cardiaomyopathy. The aneurysm was not visualized without contrast agent. Courtesy to Dr. McCarty, London, Ontario (AVI 25472 kb)
Takotsubo cardiomyopathyTakotsubo cardiomyopathy, 4 chamber view, end-diastolic frame (AVI 13076 kb)
Takotsubo cardiomyopathy with LV thrombus attached to the apical septum (arrow) (AVI 71495 kb)
Abnormal LV trabecularization, 4-chamber view (left), 2-chamber view (right). The trabeculations show up as dark recesses in the opacified (bright) cavity. The “low MI” contrast mode was used because of its higher spatial resolution which is sometimes more suitable for display of the apical trabeculations than the “very low MI” setting. However, swirling may impair assessment of the apical LV cavity when using the “low MI” contrast mode. For most LV applications such as measurement of the LV volumes the “very low MI” mode is the first choice, because it provides more homogeneous opacification of the entire LV. However, the pixels are larger, see Fig. 2.54 (AVI 33070 kb)
Corresponding recordings to Fig. 2.53 when using the “very low MI” contrast setting. Note the lower spatial resolution which impairs the display of the trabeculations. However, these recordings are more suitable for measurements of LV volumes compared to the recordings using the “low MI” contrast mode. When noncompaction cardiomyopathy recordings with both ‘low MI’ and ‘very low MI’ contrast modes are recommended (AVI 49955 kb)
Pseudo aneurysm with rupture of the lateral/posterolateral wall (4-chamber view, left and 3-chamber view, right). The neck of the aneurysm is marked with a blue arrow (WMV 357 kb)
Pseudo aneurysm with rupture of the lateral/posterolateral wall (4-chamber view, left and 3-chamber view, right). The neck of the aneurysm is marked with a blue arrow (WMV 308 kb)
Apical LV thrombus in a 2-chamber view recorded with a mechanical index (MI) of 0.12 (left) and 0.08 (right). Only with the lower MI is the thrombus can be delineated (arrow). In some patients the contrast agent in the apical cavity may be destroyed to a larger extent using the standard “very low MI” contrast setting. This causes swirling and makes it difficult to distinguish thrombi. According to the above mentioned Trouble Shooting Guide (see Table 2.2) reduction the MI solves this problem (AVI 37804 kb)
Assessment of the LV thrombus without slightly moving the probe does not allow to display the three-dimensional structure of a LV thrombus (left), a slight sweep of the transducer should always be performed during recording a loop with at least 3 cardiac cycles (right). Often the there is an irregular shape of the thrombus, which can only be appreciated during the sweep (AVI 64346 kb)
Assessment of the LV thrombus without slightly moving the probe does not allow to display the three-dimensional structure of a LV thrombus (left), a slight sweep of the transducer should always be performed during recording a loop with at least 3 cardiac cycles (right). Often the there is an irregular shape of the thrombus, which can only be appreciated during the sweep (AVI 61403 kb)
Apical LV thrombus visible without contrast agent in the 2-chamber view (left). However, better display of the shape and extension of the thrombus during contrast echocardiography (right), Only during contrast echocardiography the underlying apical wall motion abnormalities is clearly displayed. Note the dark apical myocardium compared to the septum, which indicates no reflow after STEMI (see Chap. 7) (AVI 23001 kb)
Apical LV thrombus visible without contrast agent in the 2-chamber view (left). However, better display of the shape and extension of the thrombus during contrast echocardiography (right), Only during contrast echocardiography the underlying apical wall motion abnormalities is clearly displayed. Note the dark apical myocardium compared to the septum, which indicates no reflow after STEMI (see Chap. 7) (AVI 44982 kb)
No reliable detection of LV thrombi without contrast agent in the 4-chamber view (left). (WMV 437 kb)
After injection of the contrast agent, thrombi are seen attached to RV and LV-apex (WMV 1463 kb)
Biplane recording of the RV inflow tract with detection of membrane-like structures in the (arrows) (AVI 1670 kb)
Biplane recording of the RV inflow tract in diastole (left) and systole (right) showing a round, smooth and echo-free mass. Differential diagnosis include is a mobile thrombus or a cyst. A tumor is unlikely due to the lack of opacification which indicates no vascularization. A ball thrombus is usually echogenic on the native echocardiogram. The membrane-like mobile structure in the right atrium is suspicious of a cyst, but the diagnosis needs to be confirmed with contrast echocardiography. Cysts in the left and right heart chambers should be assessed with left heart contrast agents in order to exclude a tumor (AVI 1794 kb)
2D echocardiography without contrast agent in a patient with LV tumor. In the 4-chamber view (left) the echo dense tumor is located in the apical septal myocardium (arrows). The localization, morphology and lack of chordae exclude an abnormal papillary muscle. The LV wall motion was normal which is not typical for a thrombus. Contrast echocardiography was performed to exclude a thrombus (see Fig. 2.68) (AVI 21988 kb)
2D echocardiography without contrast agent in a patient with LV tumor. In the 4-chamber view (left) the echo dense tumor is located in the apical septal myocardium (arrows). The localization, morphology and lack of chordae exclude an abnormal papillary muscle. The LV wall motion was normal which is not typical for a thrombus. Contrast echocardiography shows contrast signals in the mass (see Fig. 2.68) (AVI 16432 kb)
Metastasis of an anaplastic breast carcinoma, modified 4-chamber view showing the largest expansion of the tumour. The tumor has a similar opacification as the adjacent myocardium. The opacification of the tumor depends on the degree of vascularization. After pressing the flash button, the entire imaging sector is bright (top right) and immediately after the flash the contrast agent is destroyed in the tumor and adjacent myocardium (bottom left). A few cardiac cycles later the contrast is replenished in the tumor and the adjacent myocardium (AVI 290520 kb)
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Becher, H., Helfen, A. (2019). LV-Function and Myocardial Diseases/Masses. In: Contrast Echocardiography. Springer, Cham. https://doi.org/10.1007/978-3-030-15962-7_2
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