Basics of Contrast Enhanced Echocardiography

  • Harald Becher
  • Andreas Helfen


Intravenously administered contrast agents are classified according their ability to pass the capillaries of the lung: the first part of the chapter deals with the right heart contrast agents which do not pass the pulmonary capillaries. Following the preparation of right heart contrast agents, practical advice is given on how to diagnose a patent foramen ovale and how to enhance Doppler signals of the tricuspid valve. The second part of the chapter provides the characteristics of the approved transpulmonary (‘left heart’) contrast agents. Recommendations are provided for safe application and appropriate imaging modalities like very low mechanical index multi-pulse techniques. This chapter is aligned to the EACVI core syllabus edition 2013, 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 Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography.

Supplementary material

Video 1.1

“Stretched PFO”. Dilatation of the left atrium results in an expansion of the superior edge of the septum secundum with left-to-right shunt due the increased left-atrial pressure (WMV 728 kb)

Video 1.2

Atrial septum aneurysm with spontaneous echo contrast on the left atrial side of the fossa ovalis (left). During the Valsalva manoeuvre and injection of agitated saline, there was permanent bulging of the atrial septum towards the RA (right). A PFO cannot be excluded using this examination (WMV 1888 kb)

Video 1.3

Sequential TEE recording (70° mid oesophageal probe position) before and after injection of agitated saline (top left to bottom right). The appearance of the contrast in the RA (top right), partial washout from blood coming from the IVC (bottom left), and finally the passage of contrast through a PFO into the LA are displayed (bottom right). (WMV 7720 kb)

Video 1.4

Subcostal colour Doppler recording of an atrial septal defect (ASD) with left-right shunt (WMV 1006 kb)

Video 1.5

Formation of bubbles due to cavitation at a mitral valve prosthesis (WMV 621 kb)

Video 1.6

An influx of intact contrast medium from the LA into the LV recorded in mid diastole. Only at an MI of 1.3 can destruction of the contrast agent be seen (WMV 1773 kb)

Video 1.7

Coded phase inversion imaging (Vivid E9 XD clear). Almost complete cancellation of all tissue signals except from the strongly reflecting structures in the area of the mitral ring on the recording before injection of the contrast agent (left). Myocardial perfusion signals are displayed in addition to the fully opacified LV after injection of the contrast agent (right). Focus position is at the level of the mitral ring (WMV 486 kb)

Video 1.8

Cadence ImagingCadence imaging, Acuson SC2000. The image was optimized for measurements of LV volumes and ejection fraction. The myocardium appears black due to cancellation of the tissue signal at a relative output intensity of −20 dB and a MI of 0.12. Excellent delineation of the boundary between compact and the trabeculated muscle layers without apical contrast swirling. Focus position at mitral ring level (WMV 2438 kb)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Harald Becher
    • 1
  • Andreas Helfen
    • 2
  1. 1.University of Alberta HospitalEdmontonCanada
  2. 2.St. Marien Hospital, Katholisches Klinikum Lünen GmbHLünenGermany

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