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Basics of Contrast Enhanced Echocardiography

  • Harald Becher
  • Andreas Helfen
Chapter

Abstract

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)

References

  1. Arias RS, et al. Misleading echocardiographic diagnosis of a prosthetic heart valve vegetation due to the cavitation phenomenon. Exp Clin Cardiol. 2009;14(4):53–5.PubMedPubMedCentralGoogle Scholar
  2. Bigelow TA, et al. The thermal index. Its strengths, weaknesses, and proposed improvements. J Ultrasound Med. 2011;30:714–34.CrossRefGoogle Scholar
  3. Bommer WJ, et al. The safety of contrast echocardiography: report of the committee on contrast echocardiography for the American Society of Echocardiography. J Am Coll Cardiol. 1984;3:6–13.CrossRefGoogle Scholar
  4. Borges AC, et al. Does contrast echocardiography with Optison induce myocardial necrosis in humans? J Am Sol Echocardiogr. 2002;15:1080–6.CrossRefGoogle Scholar
  5. Campbell RL, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014;113:599–608.CrossRefGoogle Scholar
  6. Cosyns B, et al. EACVI core syllabus; a learning framework for continuous medical education in echocardiography. Sophia Antipolis: EACVI; 2013. https://www.escardio.org/static_file/Escardio/Subspecialty/EACVI/education/EACVI-core-syllabus.pdf.Google Scholar
  7. Ionescu A. Bubble trouble: anaphylactic shock, threatened myocardial infarction, and transient renal failure after intravenous echo contrast for left ventricular cavity opacification preceding dobutamine stress echo. Eur J Echocardiogr. 2009;10:707–10.PubMedGoogle Scholar
  8. Jeon DS, et al. The usefulness of 10% air-10% blood-80% saline mixture for contrast echocardiography: Doppler measurement of pulmonary artery systolic pressure. J Am Coll Cardiol. 2002;39:124–9.CrossRefGoogle Scholar
  9. Krishnan SC, et al. Septal pouch in the left atrium. A new anatomic entity with potential for embolic complications. J Am Coll Cardiol Intv. 2010;3:98–104.CrossRefGoogle Scholar
  10. Mathias W, et al. Diagnostic ultrasound impulses improve microvascular flow in patients with STEMI receiving intravenous microbubbles. J Am Coll Cardiol. 2016;67:2506–15.CrossRefGoogle Scholar
  11. Miller DL, et al. Bioeffects considerations for diagnostic ultrasound contrast agents. J Ultrasound Med. 2008;27:611–32.CrossRefGoogle Scholar
  12. Nelson TR, et al. Ultrasound biosafety considerations for the practicing sonographer and sonologist. J Ultrasound Med. 2009;28:139–50.CrossRefGoogle Scholar
  13. Porter TR, et al. Clinical application of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography Guidelines update. J Am Soc Echocardiogr. 2018;31(3):241–74.  https://doi.org/10.1016/J.Echo.2017.11.013.CrossRefGoogle Scholar
  14. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30:1144–50.  https://doi.org/10.1046/j.1365-2222.2000.00864.x.CrossRefPubMedGoogle Scholar
  15. Rana BS, et al. Echocardiographic evaluation of patent foramen ovale prior to device closure. J Am Coll Cardiol Img. 2010;3:749–60.CrossRefGoogle Scholar
  16. Safety Group of the British Medical Ultrasound Society. Guidelines for the safe use of diagnostic ultrasound equipment. Ultrasound. 2010;18:52–9.  https://doi.org/10.1258/ult.2010.100003.CrossRefGoogle Scholar
  17. Saric M, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016;29:1–42.CrossRefGoogle Scholar
  18. Senior R, Becher H, et al. Contrast echocardiography: evidence based recommendations by European Association of Echocardiography. Eur J Echocardiogr. 2009;10:194–212.CrossRefGoogle Scholar
  19. Senior R, Becher H, et al. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging. 2017;0:1–33.Google Scholar
  20. Silvestry FE, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015;28:910–58.CrossRefGoogle Scholar
  21. Spinazzi A. Joint meeting of the cardiovascular and renal drugs advisory committee and the drug safety and risk management advisory committee, FDA, 3 May 2011.Google Scholar
  22. van Gent MWF, et al. Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study. Eur Respir J. 2009;33:85–91.CrossRefGoogle Scholar
  23. Whittingham TA. Contrast-specific imaging techniques: technical perspective. In: Quaia E, editor. Contrast media in ultrasonography: basic principles and clinical applications. Berlin: Springer; 2005. p. 43–70.CrossRefGoogle Scholar

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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