Multiparametric Stress Echocardiography

  • Harald Becher
  • Andreas Helfen


Myocardial contrast echocardiography (MCE) is recommended for the analysis of myocardial perfusion during pharmacological stress echocardiography. 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. Following the basics of myocardial perfusion the appropriate machine settings, detailed information is provided on how to perform and interpret a vasodilator stress study with MCE, the criteria of perfusion defects and imaging artefacts as well as the impact of the MCE results on clinical management.

Supplementary material

Video 6.1

Subcostal showing the liver. On the right an “interpretation” of the vascular structures (WMV 525 kb)

Video 6.2

4-chamber view, end-systolic frames. After start of the infusion of the contrast agent first no contrast agent is displayed in the myocardium (left), normal myocardial opacification at rest (middle) and very bright myocardium during vasodilation with adenosine (WMV 1101 kb)

Video 6.3

Modified 4-chamber view, end-systolic frame during adenosine stress echocardiography: subendocardial perfusion defect in the segments supplied by the LAD—mid septal, apical septal, apical and apical lateral as well as partially mid anterolateral (WMV 5979 kb)

Video 6.4

Normal adenosine stress echocardiographyAdenosinestress echocardiography, 4-chamber view, end-systolic frames during a flash replenishment sequence. Top left before the flash, next the recording during the flash, followed by frames recorded during the replenishment phase (WMV 6040 kb)

Video 6.5

Quality criteria for an optimized perfusion image (WMV 4707 kb)

Video 6.6

Visual assessment of flash replenishment recordingsMultiparametric stress echocardiographyflash replenishment recordings. Note that the same level of myocardial opacification as before the flash is reached during replenishment (best seen in the red circles) (WMV 4707 kb)

Video 6.7

Left: reduced signal intensity apical (yellow circle) and basal (white circles) with adequate LV opacification. Right: after the flash echogenic artefacts (white arrows), intramyocardial arteries filled with contrast (red arrows) and inhomogeneous opacification of the cavity (blue arrows) (WMV 4707 kb)

Video 6.8

First (left) and second end-systolic frame after the flash. The white arrows indicate artefacts, the red arrows point at small intramyocardial arteries. As the replenishment evolves, a basal attenuation is evident (yellow arrows) (WMV 4707 kb)

Video 6.9

Second (left) and third end-systolic frame after the flash. The capillary replenishment with homogenous contrast extends from the subendocardial layer to the subepicardium (white arrows). When comparing the two images, an opacification can also be seen in the basal segments despite signal attenuation (red arrows) (WMV 4707 kb)

Video 6.10

Anatomical M-mode through the mid septum and lateral wall of the 4-chamber view. The yellow line marks the completion of the replenishment. To the right of the line, there is no further increase in myocardial signal intensity (WMV 4707 kb)

Video 6.11

Displacement of the M-mode section plane towards the basal segments. With increased gain it is possible to reliably assess the duration of the replenishment, including the basal lateral segment, which appeared to be attenuated on the 2D recording shown in Fig. 6.14 (Video 6.9) (WMV 4707 kb)

Video 6.12

3-chamber viewHypertrophic cardiomyopathy3-chamber view in a patient with hypertrophic cardiomyopathy. The mid systolic frame in the third cardiac cycle after the flash shows subendocardial reduction in myocardial opacification affecting the entire circumference (WMV 5252 kb)

Video 6.13

Stress echocardiography with adenosineAdenosinestress echocardiography with in a patient with left ventricular hypertrophy, 2-chamber view, heart rate 112/min. Subendocardial reduction of the contrast intensity already in mid systole and later systole (image 3 and 4 upper row), as well as in early and mid-diastole (lower row, first and second image) (WMV 608 kb)

Video 6.14

Subendocardial perfusion defect in the basal inferoseptal in a patient with RCA stenosis (WMV 313 kb)

Video 6.15

2-chamber view, stress echocardiography with adenosine. Ischemia in the territory supplied by the RCA (basal inferior segment), no attenuation of the basal inferior. The corresponding video shows akinesia of the segment with the perfusion defect (WMV 852 kb)

Video 6.16

End-systolic frames of a flash replenishment sequence, same patient as in Fig. 6.22 (Video 6.15). There is only minor increase in signal intensity of the inferior segment while there is adequate replenishment in the other segments (WMV 5098 kb)

Video 6.17

Typical basal artefact in a 2-chamber view during an adenosine stress-echocardiography (left). After image optimization normal perfusion is displayed (right) (WMV 4434 kb)

Video 6.18a

Slim patient with good acoustic window, less than 1 cm distance between the probe and the apical pericardium. 4-chamber view (top), 3-chamber view (bottom). Reduction of the apical myocardial contrast. Note the normal signal intensity in the subendocardial layer, which excludes ischemia (WMV 640 kb)

Video 6.18b

Slim patient with good acoustic window, less than 1 cm distance between the probe and the apical pericardium. 4-chamber view (top), 3-chamber view (bottom). Reduction of the apical myocardial contrast. Note the normal signal intensity in the subendocardial layer, which excludes ischemia (WMV 1016 kb)

Video 6.19

Demonstration of the volume in which a flash causes destruction of the microbubbles. A homogeneously perfused liver is shown before the flash (left). Immediately after the flash the entire scan plane becomes dark due to the destruction of the contrast agent (middle) after rotation of the probe by 90° it becomes evident that contrast has been destroyed only in the elevational thickness of the beam (WMV 6553 kb)

Video 6.20

Anatomical M-mode through the central anteroseptal wall in an apical 3-chamber view. Respiratory movements of the heart interfere with the analysis of replenishment. Note the increase of myocardial signal intensity during the first 4 cardiac cycles after the flash and the “paradox” decrease in myocardial signal intensity after the fifth heart action (arrow) (WMV 8543 kb)

Video 6.21

Anatomical M-mode with an image plane through the apex and the mitral valve. Note insufficient contrast flow from the LA into the LV after a prolonged flash (WMV 2840 kb)

Video 6.22

Homogeneous contrast of the left ventricle following a flash (WMV 2842 kb)

Video 6.23

Iatrogenic, not flow-limiting dissection of the left coronary main stem (left), suspicion of an intermediate stenosis of the circumflex artery (right) (WMV 11378 kb)

Video 6.24

Anatomical M-mode through the middle septum and the middle anterolateral wall. Normal replenishment within 4 cardiac cycles (2.5 s) (WMV 6040 kb)

Video 6.25

Two LAD stenoses (arrows) with an FFR of 0.77 (WMV 3341 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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