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Dear Friends and Colleagues,

After many months of deliberation, the Intersocietal Commission for Accreditation of Echocardiography Laboratories (ICAEL) has announced new standards for accreditation of echocardiography laboratories throughout the United States.  These new standards recognize the important role of ultrasound contrast agents in improving the accuracy of echocardiograms, and will play a major role in guiding the appropriate use of contrast-enhanced ultrasound (CEUS) in the United States.   

ICUS supported ICAEL's development of the new standards and, within minutes of their formal announcement, ICUS disseminated this important news to all members.  This reflects ICUS' strong commitment to supporting the appropriate use of CEUS as a means of improving patient care, and to providing active and effective leadership in the CEUS field.   

The new ICAEL accreditation standards address the use of contrast agents in adult transthoracic and stress echocardiography.  

The section addressing adult transthoracic echo states: "Use of contrast for suboptimal image quality: Contrast is indicated for use when two contiguous segments are not visualized as it provides greater accuracy in determining left ventricular function.  

"A)    If contrast is used, there must be a written policy for the use of contrast agents.
"B)    If contrast is not able to be used there must be a policy for alternative imaging.
"C)    Contrast should be used in the presence of poor endocardial border definition for quantification of chamber dimensions, volumes, ejection fraction and assessment of regional wall motion.
"D)    Poor endocardial border definition is defined as the inability to detect two or more contiguous segments in any three of the apical views.
"E)    Contrast should also be used to assess conditions such as hypertrophic cardiomyopathy or when left ventricular thrombus is suspected."

In addition, the new ICAEL standards, in defining the types of adult stress echo procedures, state: "Contrast agents may be used in conjunction with treadmill, bicycle, pacing or pharmacologic stress to optimize endocardial border definition or enhance Doppler signals."

The new ICAEL standards also require echo labs to use contrast in suboptimal adult stress echocardiograms in which two or more contiguous segments are not visualized.  Part IV of the document, relating to adult stress echocardiographic testing, states: "Contrast is indicated for use when two contiguous segments are not visualized as it provides greater accuracy in determining left ventricular function.  Contrast must be used  if this is not accomplished with harmonic optimal imaging." (Emphasis added.)   

Finally, in defining the components of an adult stress echocardiogram, the document states: "Contrast is indicated for use in patients when two contiguous segments are not visualized and provides greater accuracy in determining left ventricular function.  Laboratories should have a written policy for use of contrast agents for stress echocardiography."

You will find a copy of "Changes: The Latest Revisions to the ICAEL Standards" -- the official ICAEL summary of its new standards  here (link to the attached PDF). We encourage you to review this summary as well as the complete 2010 ICAEL Standards documents available on ICAEL's website: www.icael.org/icael/apply/standards.htm.

We also wish to report efforts in Canada to recommend contrast stress echocardiograms as "a key strategy in future planning for cardiac diagnostic imaging, pending Health Canada approval."  The relevant documents also recognize the cost-effectiveness of contrast stress echocardiograms in certain circumstances, as well as "growing concerns" regarding cumulative radiation exposure with certain other imaging technology.  The relevant documents can be accessed at the Ontario Ministry of Health website: http://www.health.gov.on.ca/english/providers/program/ohtac/draft_comment.html.  

As always, we welcome your ongoing input on this and other matters impacting the CEUS field worldwide.

Best regards,
Steve Feinstein and Barry Goldberg,
Co-Presidents, International Contrast Ultrasound Society
www.ICUS-Society.org