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Scientific Papers

Contrast Echocardiography: Current and Future Applications

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Recent updates in the field of echocardiography have resulted in improvements in image quality, especially in those patients whose ultrasonographic (ultrasound) evaluation was previously suboptimal. Intravenous contrast agents are now available in the United States and Europe for the indication of left ventricular opacification and enhanced endocardial
border delineation. The use of contrast enables acquisition of ultrasound images of improved quality. The technique is especially useful in obese patients and those with lung disease. Patients in these categories comprise approximately 10% to 20% of routine echocardiographic examinations.

Stress echocardiography examinations can be even more challenging, as the image acquisition time factor is critically important for accurate detection of coronary disease. Improvements in image quality with intravenous contrast agents can facilitate image acquisition and enhance delineation of regional wall motion abnormalities at the peak level of exercise. Recent phase III clinical trial data on the use of Optison and several other agents (currently under evaluation) have revealed that for approximately half of patients, image quality substantively improves, which enables the examination to be salvaged and/or increases diagnostic accuracy. For the “difficult-toimage” patient, this added information results in (1) enhanced laboratory efficiency, (2) a reduction in downstream testing, and (3) possible improvements in patient outcome.

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Guidelines for the Cardiac Sonographer

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Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography:
Recommendations of the American Society of Echocardiography Council on Cardiac Sonography

INTRODUCTION
The impact of contrast agents (transpulmonary and agitated saline) on the clinical applications of echocardiography has been dramatic over the last decade. Currently, the Food and Drug Administration–approved indications for transpulmonary agents include the enhancement of left ventricular endocardial border definition.The augmentation of Doppler signals and intracardiac shunt detection can also be enhanced with the administration of contrast agents. The use of contrast agents in each of these clinical situations is well established and has become standard practice in many echocardiography laboratories.


The development of newer agents promises to bring additional advances in the utility of contrast echocardiography, including the real-time assessment of myocardial perfusion; coronary flow detection and flow reserve measurements; the delivery of pharmacologic or genetic therapy; and in combination with continuous ultrasonography, as a therapy for discriminatingly dissolving life-threatening blood clots. As these applications continue to expand, so must the role and responsibilities of the cardiac sonographer.

For the full article, please click here

Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography:
Recommendations of the American Society of Echocardiography Council on Cardiac Sonography

INTRODUCTION
The impact of contrast agents (transpulmonary and agitated saline) on the clinical applications of echocardiography has been dramatic over the last decade. Currently, the Food and Drug Administration–approved indications for transpulmonary agents include the enhancement of left ventricular endocardial border definition.The augmentation of Doppler signals and intracardiac shunt detection can also be enhanced with the administration of contrast agents. The use of contrast agents in each of these clinical situations is well established and has become standard practice in many echocardiography laboratories.


The development of newer agents promises to bring additional advances in the utility of contrast echocardiography, including the real-time assessment of myocardial perfusion; coronary flow detection and flow reserve measurements; the delivery of pharmacologic or genetic therapy; and in combination with continuous ultrasonography, as a therapy for discriminatingly dissolving life-threatening blood clots. As these applications continue to expand, so must the role and responsibilities of the cardiac sonographer.

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Safety of contrast-enhanced echocardiography within 24 h after acute myocardial infarction

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Aims:
Contrast-enhanced echocardiography is widely used to enhance left ventricular (LV) endocardial
border delineation in stable patients with known or suspected coronary artery disease. In patients
with acute myocardial infarction, accurate assessment of LV function and size is important, but data
on the safety of contrast-enhanced echocardiography in the early stage of myocardial infarction
(within 24 h) are lacking. In the current study, the experience on the safety of contrast-enhanced echocardiography
within 24 h of acute myocardial infarction is reported.

Methods and results:
A total of 115 consecutive patients (58+11 years; 77% male) admitted to the coronary
care unit for ST-elevation acute myocardial infarction underwent clinically indicated contrastenhanced
echocardiography within 24 h of hospital admission to assess LV size and function. Perflutren
(Luminityw, Bristol-Myers Squibb Pharma, Bruxelles, Belgium) was used as contrast agent. Safety was
determined evaluating vital signs, physical examination, ECG, and adverse events. On contrastenhanced
echocardiography, the mean LV ejection fraction was 44+11%, and 56% of patients had an
LV ejection fraction 45%. Administration of echo contrast did not induce any significant change in
vital signs, physical examination, and ECG. Major adverse events were not observed whereas minor
events occurred in 4% of patients (hypersensitivity at the injection site in three and transient back
pain in two).

Conclusion:
These data provide evidence on the safety of contrast-enhanced echocardiography in the
first 24 h of myocardial infarction; larger patient cohorts are needed to confirm these findings.

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Contrast agents for echocardiographic studies within 24 h after myocardial infarction

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Back to normal in the US
In April 2008, the US Food and Drug Administration (FDA)
performed a safety review of the US-approved perflutren
microsphere contrast agents (Definity and Optison) and
revised a previous black box warning. The new contraindications
are much less restrictive than the previous contraindications
and satisfy the needs of clinical echocardiography.
These changes have come after an intensive debate with
the American Society of Echocardiography but also with
significant European support. The correction of the contraindication
for contrast agents is a good example, how
inadequate decisions by the health administration can be
reversed by competent and decisive actions of scientific
and professional bodies like the ASE and EAE.
Before April 2008, the use of contrast agents was contraindicated
in patients with unstable cardiopulmonary status,
including patients with unstable angina, acute myocardial
infarction, respiratory failure, or recent worsening congestive
heart failure. The contraindications were established
temporarily after the reports of 199 serious cardiopulmonary
reactions including 11 deaths during and shortly after the
administration of contrast agents in post-marketing use.
Ten of the events were observed with Definity over 6 years
with more than 2 million applications; one fatal event was
reported with Optison for 1 million applications. At least
six of these cases (five Definity and one Optison) occurred
1–12 h after dosing and were attributed to serous underlying
conditions.

Full paper available for download as a PDF here

 

Microbubble Contrast Agents for Ultrasound Imaging

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The use of contrast agents is an essential component of abdominal
computed tomography (CT) and magnetic resonance (MR) examination.
However, the use of contrast agents in ultrasound has not been as
popular in North America, as at the time of writing they are not approved
in the US for clinical use in abdominal imaging. We have enjoyed using
contrast-enhanced ultrasound (CEUS) in Canada, where contrast agents
for ultrasound have been approved for abdominal imaging since 2001. In
our experience, CEUS is an excellent imaging modality with a strong
safety profile and superb diagnostic capability for many indications in
abdominal imaging.1 CEUS is also widely available in Europe and East
Asia, and the use of CEUS has rapidly increased over recent years. This
article provides a summary of our experience with CEUS in liver and other
abdominal imaging.

Full paper available for download as a PDF here

 
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