Ase Position Paper
Contrast Echocardiography: Current and Future Applications*

https://doi.org/10.1067/mje.2000.105462Get rights and content

Abstract

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-to-image” patient, this added information results in (1) enhanced laboratory efficiency, (2) a reduction in downstream testing, and (3) possible improvements in patient outcome. In addition, substantial research efforts are underway to use ultrasound contrast agents for assessment of myocardial perfusion. The detection of myocardial perfusion during echocardiographic examinations will permit the simultaneous assessment of global and regional myocardial structure, function, and perfusion—all of the indicators necessary to enable the optimal noninvasive assessment of coronary artery disease. Despite the added benefit in improved efficacy of testing, few data exist regarding the long-term effectiveness of these agents. Currently under evaluation are the clinical and economic outcome implications of intravenous contrast agent use for daily clinical decision making in a variety of patient subsets. Until these data are known, this document offers a preliminary synthesis of available evidence on the value of intravenous contrast agents for use in rest and stress echocardiography. At present, it is the position of this guideline committee that intravenous contrast agents demonstrate substantial value in the difficult-to-image patient with comorbid conditions limiting an ultrasound evaluation of the heart. For such patients, the use of intravenous contrast agents should be encouraged as a means to provide added diagnostic information and to streamline early detection and treatment of underlying cardiac pathophysiology. As with all new technology, this document will require updates and revisions as additional data become available. (J Am Soc Echocardiogr 2000;13: 331-42.)

Section snippets

INTRODUCTION

New ultrasonographic (ultrasound) contrast agents and new imaging technologies to detect them have recently become available to the echocardiography laboratory. Intravenous (IV) injection of ultrasound contrast agents has been documented to improve endocardial border delineation.1 Contrast enhancement of the blood-tissue boundary enables improved assessment of ventricular wall motion, wall thickness and thickening, calculation of ejection fraction, and delineation of cardiovascular structural

Contrast Agents

The ability to opacify vascular structures with strong echoes (or “contrast”) on echocardiograms by injecting agitated saline solution or other fluids containing gas bubbles has been recognized for over 30 years.3 The primary mechanism by which injection of such fluids produces ultrasound contrast was determined to be increased backscatter from inclusions of microbubbles within the injectant. Such microbubbles markedly enhanced the blood echo by introducing multiple liquid-gas interfaces.

CONTRAST ECHOCARDIOGRAPHY: CURRENT INDICATIONS

In the United States and Europe, the Food and Drug Administration (FDA) and European Union, respectively, have approved several echocardiographic contrast agents for the indication of ventricular opacification and enhancement of endocardial border definition in patients with technically suboptimal echocardiograms. Left ventricular cavity opacification (LVO) is of clinical value for the assessment of cardiac structure and ventricular performance in resting and stress echocardiography. In

FUTURE APPLICATIONS

At present, the US FDA has approved 2 contrast agents (Albunex and Optison). Several additional agents have been approved in other countries. These agents have been approved only for the indication of ventricular cavity and endocardial border enhancement. A multitude of additional agents are under development and in various phases of the regulatory approval process (Table 1). Although clinically useful as endocardial border-enhancing agents, ultrasound contrast agents have the greater potential

TRAINING AND EXPERIENCE

The basic prerequisites for independent competence in echocardiography (Training Level 2) must be met before introduction of experience with contrast. Level 2 training is defined as including a minimum of 6 months of echocardiography education, involving 300 studies with a wide variety of abnormalities.96 Special competence in stress echocardiography training, as outlined by the American Society of Echocardiography, is also recommended.97 Cardiac sonographers should be well experienced and

SUMMARY AND RECOMMENDATIONS

Currently, the use of contrast echocardiography for the improvement of suboptimal rest and stress echocardiography by enhanced definition of the endocardial border is strongly validated. This enhanced definition has enabled improved assessment of cardiac structure and function, as well as diagnostic feasibility and accuracy. The combination of IV contrast with harmonic stress echocardiography is a powerful tool for improved wall motion analysis through enhanced image quality, routinely

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