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Pitfalls in Contrast ImagingPitfalls in Contrast Imaging

Steven J. Lester, MD, FACC, FRCP(C), FASEMayo Clinic

Relevant Financial Relationship(s)None

Off Label UsageNone

Relevant Financial Relationship(s)None

Off Label UsageNone

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Stabilized gas microbubbles sized to pass through the smallest capillaries

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Agent Size (μm) Gas Shell Indication

Optison 3.0-4.5 Perflutren Albumin LVO/EBD

Definity 1.3-3.3 Perflutren Phospholipid LVO/EBD

Lumason1.5-2.5

Sulfur hexafloride

Phospholipid• LVO/EBD• Abdominal/Liver US• Urinary Tract (peds)

Avoid the PitfallsPositive Impact : Makes a Difference

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Safety : ContraindicationsSafety : Contraindications

1. Suspected hypersensitivity to the microsphere components.

1. Suspected hypersensitivity to the microsphere components.

No 30 minute monitoring period!

• Most serious reactions occurwithin 30 minutes of administration

• Most common use of diagnostic echocardiography

• Global ventricular function

• Regional wall motion

RestStress

• Most common use of diagnostic echocardiography

• Global ventricular function

• Regional wall motion

RestStress

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Innovation Workflow

For any innovation in echocardiography to be widely adopted itmust be equaled or paralleled by an innovation in workflow

Imaging Protocol (a) : Workflow EfficiencyImaging Protocol (a) : Workflow Efficiency

The “60 Second Echo”

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Impact of the “60 second Echo”Impact of the “60 second Echo”

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22.5

26.7 26.7

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Total Procedure Time Sonographer Scan Time

Min

ute

s

Routine Discretionary

P = NS P < 0.004

Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23

1= Excellent or adequate full endocardial visualization

2= Incomplete endocardial visualization

3= only epicardium visualized4= segment not visualized

1= Excellent or adequate full endocardial visualization

2= Incomplete endocardial visualization

3= only epicardium visualized4= segment not visualized

Visualization

0

20

40

60

80

100

Per

cen

t Routine 88%

Discretionary50%

DiscretionaryNo Contrast

33%

Visualization Score < 1.1

Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23

We Don’t Use Enough Contrast

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Imaging Protocol (b) : Spectral DopplerImaging Protocol (b) : Spectral Doppler

1= Excellent2= Fair3= Poor

1= Excellent2= Fair3= Poor

Spectral Doppler

0

20

40

60

80

100

PulmonaryVein

Mitral Inflow TricuspidRegurgitation

Routine Discretionary

Spectral Doppler Score = 1

Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23

Per

cen

t (%

)

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Without Contrast With Contrast

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AORTIC STENOSISAORTIC STENOSISWithout Contrast With Contrast

Structural DefinitionStructural Definition

1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

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LV AneurysmLV Aneurysm

LV Aneurysm & More

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LV Aneurysm

LV Aneurysm & More

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Structural DefinitionStructural Definition1. LV Structural Abnormalities

- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

2. Characterize intracardiac masses (tissue characterization)

1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

2. Characterize intracardiac masses (tissue characterization)

LV apical thrombus in patient post MI, no enhancement

Secondary cardiac tumor(renal sarcoma) located in RA, complete enhancement

LA myxoma, partial enhancement

Mansencal et al. Archives of Cardiovascular Disease (2009) 102, 177—183

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Structural DefinitionStructural Definition

1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

2. Characterize intracardiac masses (tissue characterization)

3. Differentiate artifacts

1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture

2. Characterize intracardiac masses (tissue characterization)

3. Differentiate artifacts

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Machine and administration frequency adjusted to provide best image

Machine and administration frequency adjusted to provide best image

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Foc

al

Are

a

Foc

al

Are

a

Single Focus Single Focus Dual Focus

Mechanical Index• Measure of output

acoustic power• High MI increases

bubble destruction

Mechanical Index• Measure of output

acoustic power• High MI increases

bubble destruction

MI 0.24 increased to 0.6

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CP1227021-1

MI = 1.4

MI = 0.2

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• System settings (focal zone misplacement)

• Dosing and administration(low concentration)

• System settings (focal zone misplacement)

• Dosing and administration(low concentration)

POTENTIAL CAUSES

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• Dosing (high concentration)

• Administration (infusion rate too fast)

• Clinician (obtain off-axis windows)

• Dosing (high concentration)

• Administration (infusion rate too fast)

• Clinician (obtain off-axis windows)

POTENTIAL CAUSES

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• System settings (high MI)

• Dosing(low concentration)

• Administration (low infusion rate)

• Poor LV function

• System settings (high MI)

• Dosing(low concentration)

• Administration (low infusion rate)

• Poor LV function

POTENTIAL CAUSES

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Avoid The PitfallsAvoid The Pitfalls

1. Contraindications (safety)2. Protocol Development

(The 60 second Echo)3. Use It4. Spectral Doppler5. Instrument Settings

1. Contraindications (safety)2. Protocol Development

(The 60 second Echo)3. Use It4. Spectral Doppler5. Instrument Settings

Tool Used to Build Excellence in ECHO

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