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How to Optimize Contrast Echocardiography | Cardiology Courses
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New 2017 recommendation on clinical practice in contrast echocardiography by the EACVI
Myocardial contrast echocardiography — Use in viability assessment and acute myocardial infarction Jiwan Pradhan , Roxy Senior. Most agents are stable and can be used for several hours after reconstitution or activation.
Contrast agents can be administered intravenously by one of two approaches. Repeated bolus injection has the advantages of ease of use.
However, far-field attenuation from excessive blood pool concentration often occurs early after injection, and blood pool concentration is not stable over time, which is a requirement for off-label perfusion imaging. Continuous venous infusion with a small pump is an approach that requires slightly more set-up time, but it results in a more reproducible and constant concentration of microbubbles in the blood pool and allows uninterrupted imaging. Because microbubbles are sufficiently small for trans-capillary transit and have been composed with inert gases and shell materials that are biocompatible, they are generally considered to be among the safest of all imaging contrast agents.
However, these particles are recognized as foreign by blood proteins such as serum complement. Other contraindications for some but not all agents include right-to-left shunts and allergy to blood products. Contrast is both safe and effective in patients who have left ventricular LV assist and extracorporeal membrane oxygenation devices. Overcoming "technically difficult" studies is of importance based the increasing use of echocardiography to guide urgent treatment decisions in critically ill patients or for making guideline-based treatment decisions such as in device therapy implantable cardioverter-defibrillator or bi-ventricular pacemaker , timing of valve surgery, or monitoring cardiotoxic drug effects.
By more clearly defining the endocardial border, LVO improves accuracy and reproducibility in the assessment of LV volumes and LV ejection fraction, particularly in those with lower quality non-contrast images. The ability to accurately evaluate contractile response in every segment and to have a high level of reader confidence are critical issues in stress echocardiography and when resting echocardiography is used to evaluate for ischemia in a patient with resting chest pain. Accordingly, LVO plays an important role in stress echocardiography where microbubble contrast can increase the number of interpretable myocardial segments at rest and during stress and reduce the percentage of studies that are technically limited in quality.
Current Indications for Contrast Echocardiography
Myocardial contrast echocardiography refers to the detection of contrast material present within the myocardial microcirculation. Quantitative myocardial contrast echocardiography, which relies on kinetic modeling of contrast in the microcirculation, has been used for a variety of applications in ischemic and non-ischemic heart disease. This topic has been reviewed elsewhere and is not included in this brief review.
The positive impact that contrast has been shown to have on diagnostic accuracy, cost, reproducibility, and reader confidence in a wide variety of situations has led to practice guidelines from the American Society of Echocardiography regarding its use. In clinical practice, it is often important to consider the clinical circumstance when deciding on the impact of contrast.
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- Contrast echocardiography in daily routine practice.
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For example, contrast may have little role when the primary aim is to evaluate for the presence of a pericardial effusion. On the other hand, issues of reliability, reproducibility, accuracy, and confidence can justify the use of contrast in situations when image quality is adequate but marginal, such as the need to detect a regional wall motion abnormality or exclude an apical thrombus.
The American Society of Echocardiography guidelines on contrast echocardiography provide a detailed description of policies that must be implemented regarding contrast use and the roles of different healthcare providers in this process. An echocardiography laboratory must possess imaging systems with the specific ultrasound detection algorithms that have been developed for enhancing contrast signal based on their ability to generate non-linear signals.
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