Contrast echocardiography: a practical guideline from the British Society of Echocardiography

Abstract

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

Keywords: Echocardiography; Guideline; Ultrasound contrast agents.

Fig. 1

Vueject® pump produced by Bracco for continuous SonoVue infusion

Fig. 2

Illustration of the withdrawal of Luminity from the vial using a venting needle, the preparation and administration of a continuous infusion and a diluted bolus injection (Permission to publish images granted by Pharmanovia)

Fig. 3

The workflow in an echocardiography laboratory using a PSD

Fig. 4

There are multiple consecutive pulses in every scanline, 3 of them are displayed in the top row. Second row represents the corresponding received pulses. The received tissue (linear scatterer) signals are combined by adding the two half amplitude signals and subtracting the full amplitude signal. For tissue, the echoes cancel one another, leading to tissue suppression. The third row represents corresponding signals received from microbubbles (nonlinear scatterers). The shape of the full height pulse is different from the half height pulse resulting in a significant “nonlinear” signal remaining after the sum of the received signals from the two half height pulses are subtracted from the full height pulse (Permission to publish images granted by Philips Healthcare)

Fig. 5

a Unenhanced apical 4 chamber with a diastolic LV volume of 103 ml. b Contrast enhanced apical 4 chamber in diastole measuring a LV volume of 114 ml. c Unenhanced apical 2 chamber measuring a diastolic volume of 105 ml. d Contrast enhanced apical 2 chamber in diastole measuring a LV volume of 127 ml

Fig. 6

a Steady state perfusion reveals a mass in the LV apex perfused with microbubbles. b Microbubbles are transiently destroyed with a high MI flash. c There is replenishment of microbubbles seen in the mass post flash suggesting a highly vascular structure, this is highly suspicious of a tumour

Fig. 7

A At peak stress a steady state of contrast is seen throughout the myocardium. B A high MI flash is delivered, and microbubbles are temporarily cleared from the myocardial capillaries. C Myocardial replenishment of microbubbles are seen after one cardiac cycle, with an artefact in the basal anterolateral segment (see Additional file 1: Video S1). Artefact is commonly seen here as lateral resolution is lower than axial definition. The artefact is characterised by full thickness defect which extends beyond the myocardium as opposed to a true defect which is usually subendocardial and fills from the epicardium to the endocardium after 2 secs (see text)

Fig. 8

a Steady state of myocardial perfusion at peak stress with a heart rate of 120 beats per minute. b Microbubbles are cleared with a high MI flash. c Delayed appearance of contrast with a reduced intensity in the sub endocardium seen in the apical segment after 4 cardiac cycles (see Additional file 2: Video S2)

Fig. 9

a With focussed view of the septum, which is affected during LBBB, wall thickening at end diastole is shown. b Wall thickening at end systole is shown. There is no discernible increase in wall thickening suggestive of possible ischaemia in the septum

Fig. 10

a Steady state of myocardial perfusion at rest is shown in the same patient as Fig. 9. b Microbubbles are cleared with a high MI flash. c Myocardial replenishment of microbubbles are seen after one cardiac cycle, suggesting normal coronary blood flow, hence no myocardial ischaemia despite reduced wall thickening (see Additional file 3: Video S3)