Contrast Echo Final

8/2/2019 Contrast Echo Final

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Contrast Echocardiography


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Left ventricular opacification

Myocardial perfusion Assessment of reperfusion andmyocardial viability


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Improved endocardial border

delineation reduced inter- and intra-observer variability

improved detection of regional

wall motion abnormalities

improved calculation of LVvolumes and ejection fraction


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Contrast EchocardiographyInter-institutional agreement according to image quality

Hoffmann et al.J Am Coll Cardiol1996;27:330


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Contrast EchocardiographyNA, 67 y.o. male


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Contrast EchocardiographyNA, 67 y.o. male


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Contrast EchocardiographyEffect of left ventricular opacification on accuracy of DbE

Dolan et al.Am Heart J2001;142:908


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Left ventricular opacification

Myocardial perfusion Assessment of reperfusion andmyocardial viability


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Contrast EchocardiographyReal-time perfusion imaging using power modulation


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Contrast EchocardiographyMCE versusMIBI for assessment of myocardial blood volume

Wei et al.Am J Physiol2001,280:H1896


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How do we get from myocardial bloodvolume to myocardial blood flow ?

DYNAMIC IMAGING


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Contrast EchocardiographyQuantification of myocardial blood flow


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Van Camp et al.,JASE2003;16:263


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Contrast EchocardiographyMN, 50 y.o. male

Peltier et al.JACC2004;43:257


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DIPYRIDAMOLEMCE


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Contrast EchocardiographyDipyridamole real-time PowerModulation



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Contrast EchocardiographyDipyridamole RTCE: Prognostic implications

Tsusui et al.JCirculation 2005;112:1444


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Contrast EchocardiographyT.V.H. - F - 46 year old

10.43 am: ECG


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11.43 amCoronary angiography


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11.53 amDirect angioplasty and stenting


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Contrast EchocardiographyAssessment of the no-reflow phenomenon by i.c.MCE

Ito et al. Circulation 1992;85:1699.


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Contrast EchocardiographyDetection of myocardial viability with intravenousMCE

Swinburn et al.J Am Coll Cardiol2001;38:19.


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Contrast EchocardiographyContrast Echocardiography

To DiagnoseTo DiagnoseAcute Myocardial InfarctionAcute Myocardial Infarction


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The ProblemThe Problem

Over 5 million ED visits in US for chest pain (CP)Over 5 million ED visits in US for chest pain (CP)

Only 10Only 10--30% of them actually will have a AMI30% of them actually will have a AMI(acute MI)(acute MI)

EKG diagnoses onlyEKG diagnoses only

3030--40% of AMI40% of AMI Blood work,Blood work,

includingincludingtroponins,troponins,take time totake time toreturnreturn

Troponins takeTroponins takeseveral hoursseveral hoursdetect afterdetect afterinfarctioninfarction


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The Problem Part IIThe Problem Part II

When AMI is not immediately diagnosedWhen AMI is not immediately diagnosedfrom EKG, treatment is delayed untilfrom EKG, treatment is delayed untiltroponins turn positivetroponins turn positive

Many are admitted for rule out becauseMany are admitted for rule out becausetheir troponins are negative in EDtheir troponins are negative in ED

Cost for rule out admissions is $10 billionCost for rule out admissions is $10 billionin United Statesin United States

5% of pts with AMI are5% of pts with AMI areinadvertently dischargedinadvertently discharged


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Wouldnt It Be GreatWouldnt It Be Great

If there was a test immediatelyIf there was a test immediatelyavailable to diagnose or risk stratifyavailable to diagnose or risk stratifypatientspatients

Low risk patients could be safelyLow risk patients could be safelydischarged without admissiondischarged without admission

High risk patients could be admittedHigh risk patients could be admitted

to the appropriate level of care andto the appropriate level of care andtreatedtreated


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The ContendersThe Contenders

There are a number of imagingThere are a number of imagingmodalities that try to address thismodalities that try to address thisproblemproblem

Traditional EchoTraditional Echo SPECTSPECT

CTCT

MRMR

Each provides important informationEach provides important informationbut has significant downsidesbut has significant downsides


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Traditional EchoTraditional Echo


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Traditional EchoTraditional Echo

Traditional echocardiography is used to diagnoseTraditional echocardiography is used to diagnoseAMI by analyzing regional wall thickening andAMI by analyzing regional wall thickening andhypokinesishypokinesis

In patients presenting to the ED with CP and nonIn patients presenting to the ED with CP and non--

diagnostic EKG, specificity is only 53diagnostic EKG, specificity is only 53--57% for57% forAMI and 78% for cardiac ischemiaAMI and 78% for cardiac ischemia

FalseFalse--negative studiesnegative studiesreported in 1% of ptsreported in 1% of ptswith AMIwith AMI

Poor image quality,Poor image quality,especially in patientsespecially in patientswith suboptimalwith suboptimalwindowswindows


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SPECTSPECT

Non-transmural MI with stress induced ischemia


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SPECTSPECT

TechnetiumTechnetium--99 used to evaluate myocardial99 used to evaluate myocardialblood flow (MBF) several hours after injectionblood flow (MBF) several hours after injection

Effective at reducing rule out admissions by 32%Effective at reducing rule out admissions by 32%

Studies show good sensitivity and negativeStudies show good sensitivity and negative

predictive value but performed using lowpredictive value but performed using low--riskriskpatients and using CK or CKpatients and using CK or CK--MB as gold standardMB as gold standard

33--4% of LV myocardium must be affected before4% of LV myocardium must be affected beforeperfusion defect visibleperfusion defect visible

Hence small troponinHence small troponin--positive AMIs missedpositive AMIs missed SPECT unable to differentiate between old andSPECT unable to differentiate between old and

new infarctionsnew infarctions

Downsides also include isotope issues and needDownsides also include isotope issues and needfor study to be performed in Nuc Med deptfor study to be performed in Nuc Med dept


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CTCT

Multidetector CT showing a high-grade proximal LAD stenosis


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CTCT

Benefits of being able to examine coronaryBenefits of being able to examine coronaryanatomy, vessel stenosis, vessel remodeling,anatomy, vessel stenosis, vessel remodeling,ventricular function and to exclude other seriousventricular function and to exclude other seriouscauses of CPcauses of CP

CT with calcium score good at diagnosing CADCT with calcium score good at diagnosing CADbut not whether CAD is causing CPbut not whether CAD is causing CP

Difficult to evaluateDifficult to evaluatemyocardium in the settingmyocardium in the settingof tachycardia and previousof tachycardia and previous

stent placementstent placement Difficult to evaluate smallDifficult to evaluate small

arteriesarteries

Pts exposed to radiationPts exposed to radiationand contrastand contrast


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Cardiac Magnetic ResonanceCardiac Magnetic Resonance

Sub-endocardial infarction in inferior left ventricular wall


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Cardiac Magnetic ResonanceCardiac Magnetic Resonance

IV Gadolinium used to assess myocardialIV Gadolinium used to assess myocardialperfusion, wall motion abnormalities andperfusion, wall motion abnormalities andcoronary anatomycoronary anatomy

Benefits of high resolution, no radiation,Benefits of high resolution, no radiation,

no nephrotoxic contrastno nephrotoxic contrast Drawbacks include motion artifact limitingDrawbacks include motion artifact limiting

evaluation of small arteries, limitedevaluation of small arteries, limitedavailability of MR machinery, unsuitableavailability of MR machinery, unsuitablefor patients with pacemakers and ptfor patients with pacemakers and ptclaustrophobiaclaustrophobia

Sensitivity 72% and specificitySensitivity 72% and specificity87% compared to angiography87% compared to angiography


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We Need Something BetterWe Need Something Better

Ideal imaging modality would be:Ideal imaging modality would be: SafeSafe

Highly specific and sensitiveHighly specific and sensitive

Having high negative and positive predictive valuesHaving high negative and positive predictive values

Not hampered by cardiac motionNot hampered by cardiac motion Able to be performed and interpreted at all hoursAble to be performed and interpreted at all hours

Widely availableWidely available

QuickQuick

NonNon--invasiveinvasive

RadiationRadiation--freefree

PortablePortable

InexpensiveInexpensive


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Introducing CEIntroducing CE

Contrast EchocardiographyContrast Echocardiography

Many benefits including:Many benefits including: SafetySafety

High specificity, sensitivity, negative predictiveHigh specificity, sensitivity, negative predictivevalue,value,

Good visualization despite cardiac motionGood visualization despite cardiac motion

Echo equipment is widely availableEcho equipment is widely available

QuickQuick

NonNon--invasiveinvasive

RadiationRadiation--freefree

PortablePortable

InexpensiveInexpensive


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SideSide--ByBy--Side CE, SPECT, MRSide CE, SPECT, MR

Fixed septal/apical perfusion defectFixed septal/apical perfusion defectafter MI (arrows) with CE (left),after MI (arrows) with CE (left),SPECT (middle), and delayedSPECT (middle), and delayedenhancement with MR (right)enhancement with MR (right)


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How It WorksHow It Works

Inject IV microbubblesInject IV microbubbles

Microbubbles remain exclusivelyMicrobubbles remain exclusivelyintravascular and opacity systemicintravascular and opacity systemiccirculationcirculation

Evaluate wall motion with traditionalEvaluate wall motion with traditionalecho techniquesecho techniques

Evaluate myocardial perfusionEvaluate myocardial perfusion(described in a future slide)(described in a future slide)


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About The MicrobubblesAbout The Microbubbles

About 3 m in diameterAbout 3 m in diameter

(Smaller than RBC)(Smaller than RBC)

Contain gases of low diffusibility and solubilityContain gases of low diffusibility and solubility

Hemodynamically inertHemodynamically inert Microvascular rheologyMicrovascular rheology

identical to RBCsidentical to RBCs (Rheology is the study(Rheology is the study

of the deformation andof the deformation and

flow of matter under theflow of matter under theinfluence of an appliedinfluence of an appliedstress.)stress.)


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(Regional Function) RF(Regional Function) RF

Easier to determine RF with CE thanEasier to determine RF with CE thantraditional echo because endocardialtraditional echo because endocardialborders are delineated in muchborders are delineated in much

greater detailgreater detail Even smaller wall motion defects areEven smaller wall motion defects are

identifiable than with traditional echoidentifiable than with traditional echo

Interpreter confidence is increasedInterpreter confidence is increased

Interobserver and intraobserverInterobserver and intraobservervariability is decreasedvariability is decreased


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RF and Time DelayRF and Time Delay

The Dogma is that RF will only beThe Dogma is that RF will only beabnormal in the setting of active CPabnormal in the setting of active CP

The data show RF abnormalities persistThe data show RF abnormalities persist

after resolution of CP in NSTEMI, unstableafter resolution of CP in NSTEMI, unstableangina and transient ischemia because of:angina and transient ischemia because of:

Patchy microvascular and myocellular necrosisPatchy microvascular and myocellular necrosis

Subocclusive disease with severe decreases inSubocclusive disease with severe decreases in

perfusionperfusion Myocardial stunning after spontaneousMyocardial stunning after spontaneous

reperfusionreperfusion


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MBFMBF

After regional function is analyzed, highAfter regional function is analyzed, high--energy ultrasound is used to destroy theenergy ultrasound is used to destroy themicrobubblesmicrobubbles

How quickly microbubbles return dependsHow quickly microbubbles return dependson RBC velocityon RBC velocity

Microbubbles will return in 5 seconds inMicrobubbles will return in 5 seconds innormal myocardiumnormal myocardium

If microbubbles do not return in 5 secondsIf microbubbles do not return in 5 secondsthen myocardial perfusion is decreasedthen myocardial perfusion is decreased


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Another ImageAnother Image

Pt with recent AMIPt with recent AMIand occluded Cx.and occluded Cx.MP defects can beMP defects can be

seen at the lateralseen at the lateralapex and middleapex and middlelateral walllateral wall


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The Data: CE vs TIMIThe Data: CE vs TIMI

Pts presenting to ED with CP and nonPts presenting to ED with CP and non--diagnostic EKG:diagnostic EKG: CE with RF and MP is superior to TIMI score,CE with RF and MP is superior to TIMI score,

both with and without troponin values, inboth with and without troponin values, in

providing shortproviding short--, intermediate, intermediate-- and longand long--termtermprognostic informationprognostic information

(TIMI is Thrombolysis in MI scoring system(TIMI is Thrombolysis in MI scoring system

based on age, coronary risk factors, knownbased on age, coronary risk factors, knowncoronary stenosis, ST segment deviation, twocoronary stenosis, ST segment deviation, twoor more angina events in previous 24 hrs, useor more angina events in previous 24 hrs, useof ASA in previous week, elevated troponin)of ASA in previous week, elevated troponin)


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Visual DataVisual Data

Incremental value of tests performedIncremental value of tests performed

for determining risk of all eventsfor determining risk of all events

D=Demographics, C=Clinical, E=EKGD=Demographics, C=Clinical, E=EKG


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The Data: Effect of Time DelayThe Data: Effect of Time Delay

Patients presenting to ED within 12Patients presenting to ED within 12hours of CP with nonhours of CP with non--diagnostic EKG:diagnostic EKG:

No difference in detection of RF or MPNo difference in detection of RF or MP

abnormalities between pts with ongoingabnormalities between pts with ongoingCP and resolved CPCP and resolved CP

Time delay does not affect CEs abilityTime delay does not affect CEs abilityto predict events within 24 hoursto predict events within 24 hours


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The DownsidesThe Downsides

Smallest AMIs (about 1%) will be missedSmallest AMIs (about 1%) will be missed These patients also had short duration of CPThese patients also had short duration of CP

and low troponin peaksand low troponin peaks

Positive predictive value only 34%Positive predictive value only 34%because old deficits unable to bebecause old deficits unable to bedifferentiated from new deficitsdifferentiated from new deficits PPV 98% if pts with previous of AMI excludedPPV 98% if pts with previous of AMI excluded

Techs and MDs must be available toTechs and MDs must be available toperform and interpret exams at all hoursperform and interpret exams at all hours

Interpretation is subjectiveInterpretation is subjective


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Example of CE in UseExample of CE in Use

81 yo man with well81 yo man with well--controlled HTN andcontrolled HTN andno prior cardiac hxno prior cardiac hx

Presents to ED with one hour of substernalPresents to ED with one hour of substernal

CP, SOB, cramping in left armCP, SOB, cramping in left arm Occurred after eating and not duringOccurred after eating and not during

significant exertionsignificant exertion

Normal PE, EKG, CXR,Normal PE, EKG, CXR,first troponinfirst troponin

CE performed in EDCE performed in ED


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CE Saves The DayCE Saves The Day

CE in ED showed:CE in ED showed:

RF abnormality in mid and distal septum, anterior wallRF abnormality in mid and distal septum, anterior walland apexand apex

MP abnormality in same segments with gradual return ofMP abnormality in same segments with gradual return ofcontrast indicating significant residual myocardialcontrast indicating significant residual myocardial

viabilityviability Pt admitted to cardiology,Pt admitted to cardiology,

cath showed multicath showed multi--vesselvesseldisease, CABG performeddisease, CABG performedsuccessfullysuccessfully

Troponin was not positiveTroponin was not positiveuntil 8 hrs after presentationuntil 8 hrs after presentation


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Future Directions For CEFuture Directions For CE

New contrast agents being developedNew contrast agents being developedthat are targeted to inflammation,that are targeted to inflammation,angiogenesis, thrombosisangiogenesis, thrombosis

Presence of acute inflammation one wayPresence of acute inflammation one wayto differentiate new from old injuryto differentiate new from old injury

Use of new contrast agents may beUse of new contrast agents may be

expand contrast ultrasonography toexpand contrast ultrasonography toany organ accessible by ultrasoundany organ accessible by ultrasound


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THANK YOUTHANK YOU

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Contrast Echo Final