Contrast Echocardiography

ABCIC

Review Article

My Approach to Agitated Saline Contrast Echocardiography in Pediatric Patients

Karen Saori Shiraishi Sawamura et al. Márcio Miranda Brito

Abstract

Agitated saline contrast is a simple, safe, widely available echocardiography technique. It is particularly useful for evaluating right-to-left shunts and pulmonary vascular abnormalities in the pediatric population. This article presents a practical approach to using this technique in pediatric echocardiography. It reviews the underlying physiological principles, the technical aspects of preparation and image acquisition, and the main clinical applications.

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Case Report

Apical Occupation by Endomyocardiofibrosis Associated with Thrombus Diagnosed with Contrast Echocardiography and Resolved with Clinical Treatment

André Timóteo Sapalo et al. Rodolpho Cunha Luis Gustavo Gali Minna Moreira Dias Romano

Abstract

Endomyocardial fibrosis (EMF) is a neglected but prevalent disease in underdeveloped countries. Despite its frequency, it is still considered a rare disease. It is marked by the following findings: architectural distortion, ventricular filling changes, and segmental mobility changes affecting not only diastolic and systolic dynamics but also heart valve function. Apical thrombi can be formed in more advanced disease. In this case report, we revisit EMF and present the challenging case of a 52-year-old woman with New York Heart Association (NYHA) functional classification (FC) IV heart failure. Resting electrocardiography revealed sinus rhythm with left ventricular (LV) overload, high voltage vectors, rectified ST-segment depression, and a negative T-wave in the anterolateral region compatible with the strain pattern. The evaluation of echocardiographic images showed marked left atrial dilation, no ventricular dilatation, and hyper-refringent apical occupation within the LV suggestive of a large sessile thrombus superimposed on the endocardial fibrous layer. Although surgery is the most supported approach in the literature in such situations, this patient was treated with oral anticoagulants (OAC) for 1 month and 24 days. The patient progressed well with an improved NYHA FC. Endocavitary contrast echocardiography performed 2 months after OAC initiation showed regression of the apical thrombus image.

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ABCIC

Review Article

My Approach to Contrast Echocardiography

Miguel Osman Dias Aguiar et al. Alessandra Joslin Oliveira Carolina Stangenhaus Wilson Mathias Junior

Introduction

Contrast echocardiography (CE) uses ultrasound enhancing agents (UEA) that, when introduced into the bloodstream and subjected to ultrasound (US), contrast the blood due to the great reflective capacity of microbubbles. It completely opacifies the left ventricle (LV), with better definition of endocardial borders, Doppler signal enhancement, and myocardial perfusion (MP).

Commercially available second-generation UEA are composed of high molecular weight gases surrounded by an outer shell of albumin, phospholipid, or polymer. These inert structures aggregate and remain within the intravascular space, presenting kinetics similar to those of red blood cells but at less than half their size (1.0–4.5 µm), which allows them to pass the pulmonary capillary barrier and reach the left chambers. They are predominantly excreted through the lungs, have a high metabolism (half-life, 10–12 min), do not deposit in the tissues, and, unlike iodinated contrast agents, present no known risk factors of nephrotoxicity.^,

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ABCIC

Editorial

Difficulty Introducing Contrast Echocardiography in Daily Clinical Practice in South America: A Matter of Economy?

Ricardo Ronderos

Contrast echocardiography has shown invaluable utility in the clinical setting during the last 20 years. Most studies have demonstrated its successful application in different clinical scenarios. Ultrasound contrast agents (UCA) have evolved incredibly since their first-generation iterations at the end of the last century. From weak and short-term duration agents like Levovist™ to the development of fluorocarbons with simple storage requirements like Definity™ and Sonovue™, significant improvements have been achieved and the logistics in echocardiography labs became easier. Nevertheless, their clinical application did not increase as expected, especially in South America.

To analyze this fact, we must consider the probability of a new diagnostic technique becoming a regular and widespread diagnostic tool. A new diagnostic technique should be superior to its predecessors and available in different clinical scenarios; feature simple instrumentation, simple interpretation, well-defined normal patterns; be attractive and comprehensive in terms of image quality; and be cost-effective to ensure acceptance by health system financiers.^, ()

[…]

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Editorial

Ventriculography: When to Choose to Perform It?

Gabriella Cunha Lima

The current guidelines address the indications for left heart catheterization associated with coronary angiography, but most of these instructions do not mention ventriculography, as this test is often at the operator’s discretion. For many years, ventriculography was used as the gold standard method for ventricular function. This mini editorial presents some insights to fill this gap.

Some complications may occur concerning ventriculography, such as contrast-induced nephropathy (CIN) in approximately 1% of patients without predisposing factors and in 10% to 30% of those with risk factors, embolization, arrhythmia, cardiac tamponade, and increased radiation exposure.

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ABCIC

Case Report

A Rare Cause of Hypoxemia

Lisete Lopes et al. Patrícia Vaz Silva Dina Rodrigues António Pires

Abstract

An unroofed coronary sinus is a very rare cardiac anomaly that is commonly associated with a persistent left superior vena cava. Its diagnosis is often difficult, but clinical signs and echocardiographic findings of an interatrial shunt should raise its suspicion. The authors describe the case of a child with chronic hypoxemia whose diagnostic work-up revealed an unroofed coronary sinus and persistent superior left vena cava.

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Case Report

Contrast echocardiography for the evaluation of tumors and thrombi

Eliza Kaori Uenishi et al. Márcia A. Caldas Ally N. R. Saroute Jeane Mike Tsutsui … Gustavo H. M. Piotto Sandra N. R. S. Falcão Wilson Mathias Jr.

Contrast echocardiography is based on intravenous injection of microbubbles that act as blood flow tracers and increase ultra-sound signal. Contrast agents have shown to improve cardiac cavities opacification and endocardial border delineation in addition to helping perfusion evaluation. Contrast echocardiography has recently been used to evaluate cardiac masses. In this report we will describe three cases evaluated by contrast echocardiography: a left atrial myxoma (benign tumor), a lung adenocarcinoma metastasis (malign tumor), and one thrombus. Contrast echocardiography showed to be valuable in the diagnosis of the different types of cardiac masses.

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Artigo Original

Contrast echocardiography in the diagnosis of intrapulmonary vascular dilations in candidates for liver transplantation

Paulo Roberto Pavarino et al. Hélio Augusto dos Reis Corbucci Carlos Henrique de Marchi Paula Fernanda da Mata Moacir Fernandes de Godoy

OBJECTIVE: To determine the importance of contrast echocardiography in the diagnosis of intrapulmonary vascular dilations in patients with severe liver disease, who are candidates for liver transplantation. METHODS: The study comprised 76 patients with chronic liver disease and no evidence of intrinsic pulmonary disease, heart failure, or congenital heart disease with intracardiac communications, who underwent transthoracic echocardiography with second harmonic imaging. Thirty-two of them underwent consecutive transesophageal study. The result of contrast echocardiography was considered positive when the presence of contrast was detected in the left cardiac chambers with a delay of 4 to 6 cardiac cycles after initial opacification of the right cardiac chambers. RESULTS: The prevalence of intrapulmonary vascular dilations was 53.9% (41/76 patients). The sensitivity, specificity, positive and negative predictive values, and accuracy of transthoracic echocardiography as compared with those of transesophageal echocardiography for confirming pulmonary vascular abnormalities in patients with liver disease were, respectively, 75%, 100%, 100%, 80%, and 87.5%. The degree of arterial oxygenation showed no correlation with the occurrence of a positive echocardiographic study. Arterial hypoxemia (PaO2 < 70 mm Hg) was observed in 9 (15.9%) of the 76 patients. The echocardiographic study was positive in 37 (55.2%) of the 67 nonhypoxemic patients and in 4 (44.4%) of the 9 hypoxemic ones. CONCLUSION: Contrast echocardiography proved to be effective, easy, and safe to use in candidates for liver transplantation. Transthoracic echocardiography may be used in the diagnostic routine of intrapulmonary vascular dilations, the transesophageal study being reserved for inconclusive cases with clinical suspicion.

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