Thomas R. Porter

Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians

The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician.

Transient Myocardial Contrast After Initial Exposure to Diagnostic Ultrasound Pressures With Minute Doses of Intravenously Injected Microbubbles Demonstration and Potential Mechanisms

BACKGROUND We have observed a transient but significant increase in myocardial contrast intensity with intravenously injected perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles that occurs on initial exposure to pulsed ultrasound (transient-response imaging). The characteristics and magnitude of this response were examined in the present study. METHODS AND RESULTS In 14 dogs, the myocardial contrast intensity produced by transient-response imaging (TRI) was compared with conventional 30-Hz imaging (CI) after a 0.005 to 0.030 mL/kg intravenous injection of PESDA. TRI was produced either by measuring myocardial contrast during triggered (1 pulse per cardiac cycle) ultrasound or by withholding real time ultrasound transmission until after microbubbles had entered the myocardium after intravenous injection. Both first-harmonic imaging (2.0 to 3.5 MHz) and second-harmonic imaging (2.0 to 2.5 MHz fundamental, 4.0 to 5.0 MHz received) were used. TRI produced over three times the anterior myocardial contrast intensity of CI (36 +/- 12 U TRI versus 11 +/- 11 U CI; P < .01), with visually better anterior and posterior myocardial contrast. The spatial extent of myocardial ischemia was easily visualized after intravenous PESDA by use of TRI and correlated closely with risk area as measured with Monastral blue (r = .99, P = .002). CONCLUSIONS TRI produces significantly greater myocardial contrast than CI and may dramatically enhance the ability of intravenous ultrasound contrast agents to identify myocardial perfusion abnormalities.

American Society of Echocardiography Consensus Statement on the Clinical Applications of Ultrasonic Contrast Agents in Echocardiography

UNLABELLED ACCREDITATION STATEMENT: The American Society of Echocardiography (ASE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASE designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.trade mark Physicians should only claim credit commensurate with the extent of their participation in the activity. The American Registry of Diagnostic Medical Sonographers and Cardiovascular Credentialing International recognize the ASEs certificates and have agreed to honor the credit hours toward their registry requirements for sonographers. The ASE is committed to resolving all conflict-of-interest issues, and its mandate is to retain only those speakers with financial interests that can be reconciled with the goals and educational integrity of the educational program. Disclosure of faculty and commercial support sponsor relationships, if any, have been indicated. TARGET AUDIENCE This activity is designed for all cardiovascular physicians, cardiac sonographers, and nurses with a primary interest and knowledge base in the field of echocardiography; in addition, residents, researchers, clinicians, sonographers, and other medical professionals having a specific interest in contrast echocardiography may be included. OBJECTIVES Upon completing this activity, participants will be able to: 1. Demonstrate an increased knowledge of the applications for contrast echocardiography and their impact on cardiac diagnosis. 2. Differentiate the available ultrasound contrast agents and ultrasound equipment imaging features to optimize their use. 3. Recognize the indications, benefits, and safety of ultrasound contrast agents, acknowledging the recent labeling changes by the US Food and Drug Administration (FDA) regarding contrast agent use and safety information. 4. Identify specific patient populations that represent potential candidates for the use of contrast agents, to enable cost-effective clinical diagnosis. 5. Incorporate effective teamwork strategies for the implementation of contrast agents in the echocardiography laboratory and establish guidelines for contrast use. 6. Use contrast enhancement for endocardial border delineation and left ventricular opacification in rest and stress echocardiography and unique patient care environments in which echocardiographic image acquisition is frequently challenging, including intensive care units (ICUs) and emergency departments. 7. Effectively use contrast echocardiography for the diagnosis of intracardiac and extracardiac abnormalities, including the identification of complications of acute myocardial infarction. 8. Assess the common pitfalls in contrast imaging and use stepwise, guideline-based contrast equipment setup and contrast agent administration techniques to optimize image acquisition.

Right Ventricular Outflow Versus Apical Pacing in Pacemaker Patients with Congestive Heart Failure and Atrial Fibrillation

Introduction: Prior studies suggest that right ventricular apical (RVA) pacing has deleterious effects. Whether the right ventricular outflow tract (RVOT) is a more optimal site for permanent pacing in patients with congestive heart failure (CHF) has not been established.

Improved myocardial contrast with second harmonic transient ultrasound response imaging in humans using intravenous perfluorocarbon-exposed sonicated dextrose albumin

OBJECTIVES The objectives of this study were to determine whether a new method of ultrasound imaging (transient response imaging) could improve the myocardial contrast after intravenous injections of perfluorocarbon-exposed sonicated dextrose albumin microbubble contrast medium in humans. BACKGROUND We have shown in animals that very low doses of intravenous contrast medium can produce transient but significantly better myocardial contrast when diagnostic ultrasound pulses are interrupted (delivered only once per cardiac cycle) instead of conventional 25- to 30-Hz frame rate imaging. METHODS In 14 patients with normal rest wall motion, the peak myocardial contrast produced by transient response imaging was compared with that produced by conventional harmonic ultrasound imaging after injections of low doses (0.0025 to 0.01 ml/kg) of intravenous contrast medium. All studies were performed with second harmonic imaging (2.0 to 2.5 MHz-transmitted frequency). Blood pressure, oxygen saturation, respiratory rate and pulse were monitored before and after each injection. RESULTS The intravenous contrast medium in the doses given produced no hemodynamic changes and no significant side effects in any patients. Overall, the mean (+/-SD) anterior and posterior myocardial contrast produced was significantly greater with transient response imaging than with conventional harmonic ultrasound imaging (anterior: 37 +/- 20 U transient response imaging vs. 18 +/- 14 U conventional harmonic imaging; posterior: 17 +/- 14 U transient response imaging vs. 5 +/- 5 U conventional; p< 0.01). With the sample size of 14 patients, the study had 80% power to detect a true difference of 18 U for anterior myocardial contrast and 90% power to detect a difference of 12 U for posterior contrast. Visually evident anterior or apical myocardial contrast was observed in 14 of 15 patients with transient response imaging but in only 7 patients with conventional harmonic imaging. Posterior or basal myocardial contrast was evident in 10 patients with transient response imaging but in only 1 patient with conventional harmonic imaging. CONCLUSIONS Transient response imaging produces significantly better myocardial contrast than conventional harmonic imaging in humans and can be produced safely with minute quantities of intravenous perfluorocarbon.

Detection of Myocardial Perfusion in Multiple Echocardiographic Windows With One Intravenous Injection of Microbubbles Using Transient Response Second Harmonic Imaging

OBJECTIVES The purpose of this study was to prove that transient response harmonic imaging could detect normal and abnormal myocardial perfusion in multiple echocardiographic windows with one intravenous injection of microbubbles in humans. BACKGROUND Myocardial ultrasound contrast can be produced from intravenous perfluorocarbon-exposed sonicated dextrose albumin, and ultrasound can be significantly improved by briefly suspending the interval between frame rates. Whether this contrast can noninvasively quantify myocardial perfusion in humans is unknown. METHODS In 28 patients, harmonic transient response imaging was used to image the heart in multiple different imaging planes after one intravenous injection of ultrasound contrast agent. Twenty-five of these 28 patients had a repeat injection during dipyridamole stress. In the primary view, the ultrasound transmission rate was one frame per cardiac cycle; in secondary and tertiary views, the transmission rate was once every multiple cardiac cycles. Regional myocardial contrast was visually assessed and quantified off-line. Quantitative rest thallium and dipyridamole stress sestamibi imaging was also performed. RESULTS Perfusion abnormalities were evident in the secondary and tertiary views only with one frame every multiple cardiac cycles. Regional peak myocardial videointensity (PMVI) correlated closely with regional tracer uptake in individual patients both at rest (r = 0.84) and during stress (r = 0.88). A PMVI ratio (abnormal region divided by the region with highest nuclear uptake) < 0.6 in any view had a 92% sensitivity and a 84% specificity in identifying a regional nuclear perfusion abnormality. CONCLUSIONS Transient response imaging produces myocardial contrast in multiple views with one intravenous injection of contrast agent and can accurately identify regional myocardial perfusion abnormalities.

Real-time perfusion imaging with low mechanical index pulse inversion Doppler imaging

OBJECTIVES We sought to determine how successful pulse inversion Doppler (PID) imaging would be in detecting myocardial perfusion defects during dobutamine stress echocardiography. BACKGROUND By transmitting multiple pulses of alternating polarity (PID) at a low mechanical index, myocardial contrast enhancement from intravenously injected microbubbles can be detected using real-time frame rates. Pulse inversion Doppler imaging was performed in 117 patients during dobutamine stress echocardiography by using an intravenous bolus of a perfluorocarbon-filled, albumin-(Optison: n = 98) or liposome- (Definity: n = 19) encapsulated microbubble and a mechanical index of <0.3. The visual identification of myocardial contrast defects and wall motion abnormalities was determined by blinded review. Forty of the patients had quantitative angiography (QA) performed to correlate territorial contrast defects with stenosis diameter >50%. RESULTS There was a virtual absence of signal from the myocardium before contrast injections in all patients. Bright myocardial opacification at peak stress was observed in at least one coronary artery territory at frame rates up to 25 Hz in 114 of the 117 patients during dobutamine stress echocardiography. Regional myocardial contrast defects at peak stress were observed in all 30 patients with >50% stenosis in at least one vessel (13 with single-vessel and 17 with multivessel disease). Contrast defects were observed in 17 territories subtended by >50% diameter stenosis that had normal wall motion at peak stress. Overall agreement between QA and myocardial contrast enhancement on a territorial basis was 83%, as compared with 72% for wall motion. CONCLUSIONS Pulse inversion Doppler imaging allows the detection of myocardial perfusion abnormalities in real-time during stress echocardiography and will further add to the quality and sensitivity of this test.

Noninvasive In Vivo Clot Dissolution Without a Thrombolytic Drug Recanalization of Thrombosed Iliofemoral Arteries by Transcutaneous Ultrasound Combined With Intravenous Infusion of Microbubbles

BACKGROUND Previous in vivo studies have shown that microbubbles not only enhance the effectiveness of thrombolytic agents in the presence of ultrasound but may also augment clot dissolution without thrombolytic drugs. METHODS AND RESULTS The objective of this study was to examine the efficacy of arterial clot disruption by a noninvasive, nonlytic approach with intravenous administration of perfluorocarbon-exposed sonicated dextrose albumin (PESDA) and transcutaneous delivery of ultrasound alone. Pairs of iliofemoral arteries in 10 rabbits were randomized to receive transcutaneous ultrasound treatment or no ultrasound treatment after an acute artery thrombotic occlusion and intravenous PESDA infusion. Five arteries from 3 additional rabbits served as controls (ultrasound alone). All 10 iliofemoral arteries treated with PESDA + ultrasound were recanalized by angiography after ultrasound treatment. None of the 10 contralateral arteries treated with PESDA alone and none of the 5 arteries treated with ultrasound alone were patent after 1 hour. D-Dimer levels did not change after intravenous PESDA + ultrasound-mediated reperfusion. CONCLUSIONS In vivo arterial clot dissolution can be achieved with intravenous microbubbles and transcutaneous ultrasound delivery alone. This technique has potential for clinical application in patients with acute arterial and venous thrombotic occlusions.

Thrombolytic enhancement with perfluorocarbon-exposed sonicated dextrose albumin microbubbles.

Whereas low-intensity, high-frequency ultrasound (US) alone appears to cause minimal thrombolysis, US combined with air-filled microbubbles does increase the amount of urokinase (UK)-mediated clot lysis (CL). Because this phenomenon may be mediated by cavitation-induced streaming, we hypothesized that perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles, which are more stable than air-filled microbubbles, may also enhance US-induced thrombolysis. We measured the percentage CL of equally sized thrombi (1.0 +/- 0.1 mg) made from freshly drawn blood incubated for 2 hours and then exposed to 20 kHz US (0.846 MPa peak negative pressure). The thrombi were bathed in 4 ml of saline solution, UK alone (20,000 U), PESDA alone, or a combination of PESDA with UK. The percentage CL achieved with PESDA and therapeutic US was also compared with the percentage CL achieved with room air-filled sonicated dextrose albumin (RASDA) microbubbles. When compared with US alone (24% +/- 13% CL) or UK alone (17% +/- 3% CL), PESDA plus US produced significantly better CL (43% +/- 17%; p< 0.05). PESDA combined with US also produced significantly greater CL than RASDA combined with US (28% +/- 9%; p < 0.05). The optimal CL was achieved with a combination of PESDA with UK with US (60% +/- 14% CL). We conclude that PESDA microbubbles alone may be capable of inducing thrombolysis when insonified with a low-frequency transducer.

Real-Time Assessment of Myocardial Perfusion and Wall Motion During Bicycle and Treadmill Exercise Echocardiography: Comparison With Single Photon Emission Computed Tomography

OBJECTIVES We sought to determine the feasibility and accuracy of real-time imaging of myocardial contrast echocardiography (MCE) in detecting myocardial perfusion defects during exercise echocardiography compared with radionuclide tomography. BACKGROUND Ultrasound imaging at a low mechanical index and frame rate (10 to 20 Hz) after intravenous injections of perfluorocarbon containing microbubbles has the potential to evaluate myocardial perfusion and wall motion (WVM) simultaneously and in real time. METHODS One hundred consecutive patients with intermediate-to-high probability of coronary artery disease underwent treadmill (n = 50) or supine bicycle (n = 50) exercise echocardiography. Segmental perfusion with MCE and WM w ere assessed in real time before and at peak exercise using low mechanical index (0.3) and frame rates of 10 to 20 Hz after 0.3 ml bolus injections of intravenous Optison (Mallinckrodt Inc., San Diego, California). All patients had a dual isotope (rest thallium-201, stress sestamibi) study performed during the same exercise session, and 44 patients had subsequent quantitative coronary angiography. RESULTS In the 100 patients, agreement between MCE and single photon emission computed tomography (SPECT) was 76%, while it was 88% between MCE and WM assessment. Compared with quantitative angiography, sensitivity of MCE, SPECT and WM was comparable (75%), with a specificity ranging from 81% to 100%. The combination of MCE and WM had the best balance between sensitivity and specificity (86% and 88%,respectively) with the highest accuracy (86%). CONCLUSIONS The real-time assessment of myocardial perfusion during exercise stress echocardiography can be achieved with imaging at low mechanical index and frame rates. The combination of WM and MCE correlates well with SPECT and is a promising important addition to conventional stress echocardiography.