A right atrial mass and a pseudomass

Right atrial (RA) masses are rare entities often detected incidentally during imaging studies. Leading etiologies of right atrial masses are tumor, thrombi, and vegetations. We present two cases of right atrial masses, a cardiac lipoma and an artifact. Clinical and echocardiographic characteristics of benign cardiac tumors are reviewed. We then highlight the importance of considering artifact in the differential diagnosis of atrial masses. Finally, we discuss echocardiographic characteristics of right atrial masses that may provide clues for diagnosis. Right atrial masses, often detected incidentally during imaging studies, are uncommon and can be due to many etiologies including tumors, thrombus, vegetations, normal variants, and artifacts. We describe 2 patients with RA masses detected on routine transthoracic echocardiogram.     

Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches

This study was conducted in 46 patients with cardiac thrombi, 15 patients with atrial myxomas, and 32 patients with other cardiac or paracardiac tumors. Diagnoses were subsequently proven by surgery, autopsy, computed tomography, magnetic resonance imaging, or angiography in all patients. All patients underwent precordial and transesophageal two-dimensional echocardiography to assess the various mass detection rates. Atrial myxomas and predominantly left-sided cardiac tumors were identified by both echocardiographic techniques with comparable detection rates. Left ventricular apical thrombi were detected more frequently by precordial echocardiography. In contrast, transesophageal echocardiography was superior in visualizing left atrial appendage thrombi, small and flat thrombi in the left atrial cavity, thrombi and tumors in the superior vena cava, and masses attached to the right heart and the descending thoracic aorta. These data indicate that transesophageal echocardiography leads to a clinically relevant improvement of the diagnostic potential in patients in whom cardiac masses are suspected or have to be excluded in order to ensure the safety of clinical procedures.     

A pedunculated left ventricular hemangioma initially misdiagnosed as thrombus in a woman with atypical chest pain

The incidence of cardiac masses increased as echocardiography is becoming increasingly popular. Benign tumors of the heart constitute about 72% of all primary cardiac neoplasms and hemangioma accounts for 5–10% of benign cardiac tumors. Cardiac hemangiomas are generally asymptomatic and diagnosed incidentally during echocardiography or magnetic resonance imaging (MRI). We reported a 52-year-old woman presented with atypical chest pain and exertional dyspnea. The echocardiographic examination revealed a hyperechoic round mass in the left ventricle. With an initial diagnosis of left ventricular thrombus, the patient underwent cardiac MRI. The mass was found compatible with cardiac hemangioma. It was removed surgically and histopathologic evaluation identified a cardiac hemangioma. As reports of cardiac hemangioma are extremely rare and cardiac masses are mostly thought to be thrombi or myxomas (being the most common primary cardiac tumor), such hemangioma cases warrant attention as possibility of hemangioma should also be kept in mind.     

Evaluation by electron beam computed tomography of intracardiac masses suspected by transoesophageal echocardiography.

OBJECTIVES: To assess the suitability of electron beam computed tomography (EBT) in evaluating and subsequently managing cardiac masses suspected as a result of examination by transthoracic and transoesophageal cross sectional echocardiography. DESIGN AND PATIENTS: In 76 consecutive patients with suspected cardiac masses, the impact of the EBT examination was analysed by reviewing whether EBT examination altered management by confirming or excluding a mass, whether EBT imaging substantially contributed to decision-making, and lastly whether EBT influenced the decision to operate on the patient. RESULTS: EBT modified the diagnosis or confirmed results which had been questionable with cross sectional echocardiography in 53 cases (70%): these cases included those with anatomical features such as dense calcifications or fatty structures (n = 20), lipomatous lesions (n = 5), equivocal thrombi (n = 5), pericardial masses (n = 5), or hydatid cysts (n = 2). EBT gave information over and above cross sectional echocardiography in all patients with malignant tumours (n = 16) by providing a better delineation of the relation between intracavity masses and normal structures, including the mural site of tumour attachment and tumour extension to the great vessels and the adjacent extracardiac mediastinal structures. EBT provided no additional information over cross sectional echocardiography in the remaining patients (n = 23), particularly in those with myxomas (n = 11) or small valvar lesions (n = 6). EBT only confirmed that the lesion was well demarcated, limited in extent, or not associated with a mass. CONCLUSIONS: EBT has considerable potential for clinical management and surgical planning and may help clinicians to decide against surgery, particularly in patients with unresectable tumours.     

Magnetic resonance imaging of cardiac masses

INTRODUCTION: Cardiac magnetic resonance imaging plays a pivotal role in the diagnostic workup of cardiac masses. In many cases it is possible to arrive at a likely diagnosis, while features suggestive of a conclusive diagnosis are detected in a small number of cases. METHODS: An internal audit of all patients referred with a cardiac mass detected on echocardiography was conducted for the period 2004-2007. Twenty-two cases were identified and MR characteristics including localization, tissue characteristics, primary nature versus secondary deposits and extracardiac features were studied. RESULTS: Six masses were intramyocardial, eleven were intracavitary and three were extraeardiac in localization. A highly probable diagnosis was possible in fourteen cases including six primary tumors, three extracardiac tumors, three secondary deposits and two thrombi. ConclusioN: A highly probable diagnosis was possible in half of our patients with cardiac masses on echocardiography referred for cardiac magnetic resonance imaging in the p receding three-year period. It was also possible to determine localization, extent of disease and relation to adjacent structures.     

Diagnosis of left atrial appendage thrombi by multiplane transesophageal echocardiography: interlaboratory comparative study.

BACKGROUND: Transesophageal echocardiography (TEE) is regarded as the method of choice for imaging left atrial appendage thrombi (LAAT). However, the interobserver variability among 2 independent echocardiographic laboratories in diagnosing LAAT by multiplane TEE has not yet been assessed. METHODS AND RESULTS: The videorecordings of 50 patients in atrial fibrillation (25 from each laboratory) were blindly reviewed by 1 experienced observer from each institution. LAAT were assessed as present, absent or questionable. Indications for TEE were: cardioversion (n=17), valve disease (n=13), endocarditis (n=12), or embolism (n=8). The prevalence of LAAT was 10% (observer 1) vs 12% (observer 2). A questionable LAAT was assessed in 6% vs 12% and a LAAT was excluded in 84% vs 76%, respectively. By head-to-head comparison, disagreement occurred in 11 cases (22%, kappa=0.5). Discrepant results were not related to the echocardiographic equipment. Problems occurred because of reverberation artifacts of the ridge between the left atrial appendage and left upper pulmonary vein (n=5), and in differentiating LAAT from spontaneous echocardiographic contrast (n=4) or an echogenic atrioventricular groove (n=1). The differentiation of pectinate muscles from LAAT was the reason for disagreement in only 1 case. Eliminating the category of questionable thrombi increased the kappa value to 0.65. In 5 patients undergoing cardiac surgery, both observers had agreed on the presence (n=1) or absence (n=4) of LAAT, and intraoperatively the results of TEE were confirmed. CONCLUSION: Even with multiplane TEE, interobserver variability among 2 independent echocardiographic laboratories for diagnosing LAAT remains high because of problems in differentiating LAAT from spontaneous echocardiographic contrast and reverberation artifacts.     

In vivo ultrasonic tissue characterization of human intracardiac masses

Interactions between an ultrasonic signal and cardiac tissue have been used to characterize the histologic state of myocardium in vitro. To assess the utility of in vivo ultrasonic tissue characterization, stochastic analysis was applied to the digitized echocardiographic signals from 15 patients with 2-dimensional echocardiograms suggesting intracardiac masses. Ten subjects with echocardiograms suggesting mural thrombi underwent subsequent surgery or necropsy, which confirmed thrombi in 6 and revealed no thrombi (designated artifact) in 4. Five other patients had intracardiac tumors. The amplitudes within the digitized ultrasonic signals were displayed as histograms, which were described by a parameter k that represented the degree to which each histogram departed from a totally random probability density function. In 5 of 6 thrombi, k = 0, but in all 4 artifacts, k greater than 0. The sixth thrombus had k = 0.5 due to the specular effect of the interface between the thrombus' 2 lobes. All 5 tumors had k greater than 0. Ultrasonic tissue characterization using a stochastic analysis of backscatter can be performed in vivo and helps differentiate thrombus from artifact and tumor in the heart.     

Evaluation of myocardial, hepatic, and renal perfusion in a variety of clinical conditions using an intravenous ultrasound contrast agent (Optison) and second harmonic imaging

OBJECTIVE: To assess the potential of intravenous Optison, a second generation ultrasound contrast agent, and various ultrasound imaging modes to determine myocardial, kidney, and liver perfusion in normal subjects and patients with left ventricular dysfunction or chronic pulmonary disease together with renal or hepatic dysfunction. METHODS: Five normal subjects and 20 patients underwent grey scale echocardiographic imaging of myocardium, kidney, and liver during 505 intravenous injections of Optison. Images were assessed qualitatively by two independent observers and quantitatively using video densitometry to determine the peak contrast enhancement effect. RESULTS: Qualitative analysis showed that intermittent harmonic imaging was superior to either conventional fundamental or continuous harmonic imaging for all organs. Quantitative analysis showed that the peak change in echocardiographic intensity v baseline during continuous harmonic imaging was 11 units for myocardium (p < 0.03), 7 units for kidney (NS), and 14 units for liver (p < 0.05). During intermittent harmonic imaging the peak change was significantly greater, being 33 units for myocardium (p < 0.0001), 24 units for kidney (p < 0.0002), and 16 units for liver (p < 0.001). CONCLUSIONS: Organ tissue perfusion can be demonstrated following intravenous injection of Optison, particularly when used in combination with intermittent harmonic imaging techniques. This contrast agent is effective in a variety of clinical conditions.     

Transesophageal echocardiography detects thrombus formation not identified by transthoracic echocardiography after the Fontan operation

Transesophageal echocardiography demonstrated six instances of venous thrombus formation in the inferior vena cava, right atrium and caval-pulmonary anastomosis region in four children after a modified Fontan operation. Transthoracic surface echocardiography failed to identify these thrombi in five of the six cases because of the posterior location of the thrombus or imaging interference from surgical hardware. These thrombotic episodes occurred 2 days to 5 years after the Fontan operation in children 25 to 168 months of age. Clinical features of compromised cardiac performance with cyanosis or inadequate perfusion were present during four of the six episodes. In two patients, thrombi occurred around transvenous permanent atrial pacing leads. Therapy to eliminate thrombus included surgery (two cases), anticoagulation with warfarin (three cases) and streptokinase thrombolysis (one case). Disappearance of the thrombus was confirmed by transesophageal study in three of the four cases with follow-up echocardiography. Transesophageal echocardiographic demonstration of atrial and pulmonary thrombi that could not be seen by transthoracic imaging suggests that these thrombi occur with greater frequency in patients who have undergone the Fontan operation than was previously suspected.     

The role of echocardiography in the management of the sources of embolism

The echocardiographic diagnosis of cardiac thrombi, vegetations and tumors as well as the identification of predisposing conditions such as patent foramen ovale, aortic atherosclerosis and other minor causes (e.g., mitral valve prolapse, mitral and aortic valve calcification) have crucial clinical relevance, affecting the choice of surgery and/or of pharmaceutical therapy in the setting of patients presenting embolism. The echocardiographic assessment helps not only for the retrospective diagnosis of sources of embolism but also for the prevention of events in asymptomatic patients. Echocardiography can also distinguish normal variants and artifacts from cardiac masses and tumors. Echocardiographic characterization/typology of cardiac sources of embolism is currently below par when compared with cardiac MRI, the current gold standard. Nevertheless, echocardiography remains the 'first-line' imaging tool, because of its low cost and the possibility to add easily available, functional and structural information at the patient's bedside.     

Value of CMR for the Differential Diagnosis of Cardiac Masses

ObjectivesThe goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses.BackgroundDifferentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce.MethodsWe reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed.ResultsThere were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm²; p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p = 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm²; p = 0.006) and more frequently exhibited FPP (84% vs. 47%; p = 0.03) and LGE (92% vs. 41%; p = 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%).ConclusionsCMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms.     

Clinical significance of perfusion imaging of the left atrial wall and structures in its cavity by contrast echocardiography.

This study examined whether myocardial contrast echocardiography (MCE) can visualize left atrial appendage myocardial perfusion using transesophageal echocardiography (TEE) with intracoronary injection of sonicated albumin. We also evaluated blood flow into normal structures (i.e. muscular trabeculae) and abnormal masses (i.e. fresh thrombi and myxomas) within the left atrium by MCE. TEE images were obtained with a biplane or multiplane 5 MHz transducer in 16 patients without significant coronary artery occlusive disease. Left atrial appendage myocardium was divided into 4 segments in both the transverse and longitudinal planes, and contrast opacification of each segment during MCE was visually evaluated by 2 independent observers. Visual assessment of contrast opacification of prominent muscular trabeculae within the left atrial appendage (6 patients), and of left atrial or left atrial appendage thrombi (4 patients), was also performed. The ratio of background-subtracted peak videointensity from muscular trabeculae or thrombi versus left atrial appendage myocardium was determined as corrected peak videointensity. In 3 patients with myxomas, contrast opacification of the tumor was visually assessed. Ninety-six segments of left atrial appendage myocardium were visually analyzed. Contrast opacification of the left atrial appendage myocardium was identified in 92 of 96 segments (96%, 95% confidence interval 0.90-0.98) by Observer 1 and in 91 of 96 segments (95%, 95% confidence interval 0.88-0.98) by Observer 2. MCE also enhanced the imaging of left atrial appendage muscular trabeculae, but not of left atrial or left atrial appendage thrombi. Corrected peak videointensity from thrombi was significantly lower than that from muscular trabeculae (0.15 +/- 0.11 vs 0.95 +/- 0.18, p < 0.05). All myxomas were distinctly opacified by MCE. Transesophageal MCE with intracoronary injection of sonicated albumin can image left atrial appendage myocardial perfusion. MCE allows the evaluation of blood flow into normal structures and abnormal masses within the left atrium.     

Evaluation and Management of Cardiac Tumors

Purpose of review

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

Recent findings

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for “tumor-thrombus” in renal cell carcinoma due to risk of bleeding from primary tumor.

Summary

Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

     

Clinical applications of myocardial contrast echocardiography

Myocardial contrast echocardiography is a new technique that uses microbubbles of air in conjunction with simultaneously performed 2-dimensional echocardiographic imaging. Currently, it can be used to determine myocardial perfusion in the cardiac catheterization laboratory and the operating room. For myocardial contrast echocardiography to find a broader clinical application for the assessment of myocardial perfusion, it will be necessary to opacity the myocardium from venous injection of contrast in humans. In this regard, enhancement in bubble engineering, optimization of echocardiographic systems (greater sensitivity and dynamic range), and availability of digital image enhancement techniques will be required for myocardial contrast echocardiography to realize its full clinical potential by the year 2000.     

Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion.

AIMS: Despite exclusion of left atrial thrombi by transoesophageal echocardiography, cardioversion-related thromboembolism has been reported in atrial fibrillation or flutter. To define a low-risk group for cardioversion without previous anticoagulation, patients were selected for immediate cardioversion if there were no thrombi, no echo spontaneous contrast and the outflow velocity of the left atrial appendage was greater than 0.25 m. s(-1)on transoesophageal echocardiography. METHODS AND RESULTS: Two hundred and forty-two consecutive patients referred for cardioversion of atrial fibrillation or flutter with a duration of more than 2 days and no anticoagulation therapy were examined with transoesophageal echocardiography. After the transoesophageal echocardiography examination, patients who were eligible for immediate cardioversion were anticoagulated with low molecular weight heparin (dalteparin) subcutaneously, together with warfarin prior to cardioversion. Dalteparin treatment was continued until the patient had reached therapeutic prothrombin values. Based on the transoesophageal echocardiographic findings the patients were divided into two groups: immediate cardioversion, group A, with a mean age of 62+/-13 years (n=162); or conventional warfarin treatment before cardioversion, group B, with a mean age of 67+/-10 years (P<0.05) (n=80). In group A, lone atrial fibrillation or flutter was more common (53%; 95% CI: 45-61) compared to group B (34%; 95% CI: 23-44, P<0.05), while heart disease was more common in group B (45%; 95% CI: 34-56) compared to group A (31%; 95% CI: 24-39, P<0.05). Echocardiography revealed thrombi in 5% (95% CI: 2.6-8) of the patients, left atrial size was larger, fractional shortening lower, and a higher proportion had impaired left ventricular function in group B. No thromboembolic event occurred at or after cardioversion in any of the patients; however, before planned cardioversion one transitory ischaemic attack, one lethal stroke and one cardiac death occurred in three of the patients with thrombi despite warfarin therapy. One-month follow-up maintenance of sinus rhythm was 75% in group A compared to 45% in group B (P<0.01). CONCLUSION: After using our transoesophageal echocardiographic exclusion criteria (no thrombi, no spontaneous echo contrast and left atrial appendage outflow velocity > or = 25 m. s(-1)) cardioversion can safely be performed in 2/3 of patients with atrial fibrillation or flutter without previous anticoagulation therapy. These patients maintained sinus rhythm significantly better after 1 month compared to patients with prolonged warfarin therapy before cardioversion.     

Tissue acoustic properties of fresh left ventricular thrombi and visualization by two dimensional echocardiography: Experimental observations

Although two dimensional echocardiography can detect left ventricular thrombi In certain cardiovascular disease states, there Is theoretical concern that the acoustic Impedance properties of recently formed fresh thrombi may not allow their echocardiographic visualization. If such were the case, false negative studies might occur even with technically adequate echocardiographic examinations. To determine if the tissue acoustic properties of acute thrombi allow their visualization and differentiation from surrounding intracavitary blood and adjacent myocardium with two dimensional echocardiography, an in vivo canine model of acute left ventricular thrombus was studied. In 10 dogs left ventricular thrombus was induced using coronary ligation and subendocardial injection of a sclerosing agent, sodium rlclnoleate. Acoustically distinct left ventricular thrombi were imaged by two dimensional echocardiography within hours (mean ± standard deviation 121 ± 40 minutes, range 45 to 180), and the thrombi could easily be differentiated from surrounding blood and adjacent myocardium. Thrombi with a maximal dimension as small as 0.6 cm at autopsy were highly reflective and could be imaged with echocardiography. Histologic examination of the thrombi showed characteristic features of early thrombosis. In six dogs, echocardiographic imaging revealed two acoustically distinct areas of thrombi. Gross and microscopic examination of the thrombi in these animals confirmed two distinct types of thrombus with differing histologie features.Although technical aspects of the echocardiographic examination or certain biologic features of thrombi such as thrombus size may limit the detection of thrombi by echocardiography in certain situations, our data indicate that the tissue acoustic properties of recently formed thrombi are not a primary limitation to their echocardiographic detection. These findings support the use of two dimensional echocardiography in the investigation of the natural history, prevention and therapy of left ventricular thrombus in patients during the early course of acute myocardial Infarction.     

Role of echocardiography in cancer care

For cancer therapy survivors, regular echocardiographic follow-up of left ventricular function is considered part of standard care. Metastases of tumors on the pericardium and myocardium as well as cardiac structure and function can be assessed using echocardiography. This review focuses on current and developing echocardiographic modalities for the assessment of cardiac structure and function in the cancer patient, delineates the echocardiographic diagnosis of cardiac amyloidosis, and discusses the echocardiographic features of cardiac masses including those associated with the hypercoagulable state of cancer.     

Clinical and echocardiographic diagnosis,follow up and management of right-sided cardiac thrombi

BackgroundRight-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.MethodsThis is a retrospective, single center observational study of consecutive patients over the period January 2003–2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.ResultsThe mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range – 18–50 months).ConclusionsPrompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.     

The clinical applications of contrast echocardiography.

Ultrasound contrast agents are approved for opacification of the heart chambers and to improve endocardial border definition. The myocardial contrast enhancement is also very useful for assessing thickening of the myocardium and myocardial perfusion. Several multicentre and numerous single-centre trials have demonstrated the usefulness of contrast echocardiography in clinical practice. Contrast echocardiography is probably one of the best validated echocardiographic techniques. Improved accuracy of contrast-enhanced images is not restricted to patients with a poor baseline image quality. Even with an optimal baseline image quality the borders are not as well defined as after LV opacification. Usage of contrast can improve image alignment and helps to avoid off-axis scanning. Contrast studies are particularly useful when a precise measurement of LV function is needed: 1. To decide about the need of implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT), 2. Follow-up of patients with moderate valvular disease and decision for surgical treatment, 3. Selection and monitoring of patients undergoing chemotherapy with cardiotoxic drugs, 4. Assessment of LV function in patients in intensive care and coronary care units. Optimal endocardial border delineation is crucial and often can be achieved only by ultrasound contrast: 1. Assessment of LV thrombi and masses, 2. Left ventricular non-compaction/apical hypertrophy, 3. Right ventricular dysplasia, right ventricular thrombus, 4. Stress echocardiography and regional wall motion assessment. Future echocardiography will be more 3D and more quantitative than current echocardiography. And contrast echocardiography has already proven its value for both applications.     

Differential diagnosis of left ventricular mural thrombi by myocardial contrast echocardiography: a preliminary study

Two-dimensional echocardiography has become the procedure of choice to diagnose left ventricular mural thrombi. However, small or flat thrombi may be difficult to distinguish from myocardium. The spatial distribution of the ventricular myocardial blood flow can be imaged with myocardial contrast echocardiography (MCE). The authors presumed that the absence of arterial supply to a fresh thrombus may allow MCE to distinguish between thrombus and myocardium. In the 2 cases presented here, MCE was performed with the same technique as that used for the purpose of visualization of myocardial perfusion; as a result, an apical mural thrombus, indistinct from myocardium before MCE, was visualized as a contrast defect during imaging. Conversely, myocardium that mimicked a thrombus was imaged by MCE as a contrast-opacified area. These findings suggest that MCE after reperfusion therapy is useful to distinguish mural thrombi from myocardium.