Enhanced left ventricular endocardial border delineation with an intravenous injection of SonoVue, a new echocardiographic contrast agent: A European multicenter study

The safety and efficacy of SonoVue (also referred to as BR1), a new contrast agent for delineating endocardial border of the left ventricle after intravenous administration, was assessed. Two hundred and eighteen patients with suspected coronary artery disease undergoing fundamental echocardiography for the assessment of left ventricle were enrolled in a prospective multicenter, single blind, cross-over study with random sequence allocation of four different doses of SonoVue. Endocardial border definition in the apical and parasternal views was scored as 0 = not visible, 1 = barely visible, and 2 = well visualized before and after contrast enhancement. Analysis was performed by two pairs of off-site observers. Safety of SonoVue was also assessed. Results of our study indicated that the mean improvements in the endocardial border visualization score were as follows: 3.1 +/- 7.8 (95% CI, 2.5 and 3.7) for 0.5 ml, 3.4 +/- 8.0 (95% CI, 2.8 and 4.0) for 1 ml, 3.4 +/- 7.9 (95% CI, 2.8 and 4.0) for 2 ml, and 3.7 +/- 8.0 (95% CI, 3.1 and 4.3) for 4 ml (P < 0.05 for all doses from baseline). Changes from baseline in endocardial visualization scores were also seen in the apical views (P < 0.05) and they were dose-dependent (P < 0.001). Similar enhancements of endocardial visualization scores were observed in the apical views in patients with suboptimal baseline echocardiographic images. Diagnostic confidence for assigning a score and image quality also were significantly better following contrast enhancement. No significant changes in the laboratory parameters and vital signs were noted following contrast enhancement, and the side effects were minimal. It was concluded that SonoVue is safe and effective in delineating endocardial border, including in patients with suboptimal baseline images.     

For left ventricular opacification and endocardial border definition: is it really important which contrast agent we use, or is it the imaging modality we choose?

AIMS: The purpose of this study was to prospectively compare the effect of three imaging modalities (fundamental, harmonics, and power harmonics) on left ventricular opacification and endocardial border definition with two different echo agents, Optison and Albunex. METHODS: A total of 84 patients who had suboptimal transthoracic images were studied with echo contrast agents Albunex (n=41) and Optison (n=43). Each contrast agent was examined with three different imaging modalities, fundamental, harmonics and power harmonics, respectively. Left ventricular opacification was obtained by videodensitometric analysis. Percentage of endocardial border visualization was determined by indexing circumference of visualized endocardium to total circumference. Variables were compared with respect to three imaging modalities between two different echo agents. RESULTS: Higher videointensities and higher percentages of endocardial visualization were achieved with Optison compared to Albunex with fundamental and harmonics. However, there was no significant difference between Optison and Albunex with respect to LV opacification and border visualization by power harmonics. CONCLUSION: These results indicate that left ventricular opacification and endocardial border visualization is significantly improved by using power harmonic imaging as compared to harmonics or fundamental imaging following both echo contrast agents. Furthermore, although Optison is clearly superior to Albunex in opacifying left ventricle, power harmonic imaging compensates for the less robust agent.     

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms

Objectives. This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram.Background. The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration–approved active control.Methods. This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators.Results. Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92).Conclusions. This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.     

Left ventricular opacification by intravenous contrast echocardiography.

BACKGROUND: The present study was undertaken in order to evaluate the efficacy of the intravenous administration of Albunex in obtaining left ventricular opacification and the relationship between left ventricular opacification and pulmonary pressures and cardiac function. METHODS: Fifty-two adult patients, mostly affected by ischemic heart disease, were enrolled in the study. In 37 of these patients, a complete right heart hemodynamic study was performed after Swan-Ganz catheterization. Albunex was administered in three randomized doses (0.10, 0.15 and 0.20 ml/kg) to all the patients. Left ventricular opacification was assessed both visually and using videodensitometric analysis. RESULTS: Left ventricular opacification was obtained in 93% of all the injections and an intermediate or strong opacification was obtained in 68%, while absent opacification was observed in 6% of the injections, irrespective of the contrast dose. An incremental opacification efficacy trend was observed from the lower to the higher dose, with an intermediate or strong opacification in 58 and in 77% of 0.10 and 0.20 ml/kg injections, respectively. Irrespective of the contrast dose, an enhancement of the endocardial borders was observed in 61% of the wall segments suboptimally visualized in basal conditions. The endocardial borders enhancement was obtained in 39 and in 79% of segments using the 0.10 and the 0.20 ml/kg doses, respectively. No statistically significant differences were observed between the videodensitometric parameters obtained using the three contrast doses. Finally, a significant relationship was observed between left ventricular opacification parameters and pulmonary pressures and left ventricular functional parameters, irrespective of the contrast doses considered. CONCLUSIONS: The results we obtained demonstrate the good overall efficacy of Albunex administered intravenously in order to obtain left ventricular opacification in a clinical population of cardiac patients. Moreover, they suggest that the dosage to be used clinically should preferably be at least 0.20 ml/kg, although no significant influence of contrast dosage on videodensitometric parameters has been observed. Finally, irrespective of the contrast dosage, the magnitude of left ventricular opacification appears to be influenced by the hemodynamic status of the patient.     

Contrast agent improves diagnostic value of dobutamine stress echocardiography

OBJECTIVES: Suboptimal endocardial definition reduces the diagnostic value of stress echocardiography for coronary artery disease, but intravenous infusion of a left ventricular contrast agent (Albunex) may enhance endocardial border delineation and improve the diagnostic value of dobutamine stress echocardiography. METHODS: Fifty-six patients, 38 with myocardial infarction, 16 with angina pectoris and two normal subjects, were enrolled in this study. Dobutamine was infused in scalar doses of 5 to 40 micrograms/kg/min. Intravenous infusion of Albunex (0.15 ml/kg) was administered at rest and during peak dobutamine stress during monitoring of the apical four-chamber view. The left ventricle in the apical four-chamber view was divided into six segments and an endocardial delineation score of 0 to 3 (none to excellent visualization) was given to each segment. RESULTS: Endocardial delineation score was increased after Albunex infusion from 2.0 to 2.3 in the basal-septal, 2.0 to 2.4 in the mid-septal, 1.1 to 1.8 in the apical-septal, 0.7 to 1.2 in the apical-lateral, 0.9 to 1.6 in the mid-lateral, and 1.2 to 1.9 in the basal-lateral segments during peak dobutamine administration. Endocardial border resolution in the lateral wall showed greater improvement than in the septal wall after Albunex infusion. Diagnostic values in the left anterior descending artery territory failed to improve with Albunex infusion (sensitivity 82% to 89%, specificity 94% to 89%, and accuracy 86% to 89%), whereas a higher diagnostic accuracy was noted in the left circumflex artery territory with Albunex compared to without Albunex (sensitivity 63% to 81%, specificity 88% to 98%, and accuracy 80% to 93%, p < 0.05). CONCLUSIONS: Contrast agent improves the diagnostic accuracy of dobutamine stress echocardiography in the left circumflex artery territory.     

Improved left ventricular endocardial detection by a first generation contrast agent. Effect of dose

The study of global and segmental left ventricular function forms part of every echocardiographic examination. However, this is only possible when the endocardial borders are well identified. The authors report the results of a study with Albunex, a first generation contrast agent used by intravenous injection. The object of this study was to assess the efficacy of Albunex in improving left ventricular endocardial detection compared with standard transthoracic echocardiography (TTE) and the dose-effect relationship. Forty-one patients were included prospectively at two cardiological hospital centres between 1995 and 1997, before the development of second harmonic imaging. Two patients were excluded from the study. Each patient underwent transthoracic echocardiography in the fundamental mode with an apical four-chamber view. The following procedure was adopted: 1) standard examination, 2) low dose Albunex (0.1 mg/Kg) injected via a peripheral vein, 3) high dose Albunex (0.2 mg/Kg) injected via a peripheral vein, 4) low dose Albunex injected via a central vein, 5) high dose Albunex injected via a central vein. The analysis of results was performed by two independent observers and showed that Albunex improved endocardial detection (p < 0.005); this detection was significantly better with high doses of Albunex and with central vein injection (p < 0.005); the septal border was better visualised than the lateral wall endocardium (p < 0.005) but the improvement in endocardial detection was greater for the lateral wall (p < 0.005). No complications were observed during the procedure. The authors conclude that Albunex improves left ventricular endocardial detection. This benefit is mainly due to improved lateral wall detection, and increases with higher doses of the contrast agent.     

Infusion versus bolus contrast echocardiography: a multicenter, open-label, crossover trial

BACKGROUND: In current practice, contrast echocardiography is performed with single or multiple bolus injections, which often result in an uncontrolled period of attenuation followed by transient left ventricular opacification (LVO). Because a "slow bolus" appears to reduce attenuation and prolong LVO, we hypothesized that a controlled infusion of contrast might provide a more uniform contrast effect with less attenuation and longer contrast duration. METHODS AND RESULTS: We sought to test the hypothesis by using an infusion of contrast (DEFINITY [perflutren], The DuPont Pharmaceuticals Co, Medical Imaging, North Billerica, Mass) that is stable when diluted in saline in a randomized, multicenter, controlled, crossover trial. Sixty-four patients with poor noncontrast images were recruited at 3 centers and randomly assigned to 2 single "slow" bolus injections of contrast (10 microL/kg each over a period of 30 to 60 seconds) or an infusion (1. 3 mL in 50 mL normal saline initially at 4.0 mL/min) of contrast. Patients then returned within 24 to 72 hours for the alternative form of contrast delivery. Three independent experienced echocardiographers viewed 30 seconds of videotape for all optimal baseline and optimal contrast images to score LVO and qualitatively assessed endocardial border evaluability. The duration of adequate LVO then was independently assessed by review of the entire videotape. Three independent sonographers traced single-frame, digitally captured images to measure the length of the contiguous endocardial border visualized. Both bolus and infusion administration demonstrated improved LVO (>90% by all blinded readers, P <.01) and endocardial border visualized (mean increase of 1.8 to 4.7 cm at both end-diastole and end-systole, all P <.05) as compared with baseline images. However, contrast infusion resulted in a longer duration of LVO (range of mean durations for each reader, 158 to 174 seconds longer, P <.05) and a shorter duration of attenuation (18 to 54 seconds, P <.05) compared with either bolus injection. There were no severe adverse events with contrast infusion. CONCLUSIONS: Contrast echocardiography delivered as an infusion optimizes the contrast effect by decreasing the attenuation period, extending the LVO duration, and providing a uniform contrast effect that may be useful in obtaining multiple echocardiographic views, stress echocardiography, myocardial perfusion imaging, and applications in which blood flow must be quantified.     

Enhancement of Left Ventricular Cavity Opacification by Harmonic Imaging After Venous Injection of Albunex

Venous injection of Albunex does not consistently produce left ventricular (LV) cavity opacification during conventional echocardiography. We postulated that by increasing the signal-to-noise ratio, harmonic imaging will result in more successful LV cavity opacification and provide a better assessment of regional LV systolic function. Forty-two patients with poor baseline endocardial delineation were given 10 ml intravenous injections of Albunex during continuous fundamental and harmonic imaging. Change in segmental wall-thickening scores and the confidence levels for these scores were assessed for 3 observers with various levels of experience. Compared with fundamental imaging, harmonic imaging significantly improved the success of LV cavity opacification (83% vs 62%, p <0.05). The background-subtracted video intensity within the central two thirds of the LV cavity increased threefold (from 10 ± 15 to 31 ± 29, p <0.05) with harmonic imaging. The spatial extent of opacification increased from 40% of the LV cavity during fundamental imaging to 65% with harmonic imaging (p <0.001). The confidence level for assessing regional LV systolic function improved (p <0.05) after contrast administration, particularly when observer experience was limited. We conclude that in patients with poor endocardial definition, injection of intravenous Albunex should be combined with harmonic imaging to improve LV cavity opacification.

We assessed left ventricular (LV) cavity opacification produced by venous injection of Albunex during fundamental and harmonic imaging in 42 patients. Harmonic imaging significantly increased the success rate of LV cavity opacification, the background-subtracted peak video intensity, and the spatial extent of cavity opacification; harmonic imaging also improved the confidence level for assessing regional LV systolic function, especially in readers with less experience.     

Quantitative evaluation of regional endocardial visualisation with second harmonic imaging and contrast left ventricular opacification in heart failure patients.

AIMS: Wall motion score index (WMSI) is an important prognostic indicator in heart failure (HF) patients but requires endocardial visualisation. This study evaluated the role tissue harmonic imaging (THI) and contrast opacification (LVO) for improving endocardial visualisation and the determination of WMSI in HF patients. METHODS AND RESULTS: Thirty-one HF patients and 30 controls underwent apical echocardiography with fundamental imaging (FUND), THI and THI with contrast agent (Levovist). Visualisation and motion were graded in the six segments from each of the apical two and four chamber views. Both THI and LVO reduced the percentage of non-visualised segments (FUND 13.6%, THI 5.6%, LVO 2.8%, p=0.01) in the controls, but in HF patients, only THI improved visualisation (% segments not visualised FUND 9.7%, THI 3.5%, LVO 4.8%, p=0.06). The anterior and lateral walls were the least well visualised with FUND, but improved with LVO (anterior p=0.0026, lateral p=0.0003). No improvement was seen in the inferior wall (p=0.30) or septum (p=0.2). WMSI was similar by all methods and negatively correlated with ejection fraction (FUND r=-0.69, THI r=-0.74, LVO r=-0.77, all p<0.001). CONCLUSION: THI improved endocardial visualisation in all subjects and LVO offered additional benefit in the controls, but not in HF patients. Regional endocardial visualisation was inconsistent. Thus, both patient factors and wall segment site need to be considered when using contrast agents for endocardial visualisation.     

Usefulness of left ventricular opacification with intravenous contrast echocardiography in patients with asymptomatic negative T waves on electrocardiography

OBJECTIVES: Patients with electrocardiography (ECG) abnormalities sometimes present without obvious symptoms or abnormal physical findings. In some cases, echocardiography fails to reveal abnormalities compatible with the ECG findings because of poor echocardiographic image quality. New intravenous contrast agents now enable opacification of the left ventricular cavity in the clinical setting. The usefulness of left ventricular opacification (LVO) by ultrasonic contrast agent was examined in asymptomatic patients with negative T waves on ECG. METHODS: Thirty-four consecutive patients (23 males, 11 females, mean age 68 +/- 10 years) with negative T waves without symptoms or abnormal physical findings underwent routine transthoracic echocardiography and LVO by intravenous injection of Levovist using harmonic imaging. RESULTS: Without LVO, abnormal echocardiographic findings compatible with the negative T waves were identified in 22 (65%) of the 34 patients. With LVO, the endocardial border of the left ventricle was observed in all patients and findings compatible with negative T waves were detected in 32 (94%) of the 34 patients, which was significantly higher than that without LVO (chi 2 = 9.79, p = 0.0055). Furthermore, LVO revealed additional findings in nine patients such as mural thrombus or apical thinning. In total, LVO revealed abnormal apical findings in 22 patients (65%), which was significantly higher than that without LVO (chi 2 = 10.0, p = 0.0013). CONCLUSIONS: LVO is useful for identifying abnormal findings, especially in the apex in asymptomatic patients with negative T waves on ECG.     

Contrast opacification of left ventricular myocardium following intravenous administration of sonicated albumin microspheres

Albunex is a new echocardiographic (2-D echo) contrast agent that traverses the pulmonary vasculature when injected intravenously in humans. We examined whether intravenous Albunex resulted in changes in myocardial intensity of sufficient magnitude to produce time intensity curves (TICs). Thirty mildly hypertensive patients were divided into three groups of 10. Each patient received three injections of intravenous Albunex (group I dosages: 0.01, 0.02, and 0.04 cm3/kg; group II: 0.04, 0.06, and 0.08 cm3/kg; group III: 0.08, 0.1, and 0.12 cm3/kg) and two control injections of 5% human serum albumin while imaging with 2-D echo (phased-array; apical four-chamber). Fourty-three injections showed complete opacification of the left ventricle. Videointensity analysis of digitized end-diastolic frames produced myocardial TICs (total as well as background-subtracted intensity curves) in 20 of 43 injections. By visual inspection, a myocardial contrast effect was seen in 10 of 43 injections. Detection of myocardial TICs was dose-related (0 of 7 in group I, 9 of 18 in group II, 11 of 18 in group III) and always paralleled the degree of left ventricular opacification. No myocardial contrast effect was observed in any patient during control injections of albumin or in any patient in whom the injection of Albunex did not result in left ventricular opacification. Thus myocardial opacification with intravenous Albunex can be detected simultaneously with good left ventricular opacification. The potential significance of the myocardial opacification observed is discussed.     

声诺维在心内膜缘显像及心肌灌注中的效果评价

目的评价外周静脉注射造影剂声诺维对超声心动图心内膜缘显像的增强作用及其在心肌灌注中的效果。方法分别在基础和非线性成像条件下,对90例患者注射声诺维,用二维超声进行观察心内膜缘显像的改善,并观察非线性成像条件下心肌灌注情况及不良事件。结果造影剂在右心腔显影后很快在左心腔显影,原来显示欠清的左室心内膜缘得到满意的显影,声诺维能很好显示心肌灌注情况,无严重不良事件,不良事件总发生率为6．8％,其中可能由造影剂引起的不良事件发生率1．1％。结论声诺维可满意地增强心内膜缘的显影和显示心肌灌注,是一安全的跨肺循环的声学造影剂。     

Comparison of a new intravenous echo contrast agent (BY 963) with albunex for opacification of left ventricular cavity

Transpulmonary echo contrast agents improve the evaluation of left ventricular function by two-dimensional echocardiography due to a better endocardial border delineation. To compare the contrast effect in the right and left ventricular cavities, a new transpulmonary echocontrast agent, BY 963 and Albunex were intravenously administered to five non-anaesthetized dogs. The right and left ventricular echocardiographic image intensities were quantitatively measured at 60 cardiac cycles using a commercially available ultrasound system. BY 963 and Albunex were intravenously administered at three doses: 0.01 ml/Kg, 0.05 ml/Kg and 0.1 ml/Kg. The area under the curve (AUC, intensity units x heart cycles) and peak intensity (Peak I, intensity units) were estimated for the right (RV) and left ventricular (LV) cavities at the mid ventricular level using acoustic intensitometry. BY 963 injection produced the following values: At the dose of 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 702±449, 877±470 and 890±320 intensity units x heart cycles in RV and to 542±406, 806±557 and 721±392 in LV (LV/RV ratios: 77%, 92% and 81%). Peak I was at the doses 0.01, 0.05 and 0.1 ml/Kg 29±4.7, 33±5.2 and 35±3.2 intensity units in RV and 18±5.9, 21±6.2 and 20±3.3 in LV (LV/RV ratios: 62%, 64% and 57%).Albunex also produced right and left heart opacification values: at the doses 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 416±231, 493±231 and 674±390 in RV and to 71±71, 158±102 and 277±120 in LV (LV/RV ratios: 17%, 34% abd 41%). Peak I was at the doses of 0.01, 0.05 and 0.1 ml/Kg 19±5.2, 23±5.4 and 29±4.1 in RV and 8±4.8, 13±4.7 and 17±3.2 in LV (LV/RV ratios: 42%, 57% and 59%).Intravenous injection of BY 963 leads to complete opacification of the left ventricular cavity and to high AUC values and peak intensity values at all three dosages. The loss of contrast effect from the right to the left ventricular cavity was very low: the LV/RV ratio of BY 963 was higher than that of Albunex.The new transpulmonary echo contrast agent BY 963 promises to be an excellent echo contrast agent for the noninvasive assessment of left ventricular function.     

Safety and efficacy of a new transpulmonary ultrasound contrast agent: initial multicenter clinical results

Myocardial contrast echocardiography has been found to be a safe and useful technique for evaluating relative changes in myocardial perfusion and delineating areas at risk. Although earlier contrast agents required direct delivery into the coronary arteries or aortic root, a new echocardiographic contrast agent, sonicated albumin microspheres (Albunex), has been found to cross the pulmonary circulation in experimental models. To determine the safety and preliminary efficacy of intravenous injections of Albunex in humans, 71 patients at three independent medical institutions underwent two-dimensional echocardiographic examination before, during and after the administration of three intravenous doses of Albunex, ranging from 0.01 to 0.12 ml/kg body weight. All patients provided a complete history and underwent physical and neurologic examination and laboratory and electrocardiographic evaluation before the injections; all evaluations (except for the history) were repeated at 2 h and 3 days after the injections of Albunex. The efficacy of the injections was qualitatively assessed by two independent blinded observers using a grading system of 0 to +3, with 0 indicating an absence of contrast effect and +3 indicating full opacification of the cavities examined. All injections were well tolerated and no serious side effects were noted in any of the patients. Irrespective of dose group, a cavity opacification greater than or equal to +2 was seen in the right ventricle in 212 (88%) of 240 injections and in the left ventricle in 151 (63%) of 240 injections as judged by the independent observers. The degree of ventricular cavity opacification appeared to be dose and concentration related.(ABSTRACT TRUNCATED AT 250 WORDS)     

Contrast-Enhanced Harmonic Color Doppler for Left Ventricular Opacification: Improved Endocardial Border Definition Compared to Tissue Harmonic Imaging and Optimization of Methodology in Patients with Suboptimal Echocardiograms

OBJECTIVES: This study compared the efficacy of contrast-enhanced harmonic color Doppler (C-HCD) and tissue harmonic imaging (THI) for left ventricular endocardial border delineation and explored the optimal methodology of C-HCD in patients with suboptimal echocardiograms. BACKGROUND: The value of C-HCD in improving endocardium remains unknown. Effects of harmonic velocity-encoded color Doppler (HVD) and harmonic power Doppler (HPD) as well as contrast administration and image acquisition modalities on left ventricular opacification (LVO) have not been established. METHODS: One hundred (50 HVD, 50 HPD) patients with suboptimal echocardiograms during conventional fundamental echocardiography were studied with THI and C-HCD using Levovist. Each patient underwent different random contrast administration and image acquisition modalities. Endocardial border definition score index (EBDI), blooming artifacts, contrast destruction, and salvage of suboptimal echocardiograms were calculated in each patient after contrast enhancement. RESULTS: EBDI improved from 2.05 +/- 0.61 in THI to 2.73 +/- 0.48 in HVD, and 1.98 +/- 0.73 in THI to 2.69 +/- 0.51 in HPD (both P < 0.001). The conversion of a nondiagnostic image from fundamental echocardiography to an optimal diagnostic image was 33 (33%) patients in THI compared to 77 (77%) patients in C-HCD (P < 0.001). Blooming artifacts were seen more commonly in HVD than HPD, intermittent than continuous image acquisition, and bolus than infusion administration (all P < 0.001). There was less contrast destruction in intermittent compared with continuous image acquisition (P < 0.001). Contrast destruction was similar in HVD and HPD, bolus and infusion injection of contrast. The highest salvage rate of a nondiagnostic image from THI to an optimal diagnostic image was 45.5% and 42.4% in HPD mode, with intermittent image acquisition during bolus and infusion contrast administrations. CONCLUSIONS: C-HCD seems more effective in demonstrating improved endocardial border definition compared to THI. HPD has less blooming artifacts compared with HCD. The optimal method for LVO was to use HPD with intermittent image acquisition during bolus or infusion administration of Levovist.     

Detection of resting myocardial perfusion defects by SonoVue myocardial contrast echocardiography

BACKGROUND: SonoVue is a new microbubble contrast agent containing sulfur hexafluoride. We assessed the efficacy of SonoVue myocardial contrast echocardiography (MCE) to detect resting perfusion abnormalities. Methods: Nineteen adult patients with a wall motion abnormality in a screening echocardiogram were studied. Each patient received up to four bolus injections of 2.0 mL SonoVue (Bracco Diagnostics, Inc.) during echocardiographic examination using either B-mode(n = 12)or power Doppler(n = 7)imaging. Each patient also had SPECT nuclear perfusion imaging performed. Segmental assessment of myocardial perfusion from SonoVue MCE images were compared with corresponding SPECT nuclear images. RESULTS: Using B-mode imaging, the mean number of views obtained with a single SonoVue injection ranged from 1.4 to 1.9, with 2 or 3 injections required for a complete examination. Ninety-four percent of segments were scored as diagnostic. Agreement between B-mode and SPECT images was 72% for segments with a perfusion defect, 86% for normal perfusion, and 80% for segments with either perfusion defect or normal perfusion (all views combined). Using power Doppler imaging, the mean number of views obtained with a single SonoVue injection ranged from 1.0 to 1.3, with 2 to 4 injections required for a complete examination. Sixty-eight percent of segments were scored as diagnostic. Agreement between power Doppler and SPECT images was 67% for perfusion defects, 53% for segments with normal perfusion, and 59% for segments with either perfusion defect or normal perfusion (all views combined). CONCLUSIONS: SonoVue MCE has the potential to assess myocardial perfusion at rest. B-mode imaging was more accurate than power Doppler imaging when compared with SPECT nuclear imaging.     

Effect of tissue harmonic imaging and contrast upon between observer and test-retest reproducibility of left ventricular ejection fraction measurement in patients with heart failure

AIMS: To investigate the effects of tissue harmonic imaging (THI) and contrast chamber opacification (LVO) upon measurement variability and reproducibility of echocardiographic left ventricular (LV) volume and ejection fraction (EF) measurements in patients with heart failure (HF). BACKGROUND: Echocardiography is often used in HF patients to determine LV volumes and EF. However, current echo methods are variable and may not be applicable for repeat testing in individual patients. THI and LVO have both been shown to improve endocardial visualisation, but it remains to be determined whether this results in better measurement reproducibility. METHODS: Thirty-one HF patients and 30 control subjects underwent echocardiography on two separate days. LV volumes were measured under four different imaging conditions: fundamental, THI, LVO and LVO with ECG-triggered Power Doppler. Chamber opacification, pulmonary transit time (PTT), endocardial enhancement, reproducibility and bias were assessed. RESULTS: Chamber opacification was inferior and the PTT longer in the HF patients. PTT was related to LV volumes, EF, jugular venous pressure and mitral filling pattern. THI improved endocardial visualisation, and although LVO improved endocardial visualisation in the controls, it offered no benefit over THI in the HF patients. LV volumes and EF were different for each method and THI was the least variable method for repeat measurements. CONCLUSIONS: THI improved endocardial visualisation and was the least variable of the techniques. LVO offered no further advantage in patients with HF and thus cannot be routinely advocated and since LV volumes and EF were different for each, these methods are neither comparable nor interchangeable for follow-up assessments.     

Efficacy and safety of the novel ultrasound contrast agent perflutren (definity) in patients with suboptimal baseline left ventricular echocardiographic images

Suboptimal left ventricular (LV) cavity visualization and endocardial border delineation often compromise the clinical utility of echocardiography. This study examines the safety and efficacy of perflutren, a novel ultrasound contrast agent, for LV cavity opacification and endocardial border delineation in patients with suboptimal baseline echocardiograms. In a multicenter, randomized, placebo-controlled, double-blind trial, 211 patients with suspected cardiac disease and suboptimal baseline echocardiograms were enrolled at 17 sites. Two intravenous injections of either placebo (saline) or perflutren (5 or 10 microl/kg) were given approximately 30 minutes apart. Images of the apical 4- and 2-chamber views were acquired and scored. Perflutren opacified the LV cavity after both dosages (5 and 10 microl/kg dosages). Clinically useful contrast was observed in 89% of patients who received perflutren and in 0% of patients who received placebo (p < 0.01). Quantitative assessment of LV opacification with videodensitometry showed similar results. The mean duration of clinically useful contrast was 90 seconds. Improvement in endocardial border delineation was demonstrated in 91% of patients who received perflutren and in 12% of those who received placebo (p < 0.001). Following perflutren, an average of 4 more segments per patient were evaluable compared with baseline. Salvage of nondiagnostic baseline examinations by perflutren was demonstrated in 48% of eligible subjects. The safety profile of perflutren was similar to placebo. These data indicate that administration of perflutren to patients with suboptimal baseline images is well tolerated and provides substantial LV cavity opacification and improvement in endocardial border delineation.     

The influence of Albunex on the pulmonary circulation in patients with pulmonary hypertension or left heart failure

To determine the safety of the ultrasound contrast agent Albunex,its influence on right and left heart haemodynamics in patientswith pulmonary artery hypertension or left heart failure wasassessed after intravenous injection. Patients with a left ventricular ejection fraction smaller than40% or a systolic pulmonary artery pressure greater than 40%mmHg received 0·08 and 0·22 ml . kg^–1 Albunexand 10 ml albumin in random order during right heart catheterizationand transthoracic echocardiography. Right atrial, systolic anddiastolic pulmonary artery and capillary wedge pressures weremeasured at 3 min and 5 min and cardiac output at 5 min afterthe intravenous injection of Albunex and control. The mean differencesof pre- and postinjection values and their confidence intervalswere tabulated and significance was anticipated if the confidenceinterval did not include 0. Significant changes to pre-injection values could be observedin diastolic pulmonary artery pressure 5 min after the injectionof albumin and 0·08 ml. kg^–1 Albunex, and in rightatrial pressure 5 min after the injection of 0·22 ml.kg^–1 Albunex only. Since intermediate opacification ofthe left ventricle was seen in only four patients with 0·22ml. kg^–1 Albunex, in the patients studied higher dosesof Albunex and their safety need to be assessed.     

Use of harmonic echocardiographic contrast imaging and intravenous bolus of Levovist for evaluation of the left ventricle

Harmonic imaging is a new imaging modality using nonlinear acoustic response, which is particularly sensitive for the particles of contrast agents. Our study was designed to compare the potential of harmonic echocardiographic imaging of the left ventricle using a contrast agent, Levovist to improve the detection of endocardium in patients with suboptimal image quality. 40 patients were studied using standard transthoracic apical views of the left ventricle patients using fundamental frequency and second harmonic frequency after and intravenous injection of 2.5 g Levovist. The quality of endocardial delineation in 16 standard segments was scored from 0 to 2. Endocardial visualization index was calculated as a mean of the scores to express overall diagnostic quality. Harmonic imaging with contrast significantly improved left ventricular endocardial border detection (endocardial visualization index at baseline 1.24 +/- 0.41, with contrast 1.63 +/- 0.38; p < 0.001). The improvement was qualitatively observed in all parts of the left ventricle: in apex (2.4 +/- 0.8), in the middle part (2.5 +/- 0.9) and slightly less in the basal part (2.1 +/- 1.1) as scored on a 0-3 scale. The number of invisible segments decreased from 124 (fundamental) to 50 in contrast harmonic mode. The persistence of the contrast enhancement, prolonged in harmonic as compared to fundamental imaging (284 +/- 136s vs 117 +/- 87s; p < 0.001) enabled convenient recording of all necessary views. Harmonic imaging after an intravenous injection of Levovist significantly improves the visualization of left ventricular endocardial border. Prolonged contrast effect after a single bolus enhances the pertinence of the method in clinical practice.