WHAT IS WRONG
ABOUT THESE
CONTRAST
STUDIES
Laura Johnson RDCS
Aurora Cardiovascular services
Aurora Health Care
Milwaukee, WI.
ARTIFACTS
COMMON CAUSES
EFFECTS
TECHNICAL TIPS
Common Causes
Improper system setting
Improper administration
Rib artifact
1
System Controls - Features
Focus
Transmit Power (MI)
Adjusts where the beam is focused
Regulates intensity of ultrasound sent into the body
Deeper target needs more intensity
Receiver Gain
Compression ( Dynamic Range)
Boost amplification of received echos
Displays range of “shade os grey”
SWIRLING
EFFECT
Swirling Effect
Inadequate LV opacification
Commonly seen in the LV apex apical
window
Occurs with
Inappropriate settings
Insufficient amount of contrast administered
2
Avoid Swirling -Technical Tips
Decrease the Mechanical Index
MI range of 0.1 to 0.8
Adjust the focus mid to near field
Increase the contrast amount
3
Not enough contrast?
Additional contrast given
MI .19
4
MI .39
ATTENUATION
Attenuation Artifact
Shadowing in mid to far field
Occurs when a high concentration of
micro bubbles exist
Ultrasound energy is backscatter
Unable to transmit through the far field
5
Avoid Attenuation - Technical
Tips
Slow administration of the contrast
followed by a slow flush
Stop administration of contrast when
attenuation is present
6
Image obtained immediately
following contrast injection
30 seconds after contrast injection
One minute after contrast injection
7
RIB ARTIFACT
Rib artifact
Usually occurs in apical 4 chamber
view
Generates a straight line shadow
8
Avoid Rib artifact – Technical Tip –
realign image
9
What’s wrong with these
contrast images
10
11
12
Clinical Applications of
Case 1
Contrast Echocardiography
Incremental Value
Mani A. Vannan, MBBS, FACC
Professor of Clinical Medicine
Joseph M. Ryan Chair in CV Medicine
Director Cardiovascular Imaging
Director,
Ohio State University
Columbus, OH
Conflict of Interest:
• 38 year old man
• ESRD,, listed for renal transplant,
p
, HTN
• Dyspnea and chest pain – few months
• Echo for LV function
Siemens - Advisory Board, Speakers Honorarium
and Research Support
and
Bristol Myers Medical Imaging - Speakers Honorarium
and Research Support
Case 1
Case 1
4C
2C
APLAX
4C
Case 1
Case 1
PRE CONTRAST
PRE CONTRAST
• What is the global LV function ?
a) Normal
b) Abnormal
• Is there LVH ?
a) Yes
b) No
- Concentric
- Mild LV systolic dysfunction
- Estimated EF ~40 %
1
Case 1
Case 1
PRE CONTRAST
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
• Is there LV Clot ?
a) Yes
- Possible clot or trabeculation
b) No
4C
4C
Case 1
POST- CONTRAST (DEFINITY®)
Case 1
PRE CONTRAST
POST- CONTRAST (DEFINITY®)
2C
APLAX
2C
PRE CONTRAST
APLAX
Case 1
Case 1
POST- CONTRAST (DEFINITY®)
POST- CONTRAST (DEFINITY®)
• What is the global LV function ?
a) Normal
b) Abnormal
• Is there LVH ?
a) Yes
b) No
- Concentric
- Mild LV systolic dysfunction
- Estimated EF ~40 %
2
Case 1
Case 1
POST- CONTRAST (DEFINITY®)
CLINICAL COURSE
• Resting LV systolic dysfunction
• Is there LV Clot ?
a) Yes
b) No
- Trabeculation
- Pre contrast: “Possible clot or trabeculation”
• No Regional wall motion abnormality
• Concentric LVH
• No LV clot
• No anticoagulation
Case 1
Case 2
BENEFIT OF CONTRAST
• Superior delineation of apical anatomy
• Increased confidence of interpretation
• Clinical decision-making
• 48 year old man
• SOB,, cough
g and dizziness
• No other significant medical history
• Echo for LV function
Case 2
Case 2
4C
2C
APLAX
4C
3
Case 2
Case 2
PRE CONTRAST
• What is the global LV function ?
a) Normal
b) Abnormal
Case 2
- Estimated EF > 65 %
Case 2
PRE CONTRAST
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
• Is there LVH ?
a) Yes
b) No
- Concentric with ASH
4C
Case 2
4C
Case 2
POST- CONTRAST (DEFINITY®)
4C
2C
PRE CONTRAST
2C
4
Case 2
POST- CONTRAST (DEFINITY®)
Case 2
PRE CONTRAST
APLAX
APLAX
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
SAX
SAX
Case 2
Case 2
POST- CONTRAST (DEFINITY®)
POST- CONTRAST (DEFINITY®)
• What is the global LV function ?
a) Normal
b) Abnormal
- Estimated EF > 65 %
• Is there LVH ?
a) Yes
b) No
- ASH,
ASH not concentric
Case 2
Case 2
CLINICAL COURSE
BENEFIT OF CONTRAST
• Hyperdynamic LV systolic function
• No Regional wall motion abnormality
• Asymmetric Septal LVH
• Established diagnosis - HCM
• Clinical decision-making and triage
• Possible HCM
• Diastolic “heart failure”
• Needs Holter and / or EP evaluation
5
Case 3
Case 3
• 66 year old woman
• Non-sustained VT and syncope
y
p
• Pre-ICD Echo for LV function
4C
2C
APLAX
Case 3
Case 3
PRE CONTRAST
PRE CONTRAST
• What is the global LV function ?
• Is there LV Clot ?
a) Normal
b) Abnormal
a) Yes
b) No
- Severe LV systolic dysfunction
- Estimated EF ~ 20 %
Case 3
POST- CONTRAST (DEFINITY®)
4C
Case 3
PRE CONTRAST
4C
POST- CONTRAST (DEFINITY®)
2C
PRE CONTRAST
2C
6
Case 3
Case 3
POST- CONTRAST (DEFINITY®)
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
• What is the global LV function ?
a) Normal
b) Abnormal
- Severe LV systolic dysfunction
- Estimated EF ~ 20 %
APLAX
APLAX
Case 3
Case 3
POST- CONTRAST (DEFINITY®)
CLINICAL COURSE
• Severe LV systolic dysfunction
• Is there LV Clot ?
a) Yes
b) No
- Large
L
apical
i l clot
l t
• Global wall motion abnormality
• Large
a ge LV ap
apical
ca cclot
ot
• Surgery to remove clot
• Surgical patch defibrillator
• Dor procedure
• Anticoagulation
Case 3
Case 4
BENEFIT OF CONTRAST
• 67 year old woman
• Important finding – LV clot
• HTN and DM
• Clinical decision-making and triage
• Hypotension and on pressors
• Abnormal EKG
7
Case 4
Case 4
PRE CONTRAST
• What is the global LV function ?
a) Normal - Probably normal
b) Abnormal
4C
2C
APLAX
Case 4
POST- CONTRAST (DEFINITY®)
4C
Case 4
PRE CONTRAST
4C
Case 4
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
2C
2C
Case 4
POST- CONTRAST (DEFINITY®)
POST- CONTRAST (DEFINITY®)
PRE CONTRAST
• What is the global LV function ?
a) Normal - hyperdynamic
b) Abnormal
APLAX
APLAX
8
Case 4
Case 4
POST- CONTRAST (DEFINITY®) MCE
LV CAVITY DOPPLER
4C
APLAX
Case 4
Case 4
CLINICAL COURSE
BENEFIT OF CONTRAST
• Hyperdynamic LV systolic function
• Pressors discontinued
• Defined function-perfusion status
• B blockers and ASA
• Clarified hemodynamics
• Clinical decision-making and triage
• Renal function improved
• Coronary angiography
• PCI to LAD
What You See Is What You Want
Role of Contrast in Clinical Echocardiography
• Valuable in Everyday Clinical Echocardiography
• It is
i nott about
b t “Pretty”
“P tt ” Pictures
Pi t
• It is about Information And Interpretation
• Influences Clinical-Decision Making
9