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Follow advice on contrast echo for optimum patient benefit

EuroEcho-Imaging 2017

Professor Roxy Senior, cardiologist and Director of Echocardiography at the Royal Brompton Hospital in London, the largest echocardiography department in the UK, discusses his career to date, and his role as lead author on a consensus document (published in the European Heart Journal – Cardiovascular Imaging) that will shape how contrast echocardiography (echo) is used in diagnosis.


senior-2011.jpgWhy did you choose to specialise in echo?

In my undergraduate days what interested me was cardiac physiology, and I decided at that time that I wanted to become a cardiologist. This led to my interest in echo, because it offered a real-time insight into the physiology of various cardiac conditions at the patient’s bedside, with major clinical implications in terms of patient management.

What have been the key developments in echo during your career?

The very first echo that I performed was in “M mode”. I was part of the evolution of echo into 2D, Doppler, colour flow, and transoesophageal echo. Stress echo allowed us for the first time to study cardiac mechanics in real time during physiological activity. However, the most striking development was the ability of echo to evaluate myocardial perfusion. Until recently, this was considered the holy grail of echo because it remained so elusive.

What do the latest data for contrast echo indicate?

There has been a flurry of large multicentre studies, randomised trials, and large single-centre studies that indicate that contrast echo improves the accuracy of assessing left ventricular function and myocardial perfusion, and that it delivers incremental diagnostic and prognostic information beyond that of the wall motion assessment provided during stress echo.

What do you think have been your most important achievements during your career?

My major achievement was the development of myocardial perfusion using microbubbles, especially in combination with stress echo. This allowed the simultaneous assessment of perfusion and function, which is unique in cardiology. It provides incremental information beyond cardiac structure and function. I led several large multicentre trials to develop the technique and bring it to the forefront of the profession. I was also involved in the development of carotid ultrasound and stress echo to assess atherosclerosis and ischaemia simultaneously. This provides a synergistic prognostic value for patients presenting with chest pain. My group was also the first to appraise a portable ultrasound system to screen for cardiac dysfunction in the community. Finally, I introduced the concept of evaluating transvalvular flow rate in aortic stenosis. More work is being done on this.

You are the lead author of a recent consensus paper on contrast echo. Why is it important to have such a paper?

Contrast echo is now an established technique in clinical cardiology, but despite its availability, its clinical use remains low. The uptake of contrast in stress echo is relatively high compared to its use in resting echo, but contrast in stress echo is not optimally used in many  parts of Europe and the USA. The use of myocardial perfusion remains very low. Although contrast safety issues have been addressed, lingering concerns remain. As a result of the new data that have emerged over the last five years, contrast echo and contrast protocols have become more established. And, the usefulness of contrast echo has been demonstrated in clinical conditions in which it was not recommended before. Therefore, the paper brings together all the evidence and highlights the key features of where contrast use benefits patients. It recommends that contrast must be used in certain cardiac conditions, and that non-usage will disadvantage patients.

What were the key recommendations of the paper?

The document has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols. Contrast must be used for the accurate assessment of LV structure and function if image quality is inadequate or if reproducible assessment of LV ejection fraction (EF) is required, even if the images are of adequate quality. For those undergoing stress echo, contrast should be used in patients with inadequate resting images, and should be used even if resting images are adequate but deteriorate during inspiration, mimicking cardiac motion during stress. In labs with adequate training myocardial perfusion must be assessed in addition to function during stress echo.

The recommendation paper is very comprehensive, and provides advice on contrast agents and imaging modalities, routes of administration, and the clinical safety of the agents, as well as training and accreditation requirements, and protocols for clinical practice.

What is your advice for putting the recommendations of the paper into clinical practice?

Three contrast agents are approved for clinical use and are all readily available. The labs should now use the protocols mentioned in the paper, and train individuals as suggested for implementation of contrast use.

What advice did you receive from your mentors that you now pass on to those whom you mentor?

I have always been taught that enthusiasm, diligence, persistence, and sincerity are the backbone of any achievements, and I pass that on.

You are speaking at the “Advanced echo techniques II: basics, indications, protocols and interpretation” session. Why is this a useful session to attend?

I will be talking about the recent advances in stress echo, and the future for the technique. This talk will give an insight into how much the technique has advanced over the years and what more it can provide in the future.