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Improved accuracy of global and regional assessment of global and regional systolic function as well as ventricular volumes and ejection fraction

The evidence for use of contrast in clinical echocardiography: Left Ventricular Opacification – LVO


Optison [1], Sonovue [2] and Luminity [3] have all been assessed for improvement of endocardial border delineation (EBD) during echocardiography in patients with sub-optimal image quality during unenhanced studies. These studies involved hundreds of patients and demonstrated that all three agents increased length of EBD (during end-systole and end-diastole), caused effective left ventricular opacification (LVO) and were able to ‘salvage’ an otherwise non-diagnostic study. When compared against a first-generation contrast agent, a markedly lengthier duration of action was noted for all second-generation agents.

As a consequence of this improved EBD and LVO, contrast imaging allows accurate calculation of ventricular volumes and ejection fraction and is superior to non-contrast enhanced harmonic imaging. Numerous studies have demonstrated this [4-7] and, in a multi-centre and multi-modality imaging study, LV volumes and LV EF as assessed by contrast echocardiography were as accurate as cardiac MRI and had the least inter-observer variability of all tests evaluated [8]. No trial has ever shown contrast echocardiography to be inferior to another modality for the assessment of LV EF and LV volumes.

A recent study [9] also demonstrated the beneficial cost impact of contrast use during resting transthoracic echocardiography studies. 632 patients with sub-optimal image quality received contrast (Definity) and, amongst other factors, management decisions were compared before and after contrast administration. The percentage of uninterpretable studies was dramatically reduced (11.7% to 0.3%), further diagnostic tests were avoided in 32% of patients, drug management was altered in 10% and a cost/benefit analysis yielded a cost saving of $122 per patient [9].

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1. Healthcare. G. OPTISON Prescribing information., 2008
2. EMEA Scientific discussion. Sonovue, European Public Assessment Report., 2004
3. Luminity Summary of Product Characteristics
4. Hundley WG, Kizilbash AM, Afridi I, Franco F, Peshock RM, Grayburn PA. Administration of an intravenous perfluorocarbon contrast agent improves echocardiographic determination of left ventricular volumes and ejection fraction: comparison with cine magnetic resonance imaging. J Am Coll Cardiol 1998;32(5):1426-32
5. Reilly JP, Tunick PA, Timmermans RJ, Stein B, Rosenzweig BP, Kronzon I. Contrast echocardiography clarifies uninterpretable wall motion in intensive care unit patients. J Am Coll Cardiol 2000;35(2):485-90
6. Yu EH, Sloggett CE, Iwanochko RM, Rakowski H, Siu SC. Feasibility and accuracy of left ventricular volumes and ejection fraction determination by fundamental, tissue harmonic, and intravenous contrast imaging in difficult-to-image patients. J Am Soc Echocardiogr 2000;13(3):216-24
7. Malm S, Frigstad S, Sagberg E, Larsson H, Skjaerpe T. Accurate and reproducible measurement of left ventricular volume and ejection fraction by contrast echocardiography: a comparison with magnetic resonance imaging. J Am Coll Cardiol 2004;44(5):1030-5
8. Hoffmann R, von Bardeleben S, ten Cate F, Borges AC, Kasprzak J, Firschke C, et al. Assessment of systolic left ventricular function: a multi-centre comparison of cineventriculography, cardiac magnetic resonance imaging, unenhanced and contrast-enhanced echocardiography. Eur Heart J 2005;26(6):607-16
9. Kurt M, Shaikh KA, Peterson L, Kurrelmeyer KM, Shah G, Nagueh SF, et al. Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort. J Am Coll Cardiol 2009;53(9):802-10