Tips and Tricks in Contrast

Echocardiography

Roxy Senior

Professor of Cardiology

Royal Brompton Hospital London

Imperial College London

Summary of Main Recommendations by

EACVI-2017

• Contrast must be used if >=2seg not visualised

• To better assess structural abnormalities especially apical

• In SE even if all segments visualised at rest if images deteriorate

during deep inspiration contrast must be used

• Myocardial perfusion assessment is recommended in SE if

expertise exist

R.Senior et al Eur Heart J – Cardiovasc Imaging 2017; 18: 1205

76yr woman admitted to ITU with

worsening COVID 19 Pneumonia

haemodynamic

instability.

Recurrent arrhythmia

↑Trop I,D-Dimer,BNP

Echo requested to

assess LV

function,RWMA.

Contrast Echo

71 yr male admitted in HDU with Respiratory Failure

H/o of heart failure

↑Trop I,BNP,D-Dimer

Echo requested to

assess cardiac

function

Contrast Echo

• 29-year-old obese Asian female

• Atypical chest pain

• Diabetic for 2 years

• Normal resting ECG

Ex Echo

Dwivedi and Senior.. Brit Med J. 2006:332:643.

61 yr male with atypical angina -EXEcho

Relation between Transmit Power(MI), tissue

and microbubble response

Microbubble Tissue

1.0

0.5

<0.2

0

Implosion Harmonic ++

Harmonics ++ Harmonics+

Harmonics weak

Fundamental strong

Harmonic weak

Fundamental strong

Power(MI)

MI

• Better Tissue cancellation

• Better signal to noise ratio

• More uniform LV opacification as contrast is not

destroyed

• Less amount of contrast used

• Perfusion of myocardial walls and masses can be

assessed simultaneously with wall motion

Low MI-Contrast Specific Imaging(multipulse)

Optimal Image Acquisition

Homogenous opacificationClear visualisation of endo/epicardiumAppreciation of wall thickeningNo basal attenuation or apical artifact

Attenuation artifact

Bloooming artifact

Other types of attenuation artifacts

Senior et al AHJ 1998:

Swirling

Excessive bubble destruction in the near field (apex) that may

be due to a combination of factors:

high MI-int MI,

insufficient contrast administration or severe LV dysfunction

with sluggish flow at the apex.

Overcoming Swirling

Decrease the mechanical index-always use low MI contrast

specific setting,

increase contrast dose,

Perfusion Imaging

Take Home message

• Use low MI Contrast specific imaging option

• Slow bolus

• Obtain uniform LV opacification with some myocardial

opacification

• Optimum gain and keep focus at the mitral valve level but

move towards apex if there is apical artifact