Top

Current Heart Failure Reports

Published in:

02-02-2024 | Echocardiography | Review

Contrast Echocardiography in Heart Failure: Update 2023

Authors: Harald Becher, Waleed Alhumaid, Jonathan Windram, Jonathan Choy

Published in: Current Heart Failure Reports | Issue 2/2024

Abstract

Purpose of Review

The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018.

Recent Findings

The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease.

Summary

Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.

McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–726. https://doi.org/10.1093/eurheartj/ehab368.CrossRefPubMed

Malik SB, Chen N, Parker RA 3rd, Hsu JY. Transthoracic echocardiography: pitfalls and limitations as delineated at cardiac CT and MR imaging. Radiographics. 2017;37(2):383–406. https://doi.org/10.1148/rg.2017160105.CrossRefPubMed

Hoffmann R, Barletta G, von Bardeleben S, Vanoverschelde JL, Kasprzak J, Greis C, Becher H. Analysis of left ventricular volumes and function: a multicenter comparison of cardiac magnetic resonance imaging, cine ventriculography, and unenhanced and contrast-enhanced two-dimensional and three-dimensional echocardiography. J Am Soc Echocardiogr. 2014;27(3):292–301. https://doi.org/10.1016/j.echo.2013.12.005.CrossRefPubMed

Porter TR, Mulvagh SL, Abdelmoneim SS, Becher H, Belcik JT, Bierig M, Choy J, Gaibazzi N, Gillam LD, Janardhanan R, Kutty S, Leong-Poi H, Lindner JR, Main ML, Mathias W Jr, Park MM, Senior R, Villanueva F. Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography Guidelines Update. J Am Soc Echocardiogr. 2018;31(3):241–74. https://doi.org/10.1016/j.echo.2017.11.013.CrossRefPubMed

• Porter TR, Feinstein SB, Senior R, Mulvagh SL, Nihoyannopoulos P, Strom JB, Mathias W Jr, Gorman B, Rabischoffsky A, Main ML, Appis A. CEUS cardiac exam protocols International Contrast Ultrasound Society (ICUS) recommendations. Echo Res Pract 2022;9(1):7. https://doi.org/10.1186/s44156-022-00008-3. Most recent review of indications for contrast echocardiography and exam protocols.

Lantheus Medical Imaging Definity (perflutren lipid microsphere) package insert Available at: http://www.definityimaging.com/prescribing_info.html Accessed 01/06/2023

Bracco Lumason (sulfur hexafluoride lipid-type A microspheres) package insert Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/203684s009lbl.pdf Accessed 10/05/2023

Bracco SonoVue (sulfur hexafluoride lipid-type A microspheres) package insert Available at: https://www.ema.europa.eu/en/documents/product-information/sonovue-epar-product-information_en.pdf Accessed 10/05/2023

GE imaging Optison (Perflutren Protein-Type A Microspheres Injectable Suspension, USP) package insert. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020899s015lbl.pdf Accessed 10/05/2023

10.

Becher H, Helfen A. LV function and myocardial disease/masses. In: Becher H and Helfen A. Contrast Echocardiography. Echocardiography Compendium for Clinical Practice. 2019 Springer/Nature, London. https://doi.org/10.11007/978-3-030-15962-7.

11.

Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancelloti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Image. 2017;18(11):1205–1205. https://doi.org/10.1093/ehjci/jex182.CrossRef

12.

Lang RM, Bierig M, Devereux RB, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocard. 2015;28(1):1-39.e14. https://doi.org/10.1016/j.echo.2014.10.003.CrossRef

13.

Zhao H, O’Quinn R, Ambrose M, Jagasia D, Ky B, Wald J, Ferrari VA, Kirkpatrick JN, Han Y. Contrast-enhanced echocardiography has the greatest impact in patients with reduced ejection fractions. J Am Soc Echocardiogr. 2018;31(3):289–96. https://doi.org/10.1016/j.echo.2017.09.003.CrossRefPubMed

14.

• Lee KC, Liu S, Callahan P, Green T, Jarrett T, Cochran JD, Mei Y, Mobasseri S, Sayegh H, Rangarajan V, Flueckiger P, Vannan MA. Routine use of contrast on admission transthoracic echocardiography for heart failure reduces the rate of repeat echocardiography during index admission. J Am Soc Echocardiogr. 2021;34(12):1253-1261. https://doi.org/10.1016/j.echo.2021.07.008. Largest clinical study (9,115 admissions) on routine use of ultrasound enhancing agents in the first TTE examination for heart failure irrespective of image quality.

15.

Alherbish A, Becher H, Alemayehu W, Paterson DI, Butler CR, Anderson TJ, Ezekowitz JA, Shanks M. Alberta Heart investigators. Impact of contrast echocardiography on accurate discrimination of specific degree of left ventricular systolic dysfunction and comparison with cardiac magnetic resonance imaging. Echocardiography. 2018;35(11):1746–54. https://doi.org/10.1111/echo.14152.CrossRefPubMed

16.

Khaled S, Hachicha Z, Elkhateeb O. Left ventricular thrombus in myocardial infarction after successful primary percutaneous coronary intervention: prevalence and predictors—a middle eastern single-centre experience. CJC Open. 2020;2:104–10. https://doi.org/10.1016/j.cjco.2020.02.001.CrossRefPubMedPubMedCentral

17.

• Levine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, Shah ZI, Shenoy C, Spinler SA, Vallurupalli S, Lip GYH; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Management of patients at risk for and with left ventricular thrombus: a scientific statement from the American Heart Association. Circulation. 2022;146(15):e205-e223. https://doi.org/10.1161/CIR.0000000000001092. Most recent recommendation of the American Heart Association on the use of UEAs for assessment of LV thrombus confirming previous recommendations of the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

18.

Weinsaft JW, Kim RJ, Ross M, et al. Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left ventricular thrombus. JACC Cardiovasc Imaging. 2009;2:969–79. https://doi.org/10.1016/j.jcmg.2009.03.017.CrossRefPubMedPubMedCentral

19.

Weinsaft JW, Kim J, Medicherla CB, et al. Echocardiographic algorithm for post-myocardial infarction lv thrombus: a gatekeeper for thrombus evaluation by delayed enhancement CMR. JACC J Am Coll Cardiol Img. 2016;9(2016):505–15. https://doi.org/10.1016/j.jcmg.2015.06.017.CrossRef

20.

Citro R, Okura H, Ghadri JR, et al. Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE). J Echocardiogr. 2020;18(4):199–224. https://doi.org/10.1007/s12574-020-00480-y.CrossRefPubMedPubMedCentral

21.

Lehman EP, Cowper PA, Randolph TC, Kosinski AS, Lopes RD, Douglas PS. Usefulness and cost-effectiveness of universal echocardiographic contrast to detect left ventricular thrombus in patients with heart failure and reduced ejection fraction. Am J Cardiol. 2018;122(1):121–8. https://doi.org/10.1016/j.amjcard.2018.03.016.CrossRefPubMed

22.

Cwajg JM, Cwajg E, Nagueh SF et al. End-diastolic wall thickness as a predictor of recovery of function in myocardial hibernation: relation to rest-redistribution T1–201 tomography and dobutamine stress echocardiography. J Am Coll Cardiol 35(2000): 1152–1161 https://doi-org.login.ezproxy.library.ualberta.ca/https://doi.org/10.1016/s0735-1097(00)00525-8

23.

Pradhan J, Senior R. Assessment of myocardial viability by myocardial contrast echocardiography: current perspectives. Curr Opin Cardiol. 2019;34(5):495–501. https://doi.org/10.1097/HCO.0000000000000650.CrossRefPubMed

24.

Becher H, Helfen A. Stress echocardiography. In: Becher H and Helfen A. Contrast Echocardiography. Echocardiography Compendium for Clinical Practice. 2019 Springer/Nature, London https://doi.org/10.11007/978-3-030-15962-7

25.

Xie F, Qian L, Goldsweig A, Xu D, Porter TR. Event-free survival following successful percutaneous intervention in acute myocardial infarction depends on microvascular perfusion. Circ Cardiovasc Imaging. 2020;13(6):e010091. https://doi.org/10.1161/CIRCIMAGING.119.010091.CrossRefPubMed

26.

Wang L, Ma Y, Jin W, Zhu T, Wang J, Yu C, Zhang F, Jiang B. Coronary microcirculation dysfunction evaluated by myocardial contrast echocardiography predicts poor prognosis in patients with ST-segment elevation myocardial infarction after percutaneous coronary intervention. BMC Cardiovasc Disord. 2022;22(1):572. https://doi.org/10.1186/s12872-022-02947-5.CrossRefPubMedPubMedCentral

27.

Lee DZJ, Chan RH, Montazeri M, Hoss S, Adler A, Nguyen ET, Rakowski H. Left ventricular apical aneurysms in hypertrophic cardiomyopathy: equivalent detection by magnetic resonance imaging and contrast echocardiography. J Am Soc Echocardiogr. 2021;34(12):1262–72. https://doi.org/10.1016/j.echo.2021.07.015.CrossRefPubMed

28.

Cotter B, Raisinghani A, De Maria AN. Established and emerging roles for ultrasound. Clin Cardiol. 2022;45(11):1114–22. https://doi.org/10.1002/clc.23924.CrossRefPubMedPubMedCentral

29.

Nishimura M, Igata S, Wong DJ, et al. Hypertrabeculation as a noncompaction phenotype in dilated cardiomyopathy defined by contrast echocardiography. JACC Cardiovasc Imaging. 2019;12(7 Pt 1):1287–8. https://doi.org/10.1016/j.jcmg.2019.01.020.CrossRefPubMed

30.

Adabifirouzjaei F, Igata S, DeMaria AN. Hypertrabeculation; a phenotype with heterogeneous etiology. Prog Cardiovasc Dis. 2021;68:60–9. https://doi.org/10.1016/j.pcad.2021.07.007.CrossRefPubMed

31.

Urbano-Moral JA, Gonzalez-Gonzalez AM, Maldonado G, Gutierrez-Garcia-Moreno L, Vivancos-Delgado R, De Mora-Martin M, Rodriguez-Palomares JF, Evangelista-Masip A. Contrast-enhanced echocardiographic measurement of left ventricular wall thickness in hypertrophic cardiomyopathy: comparison with standard echocardiography and cardiac magnetic resonance. J Am Soc Echocardiogr. 2020;33(9):1106–15. https://doi.org/10.1016/j.echo.2020.04.009.CrossRefPubMed

32.

Kurt M, Shaikh KA, Peterson L, Kurrelmeyer KM, Shah G, Nagueh SF, Fromm R, Quinones MA. Zoghbi WA 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. https://doi.org/10.1016/j.jacc.2009.01.005.CrossRefPubMed

33.

Hwang HJ, Sohn IS, Kim WS, Hong GR, Choi EY, Rim SJ, Lee SC, Chung WJ, Choi JH, Seo HS, Yoon SJ, Cho KI, Kim HS, Yoon HJ. The clinical impact of bedside contrast echocardiography in intensive care settings: a Korean multicenter study. Korean Circ J. 2015;45(6):486–91. https://doi.org/10.4070/kcj.2015.45.6.486.CrossRefPubMedPubMedCentral

34.

• Main ML, Fu JW, Gundrum J, LaPointe NA, Gillam LD, Mulvagh SL. Impact of contrast echocardiography on outcomes in critically ill patients. Am J Cardiol. 2021;150:117-122. https://doi.org/10.1016/j.amjcard.2021.03.039. Largeest clinical study on impact of contrast echocardiography on outcome in critically ill patients – a large proportion with heart failure. In this retrospective observational study, the outcome of 51,141 patients who underwent contrast echocardiography was compared with the outcome of patients who did not receive contrast agents during echocardiography. Statistically significant lower rates of subsequent TTE and TEE during the index hospitalization and with a shorter ICU length of stay was found in patients who underwent enhanced echocardiography.

35.

Main ML, Hibberd MG, Ryan A, Lowe TJ, Miller P, Bhat G. Acute mortality in critically ill patients undergoing echocardiography with or without an ultrasound contrast agent. JACC Cardiovasc Imaging. 2014;7(1):40–8. https://doi.org/10.1016/j.jcmg.2013.08.012.CrossRefPubMed

36.

Fine NM, Abdelmoneim SS, Dichak A, Kushwaha SS, Park SJ, Mulvagh SL. Safety and feasibility of contrast echocardiography for LVAD evaluation. JACC Cardiovasc Imaging. 2014;7(4):429–30. https://doi.org/10.1016/j.jcmg.2013.08.016.CrossRefPubMed

37.

Schinkel AFL, Akin S, Strachinaru M, Muslem R, Soliman OII, Brugts JJ, Constantinescu AA, Manintveld OC, Caliskan K. Safety and feasibility of contrast echocardiography for the evaluation of patients with HeartMate 3 left ventricular assist devices. Eur Heart J Cardiovasc Imaging. 2018;19(6):690–3. https://doi.org/10.1093/ehjci/jex177.CrossRefPubMed

38.

Bleakley C, Smith R, Garfield B, Jackson T, Remmington C, Patel BV, Price S. Contrast echocardiography in VV-ECMO-dependent patients with COVID-19. J Am Soc Echocardiogr. 2020;33(11):1419–20. https://doi.org/10.1016/j.echo.2020.07.012.CrossRefPubMedPubMedCentral

39.

Janus SE, Hajjari J, Al-Kindi S, et al. Contrast-enhanced echocardiographic detection of severe aortic insufficiency in veno-arterial extracorporeal membrane oxygenation. Echocardiography. 2020;37:905–7. https://doi.org/10.1111/echo.14752.CrossRefPubMed

40.

• Lashin H, Shepherd S, Smith A. Contrast-enhanced echocardiography application in patients supported by extracorporeal membrane oxygenation (ECMO): a narrative review. J Cardiothorac Vasc Anesth. 2022;36(7):2080-2089. https://doi.org/10.1053/j.jvca.2021.04.031. Comprehensive review of the use of contrast-enhanced echocardiography (CEE) in ECMO-supported patients. The role of CEE in guiding implantation, assessment, diagnosis of complications and the safety of UEAs is reported.

41.

Baeza-Herrera LA, Hernández-Reyes JP, Lazcano-Díaz EA, Orihuela-Sandoval C, González-Ruiz FJ, Manzur-Sandoval D, Ramos-Enríquez Á, Terrazas-Cervantes E, Rojas-Velasco G. A contrast echocardiography-based protocol to rule out thrombus in venous-arterial ECMO: a proof of concept. Echocardiography. 2023;40(3):299–302. https://doi.org/10.1111/echo.15543.CrossRefPubMed

42.

Lindner JR, Belcik T, Main ML, Montanaro A, Mulvagh SL, Olson J, Olyaei A, Porter TR, Senior R. Expert consensus statement from the American Society of Echocardiography on hypersensitivity reactions to ultrasound enhancing agents in patients with allergy to polyethylene glycol. J Am Soc Echocardiogr. 2021;34(7):707–8. https://doi.org/10.1016/j.echo.2021.05.002.CrossRefPubMedPubMedCentral

43.

Hagendorff A, Kandels J, Metze M, Tayal B, Stoebe S. Valid and reproducible quantitative assessment of cardiac volumes by echocardiography in patients with valvular heart diseases—possible or wishful thinking? Diagnostics. 2023;13(7):1359. https://doi.org/10.3390/diagnostics13071359.CrossRefPubMedPubMedCentral

44.

Lindner JR. Contrast echocardiography: current status and future directions. Heart. 2021;107(1):18–24. https://doi.org/10.1136/heartjnl-2020-316662.CrossRefPubMed

45.

Porter TR, Feinstein SB, Ten Cate FJ, van den Bosch AA. New applications in echocardiography for ultrasound contrast agents in the 21st century. Ultrasound Med Biol. 2020;46(5):1071–81. https://doi.org/10.1016/j.ultrasmedbio.2020.01.004.CrossRefPubMed

46.

• Albulushi A, Olson J, Xie F, Qian L, Mathers D, Aboeata A, Porter TR. Effect of intermittent high-mechanical index impulses on left ventricular strain. J Am Soc Echocardiogr. 2021;34(4):370–376. https://doi.org/10.1016/j.echo.2020.11.013. First clinical study showing that a commercially available contrast agent can improve LV systolic function when imaging is performed with a commercially available ultrasound canner.

Title: Contrast Echocardiography in Heart Failure: Update 2023
Authors: Harald Becher
Waleed Alhumaid
Jonathan Windram
Jonathan Choy
Publication date: 02-02-2024
Publisher: Springer US
Keywords: Echocardiography
Echocardiography
Heart Failure
Cardiac MRI
Transthoracic Echocardiography
Published in: Current Heart Failure Reports / Issue 2/2024
Print ISSN: 1546-9530
Electronic ISSN: 1546-9549
DOI: https://doi.org/10.1007/s11897-024-00647-z

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 2/2024

Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions—Part II: Combination Therapy

Impact of Frailty on Heart Failure Prognosis: Is Sex Relevant?

Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions – Part I: Loop Diuretics

Heart Failure: a Punch from the Gut

Evolutions in Combined Heart-Kidney Transplant

Fabry Disease: Cardiac Implications and Molecular Mechanisms

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials