Lester - Pitfalls In Contrast Imaging -...
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Transcript of Lester - Pitfalls In Contrast Imaging -...
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Pitfalls in Contrast ImagingPitfalls in Contrast Imaging
Steven J. Lester, MD, FACC, FRCP(C), FASEMayo Clinic
Relevant Financial Relationship(s)None
Off Label UsageNone
Relevant Financial Relationship(s)None
Off Label UsageNone
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Stabilized gas microbubbles sized to pass through the smallest capillaries
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Agent Size (μm) Gas Shell Indication
Optison 3.0-4.5 Perflutren Albumin LVO/EBD
Definity 1.3-3.3 Perflutren Phospholipid LVO/EBD
Lumason1.5-2.5
Sulfur hexafloride
Phospholipid• LVO/EBD• Abdominal/Liver US• Urinary Tract (peds)
Avoid the PitfallsPositive Impact : Makes a Difference
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Safety : ContraindicationsSafety : Contraindications
1. Suspected hypersensitivity to the microsphere components.
1. Suspected hypersensitivity to the microsphere components.
No 30 minute monitoring period!
• Most serious reactions occurwithin 30 minutes of administration
• Most common use of diagnostic echocardiography
• Global ventricular function
• Regional wall motion
RestStress
• Most common use of diagnostic echocardiography
• Global ventricular function
• Regional wall motion
RestStress
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Innovation Workflow
For any innovation in echocardiography to be widely adopted itmust be equaled or paralleled by an innovation in workflow
Imaging Protocol (a) : Workflow EfficiencyImaging Protocol (a) : Workflow Efficiency
The “60 Second Echo”
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Impact of the “60 second Echo”Impact of the “60 second Echo”
25.2
22.5
26.7 26.7
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Total Procedure Time Sonographer Scan Time
Min
ute
s
Routine Discretionary
P = NS P < 0.004
Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23
1= Excellent or adequate full endocardial visualization
2= Incomplete endocardial visualization
3= only epicardium visualized4= segment not visualized
1= Excellent or adequate full endocardial visualization
2= Incomplete endocardial visualization
3= only epicardium visualized4= segment not visualized
Visualization
0
20
40
60
80
100
Per
cen
t Routine 88%
Discretionary50%
DiscretionaryNo Contrast
33%
Visualization Score < 1.1
Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23
We Don’t Use Enough Contrast
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Imaging Protocol (b) : Spectral DopplerImaging Protocol (b) : Spectral Doppler
1= Excellent2= Fair3= Poor
1= Excellent2= Fair3= Poor
Spectral Doppler
0
20
40
60
80
100
PulmonaryVein
Mitral Inflow TricuspidRegurgitation
Routine Discretionary
Spectral Doppler Score = 1
Lester SJ et al. J Am Soc Echocardiogr 2006 Jul; 19(7):919-23
Per
cen
t (%
)
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Without Contrast With Contrast
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AORTIC STENOSISAORTIC STENOSISWithout Contrast With Contrast
Structural DefinitionStructural Definition
1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
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LV AneurysmLV Aneurysm
LV Aneurysm & More
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LV Aneurysm
LV Aneurysm & More
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Structural DefinitionStructural Definition1. LV Structural Abnormalities
- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
2. Characterize intracardiac masses (tissue characterization)
1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
2. Characterize intracardiac masses (tissue characterization)
LV apical thrombus in patient post MI, no enhancement
Secondary cardiac tumor(renal sarcoma) located in RA, complete enhancement
LA myxoma, partial enhancement
Mansencal et al. Archives of Cardiovascular Disease (2009) 102, 177—183
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Structural DefinitionStructural Definition
1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
2. Characterize intracardiac masses (tissue characterization)
3. Differentiate artifacts
1. LV Structural Abnormalities- Apical hypertrophy- Aneurysm / pseudoaneurysm- Thrombus- Noncompaction- Myocardial rupture
2. Characterize intracardiac masses (tissue characterization)
3. Differentiate artifacts
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Machine and administration frequency adjusted to provide best image
Machine and administration frequency adjusted to provide best image
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Foc
al
Are
a
Foc
al
Are
a
Single Focus Single Focus Dual Focus
Mechanical Index• Measure of output
acoustic power• High MI increases
bubble destruction
Mechanical Index• Measure of output
acoustic power• High MI increases
bubble destruction
MI 0.24 increased to 0.6
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CP1227021-1
MI = 1.4
MI = 0.2
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• System settings (focal zone misplacement)
• Dosing and administration(low concentration)
• System settings (focal zone misplacement)
• Dosing and administration(low concentration)
POTENTIAL CAUSES
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• Dosing (high concentration)
• Administration (infusion rate too fast)
• Clinician (obtain off-axis windows)
• Dosing (high concentration)
• Administration (infusion rate too fast)
• Clinician (obtain off-axis windows)
POTENTIAL CAUSES
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• System settings (high MI)
• Dosing(low concentration)
• Administration (low infusion rate)
• Poor LV function
• System settings (high MI)
• Dosing(low concentration)
• Administration (low infusion rate)
• Poor LV function
POTENTIAL CAUSES
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Avoid The PitfallsAvoid The Pitfalls
1. Contraindications (safety)2. Protocol Development
(The 60 second Echo)3. Use It4. Spectral Doppler5. Instrument Settings
1. Contraindications (safety)2. Protocol Development
(The 60 second Echo)3. Use It4. Spectral Doppler5. Instrument Settings
Tool Used to Build Excellence in ECHO
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