Top 10 Facts in Contrast Echocardiography. Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE

Transcription

1 Top 10 Facts in Contrast Echocardiography Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE

2 Presenter Disclosure The following relationship exist related to this presentation: Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE None

3 10 ASE Consensus 9 Key Points 1. Assessment of LV function 2. Improves cardiac structure definition 3. Contrast stress echo 4. Contrast and the ED echo 5. Contrast use in the ICU 6. Contrast use in cardiac interventions 7. Contrast use in complex congenital lesions 8. Team approach 9. Cost effectiveness of contrast 10. ICAEL standards with contrast

4 1. Assessment of LV Function Ejection fraction & Volumes Variability& Reliability Chemo patients Heart Failure Post transplant LV remodeling

5 Chemo Patient

6 Chemo Patient

7 Chemo Patient

8 Chemo Patient

9 Chemo Patient

10 2. Cardiac Structure Definition LV Apical hypertrophy LV Non compaction Apical Thrombus Apical Aneurysm Pseudoaneurysm Extra cardiac structures Doppler enhancement

11 LV Noncompaction

12 LV Noncompaction

13 Apical Thrombus

14 Next Case Importance of Off Axis Views Elderly female sent to the echo lab for a transthoracic echo Pre-Op echo for bladder surgery No previous cardiac history

15 Apical 4 Chamber View

16 Off Axis Apical

17 Apical 4 with Contrast

18 Apical Area with Contrast

19 Off Axis Apical with Contrast

20 Apical Zoom with Contrast

21 Next Case 54 year old female Presented with chest pain and shortness of breath to the ED Admitted and transthoracic echo ordered

22 Parasternals

23 Apicals

24 5 Months Later.. Patient returns to Cardiology Clinic No complaints Feeling much better Walks 1 mile per day Echo ordered for follow-up on WMA

25 Apical 2

26 Apical 4

27

28 Aortic Dissection & Contrast TTE & TEE Linear artifacts True lumen

29 R/O Dissection Case Patient History 72 y/o female with history of chest and back pain Hypertensive Indication for TEE R/O aortic dissection

30 Parasternal Long Axis

31 TEE Ascending Aorta

32 TEE Ascending Aorta

33 Doppler Enhancement

34 3. Stress Echo High heart rates Lung interference Impost images in 1 minute Different position

35 Stress Echo

36 4 & 5. Contrast in the ED & ICU

37 Contrast in the ED & ICU Portable Cost effective Better diagnostic accuracy Technically difficult patients Supine Ventilated Surgical incisions/bandages Chest tubes

38 Echo in the ED & ICU Suboptimal endocardial definition Accurate assessment of global and regional ventricular function Define pathology Rupture Thrombus Dissection

39 Echo done in the ICU Elderly female Patient was ventilated and unable to roll onto left side Echo ordered portable in the ICU to evaluate left ventricular function

40 Apical 4 Chamber View

41 Apical Thrombus

42 6. Contrast Use with Cardiac Interventions Alcohol Septal Ablations Decreases gradient in LVOT by direct injection of alcohol into coronary artery that feeds proximal septum Image contrast in septum to evaluate area fed by septal perforator prior to alcohol injection Monitor LVOT gradient

43 Pre Alcohol Septal Ablation

44 Pre Alcohol Septal Ablation Gradient

45 Contrast Alcohol Septal Ablation

46 Post Alcohol Septal Ablation

47 Team Approach

48 7. Complex Congenital Lesions Single ventricle Difficult to see endocardial definition Help with evaluating left ventricular function

49 8. Team Approach to Contrast Do what s right for the patient Policies in place Standing orders Train sonographers to administer IVS & contrast Train nurses on the floors Communicate with contrast administrator Train staff to monitor

50 9. Cost Effectiveness of Contrast Echo w/contrast is still portable Reduces the need for additional testing Echo with contrast still cost less than other cardiac procedures Nuclear may require 2 day testing Increases length of stay

51 Contrast Reimbursement Hospital Outpatient Medicare Payments Stress Echo - C payment $650; $499. of $151 Transthoracic Echo C payment $650; $499. of $151

52 Cost Efficiency of Contrast Downstream Testing Reduced ~33%, with an avg. savings of $122 per patient Enhanced Diagnostic Accuracy Reducing false - & + rate Stress Echo Downstream Testing 12% with contrast; 42% with no contrast $238 savings if contrast was used and avoided a stress nuclear study

53 10. Do read the latest ICAEL Standards Contrast verbage included! In effect December, 2010

54 ICAEL Contrast Standards If contrast is used, there must be a written policy for the use of contrast agents. If contrast is not able to be used there must be a policy for alternative imaging. Contrast should be used in the presence of poor endocardial border definition for quantification of chamber dimensions, volumes, ejection fraction and assessment of regional wall motion.

55 ICAEL Contrast Standards Poor endocardial border definition is defined as the inability to detect two or more contiguous segments in any three of the apical views. Contrast should also be used to assess conditions such as hypertrophic cardiomyopathy or when left ventricular thrombus is suspected.

56 ICAEL: Stress Echo & Contrast "Contrast agents may be used in conjunction with treadmill, bicycle, pacing or pharmacologic stress to optimize endocardial border definition or enhance Doppler signals." Contrast is indicated for use when two contiguous segments are not visualized as it provides greater accuracy in determining left ventricular function.

57 ICAEL: Equipment Standards The system should include harmonic capabilities and instrument settings to enable optimization of ultrasound contrast agents.

58 *What happens if we don t use contrast? Decrease in the quality of our echocardiograms Inaccurate interpretation of echocardiograms Misdiagnosis of echocardiograms Loss of progression of contrast agents Increase in costs and length of stay due to additional need for cardiac procedures

59 Thanks for your attention!