Where Contrast Administration Makes a Difference Contrast 2017 State of the Art

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Eileen Chambers
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Gillam, MD, MPH, FASE Chair, Cardiovascular Medicine Medical Director, CV

1 Where Contrast Administration Makes a Difference Contrast 2017 State of the Art Linda D. Gillam, MD, MPH, FASE Chair, Cardiovascular Medicine Medical Director, CV Service Line Morristown Medical Center/Atlantic Health System Morristown, NJ Professor of Medicine Thomas Jefferson University No disclosures 1

2 Contemporary Ultrasound Contrast Agents Stabilized gas microspheres sized to pass through the smallest capillaries Microsphere: 2-5 m RBC: 6-8 m Burns. In: Rumack et al, eds. Diagnostic Ultrasound. Vol 1. 2nd ed. St. Louis: Mosby; 1998:57. Currently available agents 2

Interaction of Ultrasound and Microbubbles Linear

POWER Fundamental enhancement POWER Harmonic enhancement

Diagnostic Ultrasound. Vol. 1. 2nd ed. St.

Principles of Harmonic Imaging Tissue and blood reflect

5 MHz Microbubbles reflect at both the fundamental and

3 Interaction of Ultrasound and Microbubbles Linear resonance Nonlinear resonance Transient scattering POWER POWER Fundamental enhancement POWER Harmonic enhancement Bubble disruption Burns. In Rumack et al, eds. Diagnostic Ultrasound. Vol. 1. 2nd ed. St. Louis: Mosby; 1998:57. Principles of Harmonic Imaging Tissue and blood reflect at the fundamental frequency 2.5 MHz Microbubbles reflect at both the fundamental and the harmonic frequencies 2.5 MHz 2.5 MHz 2.5 MHz + 5 MHz Burns. In Rumack et al, eds. Diagnostic Ultrasound. Vol. 1. 2nd ed. St. Louis: Mosby; 1998:57. 3

4 Fundamental and Harmonic Contrast Imaging Tissue Contrast Schrope and Newhouse. Ultrasound Med Biol. 1993;19:567. Shapiro et al. Am J Roentgenol. 1998; 171: It s all about signal to noise! 4

5 Machine Settings For most applications Aim to maximize non-linear harmonic reflecting responses (MI ) Improves signal to noise vs tissue Equipment Optimized settings (presets) Contrast agent specific Transducer specific For perfusion applications Controlled bubble destruction Works best with equipment specifically equipped to do perfusion imaging Outcomes Cost effectiveness Impact on therapeutic strategy Impact on diagnostic and prognostic thinking Diagnostic capacity Technical capability and Operational excellence Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134: Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:

Outcomes Cost effectiveness Rx: Devices/ intervention for AS Prognosis/dx related to LV function and gradients LVEF, Quantitation of gradients LVO/EBD, Doppler enhancement Guyatt GH, Tugwell PX,

6 Outcomes Cost effectiveness Rx: Devices/ intervention for AS Prognosis/dx related to LV function and gradients LVEF, Quantitation of gradients LVO/EBD, Doppler enhancement Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134: Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:

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9 Case Examples Left Ventricular Opacification 62 yo female with aortic and mitral valve disease Is the EF <60% Accurate LVEF needed for clinical decision making 9

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12 LVEF 64% Stress echo 12

13 With thanks to Sharon Mulvagh 62 yo female with atrial fibrillation (spontaneously converted) and dyspnea 13

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15 Dx: Apical HCM Not CAD Another myopathy 15

16 With thanks to Sharon Mulvagh, MD Mulvagh: J Am Soc Echocardiogr 21:1179, yo male with NYHA Class III Heart Failure 16

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18 76 yo female with syncope 18

19 4.4mps 19

20 32 yo male with atrial fibrillation and family history of SCD 20

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22 Dx: ARVD 22

23 Myocardial Contrast Perfusion Thanks to Tom Porter, MD Post PCI Thanks to Tom Porter 23

24 Safety Concerns 24

25 Class Box Warning Old contraindications 25

26 Current for all agents Lumason and pediatric 26

27 CARPA Complement Activation Related Pseudo-Allergy CARPA Signs and Symptoms Angioedema Bronchospasm Cyanosis Hypotension Low back pain Pruritis Urticaria Tingling sensation Hypoxemia Sneezing 27

28 Acute Hypersensitivity Reactions IgE mediated type I Reaction after repeated exposure Reaction is stronger upon repeated exposure Reaction does not cease without treatment CARPA No prior exposure necessary Reaction is milder or absent upon repeated exposures Spontaneous resolution Szebeni J. Toxicology 2005:216: Note that prior allergic reaction is contra-indication to use of same/similar agent 28

29 Event Rates for Commonly Performed Cardiovascular Procedures Procedure Event Rate Event Coronary Angiography Exercise Treadmill Testing 1:1000 Death 1:2500 MI or Death SPECT Exam or Radionuclide Ventriculography 1:1000 to 1:10,000 Fatal Malignancy Contrast Echocardiography 1:500,000 Death Pulmonary Hypertension 29

30 Using propensity matching, CE associated with a 28% lower mortality at 48 h in comparison with patients undergoing ntte 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 Cardiovascular imaging 2014;7:

31 Interatrial Shunt Parker JM et al. Am J Cardiol2013;112:

32 Kalra A et al. JACC Cardiovasc Imaging 2014;7: Cost-effectiveness 32

Thx to Michael Main Outcomes Cost effectiveness Impact on therapeutic strategy Impact on diagnostic and prognostic thinking Diagnostic capacity Technical capability and Operational excellence Guyatt

33 Thx to Michael Main Outcomes Cost effectiveness Impact on therapeutic strategy Impact on diagnostic and prognostic thinking Diagnostic capacity Technical capability and Operational excellence Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134: Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:

34 And yet contrast is underutilized Contrast Echocardiography as a Percentage of Total Echocardiography 5.00% 4.50% 4.00% 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% FDA Black Box Warning *through June 2015 Thx to Michael Main Arlington Medical Resources 34

35 Obstacles Internal (Lab operations) Time Orders Consent Personnel with IV skills / Scope of practice Access to agent External Cost considerations Black box warning STREAMLINE Decision Order/ Consent Personnel Agent Machine Optimization / Protocols 35

36 Decision Order/ Consent Personnel Agent Machine Optimization/ Protocols Decision Order/ Consent Personnel Agent Machine Optimization/ Protocols 36

37 Reduce/eliminate time to obtain order Incorporate order for contrast into order for echocardiogram Standing orders a written document containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical situations Develop policy for consent Order/ Decision Consent Personnel Agent Machine Optimization/ Protocols 37

38 Have ready access to personnel trained to insert IV and administer agent Create staffing model that ensures that echo labs have qualified non-sonographer personnel available» RN»?Cardiology fellow Cross-train sonographers ( scope of practice/personal preference) In hospital on floors In-service for nursing staff Decision Order/Conse nt Personnel Agent Machine Optimization / Protocols 38

39 Have ready access to agent/equipment Consider storing in high use sites (ICU s) Decision Order/Cons ent Personnel Agent Machine Optimization/ Protocols 39

40 Optimize machine settings Presets Agent specific Transducer specific Frequency specific Focal zone Protocols Infusion rate Look at more than the LV blood pool RV Great vessels Doppler Resource person 40

41 Cost Considerations There is inadequate reimbursement to cover the cost of contrast Solutions: For outpatient studies, there is reimbursement Document guideline driven indication For inpatient studies, cost of agent can be recaptured by reduction in other costs Create/defend contrast budget Indication for Study With thanks to Jonathan Lindner Chest pain - angina? LV Thrombus Stress echo DLVEF (chemo) Quality of Images poor fair good LVEF for ICD or BiV Dyspnea Hypotension Aortic dissection Atrial fibrillation Valve disease Pericardial disease 41

42 Summary Contrast has been repeatedly shown to improve the accuracy and reproducibility of LV volume /EF assessment Multiple off label uses Safety profile is excellent After hit triggered by black box warning utilization is increasing Summary Thoughtful approach to streamlining all steps in utilization chain is essential to optimal utilization and appropriate use of health care resources 42

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Steven J. Lester, MD, FACC, FRCP(C), FASE Mayo Clinic. Relevant Financial Relationship(s) None. Off Label Usage

Steven J. Lester, MD, FACC, FRCP(C), FASE Mayo Clinic Relevant Financial Relationship(s) None Off Label Usage 1 2 1. Define ultrasound contrast? 2. Recognize the interaction of the bubbles with ultrasound