Top 10 Facts in Contrast Echocardiography Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE
Presenter Disclosure The following relationship exist related to this presentation: Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE None
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
1. Assessment of LV Function Ejection fraction & Volumes Variability& Reliability Chemo patients Heart Failure Post transplant LV remodeling
Chemo Patient
Chemo Patient
Chemo Patient
Chemo Patient
Chemo Patient
2. Cardiac Structure Definition LV Apical hypertrophy LV Non compaction Apical Thrombus Apical Aneurysm Pseudoaneurysm Extra cardiac structures Doppler enhancement
LV Noncompaction
LV Noncompaction
Apical Thrombus
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
Apical 4 Chamber View
Off Axis Apical
Apical 4 with Contrast
Apical Area with Contrast
Off Axis Apical with Contrast
Apical Zoom with Contrast
Next Case 54 year old female Presented with chest pain and shortness of breath to the ED Admitted and transthoracic echo ordered
Parasternals
Apicals
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
Apical 2
Apical 4
Aortic Dissection & Contrast TTE & TEE Linear artifacts True lumen
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
Parasternal Long Axis
TEE Ascending Aorta
TEE Ascending Aorta
Doppler Enhancement
3. Stress Echo High heart rates Lung interference Impost images in 1 minute Different position
Stress Echo
4 & 5. Contrast in the ED & ICU
Contrast in the ED & ICU Portable Cost effective Better diagnostic accuracy Technically difficult patients Supine Ventilated Surgical incisions/bandages Chest tubes
Echo in the ED & ICU Suboptimal endocardial definition Accurate assessment of global and regional ventricular function Define pathology Rupture Thrombus Dissection
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
Apical 4 Chamber View
Apical Thrombus
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
Pre Alcohol Septal Ablation
Pre Alcohol Septal Ablation Gradient
Contrast Alcohol Septal Ablation
Post Alcohol Septal Ablation
Team Approach
7. Complex Congenital Lesions Single ventricle Difficult to see endocardial definition Help with evaluating left ventricular function
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
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
Contrast Reimbursement Hospital Outpatient Medicare Payments Stress Echo - C8928 2010 payment $650; 2011 - $499. of $151 Transthoracic Echo C8923 2010 payment $650; 2011 - $499. of $151
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
10. Do read the latest ICAEL Standards Contrast verbage included! In effect December, 2010
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.
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.
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.
ICAEL: Equipment Standards The system should include harmonic capabilities and instrument settings to enable optimization of ultrasound contrast agents.
*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
Thanks for your attention!