Kontrastekokardiografi

Kontrastekokardiografi Reidar Winter Överläkare Hjärtkliniken Karolinska Universitetssjukhuset Professor i Medicinsk Teknik, KTH - Kungliga Tekniska Högskolan, STH Stockholm

Är det farligt att ge ultraljudskontrast?

Contra indications: 1. Significant intracardiac shunt 2. Known hypersensibilty to the agent In acute conditions: Monitoring of vital signs for 30 minutes

Slutsatser avseende säkerhet: Samtliga tillgängliga ekokontrastmedel har extremt god säkerhetsprofil Kontraindikationer: Överkänslighet mot den aktiva substansen eller mot något hjälpämne. Pulmonell hypertension med ett systoliskt lungartärtryck på > 90 mm Hg. Betydande intrakardiell shunt

Är det farligt att ge ultraljudskontrast? NEJ!

När och varför skall vi använda kontrast? Evidence-based recommendations by European Association of Echocardiography EJE 2009;10:194-212 www.escardio.org/communities/eae/publications/pages/papers-interest.aspx

ASE SYNOPSIS OF SUGGESTED APPLICATIONS FOR ULTRASOUND CONTRAST AGENT USE: To enable improved endocardial visualization and assessment of left ventricular (LV) structure and function when 2 contiguous segments are not seen on noncontrast images To reduce variability and increase accuracy in LV volume and LV ejection fraction (LVEF) measurements by 2-dimensional (2D) echocardiography To increase the confidence of the interpreting physician in LV functional, structure, and volume assessments To confirm or exclude the echocardiographic diagnosis of the following LV structural abnormalities, when nonenhanced images are suboptimal for definitive diagnosis Apical variant of hypertrophic cardiomyopathy Ventricular noncompaction Apical thrombus Complications of myocardial infarction, such as LV aneurysm, pseudoaneurysm, and myocardial rupture To assist in the detection and correct classification of intracardiac masses, including tumors and thrombi For echocardiographic imaging in the ICU when standard tissue harmonic imaging does not provide adequate cardiac structural definition To enhance Doppler signals when a clearly defined spectral profile is not visible and is necessary to the evaluation of diastolic and/or valvular function ASE consensus statement JASE 2008;21:1179 1201

(When two or more contiguous segments are not seen ) En vanlig dag på jobbet: En lite svårvisualiserad patient på ekolabbet Utan kontrast: Svårt att mäta EF Visuellt bedömdes EF vara lättmåttligt nedsatt

1. When two or more contiguous segments are not seen En vanlig dag på jobbet En lite svårvisualsierad patient på ekolabbet Utan kontrast: Svårt att mäta EF Visuellt bedömdes EF vara lättmåttligt nedsatt Kontasteko: 1 ml Sonovue bolus iv, EF kan nu mätas

Mätning av EF m.h.a. Kontrast:

1. When two or more contiguous segments are not seen En vanlig dag på jobbet I detta specifika fall ändrade kontrast bed av VK funktion!

Kontrast förbättrar EF och volymsmätning: (Yu et al JASE 2000;13:216-24) EF EDV ESV Kontrast THI FI

Improved accuracy of LV function assessment: EAE recommendations; EJE 2009;10:194-212

f -44, Bröstsmärtor och ST-lyft Tako-Tsubo Kardiomyopati

f -44, Bröstsmärtor och ST-lyft

Multicenterstudie; Regional hypokinesi Hoffmann JACC 2006;47:121-8 Kontrasteko gold standard för analys av regional väggrörlighet?

Patientfall Man f 1964 Kraftigt överviktig 164 cm/155 kg Tid AMI o hjärtsvikt, EF 40 % -00 Tid missbrukare Nu inlagd m tilltagande svikt, slarvat m med EKO inneliggande

2D eko Pga. suboptimal bildkvalitet ges 1 ml Sonovue som iv. bolus

Kontrasteko Sonovue gavs pga dålig bildkvalitet, INTE pga trombmisstanke

Patientfall: 80 årig man Rökare Inlagd pga. suspekt hjärtsvikt 22:a Nov 2007 Eko Uttalat nedsatt systolisk VK funktion; EF 15% Normal angio ( Icke-ischemisk dilaterad CMP) Frekventa Non-sustained VT Plan ICD Påtaglig klinisk förbättring med medicinering; NYHA IIIb II, Inga kvavarande VT episoder vid mobilisering på avdelningen Eko 4:e Dec för att se om EF hade förbättrats > 35 %

Eko 23 Nov 4 Dec Viss förbättring av EF, fortsatt ICD indication MEN

Eko 4 Dec Förtjockning av myokardiet apikalt 1 ml Sonovue bolus ges

Insköljningssekvens, 1 ml Sonovue iv bolus visar apikal mural tromb som inte laddar kontrast

Inneliggande STEMI:

Inneliggande STEMI, kontrast:

Inneliggande STEMI:

991 post MI pts 156 ges kontrast pga susp VK tromb Apical tromb kan inte diagnosticeras utan kontrast Siebilink et al. Coron Artery Dis 2009;20:462 466

The clinical usefulness of a sonographer driven contrast echocardiography routine A single center experience Shahgaldi K 1,2, Lopez A 1, Fernström B 1, Sahlén A 1, Reidar Winter 1,2 1 Department of Cardiology, Karolinska University Hospital, Huddinge, Stockholm, 2 School of Technology and Health, Royal Institute of Technology, Stockholm The aim of this observational study was to explore the use and cost effectiveness of contrast echocardiography in the clinical context when implemented in a sonographer driven routine at our department. Contrast echocardiography (CE) has been proven to be cost effective in selected clinical cases and is currently recommended for use in cases with suboptimal image quality and/or in cases where there are specific morphological questions, i.e. suspicion of apical thrombus, apical hypertrophy and non-compaction cardiomyopathy (fig. 1). Despite the proven clinical usefulness, the implementation of CE in everyday clinical routine has been somewhat cumbersome. Over a period of one year, 5657 digitally stored transthoracic echocardiographic examinations (TTE) were screened for the use of CE. Of these 4232 could be analyzed using a digital work station. A total of 466 TTE (11%) were found to be CE exams. Indications for CE were stress echocardiography (49%), suboptimal image quality (28%) and suspected thrombus (18%). In the remaining 5% there the indication could not be established. Interestingly, 10 patients (2%, fig. 1a) were contrast was administered due to suboptimal image quality were revealed to have a left ventricular thrombus. In 91 % of the TTE there was an improvement of the number of visualized segments using CE. 20 % of the TTE showed an improvement of 1-3 segments, 38% had an improvement of 4-6 segments, 22% 7-9 segments, and 11 % 10-12 segments improvement. No adverse events were observed in the 466 patients that received contrast agent A (SonoVue ). B C Figure 1. A patient where contrast was given due to suboptimal image quality. An unexpected apical thrombus was revealed using bolus injection of SonoVue (A). A patient with good image quality where contrast was given due to suspected apical thrombus. Contrast image exposed a non-compaction cardiomyopathy (B). Contrast echocardiography study due to reduced image quality in the apical segments. Astonishingly the examination revealed an apical hypertrophy (C). Contrast echocardiography is safe and clinically useful when implemented in a sonographer driven routine. There is a consistent improvement of image quality when contrast is given due to suboptimal image quality. In this study there were a significant number of LV thrombus findings in patients even when this was not suspected.

Huddinge erfarenhet av Sonographer driven contrast admin : 466/4232 (11%) kontrastus 10 VK tromber! Även EAE rec innebär för konservativa indikationer?

Pat 54 årig man Lärare Remitterad till hjärtmott pga tilltagande trötthet och dyspné Initialt eko visade lätt VK hypertrofi med normal EF och hållpunkter för diastolisk dyfunktion. Remitteras till stresseko

Initialt Eko

Stresseko utan ischemitecken, men: Hypertrabekulering, uppfyller kriterier* for Non-Compaction Cardiomyopathi (NCCMP) *Jenni et al. Heart 2001;86:666 671.

70 årig kvinna Patientfall: Remitterad till pga trötthet och andfåddhet Avvikande apikal kontraktion Kontrast

Case 5: Apikal Hypertrof kardiomyopati

Aortastenos

Lite praktikaliteter, fallgropar och artefakter

Administration; infusion eller bolus? Intravenöst INFUSION BOLUS

KONTRASTMEDEL INFUSION BOLUS INJEKTION

Intravenös inj/inf INFUSION BOLUS Sonovue/NaCl 5/5 ml, 0.8-1.2ml/min Optison/NaCl 3/10 ml, 1-1.5 ml/min Sonovue 1-1.5 ml + 0.5 rep Optison 0.5-1 ml + 0.3 rep +/- +/- Steady state intensitet Up and down Kräver specialpump Kort duration Mer krävande administration Enklare att administrera

The impact of Mechanical Index (MI) MI + 1,2 Destruktion av bubblor MI - 0,3 Bra kantdetektion, men destruktion i myokardiet 0.1 Synlig perfusion men nedsatt penetration och kantdetektion

Sonovue Bolus: The impact of contrast dose (MI 0.15) 0,25 ml Ingen attenuering men apikal swirling och dålig kantdetektion Relativt god kantdetektion, Ingen attenuering 0,5 ml 1 ml Mycket skarp kantdetektion apikalt och midventrikulärt, men lite attenuation i basala VK

Impact of presets Adult echo preset, Tissue Harmonics, MI 1.2 Adult echo preset, Tissue Harmonics, MI 0.3 LVO preset, issue Harmonics, MI 0.2 Low MI preset (power modulation), MI 0.1

Nyttan av dedicerade kontrast inställningar: Patient med apikal hypertrofi: THI med MI 1,2 THI med MI 0.3 THI med MI 1,2 Power modulation med MI 0.3

Revbensskugga:

Patientexempel Pat med utbredd apikal akinesi

Viktigt att scanna genom hela caviteten för att utesluta apikal tromb:

Stresseko Kontrast Förbättrad kantdetektion Icke-diagnostiska undersökningar 20% 1%!!

EAE rec: EAE recommendations; EJE 2009;10:194-212

Contrast Intensity FLASH Kontrasteko för Myokardperfusion Flash Contrast Imaging Quantification:... Partially reperfused Fully Reperfused Fully Perfused Contrast Destroyed (1 - exponential) curve fit Low Power Real-time MI < 0.2 High Power Real-time MI > 0.7 Low Power Real-time MI < 0.2 Time

SPECT MCE Traditional Stress echo

Real Time Perfusion - RTP LAD Occlusion: Adapting a parametric standard curve, perfusion parameters can be estimated: y = A ( 1-e -ßt ) A = perfusion level = blood volume ß =1/T = refilling rapidity= blood velocity S = A ß = refilling rate= blood flow Refilling Time T, 1/b Plateau level: A Slope = Ab A

MCE for RTP, välvaliderat sedan länge... EAE recommendations, EJE 2009;10:194-212

3D kontrast och 3D perfusion

3D eko med och utan kontrast:

Ex Post AMI pat med apikal tromb

DASE 3D Kontrasteko; Triplane + FV 9 slice view Rest: Stress: Inferior + Apikal Ischemi

Perhaps gaining acquisition time but Pratali et al. Cardiovasc Ultrasound 2010;8:10 Varnero et al. Cardiovasc Ultrasound 2008;6:31 Analysis time Feasibility

3D Perfusion The new kid on the block

MCE vs MRI prediction of recovery: Biagini et al. Am J Cardiol 2006;97:361-66

77 årig man med brsm, tidigare infarkt Apikal anteroseptal akinesi

RTP Kapillär integritet Viabelt myokard!

2004 2007

Ex 29 årig man, andningskorr brsm Man 29 år 65 kilo, 180 cm Rökare Andningskorrelerade brsm AmbulansEKG: HIA för evaluering

2D eko

Kontrast Eko Inferolateral transmural perfusionsdefekt Angio/PCI ( Therapy guidance by Bedside Echo )

Kranskärlsröntgen

Suspected ACS Contrast ECHO TIMI scoring: CE mtimi TIMI CE mtimi TIMI CE mtimi TIMI Tong et al, JACC 2005;46:920-7 Early events (< 24 h) Intermediate (30 d) Late (24 months) CE potentially useful for upstream risk stratification?

MPE for risk scoring Prospektiv studie 1886 pt Wei et al, JASE 2010;23:636-42 CE potentially useful for upstream risk stratification?

Sammanfattning Kontrast kan (och bör!) användas mer Morfologiska oklarheter Nedsatt bildkvalitet Säkrare mätningar, ( EF, Volymer ) Bedside eko ( även perfusion) Stresseko, ( framförallt WM, men även perfusion ) EAE rek indikationer: Nedsatt bildkvalitet ( > 2 segment ) Morfologiska oklarheter, behov av säkrare mätning EF, vol, etc Spec susp Tromb AHT Non-compaction CMP Pseudoaneurysm

Bubbles to the people