SLIDE 1 Jean Jean-
Louis J. Vanoverschelde Vanoverschelde, MD, PhD , MD, PhD
Contrast Echocardiography Contrast Contrast Echocardiography Echocardiography
Universit Université é catholique de catholique de Louvain Louvain Brussels, Belgium Brussels, Belgium
SLIDE 2 Contrast Contrast Echocardiography Echocardiography
Transit time of red blood cells Transit time of red blood cells
0.0 0.0 0.1 0.1 0.2 0.2 0.3 0.3 0.4 0.4 0.5 0.5 0.6 0.6 0.7 0.7
Transit time of Transit time of µ µbubbles bubbles
0.00 0.00 0.25 0.25 0.50 0.50 0.75 0.75 1.00 1.00
Jayaweera Jayaweera et al. et al. Circ. Res.
1994
2 2 4 4 6 6 8 8 10 10
Diameter Diameter
( (µ µm) m) 20 20 40 40 60 60 80 80 100 100 10 102
2 x 120
x 120
8.10 8.108
8
ml ml-
1
4.3 4.3 µ µm m
Relation of Relation of µ µbubbles to red blood cells bubbles to red blood cells
SLIDE 3
Contrast Contrast Echocardiography Echocardiography
ultrasound ultrasound pressure pressure µ µbubble bubble radius radius
compression compression rarefaction rarefaction Effect of low acoustic energy on Effect of low acoustic energy on µ µbubbles size bubbles size
SLIDE 4
Contrast Contrast Echocardiography Echocardiography
ultrasound ultrasound pressure pressure µ µbubble bubble radius radius
compression compression rarefaction rarefaction Effect of high acoustic energy on Effect of high acoustic energy on µ µbubbles bubbles
SLIDE 5 Contrast Contrast Echocardiography Echocardiography
0 kPa 0 kPa 100 kPa 100 kPa 1MPa 1MPa
Non Non-
- linear scattering properties
linear scattering properties Fundamental and harmonic Fundamental and harmonic frequencies frequencies Non Non-
- linear scattering properties
linear scattering properties Harmonic frequency Harmonic frequency µ µbubble destruction bubble destruction Stimulated acoustic emission Stimulated acoustic emission
MI < 0.3 MI < 0.3 MI > 1.0 MI > 1.0
Effect of acoustic energy on Effect of acoustic energy on µ µbubbles scattering properties bubbles scattering properties
SLIDE 6
Contrast Contrast Echocardiography Echocardiography
Time (ms) Time (ms)
80 80 160 160 240 240 320 320
Intensity (dB) Intensity (dB)
8 8 16 16 24 24
Destruction of contrast by ultrasound Destruction of contrast by ultrasound
SLIDE 7
SLIDE 8
SLIDE 9
SLIDE 10
SLIDE 11
SLIDE 12 Contrast Contrast Echocardiography Echocardiography
- Left ventricular opacification
Left ventricular opacification
Myocardial perfusion
- Assessment of reperfusion and
Assessment of reperfusion and myocardial viability myocardial viability
SLIDE 13 Contrast Contrast Echocardiography Echocardiography
Improved Improved endocardial border endocardial border delineation delineation
reduced inter inter-
and intra intra-
variability variability
improved detection of
regional wall motion motion abnormalities abnormalities
improved calculation of LV volumes
and ejection and ejection fraction fraction Left ventricular opacification Left ventricular opacification
SLIDE 14 Contrast Contrast Echocardiography Echocardiography
Inter Inter-
- institutional agreement according to image quality
institutional agreement according to image quality Agreement in % Agreement in %
Hoffmann et al. Hoffmann et al. J Am Coll Cardiol J Am Coll Cardiol 1996;27:330 1996;27:330
20 20 40 40 60 60 80 80 100 100 120 120
A A B B C C D D E E
SLIDE 15
Contrast Contrast Echocardiography Echocardiography
SLIDE 16
Contrast Contrast Echocardiography Echocardiography
SLIDE 17
Contrast Contrast Echocardiography Echocardiography
NA NA, , 6 67 7 y.o. male y.o. male
SLIDE 18
Contrast Contrast Echocardiography Echocardiography
NA NA, , 6 67 7 y.o. male y.o. male
SLIDE 19 Contrast Contrast Echocardiography Echocardiography
Effect of left ventricular opacification on accuracy of DbE Effect of left ventricular opacification on accuracy of DbE
Dolan et al. Dolan et al. Am Heart J Am Heart J 2001;142:908 2001;142:908
% WTh % WTh Sensitivity Sensitivity Specificity Specificity Accuracy Accuracy
(%) (%)
20 20 40 40 60 60 80 80 100 100
* *
LVO LVO no LVO no LVO
SLIDE 20 Contrast Contrast Echocardiography Echocardiography
- Left ventricular opacification
Left ventricular opacification
Myocardial perfusion
- Assessment of reperfusion and
Assessment of reperfusion and myocardial viability myocardial viability
SLIDE 21 Contrast Contrast Echocardiography Echocardiography
Real Real-
- time perfusion imaging using power modulation
time perfusion imaging using power modulation
SLIDE 22 Contrast Contrast Echocardiography Echocardiography
Wei Wei et al. et al. Am J Am J Physiol Physiol 2001,280:H1896. 2001,280:H1896.
1 1 2 2 4 4 5 5
LAD / Cx ratio LAD / Cx ratio
3 3
LAD LAD Ado Ado LAD stenosis LAD stenosis + Ado + Ado
MCE MBV MCE MBV µ µspheres spheres
99m 99mTc
Tc-
MIBI
LAD adenosine LAD adenosine LAD stenosis + LAD stenosis + adenosine adenosine LAD occlusion LAD occlusion
MCE versus MIBI for assessment of myocardial blood volume MCE versus MIBI for assessment of myocardial blood volume
SLIDE 23
Contrast Contrast Echocardiography Echocardiography How do we get from myocardial blood volume How do we get from myocardial blood volume to myocardial blood flow ? to myocardial blood flow ?
DYNAMIC IMAGING DYNAMIC IMAGING
SLIDE 24 Contrast Contrast Echocardiography Echocardiography
time time Quantification of myocardial blood flow Quantification of myocardial blood flow Flash Flash
1 1st
st cardiac
cardiac cycle cycle 2 2nd
nd cardiac
cardiac cycle cycle 3 3rd
rd cardiac
cardiac cycle cycle 4 4th
th cardiac
cardiac cycle cycle 5 5th
th cardiac
cardiac cycle cycle
SLIDE 25 Contrast Contrast Echocardiography Echocardiography
Real Real-
- time perfusion imaging using power modulation
time perfusion imaging using power modulation
Van Camp et al., Van Camp et al., JASE JASE 2003;16:263 2003;16:263
SLIDE 26 Contrast Contrast Echocardiography Echocardiography
Real Real-
- time perfusion imaging using power modulation
time perfusion imaging using power modulation
Van Camp et al., Van Camp et al., JASE JASE 2003;16:263 2003;16:263
SLIDE 27 Contrast Contrast Echocardiography Echocardiography
Time (s) Time (s)
2 2 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18
Video intensity Video intensity
2 2 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18
Stenosis + Adenosine Stenosis + Adenosine Real Real-
- time perfusion imaging using power modulation
time perfusion imaging using power modulation
Van Camp et al., Van Camp et al., JASE JASE 2003;16:263 2003;16:263
SLIDE 28 Contrast Contrast Echocardiography Echocardiography
Microsphere blood flow Microsphere blood flow
(ml.min (ml.min-
1.g
.g-
1)
)
β β slope (s slope (s-
1)
) Microsphere blood flow Microsphere blood flow
(ml.min (ml.min-
1.g
.g-
1)
)
Real Real-
- time perfusion imaging using power modulation
time perfusion imaging using power modulation
1 1 2 2 3 3 4 4 0.00 0.00 0.25 0.25 0.50 0.50 0.75 0.75 1.00 1.00 1.25 1.25 1.50 1.50 1.75 1.75
y = 0.45x y = 0.45x -
6.26 r = 0.93 r = 0.93
1 1 2 2 3 3 4 4 5 5 10 10 15 15 20 20 25 25
y = 5.91x y = 5.91x -
0.69 r = 0.91 r = 0.91
A x A x β β (dB (dB· ·s s-
1)
)
Van Camp et al., Van Camp et al., JASE JASE 2003;16:263 2003;16:263
SLIDE 29 Contrast Contrast Echocardiography Echocardiography
MN MN, , 50 y.o. male 50 y.o. male
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
SLIDE 30 Contrast Contrast Echocardiography Echocardiography
DIPYRIDAMOLE MCE DIPYRIDAMOLE MCE
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
MN MN, , 50 y.o. male 50 y.o. male
SLIDE 31 Contrast Contrast Echocardiography Echocardiography
DIPYRIDAMOLE MCE DIPYRIDAMOLE MCE DIPYRIDAMOLE SPECT DIPYRIDAMOLE SPECT
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
MN MN, , 50 y.o. male 50 y.o. male
SLIDE 32 Contrast Contrast Echocardiography Echocardiography
DIPYRIDAMOLE MCE DIPYRIDAMOLE MCE DIPYRIDAMOLE SPECT DIPYRIDAMOLE SPECT
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
MN MN, , 50 y.o. male 50 y.o. male
SLIDE 33 Contrast Contrast Echocardiography Echocardiography
Dipyridamole real Dipyridamole real-
time Power Modulation ime Power Modulation Time (s) Time (s)
2 2 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18
Videointensity Videointensity (dB) (dB)
2 2 4 4 6 6 8 8 10 10 12 12
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
SLIDE 34 Contrast Contrast Echocardiography Echocardiography
Dipyridamole real Dipyridamole real-
time Power Modulation ime Power Modulation
Rest Rest Dip Dip Rest Rest Dip Dip Rest Rest Dip Dip Rest Rest Dip Dip
β β slope (s slope (s-
1)
)
0.00 0.00 0.25 0.25 0.50 0.50 0.75 0.75 1.00 1.00 1.25 1.25 < 50% < 50% 70 70-
90% 50 50-
70% > 90% > 90% * * * * * * † † * * † †
n=292 n=292 n=32 n=32 n=92 n=92 n=42 n=42
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
SLIDE 35 Contrast Contrast Echocardiography Echocardiography
Dipyridamole real Dipyridamole real-
time Power Modulation ime Power Modulation % luminal diameter stenosis % luminal diameter stenosis β β reserve reserve
20 20 40 40 60 60 80 80 100 100 1 1 2 2 3 3
y = 2.65 (1 y = 2.65 (1-
e-
0.09(x-
100))
) r = 0.85 r = 0.85
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
SLIDE 36 Contrast Contrast Echocardiography Echocardiography
Peltier Peltier et al. et al. J JACC ACC 2004;43:257 2004;43:257
Dipyridamole real Dipyridamole real-
time Power Modulation ime Power Modulation
100 100 75 75 50 50 25 25
Specificity (%) Specificity (%)
100 100 75 75 50 50 25 25 100 100 75 75 50 50 25 25
Sensitivity (%) Sensitivity (%) Specificity (%) Specificity (%) β β reserve reserve A * A * β β reserve reserve
Area under the curve Area under the curve =0.85 =0.85 Area under the curve Area under the curve =0.86 =0.86
100 100 75 75 50 50 25 25
SLIDE 37 Contrast Contrast Echocardiography Echocardiography
Dipyridamole RTCE: Prognostic implications Dipyridamole RTCE: Prognostic implications Years Years Event fre survival (%) Event fre survival (%)
Tsusui Tsusui et al. et al. J JCirculation Circulation 2005;112:1444 2005;112:1444
Normal MP Normal MP Fixed perfusion defect Fixed perfusion defect Inducible perfusion defect Inducible perfusion defect Fixed + inducible perfusion defect Fixed + inducible perfusion defect
P<0.001 P<0.001
20 20 40 40 80 80 100 100 60 60 1 1 2 2 3 3 4 4 5 5
SLIDE 38 Contrast Contrast Echocardiography Echocardiography
- Left ventricular opacification
Left ventricular opacification
Myocardial perfusion
- Assessment of reperfusion and
Assessment of reperfusion and myocardial viability myocardial viability
SLIDE 39 Contrast Contrast Echocardiography Echocardiography
T.V.H. T.V.H. -
♂ -
46 year old 10.43 am : ECG 10.43 am : ECG 10.43 am : ECG
SLIDE 40 Contrast Contrast Echocardiography Echocardiography
11.43 am Coronary angiography 11.43 am Coronary angiography T.V.H. T.V.H. -
♂ -
46 year old
SLIDE 41
SLIDE 42
SLIDE 43 Contrast Contrast Echocardiography Echocardiography
11.53 am : direct angioplasty and stenting 11.53 am : direct angioplasty and stenting T.V.H. T.V.H. -
♂ -
46 year old
SLIDE 44
SLIDE 45
SLIDE 46 Contrast Contrast Echocardiography Echocardiography
Ito et al. Ito et al. Circulation Circulation 1992;85:1699. 1992;85:1699.
Before PTCA Before PTCA After PTCA After PTCA
* * *** ***
Average segmental score Average segmental score
0.0 0.0 0.2 0.2 0.4 0.4 0.6 0.6 0.8 0.8 1.0 1.0 1.2 1.2 1.4 1.4 1.6 1.6 1.8 1.8
Acute Acute Chronic Chronic Assessment of the Assessment of the « « no no-
reflow » » phenomenon by i.c. MCE phenomenon by i.c. MCE
SLIDE 47
SLIDE 48
SLIDE 49
SLIDE 50
After FLASH After FLASH After refill After refill MIBI SPECT MIBI SPECT
SLIDE 51 Contrast Contrast Echocardiography Echocardiography
Detection of myocardial viability with Detection of myocardial viability with intravenous intravenous MCE MCE Early MCE Early MCE Late MCE Late MCE Sensitivity Sensitivity 21% 21% 62% 62% Specificity Specificity 89% 89% 85% 85% PPV PPV 63% 63% 78% 78% NPV NPV 57% 57% 72% 72%
Swinburn Swinburn et al. et al. J J Am Am Coll Cardiol Coll Cardiol 2001 2001; ;38 38: :19. 19.
SLIDE 52 Contrast Contrast Echocardiography Echocardiography
- Left ventricular opacification
Left ventricular opacification
Myocardial perfusion
- Assessment of reperfusion and
Assessment of reperfusion and myocardial viability myocardial viability
