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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
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Contemporary Ultrasound
Contrast AgentsStabilized gas microspheres sized to pass through the smallest capillaries
Burns. In: Rumack et al, eds. Diagnostic Ultrasound. Vol 1. 2nd ed. St. Louis: Mosby; 1998:57.
RBC: 6-8 m
Microsphere: 2-5 m
Currently available agents
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POWER
Interaction of Ultrasound
and Microbubbles
Linearresonance
Nonlinearresonance
Transientscattering
POWER POWER
Fundamental
enhancement
Bubble
disruption
Harmonic
enhancement
Burns. In Rumack et al, eds. Diagnostic Ultrasound. Vol. 1. 2nd ed.
St. Louis: Mosby; 1998:57.
Principles of Harmonic Imaging
2.5 MHz
2.5 MHz• Tissue and blood reflect
at the fundamental
frequency
• Microbubbles reflect at
both the fundamental and
the harmonic frequencies
2.5 MHz2.5 MHz + 5 MHz
Burns. In Rumack et al, eds. Diagnostic Ultrasound. Vol. 1. 2nd ed.
St. Louis: Mosby; 1998:57.
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Fundamental and
Harmonic Contrast Imaging
Schrope and Newhouse. Ultrasound Med Biol. 1993;19:567.
Shapiro et al. Am J Roentgenol. 1998; 171:1203-1206.
Contrast
Tissue
It’s all about signal to noise!
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Machine Settings
• For most applications
– Aim to maximize non-linear harmonic reflecting responses
(MI 0.1-0.4)
• 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
Technical capability and Operational excellence
Diagnostic capacity
Impact on diagnostic and prognostic thinking
Impact on therapeutic strategy
Cost effectiveness
Outcomes
Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134:587-594.
Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94
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LVO/EBD, Doppler enhancement
LVEF, Quantitation of gradients
Prognosis/dx related to LV function and gradients
Rx: Devices/ intervention for AS
Cost effectiveness
Outcomes
Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134:587-594.
Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94
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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
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LVEF 64%
Stress echo
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With thanks to Sharon Mulvagh
62 yo female with atrial fibrillation
(spontaneously converted) and
dyspnea
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Dx: Apical HCM
Not CAD
Another myopathy
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With thanks to Sharon Mulvagh, MD
Mulvagh: J Am Soc Echocardiogr 21:1179, 2008
52 yo male with NYHA Class
III Heart Failure
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76 yo female with syncope
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4.4mps
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32 yo male with atrial
fibrillation and family history of
SCD
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Dx: ARVD
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Myocardial Contrast Perfusion
Thanks to Tom Porter, MD
Post PCI
Thanks to Tom Porter
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Safety Concerns
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Class Box Warning
Old contraindications
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Current for all agents
Lumason®
and pediatric
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CARPA
Complement Activation Related
Pseudo-Allergy
CARPA Signs and Symptoms• Angioedema
• Bronchospasm
• Cyanosis
• Hypotension
• Low back pain
• Pruritis
• Urticaria
• Tingling sensation
• Hypoxemia
• Sneezing
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Acute Hypersensitivity
ReactionsIgE 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 2005:216:106-121
Note that prior “allergic”
reaction is contra-indication to
use of same/similar agent
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Event Rates for Commonly Performed
Cardiovascular Procedures
Procedure Event Rate Event
CoronaryAngiography
1:1000 Death
Exercise TreadmillTesting
1:2500 MI or Death
SPECT Exam orRadionuclideVentriculography
1:1000 to1:10,000
Fatal Malignancy
ContrastEchocardiography
1:500,000 Death
Pulmonary Hypertension
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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;7:40-8.
Using propensity matching , CE associated
with a 28% lower mortality at 48 h in
comparison with patients undergoing nTTE
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Interatrial Shunt
Parker JM et al. Am J Cardiol2013;112:1039-1045
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Kalra A et al. JACC Cardiovasc Imaging 2014;7:206-7.
Cost-effectiveness
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Thx to Michael Main
Technical capability and Operational excellence
Diagnostic capacity
Impact on diagnostic and prognostic thinking
Impact on therapeutic strategy
Cost effectiveness
Outcomes
Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M. A framework for clinical evaluation of diagnostic technologies. CMAJ 1986; 134:587-594.
Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94
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And yet contrast is
underutilized
Contrast Echocardiography as a
Percentage of Total
Echocardiography
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Arlington Medical Resources
FDA Black Box Warning
*through June 2015
Thx to Michael Main
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Obstacles
• “Internal” (Lab operations)• Time
• Orders
• Consent
• Personnel with IV skills / Scope of practice
• Access to agent
• “External”• Cost considerations
• Black box warning
Decision Order/
Consent
Personnel Agent Machine
Optimization
/ Protocols
STREAMLINE
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Decision Order/
Consent
Personnel Agent Machine
Optimization/
Protocols
Decision Order/
Consent
Personnel Agent Machine
Optimization/
Protocols
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– 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/
ConsentDecision Personnel Agent Machine
Optimization/
Protocols
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– 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
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– Have ready access to agent/equipment
• Consider storing in high use sites (ICU’s)
Decision Order/Cons
ent
Personnel Agent Machine
Optimization/
Protocols
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• 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
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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
Chest pain - angina?
DLVEF (chemo)
LVEF for ICD or BiV
Stress echo
Pericardial disease
Valve disease
Aortic dissection
LV Thrombus
Atrial fibrillation
Hypotension
Dyspnea
Quality of Images
poor fair good
Indication for Study
With thanks to Jonathan Lindner
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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
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