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Contrast enhancement of left ventricular imaging with shu 508A: Two-dimensional versus color flow Doppler echocardiography
364
22A
Journal o f the American Society o f Echocardiography May-June 1995
Abstracts
DODECAFLUOROPENTANE CONTRAST INJECTIONS CAN IDENTIFY MYOCARDIAL AREA AT RISK FROM FULL OCCLUSION AND SIGNIFICANT CORONARY STENOSIS IN THE CLOSED CHESTED CANINE MODEL Allan L. Klein MD, R. Daniel Murray PhD, Annitta Morehead RDCS, Susan Vaughn RN, Herve LeBreton, MD, James D. Thomas MD. The Cleveland Clinic, Cleveland, OH Dodecafluoropentane (DDFP) (EchoGen, Sonus Pharm,) is a new phase shift echo contrast agent thai results in prolonged echocardiograpnic myocardial opaciflcation after intravenous (IV) injection. The utility of 1V DDFP injections to localize the myocardial area at risk by a contrast deficit during full occlusion or significant coronary stenosis in the closed chested canine model has not been described. Six closed chested dogs were subjected to either transient ischemia using a balloon occlusion model (n=3) or a nigh grade (85 %) coronary stenosis with a teflon bead (n=3) in the LAD or circumflex (CX) territory. Intravenous injections of DDFP (0.7 mL/Kg) with dipyridamole (0.56 mg/kg) were made at baseline and after 15 minutes of occlusion and 30 minutes of reperfusion in the balloon occlusion model, l"wo-dimensional images in the parasterual midventricular short-axis or long-axis views were acquired digitally for acoustic donsitometry (HP 1500). Postmortem Evans blue/TTC staining was used to delineate per fusion beds and confirm myocardial area at risk.
24A
Conventional two-dimensional echocardiography (2D echo) does not permit assessment of the entire left ventricle in many patients. Contrast 2D echo has been shown to improve endocardial definition. Color Doppler signals increase following ultrasound contrast injections and may be useful for defining the endocardial border. To assess the value of intravenous cofitrast enhanced 2D versus color flow Doppler (CIrDop) in imaging the left ventricle, we examined 10 patients who had at least one wall that could not be visualized by conventional 2D echo. In each patient the nonvisualized wall was imaged before and during intravenous injections of a fixed dose of 10 cc of 300 mg/ml SHU 508A: 2D images were recorded following a bolus injection; color f~ow Doppler images were recorded during an injection administered at 1 cc/sec. Diastolic images were examined for the ability to assess wall thickness and systolic images were examined for the ability to assess wall motion. Images of the wall were scored: 3 = well defined; 2 = adequately defined, 1 = poorly defined; 0 = undefined. Contrast effects in the LV were observed for 27 • 38 sec by 2D echo versus 222 + 158 sec by CIrDop (p = .004). The diastolic wall thickness score averaged 0.7 + 1.3 for 2D echo versus 2.4 + 0.7 for CIrDop (p = .004). The systolic wall motion score averaged 0.6 + 1.3 for 2D echo versus 1.6 + 0.8 for CIrDop (p = .042). We conclude: 1) Contrast enhancement of the left ventricle using SHU 508A is greater with color flow Doppler than 2D echo images. 2) Contrast enhanced color flow Doppler images improve the ability to assess diaslolic wall thickness and systolic wall motion in patients with inadequate conventional echo images.
LAD Occlusion
Results; All 6 dogs had complete myocardial opacificafion (mean intensity 2.6 + 0. 2 acoustic units, AU) with DDFP at baseline. Following ischemia in the LAD or CX territory after balloon occlusion, there was a distinct contrast deficit (1.6 + 0.6 AU), compared to the adjacent perfusion bed (2.4 + 0.3). The 85% bead stenosis in the distal LAD resulted in a modest apical perfusion deficit. There was a close relationship between staining and contrast deficit. Conclusions; 1V DDFP administration may be successfully used to identify different myocardial area at risk after full occlusion and nigh grade coronary stenosis in a close chested model, using transthoracic echo.
23A
RESPIRATORY VARIATIONS IN PULMONARY VENOUS DOPPLER FLOW PATTERNS ARE INFLUENCED BY LEFT ATRIAL LOADING CONDITIONS DURING POSITIVE PRESSURE MECHANICAL VENTILATION Myung-Ho Lee, M.D., David Rubinstein, M.D., Arzu Ilercil M.D., Janet Zhu, MS., Jesus Almendral, M,D., Vtadimir Kvetan, M.D., Michele Nanna, M.D. Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. Phases of respiration during positive pressure ventilation (PPV) influence atrial mechanics. The effect of baseline atrial loading states on rbese cyclic changes is unclear. To characterize these interactions we prospectively studied 14 patients on mechanical ventilation with (group I) and without (group ll) left atrial pressure/volume overload, as indicated by LA enlargement and interatrial septal bulging into the right atrium. Methods: 14 patients on PPV who required transesophageal echocardiography were prospectively studied. Pulsed wave doppler was obtained from left or right upper pulmonary veins, with simultaneous recording of the respiratory phases Systolic(S),diastolic(D), and retrograde flow(AR) velocity integrals were measured at end inspiration (El) and end expiration (EE). Results: Greup l(n-6) S D AR D/AR El: 8.8• 11.5• @ 2.4• 9.1• EE: 8.6• 10.4• 2.1• 9.8• l-E: -0.47+2.28 * A%: 0 . 0 1 • 0.09+0.08 0.19+0.25* Group ll(n 8) El: 14.3• 8.9• @ EE: 13.4• 8.0• I-E: A%: 0,1• 0.1• (A%-EI-EE/EE, I-E=EI-EE) * inter-group comparison pa0.02
2,7• @ 1,4i0.4 1.0•
4.0• 7.2a-3.7 -3.19~2.09 *
*
@ intra-group comparison pg0.02
Conclusion: PPV-induced cyclic changes of PVF are blunted in the presence of LA pressure/volume overload, suggesting that cardiopulmonary interactions involving left atrial filling and emptying may not be operative in pressure/volume overload states.
CONTRAST ENHANCEMENT OF LEFT VENTRICULAR IMAGING WITH SHU 508A: TWO-DIMENSIONAL VERSUS COLOR FLOW DOPPLER ECHOCARDIOGRAPHY Joel S. Raichlen, M.D., V. Ras Sheth, M.D., Harry J. Kutner, B.S., Alan R. Maniet, D.O., Thomas Jefferson University, Philadelphia, PA
25A
SONICATED A L B U M I N E N H A N C E S T R A N S T H O R A C I C PULMONARY VENOUS FLOW Stephanie Cooper, M.D.; Ray Stainback, M.D.; Elyse Foster, M.D.; Nelson B. Schiller, M.D. University of California, San Francisco. B a c k g r o u n d : The transpulmonary passage of sonicated albumin (Alb) should improve detection and accuracy of measurements of left sided Doppler signals, in particular, pulmonary venous (PV) flow. Therefore, we sought to determine if Alb enhanced signal detection and improved intra and inter observer variability of transthoracic measurements of PV flow. Methods: In 17 pts, PV signals were recorded before and after 3ccs of intravenous Alb. Peak velocities and velocity time integrals (VTI) of systolic, diastolic and total pulmonary venous inflow were measured on three cardiac cycles by 2 independent observers. Doppler signals were qualitatively graded on a 1-5 scale as: 1-optimal (multiple envelopes with acceleration, peak and deceleration velocities well delineated), good 2-(one perfect envelope obtained), adequate 3 (velocity envelope indistinct but measurable), poor 4-(envelope not measurable), or undetectable -5. The mean values obtained for each variable with and without Alb were compared by a paired T-test. Interobserver variability was tested by comparing regression plots of the measurements obtained by the two observers before and after Alb. Result: There was agreement between the observers in subjective degree of enhancement in 14/17 patients. The mean grade pre-Alb was 2.4 -+ 1.0, post-Alb was 1.6 _4-.96. There was a statistically different increase (9% to 23%) in the P V flow velocities and VTIs measured by both observers before and after Alb (p=.0004, p=.0124). No statistical difference in intraobserver variability pre and post Alb was demonstrated. There was very close agreement in the measurements between the two observers both before (R2=.986) and after (R2= .979) Alb; there was no statistical difference between these correlations. Conclusion: Sonicated albumin enhanced pulmonary venous Doppler signals as evidenced by qualitative scores and statistical increases in pulsed Doppler flow velocities and V T I ' s but did not improve the already excellent reproducibility of measurable signals.
22A
Journal o f the American Society o f Echocardiography May-June 1995
Abstracts
DODECAFLUOROPENTANE CONTRAST INJECTIONS CAN IDENTIFY MYOCARDIAL AREA AT RISK FROM FULL OCCLUSION AND SIGNIFICANT CORONARY STENOSIS IN THE CLOSED CHESTED CANINE MODEL Allan L. Klein MD, R. Daniel Murray PhD, Annitta Morehead RDCS, Susan Vaughn RN, Herve LeBreton, MD, James D. Thomas MD. The Cleveland Clinic, Cleveland, OH Dodecafluoropentane (DDFP) (EchoGen, Sonus Pharm,) is a new phase shift echo contrast agent thai results in prolonged echocardiograpnic myocardial opaciflcation after intravenous (IV) injection. The utility of 1V DDFP injections to localize the myocardial area at risk by a contrast deficit during full occlusion or significant coronary stenosis in the closed chested canine model has not been described. Six closed chested dogs were subjected to either transient ischemia using a balloon occlusion model (n=3) or a nigh grade (85 %) coronary stenosis with a teflon bead (n=3) in the LAD or circumflex (CX) territory. Intravenous injections of DDFP (0.7 mL/Kg) with dipyridamole (0.56 mg/kg) were made at baseline and after 15 minutes of occlusion and 30 minutes of reperfusion in the balloon occlusion model, l"wo-dimensional images in the parasterual midventricular short-axis or long-axis views were acquired digitally for acoustic donsitometry (HP 1500). Postmortem Evans blue/TTC staining was used to delineate per fusion beds and confirm myocardial area at risk.
24A
Conventional two-dimensional echocardiography (2D echo) does not permit assessment of the entire left ventricle in many patients. Contrast 2D echo has been shown to improve endocardial definition. Color Doppler signals increase following ultrasound contrast injections and may be useful for defining the endocardial border. To assess the value of intravenous cofitrast enhanced 2D versus color flow Doppler (CIrDop) in imaging the left ventricle, we examined 10 patients who had at least one wall that could not be visualized by conventional 2D echo. In each patient the nonvisualized wall was imaged before and during intravenous injections of a fixed dose of 10 cc of 300 mg/ml SHU 508A: 2D images were recorded following a bolus injection; color f~ow Doppler images were recorded during an injection administered at 1 cc/sec. Diastolic images were examined for the ability to assess wall thickness and systolic images were examined for the ability to assess wall motion. Images of the wall were scored: 3 = well defined; 2 = adequately defined, 1 = poorly defined; 0 = undefined. Contrast effects in the LV were observed for 27 • 38 sec by 2D echo versus 222 + 158 sec by CIrDop (p = .004). The diastolic wall thickness score averaged 0.7 + 1.3 for 2D echo versus 2.4 + 0.7 for CIrDop (p = .004). The systolic wall motion score averaged 0.6 + 1.3 for 2D echo versus 1.6 + 0.8 for CIrDop (p = .042). We conclude: 1) Contrast enhancement of the left ventricle using SHU 508A is greater with color flow Doppler than 2D echo images. 2) Contrast enhanced color flow Doppler images improve the ability to assess diaslolic wall thickness and systolic wall motion in patients with inadequate conventional echo images.
LAD Occlusion
Results; All 6 dogs had complete myocardial opacificafion (mean intensity 2.6 + 0. 2 acoustic units, AU) with DDFP at baseline. Following ischemia in the LAD or CX territory after balloon occlusion, there was a distinct contrast deficit (1.6 + 0.6 AU), compared to the adjacent perfusion bed (2.4 + 0.3). The 85% bead stenosis in the distal LAD resulted in a modest apical perfusion deficit. There was a close relationship between staining and contrast deficit. Conclusions; 1V DDFP administration may be successfully used to identify different myocardial area at risk after full occlusion and nigh grade coronary stenosis in a close chested model, using transthoracic echo.
23A
RESPIRATORY VARIATIONS IN PULMONARY VENOUS DOPPLER FLOW PATTERNS ARE INFLUENCED BY LEFT ATRIAL LOADING CONDITIONS DURING POSITIVE PRESSURE MECHANICAL VENTILATION Myung-Ho Lee, M.D., David Rubinstein, M.D., Arzu Ilercil M.D., Janet Zhu, MS., Jesus Almendral, M,D., Vtadimir Kvetan, M.D., Michele Nanna, M.D. Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. Phases of respiration during positive pressure ventilation (PPV) influence atrial mechanics. The effect of baseline atrial loading states on rbese cyclic changes is unclear. To characterize these interactions we prospectively studied 14 patients on mechanical ventilation with (group I) and without (group ll) left atrial pressure/volume overload, as indicated by LA enlargement and interatrial septal bulging into the right atrium. Methods: 14 patients on PPV who required transesophageal echocardiography were prospectively studied. Pulsed wave doppler was obtained from left or right upper pulmonary veins, with simultaneous recording of the respiratory phases Systolic(S),diastolic(D), and retrograde flow(AR) velocity integrals were measured at end inspiration (El) and end expiration (EE). Results: Greup l(n-6) S D AR D/AR El: 8.8• 11.5• @ 2.4• 9.1• EE: 8.6• 10.4• 2.1• 9.8• l-E: -0.47+2.28 * A%: 0 . 0 1 • 0.09+0.08 0.19+0.25* Group ll(n 8) El: 14.3• 8.9• @ EE: 13.4• 8.0• I-E: A%: 0,1• 0.1• (A%-EI-EE/EE, I-E=EI-EE) * inter-group comparison pa0.02
2,7• @ 1,4i0.4 1.0•
4.0• 7.2a-3.7 -3.19~2.09 *
*
@ intra-group comparison pg0.02
Conclusion: PPV-induced cyclic changes of PVF are blunted in the presence of LA pressure/volume overload, suggesting that cardiopulmonary interactions involving left atrial filling and emptying may not be operative in pressure/volume overload states.
CONTRAST ENHANCEMENT OF LEFT VENTRICULAR IMAGING WITH SHU 508A: TWO-DIMENSIONAL VERSUS COLOR FLOW DOPPLER ECHOCARDIOGRAPHY Joel S. Raichlen, M.D., V. Ras Sheth, M.D., Harry J. Kutner, B.S., Alan R. Maniet, D.O., Thomas Jefferson University, Philadelphia, PA
25A
SONICATED A L B U M I N E N H A N C E S T R A N S T H O R A C I C PULMONARY VENOUS FLOW Stephanie Cooper, M.D.; Ray Stainback, M.D.; Elyse Foster, M.D.; Nelson B. Schiller, M.D. University of California, San Francisco. B a c k g r o u n d : The transpulmonary passage of sonicated albumin (Alb) should improve detection and accuracy of measurements of left sided Doppler signals, in particular, pulmonary venous (PV) flow. Therefore, we sought to determine if Alb enhanced signal detection and improved intra and inter observer variability of transthoracic measurements of PV flow. Methods: In 17 pts, PV signals were recorded before and after 3ccs of intravenous Alb. Peak velocities and velocity time integrals (VTI) of systolic, diastolic and total pulmonary venous inflow were measured on three cardiac cycles by 2 independent observers. Doppler signals were qualitatively graded on a 1-5 scale as: 1-optimal (multiple envelopes with acceleration, peak and deceleration velocities well delineated), good 2-(one perfect envelope obtained), adequate 3 (velocity envelope indistinct but measurable), poor 4-(envelope not measurable), or undetectable -5. The mean values obtained for each variable with and without Alb were compared by a paired T-test. Interobserver variability was tested by comparing regression plots of the measurements obtained by the two observers before and after Alb. Result: There was agreement between the observers in subjective degree of enhancement in 14/17 patients. The mean grade pre-Alb was 2.4 -+ 1.0, post-Alb was 1.6 _4-.96. There was a statistically different increase (9% to 23%) in the P V flow velocities and VTIs measured by both observers before and after Alb (p=.0004, p=.0124). No statistical difference in intraobserver variability pre and post Alb was demonstrated. There was very close agreement in the measurements between the two observers both before (R2=.986) and after (R2= .979) Alb; there was no statistical difference between these correlations. Conclusion: Sonicated albumin enhanced pulmonary venous Doppler signals as evidenced by qualitative scores and statistical increases in pulsed Doppler flow velocities and V T I ' s but did not improve the already excellent reproducibility of measurable signals.