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Open access

Use of microbubble contrast in the diagnosis of a left ventricular papillary fibroelastoma

Jenny Duke, Kim Greaves, and Andrew Dettrick


A papillary fibroelastoma is a rare, avascular, cardiac tumour that is often found incidentally using transthoracic echocardiography (TTE). Peripheral i.v. injection of a microbubble contrast agent is often used to characterize abnormal masses within the heart allowing further delineation of physical features, the area of attachment, and vascularity of the mass in order to differentiate the growth from a tumour or a thrombus. This case highlights a potential pitfall when assessing a cardiac tumour's vascularity using contrast TTE. A cardiac mass was identified on a TTE of a 53-year-old man and was further investigated with microbubble contrast-enhanced TTE. Contrast TTE imaging suggested a vascularized structure in the left ventricle. However, after histological examination the tumour was found to be entirely avascular.

Learning points

  • Differentiation of cardiac tumour is usually best performed with contrast echocardiography.

  • Contrast echocardiography may not be best tool to determine if cardiac mass is vascularized.

  • A papillary fibroelastoma can appear vascularized with contrast echocardiography due to it's frond-like structures.

  • Physicians should be aware of this potential confusion when assessing a cardiac tumour in patients.

Open access

Update on the safety and efficacy of commercial ultrasound contrast agents in cardiac applications

Andrew W Appis, Melissa J Tracy, and Steven B Feinstein

Ultrasound contrast agents (UCAs) are currently used throughout the world in both clinical and research settings. The concept of contrast-enhanced ultrasound imaging originated in the late 1960s, and the first commercially available agents were initially developed in the 1980s. Today's microbubbles are designed for greater utility and are used for both approved and off-label indications. In October 2007, the US Food and Drug Administration (FDA) imposed additional product label warnings that included serious cardiopulmonary reactions, several new disease-state contraindications, and a mandated 30 min post-procedure monitoring period for the agents Optison and Definity. These additional warnings were prompted by reports of cardiopulmonary reactions that were temporally related but were not clearly attributable to these UCAs. Subsequent published reports over the following months established not only the safety but also the improved efficacy of clinical ultrasound applications with UCAs. The FDA consequently updated the product labeling in June 2008 and reduced contraindications, although it continued to monitor select patients. In addition, a post-marketing program was proposed to the sponsors for a series of safety studies to further assess the risk of UCAs. Then in October 2011, the FDA leadership further downgraded the warnings after hearing the results of the post-marketing data, which revealed continued safety and improved efficacy. The present review focuses on the use of UCAs in today's clinical practice, including the approved indications, a variety of off-label uses, and the most recent data, which affirms the safety and efficacy of UCAs.

Open access

Stress echocardiography in patients with morbid obesity

Benoy N Shah and Roxy Senior

The incidence of significant obesity is rising across the globe. These patients often have a clustering of cardiovascular risk factors and are frequently referred for noninvasive cardiac imaging tests. Stress echocardiography (SE) is widely used for assessment of patients with known or suspected coronary artery disease (CAD), but its clinical utility in morbidly obese patients (in whom image quality may suffer due to body habitus) has been largely unknown. The recently published Stress Ultrasonography in Morbid Obesity (SUMO) study has shown that SE, when performed appropriately with ultrasound contrast agents (whether performed with physiological or pharmacological stress), has excellent feasibility and appropriately risk stratifies morbidly obese patients, including identification of patients who require revascularization. This article reviews the evidence supporting the use of echocardiographic techniques in morbidly obese patients for assessment of known or suspected CAD and briefly discusses other noninvasive modalities, including magnetic resonance and nuclear techniques, comparing and contrasting these techniques against SE.

Open access

Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation

Benoy N Shah, Anita MacNab, Jane Lynch, Reinette Hampson, Roxy Senior, and Richard P Steeds

Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.

Open access

Successful percutaneous closure of spiral atrial septal defect

Mashail Alobaidan, A Saleem, H Abdo, and J Simpson


The case report of a 15-year-old patient with an unusual form of atrial septal defect is described. Echocardiography showed separation of the secundum and primum atrial septums due to abnormal posterior and leftward attachment of the primum septum into the roof of the left atrium. The morphology has been variably described as a ‘double’ atrial septum or ‘spiral’ atrial septal defect. Despite the technical challenge of this form of atrial septal defect, it was effectively closed by ensuring that all relevant septal structures were incorporated between the discs of the occlusion device. This was associated with a stable position and good medium-term outcome. This contrasts with the experience of others where device embolisation or technical failure has been described.

Learning points

  • The spiral atrial septal defect is characterised by an apparently ‘double’ atrial septum.

  • Such atrial septal defects (ASDs) have been associated with a high rate of technical failure of transcatheter closure.

  • 3D echocardiography assists in understanding the anatomy of the defect.

  • Following deployment of the ASD occlusion device transoesophageal echocardiography is essential to ensure that both septum primum and secundum are between the occluder discs.

  • Catheter closure can be successful if close attention is paid to the morphology of the defect and incorporation of margins within the discs of the septal occluder.

Open access

The 34th Annual Advances in Contrast Ultrasound International Bubble Conference, Chicago 2019: synopsis and take-home messages

Stella Kyung, Alan Goldberg, Steven Feinstein, Stephanie Wilson, Sharon Mulvagh, and Petros Nihoyannopoulos

The 34th annual Advances in Contrast Ultrasound (ACU) International Bubble Conference convened in Chicago, IL, USA, on September 5–6, 2019 to feature new directions of research, preclinical and first-in-man clinical trials, and novel clinical applications highlighting the diversity and utility of contrast enhanced ultrasound (CEUS). An expert group comprising clinicians, engineers, basic scientists, government officials, attorneys, and industry partners convened to collaborate on cutting-edge ultrasound enhancement technology. Utilizing this information, the International Contrast Ultrasound Society (ICUS) continues to have cause to advocate for the safe and appropriate use of CEUS with expanding indications and applications.

Open access

A case of hepatopulmonary syndrome

James Offer, Lawrence Green, Andrew R Houghton, and Jim Campbell


This report presents the case of a 42-year-old man with liver cirrhosis who presents with breathlessness. Initial investigations are unable to explain his persistent hypoxia and a diagnosis of hepatopulmonary syndrome is considered. Saline contrast echocardiography is utilised in confirming the diagnosis. Details of this case as well as practicalities in performing and interpreting saline contrast echocardiography are reviewed.

Learning points

  • Key features of hepatopulmonary syndrome are liver disease, hypoxia and pulmonary vascular dilatations.

  • Saline contrast echocardiography is a simple inexpensive procedure to perform and key to confirming the diagnosis of hepatopulmonary syndrome. Detection can be improved by performing the scan in the stand-up position.

  • Agitated saline contrast studies are more commonly performed to identify intra-cardiac shunts. Timing of contrast arrival in the left heart chambers is key to differentiating intra-cardiac shunting from extra-cardiac pulmonary transit.

Open access

A case of right atrial appendage aneurysm mimicking a pericardial cyst on echocardiogram

Mehrnoush Toufan, Leili Pourafkari, Fariborz Akbarzadeh, and Nader D Nader


Right atrial appendage aneurysms (RAAAs) are rarely encountered. If symptomatic, they present with atrial arrhythmias or embolic events. Surgical resection is indicated for symptomatic patients. We describe a 65-year-old man presenting with palpitation for 6 months. Electrocardiogram showed atrial flutter. Transthoracic echocardiography revealed a large thin-walled cystic mass anterior to right ventricular outflow tract, which was confirmed to be a giant RAAA by contrast transoesophageal echocardiography and later by contrast-enhanced computerised tomography. The patient underwent electrocardioversion, following which he remained in sinus rhythm and was asymptomatic during the 3 months follow-up period.

Learning points

  • RAAA can present with atrial flutter.

  • Transoesophageal contrast echocardiography is the most valuable non-invasive tool in diagnosis of RAAA.

  • Although computed tomography scan is not necessary for establishing the diagnosis, it may provide useful information regarding the structural anatomy.

Open access

What is the minimum change in left ventricular ejection fraction, which can be measured with contrast echocardiography?

Tan Suwatanaviroj, Weimin He, Edith Pituskin, Ian Paterson, Jonathan Choy, and Harald Becher


There are limited data on what is the minimum change that can be detected in cancer patients undergoing treatment with cardiotoxic drugs and are referred for monitoring left ventricular (LV) function.


To assess the variability in the measurement of LV volumes and ejection fraction (EF) in contrast echocardiography and to determine the minimum detectable difference (MDD) between two EF measurements that can be deemed significant.


A total of 150 patients were divided into three groups according to EF (EF <53, 53–60, and >60%). Each group consisted of 50 randomly selected cancer patients who underwent contrast echocardiography between July 2010 and May 2014. Repeated measurements of LV volumes and EF were performed offline by a sonographer and a cardiologist. Inter-observer variability was assessed by analysis of variance. Measurement error was estimated by standard error of measurement and MDD.


The 95% confidence interval with a single measurement of EF was 2 percentage points in the groups of patients with EF <53% and EF >60%, and 2.5 percentage points for patients with EF 53–60%. The MDD for EF, end-diastolic volume and end-systolic volume that could be recognized with 95% confidence interval were 4 percentage points, 7 mL and 4 mL, respectively.


Contrast echocardiography is a reliable tool for serial measurements of EF to monitor cardiotoxicity due to chemotherapy. In a high-volume echocardiography laboratory with experienced staff, the MDD for EF of 4 percentage points on a good-quality recording demonstrates the high reproducibility of the Simpson’s method using contrast echocardiography.

Open access

Intra-cardiac echocardiography in alcohol septal ablation: a prospective comparative study against trans-thoracic echocardiography

Robert M Cooper, Adeel Shahzad, James Newton, Niels Vejlstrup, Anna Axelsson, Vishal Sharma, OIiver Ormerod, and Rodney H Stables

Alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy reduces left ventricular outflow tract gradients. A third of patients do not respond; inaccurate localisation of the iatrogenic infarct can be responsible. Transthoracic echocardiography (TTE) using myocardial contrast can be difficult in the laboratory environment. Intra-cardiac echocardiography (ICE) provides high-quality images. We aimed to assess ICE against TTE in ASA. The ability of ICE and TTE to assess three key domains (mitral valve (MV) anatomy and systolic anterior motion, visualisation of target septum, adjacent structures) was evaluated in 20 consecutive patients undergoing ASA. Two independent experts scored paired TTE and ICE images off line for each domain in both groups. The ability to see myocardial contrast following septal arterial injection was also assessed by the cardiologist performing ASA. In patients undergoing ASA, ICE was superior in viewing MV anatomy (P=0.02). TTE was superior in assessing adjacent structures (P=0.002). There was no difference in assessing target septum. Myocardial contrast: ICE did not clearly identify the area of contrast in 17/19 patients due to dense acoustic shadowing (8/19) and inadequate opacification of the myocardium (6/19). ICE only clearly localised contrast in 2/19 cases. ICE does not visualise myocardial contrast well and therefore cannot be used to guide ASA. TTE was substantially better at viewing myocardial contrast. There was no significant difference between ICE and TTE in the overall ability to comment on cardiac anatomy relevant to ASA.