The powerful microbubble: from bench to bedside, from intravascular indicator to therapeutic delivery system, and beyond

Emergence of targeted molecular imaging in atherosclerotic cardiovascular disease

Atherosclerosis, a systemic disease, remains one of the leading causes of morbidity and mortality in the world. Our improved understanding of the molecular mechanisms underlying atherosclerotic lesion progression and sudden transformation into unstable plaques, indicate complex interactions of lipid metabolism, inflammatory processes and genetic predisposition. Currently, novel imaging approaches to visualize the process of atherosclerosis, particularly at the molecular level, are actively being developed. Important targets include inflammatory and endothelial cells, as well as apoptosis and angiogenesis. The next decade should solidify the role of targeted molecular imaging in all aspects of cardiovascular medicine.

Contrast carotid ultrasound for the detection of unstable plaques with neoangiogenesis: a pilot study

OBJECTIVES

To evaluate whether contrast ultrasonography can be used to distinguish asymptomatic from symptomatic carotid plaques and provide insight into underlying pathophysiological differences.

DESIGN

Contrast carotid ultrasound was performed in both symptomatic and asymptomatic patients referred for carotid endarterectomy.

MATERIALS AND METHODS

Of 77 consecutive patients referred for carotid artery evaluation, 64 underwent carotid endarterectomy for asymptomatic cerebrovascular disease and 9 underwent urgent surgery for acute neurological deficits with hemiparesis. The endarterectomy specimens were assessed immunohistologically.

RESULTS

In all 9 patients undergoing urgent surgery, contrast ultrasonography showed the accumulation of diffuse microbubble contrast at the base of the carotid plaque. This pattern was observed only in 1/64 of the patients undergoing surgery for asymptomatic carotid disease. Immunohistologically staining of the endarterectomy specimens showed that the area of microbubble contrast at the base of the symptomatic plaques was associated with an increased number of small diameter (20-30 microm) microvessels staining for vascular endothelial growth factor (VEGF).

CONCLUSIONS

Contrast carotid ultrasonography may allow the identification of microvessels with neoangiogenesis at the base of carotid plaques, and differentiate symptomatic from asymptomatic plaques.

Quantitative analysis of scanning transmission X-ray microscopy images of gas-filled PVA-based microballoons

We report on the quantitative analysis of scanning transmission X-ray microscopy (STXM) images of gas-filled, poly(vinyl alcohol) (PVA)-based microballoons (MB) in a water environment. A model for the transmitted intensity is proposed on the basis of a perfect spherical shell stabilizing the microballoon. An extension of this model to take into account the deformation of the MBs is also presented. Taking into consideration a density gradient of the shell and the STXM resolution, we were able to explain very precisely two types of experimental STXM profiles observed on gas-filled MBs. This enables the detailed characterization of MB properties such as radius and wall thickness and the determination of their wall density with unprecedented high resolution.

Microbubble size isolation by differential centrifugation

Microbubbles used as contrast agents for ultrasound imaging, vectors for targeted drug delivery and vehicles for metabolic gas transport require better size control for improved performance. Mechanical agitation is the only method currently available to produce microbubbles in sufficient yields for biomedical applications, but the emulsions tend to be polydisperse. Herein, we describe a study to generate lipid-coated, perfluorobutane-filled microbubbles and isolate their size fractions based on migration in a centrifugal field. Polydispersity of the freshly sonicated suspension was characterized by particle sizing and counting through light obscuration/scattering and electrical impedance sensing, fluorescence and bright-field microscopy and flow cytometry. We found that the size distribution was multimodal. Smaller microbubbles were more abundant. Differential centrifugation was used to successfully isolate the 1-2 and 4-5 mum diameter fractions. Isolated microbubbles were stable over two days. After two weeks, however, more dilute suspensions (<1 vol%) were susceptible to Ostwald ripening. For example, 4-5 mum microbubbles disintegrated into 1-2 mum microbubbles. This latter observation indicated the existence of an optimally stable diameter in the 1-2 mum range for these lipid-coated microbubbles. Overall, differential centrifugation provided a rapid and robust means for size selection and reduced polydispersity of lipid-coated microbubbles.

Contrast-enhanced ultrasound imaging of intraplaque neovascularization in carotid arteries: correlation with histology and plaque echogenicity

OBJECTIVES

This study was designed to evaluate contrast-enhanced ultrasound imaging of carotid atherosclerosis as a clinical tool to study intraplaque neovascularization.

BACKGROUND

Plaque neovascularization is associated with plaque vulnerability and symptomatic disease; therefore, imaging of neovascularization in carotid atherosclerosis may represent a useful tool for clinical risk stratification and monitoring the efficacy of antiatherosclerotic therapies.

METHODS

Thirty-two patients with 52 carotid plaques were studied by standard and contrast-enhanced ultrasound imaging. In 17 of these patients who underwent endarterectomy, the surgical specimen was available for histological determination of microvessel density by CD31/CD34 double staining. Plaque echogenicity and degree of stenosis at standard ultrasound imaging were evaluated for each lesion. Contrast-agent enhancement within the plaque was categorized as absent/peripheral (grade 1) and extensive/internal (grade 2).

RESULTS

In the surgical subgroup, plaques with higher contrast-agent enhancement showed a greater neovascularization at histology (grade 2 vs. grade 1 contrast-agent enhancement: median vasa vasorum density: 3.24/mm(2) vs. 1.82/mm(2), respectively, p = 0.005). In the whole series of 52 lesions, echolucent plaques showed a higher degree of contrast-agent enhancement (p < 0.001). Stenosis degree was not associated with neovascularization at histology or with the grade of contrast-agent enhancement.

CONCLUSIONS

Carotid plaque contrast-agent enhancement with sonographic agents correlates with histological density of neovessels and is associated with plaque echolucency, a well-accepted marker of high risk lesions, but it is unrelated to the degree of stenosis. Contrast-enhanced carotid ultrasound imaging may provide valuable information for plaque risk stratification and for assessing the response to antiatherosclerotic therapies, beyond that provided by standard ultrasound imaging.

Assessment of hepatic VX2 tumors with combined percutaneous transhepatic lymphosonography and contrast-enhanced ultrasonographic imaging

AIM: To evaluate the feasibility and efficacy of percutaneous transhepatic lymphosonography (PTL) as a novel method for the detection of tumor lymphangiogenesis in hepatic VX₂ of rabbits and to evaluate combined PTL and routine contrast-enhanced ultrasonographic imaging for the diagnosis of liver cancer.

METHODS: Ten rabbits with VX₂ tumor were included in this study. SonoVue (0.1 mL/kg) was injected into each rabbit via an ear vein for contrast-enhanced ultrasonographic imaging, and 0.5 mL SonoVue was injected into the normal liver parenchyma near the VX₂ tumor for PTL. Images and/or movie clips were stored for further analysis.

RESULTS: Ultrasonographic imaging showed VX₂ tumors ranging 5-19 mm in the liver of rabbits. The VX₂ tumor was hyperechoic and hypoechoic to liver parenchyma at the early and later phase, respectively. The hepatic lymph vessels were visualized immediately after injection of contrast medium and continuously visualized with SonoVue^® during PTL. The boundaries of VX₂ tumors were hyperechoic to liver parenchyma and the tumors. There was a significant difference in the values for the boundaries of VX₂ tumors after injection compared with the liver normal parenchyma and the tumor parenchyma during PTL.

CONCLUSION: PTL is a novel method for the detection of tumor lymphangiogenesis in hepatic VX₂ of rabbits. Combined PTL and contrast-enhanced ultrasonographic imaging can improve the diagnosis of liver cancer.

Contrast-enhanced ultrasound and prostate cancer; a multicentre European research coordination project

CONTEXT

Contrast-enhanced ultrasound is a real-time imaging technique with the capability of visualizing perfusion patterns. Since tumour growth is associated with changes in vascularisation, this modality is under research for imaging of various tumour types. Studies have shown promising results for the diagnosis of prostate cancer for various imaging techniques; however, the exact value of each technique is still unclear.

OBJECTIVE

To determine the value of contrast-enhanced ultrasound (CEUS) in the detection, localisation, and follow-up of treatment for prostate cancer.

EVIDENCE ACQUISITION

In the period 2002-2006, research in four European centres regarding CEUS of the prostate was coordinated in a combined program. This paper describes and combines the results of these studies.

EVIDENCE SYNTHESIS

Various techniques were developed and researched during the period of this program. Studies showed that prostate cancer could be visualized and localized in up to 78%. Visualization of the tumour enabled better detection; targeted biopsies lead to fewer biopsies per session without loss of detection rate. A combined approach offered the highest detection rate. CEUS could be used to visualize the effects of high-intensity focussed ultrasound and hormonal therapy for prostate cancer with success, and identified patients with an early relapse. Unfortunately, pretreatment evaluation could not identify the nonresponders beforehand.

CONCLUSIONS

This research project was a first step towards routine use of CEUS in the clinical detection and follow-up of prostate cancer; and new combined studies are initiated.

New mechanisms for non-porative ultrasound stimulation of cargo delivery to cell cytosol with targeted perfluorocarbon nanoparticles

The cell membrane constitutes a major barrier for non-endocytotic intracellular delivery of therapeutic molecules from drug delivery vehicles. Existing approaches to breaching the cell membrane include cavitational ultrasound (with microbubbles), electroporation and cell-penetrating peptides. We report the use of diagnostic ultrasound for intracellular delivery of therapeutic bulky cargo with the use of molecularly targeted liquid perfluorocarbon (PFC) nanoparticles. To demonstrate the concept, we used a lipid with a surrogate polar head group, nanogold-DPPE, incorporated into the nanoparticle lipid monolayer. Melanoma cells were incubated with nanogold particles and this was followed by insonication with continuous wave ultrasound (2.25 MHz, 5 min, 0.6 MPa). Cells not exposed to ultrasound showed gold particles partitioned only in the outer bilayer of the cell membrane with no evidence of the intracellular transit of nanogold. However, the cells exposed to ultrasound exhibited numerous nanogold-DPPE components inside the cell that appeared polarized inside intracellular vesicles demonstrating cellular uptake and trafficking. Further, ultrasound-exposed cells manifested no incorporation of calcein or the release of lactate dehydrogenase. These observations are consistent with a mechanism that suggests that ultrasound is capable of stimulating the intracellular delivery of therapeutic molecules via non-porative mechanisms. Therefore, non-cavitational adjunctive ultrasound offers a novel paradigm in intracellular cargo delivery from PFC nanoparticles.

Nonspherical vibrations of microbubbles in contact with a wall: a pilot study at low mechanical index

Radially oscillating microbubbles can deform when in contact with a wall. These nonspherical shapes have a preferential orientation perpendicular to the wall. Conventional microscope setups for microbubble studies have their optical axis perpendicular to the wall (top view); consequently they have a limited view of the deformation of the bubble. We developed a method to image the bubble in a side view by integrating a mirror in the microscope setup. The image was recorded at 14.5 million frames per second by a high-speed camera. When insonified by a 1-MHz, 140-kPa ultrasound pulse, a 9-microm diameter coated bubble appeared spherical in the top view, but strongly nonspherical in the side view. Its shape was alternatively oblate and prolate, with maximum second order spherical harmonic amplitude equal to the radius.

Interaction of microbubbles with high intensity pulsed ultrasound

High intensity pulsed ultrasound, interacting with microbubble contrast agents, is potentially useful for drug delivery, cancer treatment, and tissue ablation, among other applications. To establish the fundamental understanding on the interaction of a microbubble (in an infinite volume of water) with an ultrasound pressure field, a numerical study is performed using the boundary element method. The response of the bubble, in terms of its shape at different times, the maximum bubble radius obtained, the oscillation time, the jet velocity, and its translational movement, is studied. The effect of ultrasound intensity and initial bubble size is examined as well. One important outcome is the determination of the conditions under which a clear jet will be formed in a microbubble in its interaction with a specific sound wave. The high speed jet is crucial for the aforementioned intended applications.

Intraoperative real-time contrast-enhanced ultrasound angiography: a new adjunct in the surgical treatment of arteriovenous malformations

Object

The goal of this study was to combine the use of ultrasound contrast agents with intraoperative ultrasound techniques to identify intraoperatively a patient's vascular anatomy, including feeding arteries and draining veins of an intracranial arteriovenous malformation (AVM).

Methods

The authors examined 12 consecutive patients with AVMs that had been diagnosed on the basis of preoperative findings on magnetic resonance images and digital subtraction angiograms obtained between September 2003 and December 2005. After each patient had undergone a routine craniotomy, a bolus of contrast agent was injected intravenously, and a real-time microbubble perfusion process was observed to identify the feeding arteries and draining veins of the AVM in a single cross-section. The so-called burst–refill technique was used to sweep the lesion in multiple sections and orientations to obtain information on the surrounding vascular anatomy, after which the findings were compared with those obtained during preoperative imaging.

Results

Intraoperative ultrasonography provided high-quality images in every case. Although plain imaging failed to show an identifiable AVM boundary, color Doppler flow imaging clearly delineated the shape and margin of the AVM. Nevertheless, neither mode of imaging enabled the surgeons to categorically distinguish between feeding and draining vessels.

The real-time perfusion process of microbubbles was first visualized 20 to 30 seconds after the SonoVue bolus injection, and the burst–refill technique made possible identification of the vascular anatomy of malformation lesions in multiple planes.

Conclusions

Using both an ultrasound contrast agent and the burst–refill technique provided a rapid, convenient, and precise way of locating AVM feeding arteries intraoperatively. The combined technique seems warranted in the intraoperative treatment of AVMs.

Insulin at physiological concentrations increases microvascular perfusion in human myocardium

Vascular endothelium regulates vascular tone and tissue perfusion in response to various physiological and pathological stimuli. Insulin and meal feeding increase microvascular perfusion and thus oxygen, nutrient, and hormone delivery to human skeletal muscle. Meal feeding also increases cardiac microvascular perfusion in healthy humans. To examine whether insulin at physiological concentrations increases microvascular perfusion in human myocardium, we studied 13 healthy, overnight-fasted, lean, young human volunteers by using myocardial contrast echocardiography (MCE) and insulin-clamp techniques. We measured cardiac microvascular blood volume (MBV), microvascular flow velocity (MFV), and microvascular blood flow (MBF) at baseline, 60 min, and 120 min after initiating insulin infusion at 1 mU.kg(-1).min(-1). MBF is the product of MBV and MFV and represents microvascular perfusion. Insulin increased myocardial MBV by 23% at 60 min (P < 0.01) and by 41% at 120 min (P = 0.001) without changing MFV. As a result, insulin-mediated myocardial MBF increased significantly at both 60 min (P < 0.01) and 120 min (P < 0.0005). Insulin also significantly increased brachial artery diameter, flow velocity, and total blood flow at 60 and 120 min (P < 0.05 for all). The changes in cardiac MBV correlated positively with quantitative insulin sensitivity check index (QUICKI) and negatively with body mass index but not with the steady-state glucose-infusion rates or the changes in brachial artery parameters. We conclude that insulin, at physiologically relevant concentrations, increases microvascular perfusion in human heart muscle by increasing cardiac MBV in healthy, insulin-sensitive adults. This insulin-mediated cardiac microvascular perfusion may play an important role in normal human myocardial oxygen and substrate physiology.

A stimulus-responsive contrast agent for ultrasound molecular imaging

Complement activation by targeting ligands is an important issue that governs the fate of targeted colloidal contrast agents for molecular imaging. Here, we extend previous work on a stimulus-responsive microbubble construct, in which the ligand is normally buried by a polymeric overbrush and transiently revealed by ultrasound radiation force, to show reduced complement activation and focused adhesion to cells using a physiological peptide ligand. Attachment of C3/C3b in vitro and production of soluble C3a anaphylotoxin in vitro and in vivo decreased significantly for the buried-ligand architecture vs. the conventional exposed-ligand motif and no-ligand control. Additionally, the buried-ligand architecture prevented adhesion of Arg-Gly-Tyr (RGD)-bearing microbubbles to integrin-expressing human umbilical vein endothelial cells (HUVEC) when driven by buoyancy in a static chamber, but it did not affect adhesion efficiency when activated by ultrasound radiation force pulses. These results show, for the first time, the molecular mechanism for reduced immunogenicity for the buried-ligand architecture and feasibility of targeting with this motif using a physiological ligand-receptor pair.

Sustained-release ophthalmic drug delivery systems for treatment of macular disorders: present and future applications

Macular disease currently poses the greatest threat to vision in aging populations. Historically, most of this pathology could only be dealt with surgically, and then only after much damage to the macula had already occurred. Current pathophysiological insights into macular diseases have allowed the development of effective new pharmacotherapies. The field of drug delivery systems has advanced over the last several years with emphasis placed on controlled release of drug to specific areas of the eye. Its unique location and tendency toward chronic disease make the macula an important and attractive target for drug delivery systems, especially sustained-release systems. This review evaluates the current literature on the research and development of sustained-release posterior segment drug delivery systems that are primarily intended for macular disease with an emphasis on age-related macular degeneration.Current effective therapies include corticosteroids and anti-vascular endothelial growth factor compounds. Recent successes have been reported using anti-angiogenic drugs for therapy of age-related macular degeneration. This review also includes information on implantable devices (biodegradable and non-biodegradable), the use of injected particles (microspheres and liposomes) and future enhanced drug delivery systems, such as ultrasound drug delivery. The devices reviewed show significant drug release over a period of days or weeks. However, macular disorders are chronic diseases requiring years of treatment. Currently, there is no 'gold standard' for therapy and/or drug delivery. Future studies will focus on improving the efficiency and effectiveness of drug delivery to the posterior chamber. If successful, therapeutic modalities will significantly delay loss of vision and improve the quality of life for patients with chronic macular disorders.

Contrast-enhanced intravascular ultrasound: combining morphology with activity-based assessment of plaque vulnerability

Acute coronary syndromes are the result of coronary plaque rupture in the majority of cases. Available diagnostic techniques that focus on the early detection of plaques that are prone to rupture are still limited. Increased neovascularization in the vasa vasorum of the atherosclerotic plaque has been identified recently as a common feature of inflammation and plaque vulnerability. Microbubbles, which have been used for ultrasound imaging, can be used to trace neovascularization. We present recent advances in contrast agents and contrast-enhanced intravascular ultrasound that may be used for the detection of vasa vasorum, including fundamental and harmonic contrast imaging. Identification of vasa vasorum proliferation in atherosclerotic plaques presents important clinical implications; in particular it could provide a means to detect vulnerability in vivo, thereby guiding targeted treatments.

Mechanisms by which low-intensity ultrasound improve tolerance to ischemia-reperfusion injury

Recent studies show that low-intensity ultrasound (US) increases endothelial nitric oxide (NO) levels in different models both in vitro and in vivo. Ischemia-reperfusion (I/R) injury is characterized by endothelial cell dysfunction, mainly as a result of altered shear stress responses associated with vasoconstriction, reduced capillary perfusion and excessive oxidative stress. This review provides an overview of the microvascular effects of low-intensity US and suggests that US exposure can be a method to provide tolerance to I/R damage. The hamster cheek pouch, extensively used in studies of I/R-induced injury, has been characterized in terms of changes of arteriolar diameter, flow and shear stress. The low-intensity US exposure reduces vasoconstriction and leukocyte adhesion and increases capillary perfusion during postischemic reperfusion. These effects may be the result of enhanced fluctuations in shear stress exerted by the flowing blood on the vessel wall. The fluctuations in turn are due to mechanical perturbations arising from the difference in acoustical impedance between the endothelial cells and the vessel content. We believe that periodic pulses of US may also cause a sustained reduction of oxidative stress and an enhanced endothelial NO level by increasing oscillatory shear stress during postischemic reperfusion. Low-intensity US exposure may represent a safe and novel important therapeutic target for patients with acute coronary syndromes and for treatment of chronic myocardial ischemia.

Interfacial assembly of partially hydrophobic silica nanoparticles induced by ultrasonic treatment

A sonochemical approach has effectively been applied to prepare aqueous dispersions of air-filled nanostructured quartz silica shells from surface-engineered amorphous silica nanoparticles. The non-equilibrium nature of the cavitation process and high temperature and pressure in the cavitation microbubble can lead to partial crystallization of the amorphous silica nanoparticles producing the quartz phase and a high degree of interconnection between the silica nanoparticles in the microsphere shells. The very high stability of the silica shells against collapse and aggregation is determined by the hydrophobic nature of the silica nanoparticles. Because of the shell thickness and its high density caused by sintering of the silica nanoparticles, the gas (liquid) permeability through the shell is limited thus prolonging the life time of the air-filled nanostructured silica shells.

Identification of cardiovascular dilution systems by contrast ultrasound

Indicator dilution techniques permit accurate measurements of important cardiovascular parameters, such as pulmonary blood volume (PBV) and ejection fraction (EF). However, their use is limited by the need for central catheterization. Contrast ultrasonography allows overcoming this problem. PBV and EF can be measured by a dilution system identification algorithm after detection of multiple dilution curves by an ultrasound scanner. In this paper, we present a system identification method that exploits the a priori knowledge on the dilution system and finds the optimum parameters for the parametric model representing the dilution system impulse response. No subsequent model interpolation is needed. Volume measurements show accurate in-vitro results and clinical feasibility, while 50 EF measurements in patients show a 0.88 correlation coefficient with echocardiographic biplane estimates. In conclusion, adding a priori knowledge to the system identification algorithm leads to increased accuracy and robustness of the method for PBV and EF measurements.

Diabetes mellitus and noninvasive imaging of atherosclerosis

With the aging of the baby-boom generation, non-insulin-requiring diabetes mellitus (type 2) has become a worldwide pandemic. The causes of the disease are complex and multifactorial and include genetic disposition, lifestyle choices, abnormal aging processes, and alterations in metabolic processes. The impetus for diagnosing the preclinical effects of diabetes generally has been the individual patient's risk for cardiovascular diseases, heart attack, stroke, and peripheral vascular diseases. This review highlights the newer noninvasive imaging methods designed to provide the early prevention of preclinical atherosclerosis.

Contrast-enhanced Ultrasound in Obstetrics and Gynecology

Ultrasonography is a well-established imaging modality for evaluation of gynecologic tumors. In recent years, more sophisticated technologies like the use of intravascular contrast agents led to an improvement in the ability of the practitioner to differentiate benign from malignant masses. When we consider the safety of contrast-enhanced ultrasonography in obstetrics and gynecology, we must discuss about the effect of ultrasound contrast media on embryo and fetus. The use of ultrasound contrast media in pregnant women always concerns in the obstetricians because of the principle of not exposing a fetus to any drug. Therefore, the literature was reviewed for information about those safety and efficacy because of the uncertainty about the use of contrast media during pregnancy. Based on the limited information available, mutagenic and teratogenic effects have not been described after administration of ultrasound contrast media. No effect on the fetus has been seen after contrast media. The small potential risk associated with the nonthermal bioeffects via acoustic cavitation may be considered to prohibit the use in first trimester pregnant women. In previous studies including human trials, no evidence of adverse effect was reported. Contrast-enhanced ultrasonography could prove a useful adjunct in multiple gestations and in evaluation of uteroplacental circulation. It appears to be very promising potential in obstetrics.

Mechanics of interfacial composite materials

Recent experiments and simulations have demonstrated that particle-covered fluid/fluid interfaces can exist in stable nonspherical shapes as a result of the steric jamming of the interfacially trapped particles. The jamming confers the interface with solidlike properties. We provide an experimental and theoretical characterization of the mechanical properties of these armored objects, with attention given to the two-dimensional granular state of the interface. Small inhomogeneous stresses produce a plastic response, while homogeneous stresses produce a weak elastic response. Shear-driven particle-scale rearrangements explain the basic threshold needed to obtain the near-perfect plastic deformation that is observed. Furthermore, the inhomogeneous stress state of the interface is exhibited experimentally by using surfactants to destabilize the particles on the surface. Since the interfacially trapped particles retain their individual characteristics, armored interfaces can be recognized as a kind of composite material with distinct chemical, structural, and mechanical properties.

Muscle blood flow and oxygenation measured by NMR imaging and spectroscopy

Tissue perfusion and oxygenation in many organs can be evaluated by various NMR techniques. This review focuses on the specificities, limitations and adaptations of the NMR tools available to investigate perfusion and oxygenation in the skeletal muscle of humans and animal models. A description of how they may be used simultaneously is provided as well. 1H NMR spectroscopy of myoglobin (Mb) monitors intramyocytic oxygenation. It measures the level of deoxy-Mb, from which Mb concentration, Mb desaturation/resaturation rates, muscle oxygenation changes and intracellular partial oxygen pressure (pO2) can be calculated. Positive and negative blood oxygen level-dependent (BOLD) contrasts exist in skeletal muscle. BOLD contrasts primarily reflect changes in capillary-venous oxygenation, but are also directly or indirectly dependent on muscle blood volume, perfusion, vascular network architecture and angulation, relative to the main magnetic field. Arterial spin labelling (ASL) techniques, having high spatial and temporal resolution, are the methods of choice to quantify and map skeletal muscle perfusion non-invasively. Limitations of ASL are poor contrast-to-noise ratio and sensitivity to movement; however, with the introduction of specific adaptations, it has been proven possible to measure skeletal muscle perfusion at both rest and during exercise. The possibility of combining these NMR measurements with others into a single dynamic protocol is most interesting. The 'multiparametric functional (mpf) NMR' concept can be extended to include the evaluation of muscle energy metabolism simultaneously with 31P NMR or with lactate double quantum filtered 1H NMR spectroscopy, an approach which would make NMR an exceptional tool for non-invasive investigations of integrative physiology and biochemistry in skeletal muscle in vivo.

Acoustic activation of targeted liquid perfluorocarbon nanoparticles does not compromise endothelial integrity

Perfluorocarbon nanoparticles consisting essentially of liquid perfluoro-octyl bromide (PFOB) core surrounded by a lipid monolayer can serve as highly specific site-targeted contrast and therapeutic agents after binding to cellular biomarkers. Based on previous findings that ultrasound applied at 2 MHz and 1.9 mechanical index (MI) for a 5-min duration dramatically enhances the cellular interaction of targeted PFOB nanoparticles with melanoma cells in vitro without inducing apoptosis or other harmful effects to cells that are targeted, we sought to define mechanisms of interaction and the safety profile of ultrasound used in conjunction with liquid perfluorocarbon nanoparticles for targeted drug delivery, as compared with conventional microbubble ultrasound contrast agents under identical insonification conditions. Cell-culture inserts were used to grow a confluent monolayer of human umbilical vein endothelial cells. Definity in conjunction with continuous wave ultrasound (2.25 MHz for 1 and 5 min) increased the permeability of monolayer by four to six times above the normal, decreased transendothelial electrical resistance (a sign of reduced membrane integrity), and decreased cell viability by approximately 50%. Histological evaluation demonstrated extensive disruptions of cell monolayers. Nanoparticles (both nontargeted and targeted) elicited no changes in these different measures under similar insonification conditions and did not disrupt cell monolayers. We hypothesize that ultrasound facilitates drug transport from the perfluorocarbon nanoparticles not by cavitation-induced effects on cell membrane but rather by direct interaction with the nanoparticles that stimulate lipid exchange and drug delivery.

Contrast Ultrasound Imaging of the Carotid Artery Vasa Vasorum and Atherosclerotic Plaque Neovascularization

Cardiovascular disease is associated with the aging of the population, obesity, metabolic syndrome, and diabetes. Therefore, it is important to develop non-invasive imaging systems to detect "at-risk" populations. New data suggest that contrast-enhanced ultrasound (CU) imaging of the carotid arteries enhances luminal irregularities (i.e., ulcers and plaques), improves near-wall, carotid intima-media thickness, and uniquely permits direct, real-time visualization of neovasculature of the atherosclerotic plaque and associated adventitial vasa vasorum. With continued clinical investigation, CU imaging of the carotid artery may afford an effective means to non-invasively identify atherosclerosis in "at-risk" populations while providing new standard for therapeutic monitoring.

SEA0400: A Novel Sodium-Calcium Exchange Inhibitor with Cardioprotective Properties1

The cardiac sodium-calcium exchanger (NCX) plays an important role in calcium homeostasis. It is the primary mechanism for removing calcium ions that enter myocytes through L-type calcium channels on a beat-to-beat basis. Its direction of transport is determined by the membrane potential and the ionic concentrations of Na+ and Ca2+, with the forward (or Ca2+-efflux) mode of transport being the dominant mode under physiological conditions. In contrast, the Ca2+-influx mode (or reverse mode) of NCX becomes important in certain pathophysiological conditions, such as myocardial ischemia and reperfusion. Recent discovery of compounds that inhibit the Ca2+-influx mode (or reverse mode) of NCX has generated intense research interest in the pharmacology of NCX. Among the newer NCX inhibitors described to date, 2-[4-[(2,5-difluorophenyl)methoxy]-phenoxy]-5-ethoxyaniline (SEA0400) appears particularly promising in attenuating cardiac, renal, and cerebral ischemia/reperfusion injuries in various experimental models. Moreover, the mixed results that have emerged from clinical trials evaluating the efficacy and safety of inhibitors of the sodium-hydrogen exchanger (an upstream target in relation to the sodium-calcium exchanger) in myocardial protection stimulated interest in evaluating NCX as an alternative therapeutic target. This article reviews the pharmacological profile of SEA0400, as presented in the published literature, and discusses the therapeutic potential of this compound in attenuating myocardial ischemia/reperfusion injury.

Transient permeabilization of cell membranes by ultrasound-exposed microbubbles is related to formation of hydrogen peroxide

In the present study, we addressed the interactions among ultrasound, microbubbles, and living cells as well as consequent arising bioeffects. We specifically investigated whether hydrogen peroxide (H(2)O(2)) is involved in transient permeabilization of cell membranes in vitro after ultrasound exposure at low diagnostic power, in the presence of stable oscillating microbubbles, by measuring the generation of H(2)O(2) and Ca(2+) influx. Ultrasound, in the absence or presence of SonoVue microbubbles, was applied to H9c2 cells at 1.8 MHz with a mechanical index (MI) of 0.1 or 0.5 during 10 s. This was repeated every minute, for a total of five times. The production of H(2)O(2) was measured intracellularly with CM-H(2)DCFDA. Cell membrane permeability was assessed by measuring real-time changes in intracellular Ca(2+) concentration with fluo-4 using live-cell fluorescence microscopy. Ultrasound, in the presence of microbubbles, caused a significant increase in intracellular H(2)O(2) at MI 0.1 of 50% and MI 0.5 of 110% compared with control (P < 0.001). Furthermore, we found increases in intracellular Ca(2+) levels at both MI 0.1 and MI 0.5 in the presence of microbubbles, which was not detected in the absence of extracellular Ca(2+). In addition, in the presence of catalase, Ca(2+) influx immediately following ultrasound exposure was completely blocked at MI 0.1 (P < 0.01) and reduced by 50% at MI 0.5 (P < 0.001). Finally, cell viability was not significantly affected, not even 24 h later. These results implicate a role for H(2)O(2) in transient permeabilization of cell membranes induced by ultrasound-exposed microbubbles.

Prolonging the ultrasound signal enhancement from thrombi using targeted microbubbles based on sulfur-hexafluoride-filled gas

RATIONALE AND OBJECTIVES

The objective of this study is to develop and characterize new microbubbles based on lipids and sulfur hexafluoride (SF6) for targeting thrombi as an improved ultrasound contrast agent.

MATERIALS AND METHODS

Bioconjugate ligands were inserted into the lipid-coated membranes of SF6 gas microbubbles, and their physicochemical properties were determined. Diagnostic efficacies of SF6-filled microbubbles and the contrast agent SonoVue (Bracco Imaging, Geneve, Switzerland) were compared in dogs.

RESULTS

Suspensions of lyophilized powder were reconstituted by injecting saline containing 3.1 x 10(8) SF6 microbubbles/mL with a mean diameter of 4.4 microm. More than 90% of microbubbles had diameters between 1 and 10 microm. After reconstitution, echogenicity and microbubble characteristics were unchanged for 8 hours. Targeted microbubbles increased the echogenicity of thrombi significantly and provided a longer period of optimal signal enhancement compared with nontargeted microbubbles.

CONCLUSIONS

Our thrombus-targeting microbubble contrast agent shows high echogenicity and stability and thereby enhances the visualization of intravascular thrombi and prolongs the duration of the diagnostic window.

Microbubbles assist goat liver ablation by high intensity focused ultrasound

High intensity focused ultrasound (HIFU) has been introduced to treat cancers. However, this therapy is a time-consuming procedure; destructing a deeper volume is also difficult as ultrasonic energy attenuates exponentially with increasing depth in tissues. The aim of the present study was to investigate the effects of introducing microbubbles on liver HIFU ablation. Seventeen goats were divided into groups A (n=8) and B (n=9). The livers in both groups were ablated using HIFU (1.0 MHz, 22,593 W/cm2) performed in the manner of a clinical regime using a clinical device. A microbubble agent was bolus-injected intravenously before HIFU exposure in group B. All animals in group A and seven goats in group B were euthanased to evaluate the ablation efficiency 24 h after HIFU. The necrosis rate (mm3/s), which was the volume of necrosis tissue per second of HIFU exposure, was used to judge the ablation efficiency. Pathological examinations were performed to determine whether there were residual intact tissues within the exposed volume. The other two goats in group B were used to determine the delayed pathological changes 7 days after ultrasonic ablation. The necrosis rate (mm3/s) was increased in group B (14.4647+/-4.1960 versus 33.5302+/-12.4484, P=0.0059). Pathological examinations confirmed that there were no residual unaffected tissue focuses within the exposed volume. Two remarkable changes occurred in the other two goats in group B 7 days after HIFU: there were ghost-cell islands at the periphery of the ablated tissues, and surrounding adjacent tissues outside the reactive zone necrotized. These findings showed that microbubbles could be used to assist liver HIFU ablation.

Vibrating microbubbles poking individual cells: drug transfer into cells via sonoporation

Ultrasound contrast microbubbles have the ability to enhance endothelial cell permeability and thus may be used as a new way to deliver drugs. It facilitates the transfer of extracellular molecules into cells activated through ultrasound driven microbubbles. The present study is designed to correlate the relationship between microbubble induced cell deformation and enhanced cell membrane permeability. Propidium iodide (PI) was used as a membrane integrity probe. Using high-speed imaging of vibrating microbubbles against endothelial cells and imaging transport of PI into these cells showed a direct correlation between cell deformation and resulting cell membrane permeability. The membrane permeabilization lasted for a short period without affecting endothelial cells viability. We identified that microbubbles are crucial to enhance transient cell membrane permeability. Thus, permeability of individual cells is increased. The roles of ultrasound contrast microbubbles as the trigger for improved drug efficacy are discussed.

Visualisation of needle position using ultrasonography

Anaesthetists and intensivists spend a considerable proportion of their working time inserting needles and catheters into patients. In order to access deeper structures like central veins and nerves, they have traditionally relied on surface markings to guide the needle into the correct position. However, patients may present challenges due to anatomical abnormalities and size. Irrespective of the skill of the operator, there is the ever-present risk of needle misplacement with the potential of damage to structures like arteries, nerve bundles and pleura. Repeated attempts, even if ultimately successful, cause patient suffering and probably increase the risk of infection and other long term complications. Portable and affordable, high-resolution ultrasound scanners, has accelerated the interest in the use of ultrasound guidance for interventional procedures. Ultrasound guidance offers several advantages including a greater likelihood of success, fewer complications and less time spent on the procedure. Even if the target structure is identified correctly there is still the challenge to place the needle or other devices in the optimum site. The smaller and deeper the target, the greater the challenge and potential usefulness of ultrasound guidance. As a result of limited training in the use of ultrasound we believe that many clinicians fail to use it to its full potential. A lack of understanding, with regard to imaging the location of the needle tip remains a major obstacle. Needle visualisation and related topics form the basis for this review.

Tethering Functional Ligands onto Shell of Ultrasound Active Polymeric Microbubbles

Hollow (air-filled) microparticles, i.e., microbubbles, provide a promising novel vehicle for both local delivery of therapeutic agents and simultaneous diagnostic ultrasound echo investigations. In this paper, we describe the synthetic routes for decorating the polymeric shell of a poly(vinyl alcohol)-based microbubble with low and high molecular weight ligands with pharmacological relevance. Investigations on physical properties of microbubbles and surface chemical coupling with different cargo molecules such as L-cysteine, L-lysine, poly(L-lysine), chitosan, and beta-cyclodextrin were carried out by CD and NMR spectroscopies, confocal laser scanning microscopy, and microcalorimetry. The in vitro cytotoxicity and biocompatibility of the polymer microbubbles have been also determined toward different cell lines. The results are discussed in terms of the features shown by this device, i.e., injectability, long shelf life, ease of preparation, biocompatibility, loading and cargo capacities, and functional properties.

Targeted Therapeutic Applications of Acoustically Active Microspheres in the Microcirculation

The targeted delivery of intravascular drugs and genes across the endothelial barrier with only minimal side effects remains a significant obstacle in establishing effective therapies for many pathological conditions. Recent investigations have shown that contrast agent microbubbles, which are typically used for image enhancement in diagnostic ultrasound, may also be promising tools in emergent, ultrasound-based therapies. Explorations of the bioeffects generated by ultrasound-microbubble interactions indicate that these phenomena may be exploited for clinical utility such as in the targeted revascularization of flow-deficient tissues. Moreover, development of this treatment modality may also include using ultrasound-microbubble interactions to deliver therapeutic material to tissues, and reporter genes and therapeutic agents have been successfully transferred from the microcirculation to tissue in various animal models of normal and pathological function. This article reviews the recent studies aimed at using interactions between ultrasound and contrast agent microbubbles in the microcirculation for therapeutic purposes. Furthermore, the authors present investigations involving microspheres that are of a different design compared to current microbubble contrast agents, yet are acoustically active and demonstrate potential as tools for targeted delivery. Future directions necessary to address current challenges and advance these techniques to clinical practicality are also discussed.

Time and pressure dependence of acoustic signals radiated from microbubbles

Encapsulated microbubbles are considered to be microsensors for in vivo blood pressure measurements in the cardiovascular system. To study the potential of this method, we developed a simulation and an experimental set-up that relate various characteristics of radiated acoustic signals from the microbubbles to the varying ambient pressure. Both the simulation and the experiment show that the radiated pressure from microbubbles generates a significant subharmonic component, which is modulated by changes in the ambient pressure. A time-dependent decrease of the steady-state radii within a population of microbubbles causes a phase reversal phenomenon, which explains the observed time delay in the build-up of the subharmonic modulation response. Additionally, we identify a frequency-capturing effect that indicates the termination of the nonlinear behavior of the microbubbles. Our research suggests that these subharmonic signals can be used for in vivo blood pressure measurements and highlights some of the considerations that need to be addressed in developing such techniques.

Stable polymeric microballoons as multifunctional device for biomedical uses: synthesis and characterization

Gas filled hollow microparticles, i.e., microbubbles and microballoons, are soft matter devices used in a number of diverse applications ranging from protein separation and purification in food science to drilling technology and ultrasound imaging. Aqueous dispersions of these mesoscopic systems are characterized by the stabilization of the air/water interface by a thin shell of phospholipid bilayer or multilayers or by a denatured and cross-linked proteic matrix. We present a study of a type of microballoons based on modified poly(vinyl alcohol), PVA, a synthetic biocompatible polymer, with new structural features. A cross-linking reaction carried out at the air/water interface provides polymeric air-filled microbubbles with average dimensions depending on the reaction temperature. Characterization of diameters and shell thicknesses for microbubbles obtained at different temperatures has been carried out. Conversion to solvent-filled hollow microcapsules is possible by soaking microbubbles in dimethyl sulfoxide. Microcapsules permeability to fluorescent labeled dextran molecular weight standards was correlated to the mesh size of the polymer network of the shell. Microbubbles were covalently grafted under very mild conditions with beta-cyclodextrin and poly-l-lysine with a view to assay the capability of the device for delivery of hydrophobic drugs or DNA. PVA based microballoons show a remarkable shelf life of several months, their external surface can be decorated with many biologically relevant molecules. These features, together with a tested biocompatibility, make them attractive candidates for use as multifunctional device for diagnosis and therapeutic purposes, i.e., as ultrasound reflectors in ecographic investigation and as drug platforms for in situ sonoporation.

In vivo functional NMR imaging of resistance artery control

Arterial spin labeling (ASL) in combination with NMR imaging is an in vivo technique that quantifies tissue perfusion in absolute values (ml blood x min(-1) x g tissue(-1)) with high temporal (1-10 s) and spatial (0.1-3 mm) resolution. It uses the arterial water spins as endogenous freely diffusible markers of perfusion and, hence, is a totally noninvasive method. The technique has been successfully applied to quantify baseline perfusion in many organs, including the heart, in humans and animals, and results were validated by comparison with gold standards, PET and microspheres, respectively. Because of the high sampling rate of perfusion with ASL and the possibility that measurements could be obtained without harm over indefinite periods of time, the technique has the potential for use in functional investigations of microcirculation regulation and resistance artery control in vivo. We describe examples of the use of ASL to this end. With use of specific technological developments, ASL determination of perfusion can be coupled with simultaneous acquisitions of (1)H and (31)P NMR spectroscopy data. These protocols offer new possibilities whereby the microcirculatory control of cell oxygenation and high-energy phosphate metabolism can be explored.

Vasa vasorum imaging: A new window to the clinical detection of vulnerable atherosclerotic plaques

Complications of vulnerable atherosclerotic plaques (rupture, luminal and mural thrombosis, intraplaque hemorrhage, rapid progression to stenosis, spasm, and so forth) lead to heart attacks and strokes. It remains difficult to identify what plaques are vulnerable to these complications. Despite recent developments such as thermography, spectroscopy, and magnetic resonance imaging, none of them is approved for clinical use. Intravascular ultrasound (IVUS), a relatively old yet widely available clinical tool for guiding intracoronary procedures, is increasingly used for characterization of atherosclerotic plaques. However, inability of IVUS in measuring plaque activity limits its value in detection of vulnerable plaques. In this review, we present new information suggesting that microbubble contrast-enhanced IVUS can measure activity and inflammation within atherosclerotic plaques by imaging vasa vasorum density. An increasing body of evidence indicates that vasa vasorum density may be a strong marker for plaque vulnerability. We suggest that a combination of structural assessment (cap thickness, lipid core, calcification, etc) and vasa vasorum density imaging by IVUS can serve as the most powerful clinically available tool for characterization of vulnerable plaques. Due to space limitations, all IVUS images and movies are posted on the website of the Ultimate IVUS Collaborative Project: http://www.ultimateivus.com.