Safety of echocardiographic contrast in hospitalized patients with pulmonary hypertension: a multi-center study

Safety of Lumason® (SonoVue®) in special populations and critically ill patients

Evidence for the safe use of Lumason® (SonoVue®), an ultrasound enhancing agent (UEA), in special patient populations is critical to enable healthcare professionals to make informed decisions concerning its use in such patients. Herein, we provide insight on the safety and tolerability of Lumason® in special patient populations. Findings are presented from clinical pharmacology studies conducted in patients with compromised cardiopulmonary conditions, from a retrospective study performed in critically ill patients, and from post-marketing surveillance data from over 20 years of market use of Lumason® (SonoVue®). No detrimental effects of Lumason® on cardiac electrophysiology were observed in patients with coronary artery disease (CAD), and no significant effects on pulmonary hemodynamics were noted in patients with pulmonary hypertension or congestive heart failure. Similarly, no effects on several assessments of pulmonary function (e.g., FVC) were observed in patients with chronic obstructive pulmonary disease (COPD), and no clinically meaningful changes in O2 saturation or other safety parameters were observed after administration of Lumason® to patients with diffuse interstitial pulmonary fibrosis (DIPF). The retrospective study of critically ill patients revealed no significant difference for in-hospital mortality between patients administered Lumason® for echocardiography versus those who had undergone echocardiography without contrast agent. Post-marketing surveillance revealed very low reporting rates (RR) for non-serious and serious adverse events and that serious hypersensitivity reactions were rare. These findings confirm that Lumason® is a safe and well tolerated UEA for use in special populations and critically ill patients.

Contrast-enhanced ultrasound in pediatric echocardiography

The safety and benefits of cardiac contrast-enhanced ultrasound (CEUS) have been demonstrated in children and adolescents for a variety of clinical indications, including congenital heart disease. Cardiac CEUS is performed with US and the intravenous administration of ultrasound contrast agents (UCAs). It improves transthoracic echocardiography, which can be challenging in children and adults with acoustic window limitations (e.g., from obesity) and alterations in chest wall and cardiac geometry (e.g., from prior surgical procedures). Cardiac CEUS is also used to evaluate ischemia in the follow-up of congenital and acquired heart disease. In 2019, the United States Food and Drug Administration (FDA) approved a UCA for pediatric echocardiography. This article focuses on the clinical applications of UCAs in pediatric and adult echocardiography, outlining its diagnostic value, safety and potential for future applications.

Review of ultrasound contrast agents in current clinical practice with special focus on DEFINITY® in cardiac imaging

Echocardiography is the most widely used noninvasive modality to evaluate the structure and function of the cardiac muscle in daily practice. However, up to 15-20% of echocardiograms are considered suboptimal. To enable accurate assessment of cardiac function and wall motion abnormality, the use of ultrasound microbubble contrast has shown substantial benefits in cases of salvaging nondiagnostic studies and enhancing the diagnostic accuracy in daily practice. DEFINITY^® is a perflutren based, lipid shelled microbubble contrast agent, which is US FDA approved for left ventricular opacification. The basis of ultrasound microbubbles, its development, and the clinical role of DEFINITY (characteristics, indications and case examples, side effect profile and existing evidence) is the subject of discussion in this review.

Use of Contrast Ultrasound for Renal Mass Evaluation

An introduction to the expanding modality of contrast-enhanced ultrasound is provided, along with basics on contrast agents and technique. The contrast ultrasound findings of multiple renal tumors are reviewed with examples, including clear cell renal cell carcinoma, papillary renal cell carcinoma, chromophobe renal cell carcinoma, other rare renal cell carcinoma subtypes, oncocytoma, upper tract urothelial carcinoma, lymphoma, and angiomyolipoma, followed also by brief discussions of renal infections and pseudolesions.

Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017

Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.

An Introduction to Contrast-Enhanced Ultrasound for Nephrologists

Contrast-enhanced ultrasound (CEUS) is an emerging technology with no known nephrotoxicity. CEUS has been utilized in cardiac and abdominal imaging for decades in Asia and Europe and has recently received greater attention in the United States with its approval for characterization of indeterminate liver lesions. Emerging data suggest that CEUS has potential as a diagnostic imaging tool among individuals who have contraindications to CT and MRI. Few nephrologists are aware of CEUS and even fewer are aware of its potential applications among individuals with kidney disease. This review introduces CEUS to the nephrology community and provides a basic overview of CEUS technology. Knowledge of the applications, advantages, and disadvantages of CEUS provides the framework for nephrologists to make informed decisions regarding this emerging imaging test in appropriate circumstances. This review focuses on the use of CEUS for the characterization of indeterminate kidney lesions and summarizes the most recent data, some of which specifically includes patients with chronic kidney disease (CKD). The results demonstrate that CEUS has high sensitivity and moderate specificity for detecting malignancy in indeterminate kidney lesions among individuals with and without CKD. In conclusion, CEUS is an emerging imaging technique that may have clinically useful applications for detecting malignant kidney lesions, specifically in patients with CKD. However, most of the current data come from small, single-center studies, and larger, multicenter studies are needed.

Safety With Echocardiographic Contrast Agents

In October 2007, the Food and Drug Administration mandated significant revisions to product labeling for the commercially available echocardiographic contrast agents (ECA) Definity and Optison after spontaneous healthcare provider reports of 4 patient deaths and ≈190 severe cardiopulmonary reactions occurring in close temporal relationship to ECA administration. Since then, multiple large ECA safety studies have been published and have included outpatients, hospitalized patients (including the critically ill), patients undergoing stress echocardiography, and patients with pulmonary hypertension. In addition, the Food and Drug Administration has convened 2 Advisory Committee meetings and the product labels for Optison and Definity have been substantially revised with a softening of safety restrictions. In this review, we will address the safety of ECA use in patients with serious cardiopulmonary conditions, patients with intracardiac shunts, and special patient populations including pulmonary hypertension, pediatrics, and pregnancy. In addition, we will discuss the confounding role of pseudocomplication in attribution of adverse events during diagnostic testing, the current status of the ECA Black Box Warning, and recommended safety precautions during ECA administration.

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

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.

Myocardial perfusion imaging using contrast echocardiography

Microbubbles are an excellent intravascular tracer, and both the rate of myocardial opacification (analogous to coronary microvascular perfusion) and contrast intensity (analogous to myocardial blood volume) provide unique insights into myocardial perfusion. A strong evidence base has been accumulated to show comparability with nuclear perfusion imaging and incremental diagnostic and prognostic value relative to wall motion analysis. This technique also provides the possibility to measure myocardial perfusion at the bedside. Despite all of these advantages, the technique is complicated, technically challenging, and has failed to scale legislative and financial hurdles. The development of targeted imaging and therapeutic interventions will hopefully rekindle interest in this interesting modality.

Feasibility and prognostic value of stress echocardiography in obese, morbidly obese, and super obese patients referred for bariatric surgery

BACKGROUND

Stress echocardiography (SE) is clinically used in the risk stratification and prognosis of patients with coronary artery disease. Due to multiple comorbidities, obese patients have increased risk of adverse cardiovascular events perioperatively in noncardiac surgery. The aim of this study was to investigate the feasibility of SE in morbidly obese patients undergoing bariatric surgery.

METHODS

Consecutive patients referred for SE for preoperative evaluation prior to bariatric surgery from January 2002 to July 2011 formed the study cohort. Contrast was used to define the endocardial border in patients with poor acoustic windows. All-cause mortality data were obtained from Social Security Death Index.

RESULTS

Six hundred fifty-two patients (47 ± 10 years, 84% females) with the mean follow-up of 3.0 ± 2.7 years and mean body mass index (BMI) of 47 ± 9 kg/m² were included in this analysis. Dobutamine SE was performed in 65% of patients compared to exercise SE in 35%. Patients with higher BMI were more likely to undergo dobutamine SE (P < 0.0001). Similarly, incidence of poor acoustic windows and contrast use was higher in those with increased BMI (P < 0.001). Contrast use was higher in patients undergoing dobutamine SE (39%) versus exercise (25%), (P = 0.002). 19 patients (3%) had an abnormal SE and 8 patients (1.2%) died during the follow-up period.

CONCLUSION

Stress echocardiography is feasible in the morbidly obese patients. Patients with higher BMI were more likely to undergo dobutamine SE and have higher incidence of poor acoustic windows and contrast use.