Contrast ultrasound in the assessment of patients presenting with suspected cardiac ischemia

The Human Microcirculation: Regulation of Flow and Beyond

The microcirculation is responsible for orchestrating adjustments in vascular tone to match local tissue perfusion with oxygen demand. Beyond this metabolic dilation, the microvasculature plays a critical role in modulating vascular tone by endothelial release of an unusually diverse family of compounds including nitric oxide, other reactive oxygen species, and arachidonic acid metabolites. Animal models have provided excellent insight into mechanisms of vasoregulation in health and disease. However, there are unique aspects of the human microcirculation that serve as the focus of this review. The concept is put forth that vasculoparenchymal communication is multimodal, with vascular release of nitric oxide eliciting dilation and preserving normal parenchymal function by inhibiting inflammation and proliferation. Likewise, in disease or stress, endothelial release of reactive oxygen species mediates both dilation and parenchymal inflammation leading to cellular dysfunction, thrombosis, and fibrosis. Some pathways responsible for this stress-induced shift in mediator of vasodilation are proposed. This paradigm may help explain why microvascular dysfunction is such a powerful predictor of cardiovascular events and help identify new approaches to treatment and prevention.

Abdominal contributions to cardiorenal dysfunction in congestive heart failure

Current pathophysiological models of congestive heart failure unsatisfactorily explain the detrimental link between congestion and cardiorenal function. Abdominal congestion (i.e., splanchnic venous and interstitial congestion) manifests in a substantial number of patients with advanced congestive heart failure, yet is poorly defined. Compromised capacitance function of the splanchnic vasculature and deficient abdominal lymph flow resulting in interstitial edema might both be implied in the occurrence of increased cardiac filling pressures and renal dysfunction. Indeed, increased intra-abdominal pressure, as an extreme marker of abdominal congestion, is correlated with renal dysfunction in advanced congestive heart failure. Intriguing findings provide preliminary evidence that alterations in the liver and spleen contribute to systemic congestion in heart failure. Finally, gut-derived hormones might influence sodium homeostasis, whereas entrance of bowel toxins into the circulatory system, as a result of impaired intestinal barrier function secondary to congestion, might further depress cardiac as well as renal function. Those toxins are mainly produced by micro-organisms in the gut lumen, with presumably important alterations in advanced heart failure, especially when renal function is depressed. Therefore, in this state-of-the-art review, we explore the crosstalk between the abdomen, heart, and kidneys in congestive heart failure. This might offer new diagnostic opportunities as well as treatment strategies to achieve decongestion in heart failure, especially when abdominal congestion is present. Among those currently under investigation are paracentesis, ultrafiltration, peritoneal dialysis, oral sodium binders, vasodilator therapy, renal sympathetic denervation and agents targeting the gut microbiota.

Contrast biases the autocorrelation phase shift estimation in Doppler tissue imaging

Quantitative assessment of regional myocardial function at rest and during stress with Doppler tissue imaging (DTI) plays an important role in daily routine echocardiography. However, reliable visual analysis is largely dependent on image quality and adequate border delineation, which still remains a challenge in a significant number of patients. In this respect, an ultrasound contrast agent (UCA) is often used to improve visualization in patients with suboptimal image quality. The knowledge of how DTI measurements will be affected by UCA present in the tissue is therefore of significant importance for an accurate interpretation of local myocardial motion. The aim of this paper was to investigate how signal contribution from UCA and nonlinear wave propagation influence the performance of the autocorrelation phase shift estimator used for DTI applications. Our results are based on model experiments with a clinical 2-D grayscale scanner and computational simulations of the DTI velocity estimator for synthetically-derived pulses, simulated bubble echoes and experimentally-sampled RF data of transmitted pulses and backscattered contrast echoes. The results show that destruction of UCA present in the tissue will give rise to an apparent bidirectional velocity bias of individual velocity estimates, but that spatial averaging of individual velocity measurements within a region-of-interest will result in a negative bias (away from the transducer) of the estimated mean or mean peak velocity. The UCA destruction will also have a significant impact on the measured integrated mean velocity over time, i.e., displacement. To achieve improved visualization with UCA during DTI-examinations, we either recommend that it is performed at low acoustic powers, mechanical index <or=0.3, thereby minimizing the effects from bubble rupture, or that each Doppler pulse package is preceded by a destruction burst similar to "Flash imaging" to clear the target area of contrast microbubbles.