Contrast Echocardiography in Heart Failure: Update 2023

PURPOSE OF REVIEW

The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018.

RECENT FINDINGS

The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.

Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study

OBJECTIVES

Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality.

DESIGN

Prospective, observational cohort study.

SETTING

Four tertiary hospitals in Edmonton, Alberta, Canada.

PATIENTS

Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021).

INTERVENTIONS

Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression.

CONCLUSIONS

There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.

Rationale, design and methodology of APPROACH-IS II: International study of patient-reported outcomes and frailty phenotyping in adults with congenital heart disease

BACKGROUND

In recent years, patient-reported outcomes (PROs) have received increasing prominence in cardiovascular research and clinical care. An understanding of the variability and global experience of PROs in adults with congenital heart disease (CHD), however, is still lacking. Moreover, information on epidemiological characteristics and the frailty phenotype of older adults with CHD is minimal. The APPROACH-IS II study was established to address these knowledge gaps. This paper presents the design and methodology of APPROACH-IS II.

METHODS/DESIGN

APPROACH-IS II is a cross-sectional global multicentric study that includes Part 1 (assessing PROs) and Part 2 (investigating the frailty phenotype of older adults). With 53 participating centers, located in 32 countries across six continents, the aim is to enroll 8000 patients with CHD. In Part 1, self-report surveys are used to collect data on PROs (e.g., quality of life, perceived health, depressive symptoms, autonomy support), and explanatory variables (e.g., social support, stigma, illness identity, empowerment). In Part 2, the cognitive functioning and frailty phenotype of older adults are measured using validated assessments.

DISCUSSION

APPROACH-IS II will generate a rich dataset representing the international experience of individuals in adult CHD care. The results of this project will provide a global view of PROs and the frailty phenotype of adults with CHD and will thereby address important knowledge gaps. Undoubtedly, the project will contribute to the overarching aim of improving optimal living and care provision for adults with CHD.

Comparing a knowledge-based 3D reconstruction algorithm to TomTec 3D echocardiogram algorithm in measuring left cardiac chamber volumes in the pediatric population

BACKGROUND

Three-dimensional echocardiography (3DE) is an emerging method for volumetric cardiac measurements; however, few vendor-neutral analysis packages exist. Ventripoint Medical System Plus (VMS3.0+) proprietary software utilizes a validated Magnetic resonance imaging (MRI) database of normal ventricular and atrial morphologies to calculate chamber volumes. This study aimed to compare left ventricular (LV) and atrial (LA) volumes obtained using VMS3.0+ to Tomtec echocardiography analysis software.

METHODS

Healthy controls (n = 98) aged 0-18 years were prospectively recruited and 3D DICOM datasets focused on the LV and LA acquired. LV and LA volumes and ejection fractions were measured using TomTec Image Arena 3D LV analysis package and using VMS3.0+. Pearson correlation coefficients, Bland-Altman's plots, and intraclass coefficients (ICC) were calculated, along with analysis time.

RESULTS

There was a very good correlation between Ventripoint Medical System (VMS) and Tomtec LV systolic (r²  = .88, ICC .89 [95% CI .81, .94]), and diastolic (r²  = .88, ICC .90 [95% CI .77, .95]) volumes, and between VMS and Tomtec LA diastolic (r²  = .75, ICC .89 [95% CI .81, .93]) and systolic (r²  = .88, ICC .91 [95% CI .78, .96]) volumes on linear regression models. Natural log transformations eliminated heteroscedasticity, and power transformations provided the best fit. The time (mins) to analyze volumes using VMS were less than using Tomtec (LV VMS 2.3 ± .5, Tomtec 3.3 ± .8, p < .001; LA: VMS 1.9 ± .4, Tomtec 3.4 ± 1.0, p < .001).

CONCLUSIONS

There was a very good correlation between knowledge-based (VMS3.0+) and 3D (Tomtec) algorithms when measuring 3D echocardiography-derived LA and LV volumes in pediatric patients. VMS was slightly faster than Tomtec in analyzing volumetric measurements.

Cardiovascular Imaging and Pregnancy

Cardiovascular disease (CVD) has become increasingly prevalent in women of childbearing age in the western world. This has led to CVD now being the leading cause of maternal morbidity and mortality. In the modern era optimal cardiology care is dependent on cardiovascular imaging and this is especially so in the appropriate management of the pregnant woman with CVD. CVD imaging allows for accurate risk assessment before pregnancy and guides appropriate management during pregnancy. In this article we outline the hemodynamic and structural changes that occur in the cardiovascular system in pregnancy. We examine the role of echocardiography, cardiac magnetic resonance imaging, computed tomography, and coronary angiography within the care of the pregnant patient and highlight the strengths and weaknesses of each.

"Cardio-Obstetrics": A Burgeoning Field in Need of Increased Awareness, Training, and Collaboration

Cardiovascular disease is now the leading cause of maternal mortality in the industrialised nations. This public health crisis is driven by a variety of factors, including advancing maternal age, increasing prevalence of diabetes and hypertension and the growing number of adults with congenital heart disease. To meet the needs of this complex and diverse population, the subspecialty of cardio-obstetrics has developed. By its very nature, cardio-obstetrics is a team endeavour and requires contributions from multiple disciplines to deliver optimal care. In this article, we argue that cardio-obstetrics is not a niche issue. The magnitude of the current health challenges makes it imperative that all physicians who care for women of childbearing age have a basic knowledge of how cardiovascular disease can impart risk to women during and beyond pregnancy. We address how to increase awareness within the general medical community so that health care workers are able to recognise potential issues and are aware of how to refer to appropriate specialists. We discuss how to incorporate this within cardiology training so that general cardiologists consider the implications that pregnancy has on their patients. And we reflect on the training of the obstetric cardiologists of tomorrow as this field continues to evolve.

Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient

The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.

2021 Update on Safety of Magnetic Resonance Imaging: Joint Statement From Canadian Cardiovascular Society/Canadian Society for Cardiovascular Magnetic Resonance/Canadian Heart Rhythm Society

Magnetic resonance imaging (MRI) is often considered the gold-standard test for characterizing cardiac as well as noncardiac structure and function. However, many patients with cardiac implantable electronic devices (CIEDs) and/or severe renal dysfunction are unable to undergo this test because of safety concerns. In the past 10 years, newer-generation CIEDs and gadolinium-based contrast agents (GBCAs) as well as coordinated care between imaging and heart rhythm device teams have mitigated risk to patients and improved access to MRI at many hospitals. The purpose of this statement is to review published data on safety of MRI in patients with conditional and nonconditional CIEDs in addition to patient risks from older and newer GBCAs. This statement was developed through multidisciplinary collaboration of pan-Canadian experts after a relevant and independent literature search by the Canadian Agency for Drugs and Technologies in Health. All recommendations align with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Key recommendations include: (1) the development of standardized protocols for patients with a CIED undergoing MRI; (2) patients with MRI nonconditional pacemakers and pacemaker dependency should be programmed to asynchronous mode and those with MRI nonconditional transvenous defibrillators should have tachycardia therapies turned off during the scan; and (3) macrocyclic or newer linear GBCAs should be used in preference to older GBCAs because of their better safety profile in patients at higher risk of nephrogenic systemic fibrosis.

Contrast Echocardiography without Contrast Agent for Display of Intraventricular Mass

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Contrast echocardiography was scheduled for assessment of a cardiac mass.

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A bright mass was displayed using very low MI contrast-specific imaging.

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Histologic examination showed a papillary fibroelastoma.

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Low-MI contrast imaging may help diagnose tumors with high content of fibrous tissue.

Venous Diversion Surgery Revisited: A Baffling Situation

With the increasing number of survivors with congenital heart disease (CHD) reaching adulthood, it is important for the clinician to be familiar with the various surgical options performed in this growing patient population. We describe the case of a 65-year-old female who presented with hypoxia and right-to-left shunting following a surgical repair of an atrial septal defect (ASD) secundum and anomalous pulmonary veins with a partial atrial diversion procedure in childhood. The use of multimodality cardiovascular imaging using echocardiography, computed tomography, magnetic resonance imaging, and invasive cardiac catheterization was complementary in the preoperative diagnosis and management of this unique baffling situation.

Fulminant Pneumococcal Pericarditis in a Previously Healthy Patient

Purulent pericarditis is a rare acutely life-threatening condition. Initial symptoms, signs, and investigations can be nonspecific. Echocardiography is invaluable for establishing the diagnosis and initial management. We present a case of a previously healthy patient with purulent pericarditis caused by Streptococcus pneumoniae in the absence of a primary focus of infection. The patient deteriorated rapidly with cardiac tamponade and septic shock and was managed successfully by a combined medical and surgical approach.

The immediate and long-term outcome of enhanced external counterpulsation in treatment of chronic stable refractory angina

BACKGROUND

Treatment of angina recalcitrant to conventional pharmacological therapy and revascularization remains problematic. Safe, effective and affordable treatments with high patient acceptability are desirable. Enhanced external counterpulsation (EECP) may fulfil these criteria better than many other proposed interventions.

OBJECTIVE

To examine the immediate and long-term effect of EECP in treatment of chronic stable refractory angina.

DESIGN

Prospective observational study of consecutive patients treated with EECP and follow-up for 1 year.

SETTING

Teaching hospital.

MAIN OUTCOME MEASURES

Canadian Cardiovascular Society (CCS) angina grading, weekly angina frequency and glyceryl trinitrate (GTN) use.

RESULTS

Sixty-one patients were treated with EECP and 58 completed a course of treatment. Further analysis is confined to those who completed EECP. About 52% of patients suffered from CCS III and IV angina prior to EECP. Immediately post-EECP, angina improved by at least one CCS class in 86% and by two classes in 59%. At 1-year follow-up, sustained improvement in CCS was observed in 78% of the patients. The median weekly angina frequency and GTN use were significantly reduced immediately after EECP [7 (4-14) vs. 1 (0-4) episodes per week and 7 (2-16) vs. 0 (0-2) times per week respectively, P < 0.0001; data in median (interquartile range)]. The reduction was sustained at 1-year follow-up. In 48 patients, their mean exercise time improved significantly after EECP [301 +/- 130 s vs. 379 +/- 147 s, P < 0.0001]. Major adverse treatment-related events were rare.

CONCLUSION

This study shows that for patients who fail to respond to conventional measures, a high proportion gain symptomatic benefit from EECP.

Some current controversies in heart failure (2004-2005)

The disparity between what doctor's believe and the medical facts can be frightening at times. This reflects centuries of training on how to manage patients in the absence of evidence to guide practice. Increasingly disease is becoming susceptible to treatment, requiring a change in the professional approach from the educated, hopeful guess to the application of objective data. Arrogance and certainty, born of ignorance and clutching in desperation at imaginary straws probably still have a place in medicine when conventional treatment has failed, but should play a diminishing role within the medical profession. Epidemiological association is no longer sufficient evidence to conclude that an intervention is effective; with few exceptions, randomised-controlled trials are required. A more successful and objective era of medical practice has arrived. Consequently, a greater degree of scepticism about claims of benefit is also appropriate, which should apply equally to treatments new and old. Of course, no 2 patients are alike, and the evidence-base remains a guide-map on how patients should be treated, rather than a set of rigid rules. Guidelines are guidelines and not infallible, inviolable decrees. In this article, some of the current controversies in the management of heart failure are discussed, ranging from diagnosis, diastolic heart failure, and the role of natriuretic peptides, to the lack of evidence for a clinically-relevant benefit (and therefore possible harm) from aspirin, statins, implantable defibrillators or revascularisation.