an o D Contrast Echocardiography Ultrasound contrast agents were first used in conjunction with clinical echocardiography in the mid-1970s. Early agents consisted of either agitated saline or agitated saline stabilized with indocyanine green dye. Injections were done both intravenously and more centrally at the time of cardiac catheterization. The resultant cloud of microbub- bles was used to define cardiac borders and detect shunts. Barly contrast echocardiography studies were essential for determining the nature of reflective tissue targets and iden- tilying the endocardial border and other structures with echocardiography (Fig. 4.1). It became rapidly apparent that these early contrast agents, after intravenous injection, ‘were isolated to the right heart and that their appearance in the left heart was evidence of a right-to-left shunt. SOURCE OF ULTRASOUND CONTRAST ‘The source of ultrasound contrast is now established to be microbubbles, either purposefully injected into the circula- tion or as a side effect of an intravenous injection. Tnitial theories that the microbubble targets were created by ca\- iuation at the time of injection have been dispelled. Al- though itis possible to create microbubbles due to a cavi- {ation effect, the pressure with which fluid must be injected to create cavitation effect is well beyond that encountered in routine clinical practice. Contrast occurring sponta- neously at the time of an intravenous injection is more likely due to air contamination in the injection apparatus than to creation by the injection process. Gas-containing microbubbles are intense ultrasound reflectors and typically reflect ultrasound at a level several orders of magnitude greater than non-gas-containing structures. Current ultrasound agents contain a variety of gases incliding air, of, more recently, perfluorocarbons. It should be emphasized that the increased reflectivity from amicrobubble target is due to the differential reflection of the contained gas compared with surrounding blood and tissue, 76 FIGURE 4.17. Early M-mode contrast echocardiograms recorded in the cardiae catheterization laboratory. A: The orien tation of the M-mode ultrasound beam. Br Image was recorded after injection of contrast into the left atrium and shows subse ‘quent appearance of contrast in the aorta. C: Contrast injected into the right ventricular outflow tract is shown. D: Contrast ap- pears in the aorta after a left ventricular injection, Es Image was recorded aller a supravalvular injection into the aorta, Contrast is seen exclusively in diastole with a contrast-free area due to competitive flow during aortic valve opening. (From Gramiak R, Shah PM, Kramer DH. Ultrasound cardiography: jes in anatomy and function, Radiology 1969;92:939-948, with permission.) CONTRAST AGENTS The simplest ultrasound contrast agent consists of saline microbubbles. Effective right heart contrast can be ob- tained by forcefully agitating a solution of saline between two 10-mL syringes, each of which contains 5 mL of saline and 0.1 to 0.5 mL of room air (Fig, 4.2). Forceful agitation through a three-way stopcock creates a popula- tion of microbubbles that are highly variable in size and have a tendency to rapidly coalesce. After generation by4. Contrast Echocardiography 77 4.2. ‘iwo-syringe and three-way stopcock apparatus for preparation of agitated saline contrast for intravenous inj tion. The total volume in the syringe on the left is approxim, 10 mL, which consisted initially of 9.5 mL. of saline and 0.5 ml of room air. The contrast was prepared by forcefully injecting the solution from one syringe to the other through the three-way stopcock. Turbulence within the stopcock results in the creation of a large number of microbubbles that are suitable for intra yentous injection. For opacification of right heart structures, a typical intravenous “dose” of contrast prepared in this manner ranges from 1.0 t0 5.0 ml agitation, they should be injected immediately to limit the time available for coalescence. These microbubbles, how- ever, are intense echo reflectors and can be detected in the right atrium and right ventricle (Fig. 4.3). Their size is prohibitive of passage through the pulmonary capillary bed, and their appearance in the left heart implies a pathologic right-to-left shunt. By analyzing the timing and location of appearance, the nature of this shunt can ofien be determined as being a patent foramen ovale, atrial septal defect, or pulmonary arteriovenous mallor- mation (AVM). Creation of ultrasound contrast by this technique is widely used in clinical practice and has had an excellent safety profile. Early altempls (o create a more stable population of microbubbles involved reduction of surface tension, Sur- face tension is the physical characteristic that increases the inward pressure of a bubble and is responsible for the tendency of a microbubble to collapse on itself. This ten- dency to spontaneously decrease in size due to bubble wall surface tension results in a progressive increase in the pressure within the microbubble, which in turn in creases the driving force for the contained gas to diffuse out of the bubble. These factors lead to an acceleration in the rate at which the microbubble shrinks and eventually disappears. By reducing and stabilizing surface tension, bubbles undergo less spontaneous collapse and a popula- tion of stabilized, longer lasting microbubbles can be cre: ated. Several agents including surfactant and indoeyanine green dye have been used to reduce surface tension and, create a population of smaller, more stable microbubbles, IGURE 4.3. Apical four-chamber view recorded in a patient before (top) and after (bottom) injection of saline into a left up- per extremity vein, Note the absence of contrast in any of the four chambers. After injection of intravenous contrast, there is uniform opacification of the right atrium and right ventricle ‘with no appearance of contrast in the left heart. Many of the early fundamental observations in contrast echo were made using indocyanine green dye-stabilized microbubbles (Fig. 4.1). For practical purposes, there is little need to stabilize saline microbubbles. Because their size is relatively large, they do not pass the pulmonary capillary bed, and the safety record of this easily prepared agent has been remarkable. Beginning in the early 1980s, a number of attempts were made to engineer and manu- facture microbubbles that would be uniform in size, have stability with respect to coalescence and size, and provide a homogeneous and reproducible degree of contrast. Recognition that high-intensity sonication resulted in populations of microbubbles was a major breakthrough in contrast echocardiography. The stability of the result- ant contrast agent was dependent on the solution being, sonicated and the contained gas. Through trial and err it was recognized that sonication of 5% human albumin78 — Feigenbaum’s Echocardiography resulted in creation of a relatively homogeneous popula- tion of small microbubbles consisting of a denatured al- bumin shell containing air. These microbubbles were small enough to allow transpulmonary passage, resulted in an intense contrast effect, and could be commercially prepared as a sterile solution providing reproducible con- trast effect. The major limitations of the early air-contain- ing contrast agents were their relatively large size and in- ability to pass the pulmonary capillary bed in all patients Refinements in the sonication process included replace- ‘ment of the contained gas with a high-density perfluoro- carbon instead of air and in some agents replacement of the albumin shell by a lipid membrane. A number of other approaches to the manufacture of microbubbles have also been undertaken including saccharide particles that form gas microbubbles on their surface and engineered mi- crobubble shells of various size and composition. In gen- eral, the commercially available microbubbles have an initial size of 1. to 8.0 wm and are prepared at a concen- tration of 5 X 10° to 1.2 X 10! microbubbles‘mL, de- pending on the agent. As such, the number of microbub- bles injected per “dose” is substantially greater than that seen with agitated saline, Because of their stability (in a Jow ultrasound intensity field), they have substantial per- sistence and a single injection will provide a usable con- trast effect for 3 to 10 minutes. ‘An engineered microbubble has two basic components, the outer shell and contained gas, the effects of which are reflective characteristics, duration of contrast effect, and biological activity (Fig. 4.4). Bubble shells can be designed to be either rigid or flexible and to have varying resistance +o collapse at high pressure. Recognition of these phenom. enaallows creation of microbubble populations that can be highly resistant to ultrasound destruction and therefore provide persistent contrast effect or can be easily destroyed in the ultrasound beam, resulting in simulated acoustic emission and enhanced detectability by this mechanism. The shell can be designed to allow varying degrees of per meability and outward diffusion of the contrast gas. Fi FIGURE 4.4. Schematic repre sentation of a microbubble depicts its contents and various shell char- acteristics. See text for details. Gas: Diffusibility nally, the composition of the shell can be altered to include nonreflective therapeutic compounds. Application of the latter hypothetically includes the ability to deliver chemotherapeutic or biologically active agents, including gene transfection vectors, to targeted tissue. ‘The gas contained within the shell also affects the in- tensity and duration of the effect. Because the gas-blood interface is such a potent reflector, the intensity of con- trast effect is substantially greater for any of the current generation of commercially available agents than that seen with agitated saline, largely because of the greater concentration of microbubbles. As is discussed subse- quently, many ultrasound techniques either purposefully or incidentally disrupt the microbubble shell, allowing the ‘gas to escape into the blood pool. Gases such as oxygen, nitrogen, and room air will rapidly diffuse down a con- centration gradient, resulting in rapid loss of contrast ef fect. High-density perfluorocarbons diffuse more slowly and therefore provide a longer lasting contrast effect even alter bubble shell disruption. CLINICAL USE ‘The use of contrast echocardiography can be divided into four broad categories. Detection of right-to-left shunts by detection of contrast targets in the left heart remains a primary use of contrast echocardiography. Left-to-right shunts also can be detected if a negative contrast effect is, noted in the right heart. As noted elsewhere in this text, contrast echocardiography remains the standard for the diagnosis of a patent foramen ovale. This diagnosis is es- tablished using agitated saline, which does not pass through the pulmonary capillary bed as the contrast agent is cleared by the pulmonary capillaries. Because of their small size and stability, commer- cially available perfluorocarbon-based contrast agents pass through the pulmonary capillary bed relatively unimpeded and subsequently opacity the left ventricular Rigidity Shell Initial Size Surface Properties Room Air / Nitrogen + Perflourocarbon lonic Charge Biologic Activity ‘Typical Size Potential for Disruption Incorporated Biologicals