Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography: 2018 American Society of Echocardiography Guidelines Update

2019 ACC/AHA/ASE advanced training statement on echocardiography (revision of the 2003 ACC/AHA clinical competence statement on echocardiography)

“…Both the use of agitated saline contrast in the evaluation of patients with suspected right‐to‐left shunts and the use of microbubble contrast agents (ultrasound enhancing agents) for identification of endocardial borders and detection of intracardiac thrombi are considered standard requirements for Level II training in echocardiography . Level III training in contrast echocardiography should also include instruction on the chemical composition and physical properties of ultrasound enhancing agents, advanced ultrasound equipment settings, safety issues, and protocols for cardiac mass detection and characterization …”

Safety profile of ultrasound enhancing agents in echocardiography

“…Echocardiography is a noninvasive diagnostic tool utilized extensively in clinical practice for cardiac assessment. Despite the variety of uses for echocardiography, there are a number of limitations brought about by faults in image quality and resolution . Factors including large body habitus, lung artifact, increased anterior–posterior diameter, and excessive cardiac motion result in nondiagnostic or poor‐quality images in up to 30% of patients .…”

“…Agitated saline has been used for many years to assess intra‐cardiac shunts; however, its larger bubble size makes it inappropriate for left heart evaluation . Alternatively, synthetic microbubbles, which are smaller and more consistent than agitated saline, allow for better delineation of intra‐cardiac borders and more accurate measurement of left ventricular cavity dimensions . Stress echocardiographic evaluation of ischemia relies heavily on the detection of regional wall motion abnormalities, which may be determined more readily with these newer microbubble agents …”

“…The synthetic microbubbles used in echocardiography have several unique features . On average, the size of each microbubble is about 1–5 microns, making them roughly half the size of a typical erythrocyte.…”

“…Further, the three available UEAs differ in composition, which could result in distinct adverse event profiles. In contrast to prior studies that have focused primarily on use of Optison ® and Definity ® , we prospectively evaluated the safety profiles and comparative incidences of various adverse reactions for the three different UEAs used at our center (Definity ® , Lumason ® , and Optison ® ).…”