Impact of Contrast Echocardiography on Evaluation of Ventricular Function and Clinical Management in a Large Prospective Cohort

Kurt, Mustafa; Shaikh, Kamran A.; Peterson, Leif E.; Kurrelmeyer, Karla M.; Shah, Gopi; Nagueh, Sherif F.; Fromm, Robert E.; Quiñones, Miguel Á.; Zoghbi, William A.

doi:10.1016/j.jacc.2009.01.005

Cited by 234 publications

(188 citation statements)

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“…26 These findings confirmed older studies that demonstrated that sub-optimal TTEs can be converted to diagnostic studies in 75 %-90 % of cases. [22][23][24][25]27,28 When faced with "technically limited" TTEs, consideration should be given to either discarding the data, or ordering a study with contrast enhancement, as was done in our patient's case.…”

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confidence: 86%

“…Indeed, it has been reported that suboptimal TTE images limit interpretation in anywhere from 5 % to 30 % of studies, 19,20 and obesity and pulmonary pathologies are very common culprits. 21,22 As a consequence, the use of microbubble contrast agents has grown over the past decade as a way to better assess wall motion and chamber dimensions, [23][24][25][26][27][28] but also as a way to improve the Doppler signal strength for gradient measurements. 29 In our patient, the Doppler signal was only obtained with the aid of contrast enhancement (Fig.…”

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confidence: 99%

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Morbid Obesity: Obscuring the Diagnosis of Aortic Stenosis in a Patient with Cardiogenic Wheezing

2012

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We report the case of a morbidly obese 65-year-old female who presented with repeated hypotensive episodes following dialysis. She was misdiagnosed as suffering from asthma, and eventually was found to have severe aortic stenosis. Obesity has become a common and formidable obstacle to gathering important diagnostic information in patients. Modern diagnostic lab tests and imaging modalities such as transthoracic echocardiography (TTE) can provide spurious data in the morbidly obese population, which can ultimately lead to misdiagnosis. In this clinical vignette, we discuss the relationship between the basic pathophysiologic mechanisms underlying aortic stenosis and patient clinical presentation. We also review the relevant literature and discuss the impact of obesity on the diagnosis of this condition. CASEA 65-year-old morbidly obese (body mass index of 53.5) woman on chronic intermittent hemodialysis presented to the emergency department (ED) with worsening dyspnea and wheezing provoked by minimal exertion. Her associated symptoms included dry cough, but no chest pain or fever. Although she underwent dialysis two days prior to presentation without complication, over the preceding year she had multiple ED visits for lightheadedness and hypotension following dialysis sessions.Past medical history was also notable for hypertension, type 2 diabetes, and obstructive sleep apnea (OSA). She had been bed-bound and living in an assisted living facility over the prior seven months after suffering from a fractured ankle. The patient reported a recent history of intermittent asthma treated with as-needed nebulized anti-cholinergic/ beta-agonists; however, she had never undergone formal pulmonary function testing. She had no history of tobacco use or abnormal environmental exposures. Ten days prior to presentation, the patient was admitted to the hospital with dyspnea and wheezing in addition to somnolence. On that admission, her PaCO 2 was 72.9 mmHg, and brain natriuretic peptide (BNP) was 86 pg/ml (her baseline PaCO 2 level had been in the mid-60s mmHg, and she had no prior BNP levels drawn). She was treated for presumed asthma exacerbation with oral steroids and nebulizers and also started on nocturnal non-invasive positive pressure ventilation for untreated obesity hypoventilation and OSA. Following discharge, she reported no significant improvement in her symptoms. She was seen again in the ED four days prior to presentation with hypotension following dialysis and was treated successfully with a liter fluid bolus.On arrival, the patient's temperature was 36.8°C, heart rate 68 beats/minute, blood pressure 120/74 mmHg, respiratory rate 22/min, and oxygen saturation 100 % on room air. Physical exam was remarkable for an obese female in no acute distress and oriented × 3, diffuse wheezing in all lung fields, and apparently normal S 1 and S 2 on cardiovascular examination with soft and extremely difficult to appreciate heart sounds. Volume status and jugular venous pressure were difficult to assess given her obesity and ne...

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Morbid Obesity: Obscuring the Diagnosis of Aortic Stenosis in a Patient with Cardiogenic Wheezing

2012

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“…A 1998 study of a different proprietary contrast agent resulted in a $269 per patient savings due to reduced need for further testing. 13 15 As with any technological improvement, cost-effectiveness analyses, proper case selection and use of intelligent guidelines optimizes benefit. 11 Inspired by a memorable patient encounter and the integrative medicine theme of the preceding issue of JPCRR, the review article on stinging nettle (p. 48) illustrates a natural product that can cause both harm and potential benefit.…”

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Asking Questions, Seeking Improvements

Baumgardner¹

2016

Journal of Patient-Centered Research and Reviews

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“…Contrast enhancement enables sonographers and physicians to more clearly identify left heart chamber anatomy and function. In a landmark article, Kurt et al (28) concluded that CEUS significantly improved diagnostic accuracy, resource use, and patient management. Based on the proven safety and clinical utility of UCAs, their use has been endorsed by professional society guidelines: the American Society of Echocardiography in 2000 and 2008 (37,38), the European Association of Echocardiography in 2009 (45), and the Intersocietal Commission on Adult Echo Laboratory guidelines, published in 2010 (26).…”

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Ultrasound-mediated targeted drug delivery: recent success and remaining challenges

Castle

Butts

Healey

et al. 2013

American Journal of Physiology-Heart and Circulatory Physiology

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contrast-enhanced ultrasound; gene therapy; microbubble drug delivery PRESENTLY, CONTRAST-ENHANCED ultrasound (CEUS) imaging focuses on diagnostic clinical applications. In the future, however, therapeutic uses of CEUS will create a paradigm shift for patient care and the pharmaceutical industry. Ultrasound contrast agents (UCAs) are composed of shelled microbubbles that serve as superior diagnostic agents while traversing the smallest of blood vessels resulting in unparalleled, real-time spatial and temporal imaging of intact tissues and organs. These microscopic, gas-filled microspheres acting as intravascular indicators represent ideal carrier vehicles for local delivery of ultrasound-directed drug and gene therapies. The conceptually simple application of external acoustic energy in the transformation of these inert, microspheres into powerful therapeutic systems has seemingly unlimited potential.Brief history of CEUS. All diagnostic imaging modalities use and require contrast effects to increase signal-to-noise ratios, permitting enhanced discrimination of the targets. Examples include the use of radiopaque contrast agents to create discrete image patterns using X-ray methods (ionizing radiation), thus creating enhanced detection of objects within the image plane. Similar to X-ray, positron emission tomography and radionuclide imaging procedures rely on radioactive emitters to highlight anatomy and provide information on cellular metabolism and physiology.

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Impact of Contrast Echocardiography on Evaluation of Ventricular Function and Clinical Management in a Large Prospective Cohort

Abstract: The utilization of CE in technically difficult cases improves endocardial visualization and impacts cardiac diagnosis, resource utilization, and patient management.

Cited by 234 publications

References 20 publications

Morbid Obesity: Obscuring the Diagnosis of Aortic Stenosis in a Patient with Cardiogenic Wheezing

Morbid Obesity: Obscuring the Diagnosis of Aortic Stenosis in a Patient with Cardiogenic Wheezing

Asking Questions, Seeking Improvements

Ultrasound-mediated targeted drug delivery: recent success and remaining challenges

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