European Heart Journal Advance Access originally published online on June 17, 2005
European Heart Journal 2005 26(15):1566; doi:10.1093/eurheartj/ehi349
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The use of contrast echocardiography: a matter of clinical judgement: reply
West German Heart Center Essen
Clinic of Cardiology
University of Duisburg-Essen
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E-mail address: thomas.buck{at}uni-essen.de
West German Heart Center Essen
Clinic of Cardiology
University of Duisburg-Essen
Hufelandstrasse 55
45122 Essen
Germany
In their letter, Hoffmann et al. importantly emphasize that the use of contrast echocardiography depends on the degree of accuracy, which is required for assessment of left ventricular function. Although this is indeed the most important point, it simultaneously opens the door to the equally important but difficult discussion of the criteria for the decision when an echocardiographic study for left ventricular function assessment requires contrast.
These two aspects, the desired accuracy on one side and the need for contrast enhancement on the other side, determine the decision of appropriateness. In this context, it is important to point out that the discussion of the routine use of contrast as a matter of appropriateness in our editorial1 was not for the reason to restrict the application of contrast, predominantly, but more to circumscribe the spectrum of indications where contrast enhancement for LV function assessment is important. As Hoffmann et al. implied in their letter, there are two principal populations where contrast-enhanced LV function assessment is appropriate: (i) in patients with suboptimal endocardial border delineation and (ii) for scientific studies in which a consistent high level of accuracy is required.
Regarding the use of contrast-enhanced echocardiography for scientific studies, Hoffmann et al.2 elegantly demonstrated that the interobserver variability for the determination of EF is similar for contrast-enhanced echocardiography and cardiac MRI. Regarding image quality, the discussion of appropriateness of contrast enhancement in clinical practice is more difficult. Contrast echocardiography was shown to improve image quality and endocardial border delineation almost 20 years ago.3 However, until now routine clinical application is mainly limited by the individual clinical decision whether suboptimal image quality is good enough not to use contrast or bad enough to use it. On the basis of the recommendations of the American Society of Echocardiography, suboptimal visualization is defined as two of six non-visualized segments in a standard apical view.4 Yu et al.5 proposed non-visualization of two or more contiguous endocardial segments, which seems to be more appropriate. Certainly, sufficient endocardial visualization is particularly more important for quantitative determination of EF when compared with subjective estimation. However, quantification of EF as a basic parameter is highly recommended in all transthoracic echocardiographic studies except emergency studies. Also, it is potentially not necessary in short-term follow-up studies for clinical questions not primarily related to LV function. Thus, judgement on the clinical application of contrast-enhanced LV function assessment should be primarily based on image quality, considering the importance for therapeutic decisions in each individual case.
We believe that the discussion concerning the use of contrast echocardiography in the editorial and the present two letters was of importance related to the appropriateness of routine clinical application of contrast-enhanced echocardiography for improved LV function assessment. It has to be particularly emphasized that through the study of Hoffmann et al.,2 contrast-enhanced echocardiography for LV function assessment has now been demonstrated to have similar accuracy when compared with MRI, especially pertaining to interobserver variability. As a consequence, contrast-enhanced echocardiography should be considered in scientific studies on LV function analysis as the most appropriate technique based on the combination of accuracy, feasibility, and cost effectiveness.
References
- Buck T, Erbel R. Should contrast be routinely used for echocardiographic assessment of left ventricular function? A matter of appropriateness. Eur Heart J 2005;26:534–535.
[Free Full Text] - Hoffmann R, von Bardeleben S, ten Cate F, Borges AC, Kasprzak J, Firschke C, Lafitte S, Al-Saadi N, Kuntz-Hehner S, Engelhardt M, Becher H, Vanoverschelde JL. Assessment of systolic left ventricular function. A multi-center comparison of cineventriculography, cardiac magnetic resonance imaging, unenhanced and contrast enhanced echocardiography. Eur Heart J 2005;26:607–616.
[Abstract/Free Full Text] - Erbel R, Meyer J, Brennecke R. Fortschritte in der Medizin. Berlin: Springer; 1985. 117–176.
- Mulvagh SL, DeMaria AN, Feinstein SB, Burns PN, Kaul S, Miller JG. Contrast echocardiography: current and future applications. J Am Soc Echocardiogr 2000;13:331–342.[CrossRef][Web of Science][Medline]
- Yu EHC, Sloggett CE, Iwanochko RM, Rakowski H, Siu SC. Feasibility and accuracy of left ventricular volumes and ejection fraction determination by fundamental, tissue harmonic, and intravenous contrast imaging in difficult-to-image patients. J Am Soc Echocardiogr 2000;13:216–224.[Web of Science][Medline]
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