ICUS Weekly News Monitor 12-1-2017

Journal of the American Society of Echocardiography

Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions.

Oct 27, 2017

Authors:  Zhao H, et al.

J Am Soc Echocardiogr. 2017.
Citation: yuchi


BACKGROUND: Contrast-enhanced echocardiography (CE) helps to improve image quality in patients with suboptimal acoustic windows. Despite current recommendations, contrast use remains low. The aim of this study was to identify populations that would benefit more from contrast use.

METHODS: A total of 176 subjects (137 men; mean age, 60.8 ± 13.7 years) with technically difficult transthoracic echocardiographic studies who received clinically indicated intravenous contrast were prospectively studied. The impact on clinical decision making (including alterations in medical therapy, referral, imaging, or clinical procedures) was evaluated.

RESULTS: The use of CE enabled biplane left ventricular (LV) ejection fraction measurement in 97.2% of studies and the interpretation of regional wall motion in 95% of studies. CE allowed definitive assessment of the presence or absence of LV thrombus in 99% of the cases. In the 174 patients whose ordering physicians could be reached at the time of image interpretation, changes in management occurred in 51% of subjects. There was no difference in the proportion of management changes between inpatients and outpatients (60.0% vs 48.1%, P = .225). Subjects with heart failure, cardiomyopathy, and arrhythmia had a higher proportion of changes (61.4% vs 44.2% [P = .031], 62.5% vs 45.0% [P = .028], and 72.0% vs 47.7% [P = .030], respectively). The proportion of management change after CE increased as pre-CE estimated ejection fraction decreased. Logistic regression showed that pre-CE estimated LV ejection fraction < 50% was the only significant predictor of change of management after contrast (P = .004).

CONCLUSIONS: The use of CE has a significant impact on clinical decision making in patients with suboptimal acoustic windows, especially in those with depressed pre-CE LV ejection fractions. 


Journal of Hepatology

Contrast enhanced ultrasound identifies hepatocellular carcinoma in cirrhosis: a large multicenter retrospective study.

Nov 10, 2017

pii: S0168-8278(17)32428-5doi:10.1016/j.jhep.2017.11.007.

PMID: 29133247

Authors: Terzi E(1), Iavarone M(2), Pompili M(3), Veronese L(4), Cabibbo G(5), Fraquelli M(6), Riccardi L(3), De Bonis L(1), Sangiovanni A(2), Leoni S(1), Zocco MA(3),Rossi S(4), Alessi N(5), Wilson SR(7), Piscaglia F(8),

Collaborators: Granito A(1), Salvatore V(1), Tovoli F(1), Manini MA(2), Rapaccini GL(3), Ainora ME(3), Ravetta V(4), Ghittoni G(4), Ventra A(5), Mogavero G(5).

Author information:

(1)Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of  Bologna, Bologna, Italy.

(2)A.M. & A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University ofMilan, Milan, Italy.

(3)Internal Medicine, Gastroenterology and Hepatology, Gemelli Hospital, University of Rome, Rome, Italy.

(4)Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy.

(5)Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo, Italy.

(6)Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy.

(7)Radiology and Medicine, Division of Gastroenterology, University of Calgary, Canada.

(8)Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Electronic address:   This email address is being protected from spambots. You need JavaScript enabled to view it. .

BACKGROUND & AIMS: The use of contrast enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC) in cirrhosis was questioned for therisk of false positive diagnosis in case of cholangiocarcinoma. The American College of Radiology has recently released a scheme (CEUS LI-RADS) classifying lesions at risk for HCC investigated by CEUS. Aim of the present study was tovalidate this LI-RADS scheme for the diagnosis of HCC.

METHODS: A total of 1006 nodules in 848 patients with chronic liver disease at risk for HCC collected in 5 Italian centers were retrospectively analyzed. Nodules were classified as LR-5, (HCC) if ≥ 1 cm with arterial phase hyperenhancement, and late washout (onset ≥60 seconds after contrast injection)of mild degree. Rim enhancement and/or early and/or marked washout qualified lesions as LR-M (malignant, but not specific for HCC). Other combinations qualified lesions at intermediate risk for HCC (LR-3) or probable HCC (LR-4).Diagnostic reference standard was CT/MRI diagnosis of HCC (=506) or histology (n=500).

RESULTS: Median size was 2 cm. Of 1006 nodules, HCC were 820 (81%), cholangiocarcinoma 40 (4%), regenerative nodules (±dysplastic) 116 (11%). TheLR-5 category (52% of all nodules) was 98.5% predictive of HCC, with no risk of misdiagnosis for pure cholangiocarcinoma. Sensitivity for HCC was 62%. All LR-M nodules were malignant and the majority of non-hepatocellular origin. Over 75% of cholangiocarcinomas were LR-M. The LR-3 category included 203 lesions (HCC96=47%) and the LR-4 202 (HCC 173=87%).

CONCLUSIONS: The CEUS LI-RADS class LR-5 is highly specific for HCC, enabling its use for a confident non invasive diagnosis. LAY SUMMARY A retrospective study of approximately 1000 focal lesions at risk for HCC, demonstrates that the refined definition of the typical contrast enhanced ultrasound pattern of hepatocellular carcinoma (HCC) introduced by the Liver Imaging Reporting and Data System (LI RADS) practically abolishes the risk of misdiagnosis of other malignant entities (e.g. cholangiocellular carcinoma) for HCC with negligible reduction in sensitivity. These data support the use of contrast enhanced ultrasound todiagnose hepatocellular carcinoma in cirrhosis.

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