ICUS Weekly News Monitor 4-4-2018

1.  ICUS, CEUS Basic Training, Chicago Apr 21/22

2.  ILCA,  Mar 20, 2018,  Message from the ILCA President

3.  Ultrasound in Medicine and Biology,  Jan 29, 2018,  Meta-Analysis: Contrast Enhanced Ultrasound versus conventional Ultrasound for differentiation of benign and malignant breast lesions     Authors:  Qian Li, et al

CEUS "Basic Training"


ICUS is proud to expand its educational programs in 2018 to include practical training for successful use of contrast enhanced ultrasound (CEUS) of the cardiovascular system and abdomen.

Learn when and how to use CEUS to improve patient care, outcomes and workflows.


Chicago - April 21-22, 2018

Cardiac CEUS

 Saturday, April 21 - Willis Tower, Suite 5900, Chicago, IL 60606 

Steve Feinstein, MD- Professor, Rush University Medical Center; Program Host
Thomas Porter, MD- Chair of Cardiology, University of Nebraska
Joseph Petrusa, RDCS- Manager, Rush Echocardiology Laboratory
John Grabowski, BSN, RN- Nursing Supervisor, Rush Echocardiology Laboratory 

Abdominal CEUS

 Sunday, April 22 - Willis Tower, Suite 5900, Chicago, IL 60606 

Speaker: Richard Barr, MD, PhD 
Professor of Medicine, Northeast Ohio Medical University
Host: Stephanie Wilson, MD
Professor of Medicine, University of Calgary  


A $100 registration fee per training program includes program materials and meals.  Registration does not include transportation or lodging, which should be arranged by participants themselves. 

Students and trainees will receive a $50 refund after showing appropriate ID when checking in for the program. 

Online registration links: 

Program Description

To see full agendas and course descriptions, go  

Expert lectures will address practical skills needed to implement a successful CEUS program, with multiple ultrasound systems and contrast agents available for participants to examine. Topics will include: 

  1. Microbubble contrast agents: Safety, uses, cost effectiveness. 
  2. Getting started: From set-up to injection to optimizing settings and performance.  
  3. Interpreting the images: Basic and advanced skills.
  4. CEUS economics:What you need to know about billing codes, and using CEUS to reduce the length of hospital stays and time to diagnosis. 
  5. Knobology– Break out rooms with personalized opportunities to "touch and feel" multiple ultrasound systems and contrast agents, examine settings, etc. 

Programs are suitable for physicians, sonographers, nurses, technicians, administrators, industry and others interested in CEUS. 


Dentons US LLP
Willis Tower - 233 S Wacker Dr #5900, Chicago, IL 60606

*Use entrance on Adams Street.

Note: Classes will start promptly at 8am; to ensure on-time arrival, attendees should allow extra time for security and building navigation.

For additional information, please contact:

Stephanie Wilson, MD - This email address is being protected from spambots. You need JavaScript enabled to view it. This email address is being protected from spambots. You need JavaScript enabled to view it. , Steve Feinstein, MD -  This email address is being protected from spambots. You need JavaScript enabled to view it.


International Liver Cancer Association (ILCA)

Message from the ILCA President

Mar 20, 2018

Dear colleagues,

Worldwide interest in HCC continues to grow. In 2017 Pubmed recorded over 7000 articles in which HCC was a keyword. Of these about 10% were reviews. Of course, some of these publications were in low impact journals and would not be expected to change practice in any meaningful way. However, there was at last one major clinical advance, with positive results coming from the cabozantinib trial. There are now 5 agents that are either licensed or will be, that can be used for the management of HCC. The big question will be whether these agents can be combined and if so how should they be combined or used sequentially. On the basic science side, there were many articles exploring the genetics of HCC and the expression profile of these cancers. The tumour (and liver) microenvironment was also the subject of intensive investigation.

Non-alcoholic fatty liver disease has a complex relationship with hepatocellular carcinoma. Many investigators, both in the laboratory and in the clinic are trying to get to grips with these complexities to understand how fatty liver predisposes to HCC, and from a clinical standpoint, how to define who is at risk for HCC and how to provide surveillance. New surveillance algorithms that do not necessarily include ultrasonography are required.

Contrast ultrasound agents are now available in the USA, bringing ultrasound in the US into the 21st century. It is a mystery that contrast US has been widely available elsewhere for years, but only recently in the US. In response the LI-RADS group has developed specific reporting tools for liver masses interrogated by contrast ultrasound.

At ILCA, the Executive Committee is exploring new ways to improve our “product”, to provide more services to our members and to the liver cancer community in general. More on this in future columns as these projects move to fruition.

Best wishes and regards to all,

Morris Sherman


Ultrasound in Medicine and Biology

Meta-Analysis: Contrast Enhanced Ultrasound versus conventional Ultrasound for differentiation of benign and malignant breast lesions.

Jan 29, 2018

Vol. 44, No. 5, pp. 919–929, 2018

Authors: Qian Li,* Min Hu,† Zhikui Chen,‡ Changtian Li,§ Xi Zhang,¶ Yiqing Song,‖ and Feixiang Xiang**,††

* Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; † Department of Cardiovascular Surgery, Tongji Hospitial, Tongji Medical College, Huazhong University of Science and Technology,Wuhan, China; ‡ Department of Ultrasound, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China; § Department of Ultrasound, The Southern Building, Chinese PLA General Hospital, Beijing, China; ¶ Clinical Research Unit, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‖ Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA; ** Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 JieFang Avenue,Wuhan 430022, China; and †† Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Province Key Laboratory of Molecular Imaging, 1277 JieFang Avenue,Wuhan 430022, China


This meta-analysis aimed to compare the diagnostic performance of contrast-enhanced ultrasound (CEUS), conventional ultrasound (US) combined with CEUS (US + CEUS) and US for distinguishing breast lesions. From thorough literature research, studies that compared the diagnostic performance of CEUS versus US or US + CEUS versus US, using pathology results as the gold standard, were included. Atotal of 10 studies were included, of which 9 compared the diagnostic performance of CEUS and US, and 5 studies compared US + CEUS and US. In those comparing CEUS versus US, the pooled sensitivity was 0.93 (95% CI: 0.91–0.95) versus 0.87 (95% CI: 0.85–0.90) and pooled specificity was 0.86 (95% CI: 0.84–0.88) versus 0.72 (95% CI: 0.69–0.75). In studies comparing US + CEUS versus US, the pooled sensitivity was 0.94 (95% CI: 0.92–0.96) versus 0.87 (95% CI: 0.84–0.90) and pooled specificity was 0.86 (95% CI: 0.82–0.89) versus 0.80 (95% CI: 0.76–0.84). In terms of diagnosing breast malignancy, areas under the curve of the summary receiver operating characteristic (of both CEUS (p = 0.003) and US + CEUS (p = 0.000) were statistically higher than that of US. Both CEUS alone and US + CEUS had better diagnostic performance than US in differentiation of breast lesions, and US + CEUS also had low negative likelihood ratio.


ICUS Weekly News Monitor 3-22-2018

  1. Dove Press, Ultrasound molecular imaging of breast cancer in MCF-7 orthotopic mice using gold nanoshelled poly(lactic-co-glycolic acid) nanocapsules: a novel dual-targeted ultrasound contrast agent, March 21, 2018 Authors: Li Xu, et al
  2. Uro Today, EAU 2018: Prostate Cancer Diagnosis by Three-Dimensional Contrast-Ultrasound Dispersion Imaging, March 2018 Presented by: Massimo Mischi, MD, et al.
  3. Journal of Kidney Cancer and VHL, Contrast-Enhanced Ultrasound-Guided Radiofrequency Ablation of Renal Tumors, Feb, 2018 Authors: Dan O’Neal, et al
  4. Echo Research and Practice, Discounted open access publishing


Dove Press

Ultrasound molecular imaging of breast cancer in MCF-7 orthotopic mice using gold nanoshelled poly(lactic-co-glycolic acid) nanocapsules: a novel dual-targeted ultrasound contrast agent

March 21, 2018

Authors: Li Xu,1,* Jing Du,1,* Caifeng Wan,1 Yu Zhang,1 Shaowei Xie,1 Hongli Li,1 Hong Yang,2 Fenghua Li1

1Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; 2Department of Chemistry, College of Life and Environmental Science, Shanghai Normal University, Shanghai, China

*These authors contributed equally to this work

Published 21 March 2018 Volume 2018:13 Pages 1791—1807

  1. DOI


Background: The development of nanoscale molecularly targeted ultrasound contrast agents (UCAs) with high affinity and specificity is critical for ultrasound molecular imaging in the early detection of breast cancer.

Purpose: To prospectively evaluate ultrasound molecular imaging with dual-targeted gold nanoshelled poly(lactide-co-glycolic acid) nanocapsules carrying vascular endothelial growth factor receptor type 2 (VEGFR2) and p53 antibodies (DNCs) in MCF-7 orthotopic mice model.

Methods: DNCs were fabricated with an inner PLGA and outer gold nanoshell spherical structure. Its targeting capabilities were evaluated by confocal laser scanning microscopy (CLSM) and flow cytometry (FCM) in vitro. Contrast-enhanced ultrasound imaging (CEUS) with DNCs was evaluated qualitatively and quantitatively in vitro and in MCF-7 orthotopic mice model by two different systems. The biodistribution of NCs in mice was preliminary investigated. Differences were calculated by using analysis of variance.

Results: DNCs showed a well-defined spherical morphology with an average diameter of 276.90±110.50 nm. In vitro, DNCs exhibited high target specificities (79.01±5.63% vs. 2.11±1.07%, P<0.01; 75.54±6.58% vs. 5.21±3.12%, P<0.01) in VEGFR2- and p53-positive cells compared with control cells. In vivo, CEUS displayed a significantly higher video intensity in two systems using DNCs in comparison with non-targeted PLGA@Au NCs and single-targeted NCs. Biodistribution studies revealed that more DNCs in breast cancer tissue could be detected in mice than in other NCs (P<0.05).

Conclusion: DNCs were demonstrated to be novel dual-targeted UCAs and may have potential applications in early non-invasive visualization of breast cancer.


Uro Today

EAU 2018: Prostate Cancer Diagnosis by Three-Dimensional Contrast-Ultrasound Dispersion Imaging

March 2018

Presented by: Massimo Mischi, MD Eindhoven University of Technology, Eindhoven, The Netherlands

Co-Authors: Schalk S, Huang J, Li J, Wijkstra H, Huang P

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark

Dr. Mischi and colleagues presented results of their experience using 3-D contrast ultrasound dispersion imaging. Dynamic contrast-enhanced ultrasound (DCE-US) provides the opportunity to localize prostate cancer by detection of an associated angiogenic processes. As such, dedicated DCE-US methods have been proposed, however until now these methods have been validated in 2D only, requiring the injection of an ultrasound contrast agent bolus for the analysis of each imaging plane. The need for multiple injections hampers the value of these methods for routine clinical practice. A 3D approach would overcome this problem and the full prostate volume could be analyzed by injection of a single ultrasound contrast agent bolus. The objective of this study was to investigate the feasibility of 3D contrast-ultrasound dispersion imaging for prostate cancer localization.

There were 43 patients referred for 12-core systematic biopsy who underwent 3D DCE-US. For each recording, parametric maps of dispersion and standard perfusion parameters were computed.

Three dimensional contrast ultrasound dispersion imaging

Per biopsy core, the presence of malignancy and the Gleason score were reported. Each prostate was divided in 12 sections corresponding to the biopsy locations. The 90th percentile values of the parameters in each section were compared with the corresponding biopsy outcome. Sections were considered malignant when at least half of the biopsy cores were malignant; sensitivity and specificity to prostate cancer were also evaluated.

Contrast ultrasound dispersion imaging results were superior to standard perfusion parameters. Significant difference between sections corresponding to benign and malignant biopsy cores (p<0.001) was observed. The area under the receiver operating characteristic curve strongly increased for sections consisting of ≥50% malignant cores. In a left/right analysis, sensitivity and specificity were 65% and 80%; in a per-prostate analysis, they were 94% and 50%.

The authors concluded that based on this study, quantitative 3D DCE-US by dispersion imaging can detect prostate cancer. Furthermore, a 3D approach enables the investigation of the full prostate by a single contrast bolus injection, facilitating the clinical utilization of the method. However, Dr. Mischi and colleagues recommend additional, improved validation by comparison with the histopathological analysis of corresponding radical-prostatectomy specimens.


Journal of Kidney Cancer and VHL

Contrast-Enhanced Ultrasound-Guided Radiofrequency Ablation of Renal Tumors

February, 2018

Authors: Dan O’Neal1, Tal Cohen1, Cynthia Peterson2,3, Richard G. Barr1,3

1Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA; 2Kent State University, Salem, OH, USA; 3Ultrasound Training, Southwoods Imaging, Youngstown, OH, USA


Although only limited long-term studies evaluating thermal ablation of renal masses have been performed, it appears that thermal ablation has a comparable 5-year success rate to that of partial or total nephrectomy. This technique is often used in patients who are not good candidates for partial or total nephrectomy. Contrast-enhanced ultrasound (CEUS) has been recently approved by the Food and Drug Administration for characterization of focal liver lesions in adults and pediatric patients. CEUS can be used off label for renal applications and has been used for years in Europe and Asia. It has several advantages over contrast-enhanced computed tomography for use as the technique to guide and evaluate efficacy of thermal ablation of renal masses. These include the ability to visualize small amounts of enhancement, repeat dosing to evaluate efficacy of an ablation during a procedure, thin slice thickness, and real-time visualization. Ultrasound contrast is also non-nephrotoxic and non-hepatotoxic, allowing evaluation of patients with renal insufficiency. This article reviews the use of CEUS for the guidance and follow-up of thermal ablative procedures of renal masses.

Author for correspondence: Richard G. Barr, Northeastern Ohio Medical University, Southwoods Imaging, 7623 Market Street, Youngstown, OH 44512, USA. Email: This email address is being protected from spambots. You need JavaScript enabled to view it. This email address is being protected from spambots. You need JavaScript enabled to view it.

How to cite: O’Neal D et al. Contrast-enhanced ultrasound-guided radiofrequency ablation of renal tumors. J Kidney Cancer VHL 2018; 5(1):7–14. DOI:

Copyright: O’Neal D et al.


Echo Research and Practice

Discounted open access publishing

Echo Research and Practiceis an open-access journal dedicated to publishing the latest research on echocardiography and its associated imaging modalities.  ICUS members are entitled to a 25% discount on the open-access publishing charge. The journal is indexed in Scopus, PubMed and the Web of Science’s Emerging Sources Citation Index.

Find out more at:  

ICUS Weekly News Monitor 12-21-2017

  1. ICUS,  Dec 15, 2017,  GE Healthcare - Imagination at Work: A powerful innovation in liver imaging (Extract)
  2. Journal of the American Society of Echocardiography,  Oct 17, 2017,  Right Ventricular Size and Function; Quantification of Right Ventricular Size and Function from Contrast-Enhanced by Three-Dimensional Echocardiographic Images

Authors:  Diego Medvedofsky, MD, et al.

GE Healthcare - Imagination at Work: A powerful innovation in liver imaging

Dec 15, 2017

(Extract. Courtesy of GE Healthcare. Reproduced with permission.)

Contrast-enhanced ultrasound is a valuable and affordable diagnostic tool for assessing liver lesions. It is also easy to adopt as a service with minimal investment in equipment and training. Clinician education and more clarity around procedure reimbursement are keys to its wider adoption for patients’ benefit.

Advantages of CEUS

Microbubble contrast agents have greatly expanded the utility of ultrasound in the liver, especially for evaluating liver lesions. Contrast-enhanced ultrasound (CEUS) is emerging as a quick and low-risk technique that in a variety of cases can provide a lower-cost, more immediately available alternative to CT and MR contrast exams.

CEUS exams are fast and often definitive. They may also have significant value for patients who are at risk from nephrotoxic contrast agents.

Furthermore, CEUS is relatively simple to add as a service – it requires no substantial capital investment and only a minimum of staff training. The basic steps to CEUS adoption are simple and straightforward as outlined below.

Clinician education is a key to the technique’s growth: many specialists are unaware of it or do not appreciate its full range of capabilities. It is also important to resolve issues surrounding reimbursement for the contrast portion of the procedure and to ensure that CEUS is included in decision-support software tools that help clinicians gauge the appropriateness of imaging studies.

CEUS has the built-in advantage of enabling clinicians to assess contrast enhancement patterns in real time, with better temporal resolution than other modalities. Ultrasound microbubble contrast agents allow lesion enhancement to be observed in all vascular phases in real-time imaging. Side effects from  these agents are very rare. They can be given without first assessing liver or kidney function and, if need be, multiple doses can be given repeatedly in the same imaging session.1

Among the compelling clinical benefits, a CEUS exam:

  • Costs less than MR and CT scans.
  • Avoids the radiation exposure of a CT study.
  • Saves time: A CEUS study takes approximately 10 minutes after the IV is placed and contrast given, versus 45 minutes or more inside an MR scanner bore.
  • Eliminates the challenge inherent in MR scans for claustrophobic patients, and for those who are otherwise unable to tolerate a lengthy exam and may require sedation.

In the liver, CEUS can be used to define and characterize lesions. It can help definitively distinguish benign from malignant lesions; no confirmation with CT or MR is needed. In patients at risk for hepatocellular carcinoma (HCC), liver monitoring via ultrasound is performed at intervals, such as every six months. If a lesion is observed, CEUS can be arranged on the spot and the patient can receive a diagnosis before leaving the clinic.

After treatment of a tumor, CEUS can be used to determine whether any viable malignant tissue remains. Patients can be monitored over time to ensure against recurrence. In these cases, CT or MR follow-ups may be necessary to look for new tum or elsewhere in the liver.

In view of these benefits, many care centers are exploring the addition of CEUS. Here is an overview of the basic steps involved:

Step 1: Adding ultrasound contrast agents to the formulary

CEUS procedures have been simplified by the emergence of a contrast agent FDA-approved in April 2016 for characterization of focal liver lesions in adult and pediatric patients. This agent was previously FDA-approved for use in adults with suboptimal echocardiograms to opacify the left ventricular chamber and improve delineation of the left ventricular endocardial border.

Lumason is now FDA-approved for use in liver imaging to improve the sensitivity and specificity of ultrasonography in differentiating between malignant and benign focal hepatic lesions. It is the first ultrasound contrast agent approved for use in pediatric patients.

There are generally no major issues in getting a contrast agent added to the formulary. While approval procedures differ among hospitals, here are a few essential steps to follow:

  • Work with your institution’s pharmacy committee to identify the steps to add a new drug to the formulary. If a CEUS contrast agent is already present, you may need to provide justification for a second one.
  • Complete an application for decision-makers that emphasizes:
    • The agent’s clinical value and patient safety profile.
    • The agent’s workflow benefits and FDA approval.
  • If there are issues, consult with external sources, including the contrast agent manufacturer, to identify the appropriate approval channels.

Step 2: Training the staff

An essential component of CEUS is training staff to perform the procedure and having access to personnel qualified to start the necessary IV.

The level of sonographers’ involvement in CEUS studies will vary by institution. Some physicians prefer to conduct the actual scans themselves; in those cases the sonographers may perform pre-injection images and position the patients for the exams.

Others train sonographers in the scanning procedure. As CEUS gains acceptance and procedure volumes grow, there are different options for managing IV cannulation. In some centers, nurses start the IVs. In other cases, MR or CT technologists do so. Institutions with higher CEUS volumes train sonographers for this role. The question is which model works best given the patient load and availability of qualified staff.

Step 3: Scheduling CEUS cases

Ease of scheduling adds to the benefits of CEUS. Typically, the exams are scheduled as outpatient procedures, on relatively short lead times. Referring physicians should be instructed to specify  ultrasound contrast on their orders. Where this does not occur, the radiologist needs to call the referring physician back and have the contrast instruction added.

There are two basic models for scheduling cases. The first is to pre-schedule patients, reserving a day or an afternoon for contrast cases. This has the advantage of ensuring that CEUS champions and IV placement personnel are available on site. On the other hand, it may forfeit the opportunity to perform  cases on the spot where warranted.

In the second model, the department allows add-on CEUS studies. For example, when a suspicious liver lesion is detected in a new patient, a physician can order and perform a CEUS exam on the same day, instead of waiting days or weeks for a CT or MRI appointment. An advantage of the same-day “add-on” CEUS study is that it avoids the risk of the patient failing to show up for a second appointment. More important, CEUS can immediately rule out malignancies, or confirm them so that the referring physicians can be notified and the patients’ care expedited.

Generally speaking, CEUS practices start with pre-scheduled exams and move up to performing add-on cases as volume grows and the staff becomes comfortable with the procedure.

Step 4: Educating clinicians

Education about CEUS and its clinical value is vital to its wider acceptance. For example, some radiologists may need to be shown evidence that CEUS has clinical value, poses minimal risk to patients, and will not consume more of their limited time. In addition, before embarking on a CEUS practice, it is essential to make presentations to the clinical teams that comprise the main sources of referrals: hepatologists for patients with liver masses, oncologists for patients with cancer. Presentations need to demonstrate the benefits of CEUS to clinical practice.

Remember to educate your Department leaders who should not  be overlooked in education; the better they understand the benefits of CEUS, the more likely they will be to approve its use. Practitioners should seek hands-on clinical experience. Ways to do so include visiting an existing center with a CEUS practice to observe cases, identifying and consulting with a few goto experts, and working with ultrasound vendors to evaluate imaging systems and view technology demonstrations.

Billing and reimbursement

While a CPT code exists for the contrast agent itself, no such code yet exists for the professional component of the contrast portion of the ultrasound exam. For hospitals serving indigent patients, CEUS enables savings because the exams cost significantly less than CT or MRI. Otherwise, uncertainty about reimbursement gives some physicians pause.

With wider adoption, CEUS promises to bring new excitement and potentially game-changing benefits to a long standing, tried-and-true liver imaging technology. It can reinforce ultrasound as a robust imaging modality.

Adding CEUS: Tips to smooth the process

It is not difficult to add contrast-enhanced ultrasound as a technique for evaluating liver lesions. Here are a few ideas for helping the process ramp up smoothly.

  • Identify current IV placement resources and utilize their expertise when possible.
  • Identify a few enthusiastic sonographers to train in the CEUS technique. They are likely to find it invigorating to learn about a new and powerful ultrasound procedure.
  • Identify one or two radiologists to champion CEUS and drive implementation.
  • Educate referring physicians on the clinical benefits of CEUS for evaluating liver lesions and instruct them to add it as an option on their orders.


  1. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver – update 2012 AWFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS AND ICUS. Ultrasound in Med. & Biol., Vol. 39, No. 2, pp. 187–210, 2013. ©2013 World Federation for Ultrasound in Medicine & Biology.

Imagination at work may not be available in all countries and regions. Contact a GE Healthcare Representative for more information.

Data subject to change.

© 2017 General Electric Company . February 2017/JB46265US

GE, the GE Monogram and imagination at work are trademarks of General Electric Company.

Reproduction in any form is forbidden without prior written permission from GE. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.


Journal of the American Society of Echocardiography

J Am Soc Echocardiogr 2017;30:1193-202

Oct 17, 2017

Right ventricular Size and Function

Quantification of Right Ventricular Size and Function from Contrast-Enhanced Three-Dimensional Echocardiographic Images

Authors:  Diego Medvedofsky, MD, Victor Mor-Avi, PhD, Eric Kruse, RDCS, Brittney Guile, RDCS Boguslawa Ciszek, RDCS, Lynn Weinert, RDCS, Megan Yamat, RDCS, Valentina Volpato, MD, Karima Addetia, MD, Amit R. Patel, MD, and Roberto M. Lang, MD, Chicago, Illinois


  • We hypothesized that contrast enhancement during 3D echocardiographic imaging would improve the accuracy of RV volume and function analysis.
  • This hypothesis was tested by comparing measurements obtained from nonenhanced and contrast-enhanced images against cardiac magnetic resonance reference images.
  • Contrast enhancement improved the visualization of RV endocardial borders, resulting in more accurate and more reproducible measurements.
  • This approach may be particularly useful in patients with suboptimal image quality.


Three-dimensional (3D) echocardiography directly assesses right ventricular (RV) volumes without geometric assumptions, despite the complex shape of the right ventricle, and accordingly is more accurate and reproducible than the two-dimensional methodology, which is able to measure only surrogate parameters of RV function. Volumetric analysis has been hampered by frequent inability to clearly visualize RV endocardium, especially the RV free wall, in 3D echocardiographic images. The aim of this study was to test the hypothesis that RV contrast enhancement during 3D echocardiographic imaging would improve the accuracy of RV volume and function analysis.


Thirty patients with a wide range of RV size and function and image quality underwent transthoracic 3D echocardiography with and without contrast enhancement and cardiovascular magnetic resonance imaging on the same day. RV end-diastolic and end-systolic volumes and ejection fraction were measured from contrast-enhanced and nonenhanced 3D echocardiographic images and compared with cardiovascular magnetic resonance reference values using linear regression and Bland-Altman analyses. Blinded repeated measurements were performed to assess measurement variability.


RV contrast enhancement was feasible in all patients. RV volumes obtained both with and without contrast enhancement correlated highly with cardiovascular magnetic resonance (end-diastolic volume, r = 0.90 and r = 0.92; end-systolic volume, r = 0.92 and r = 0.94, respectively), but the correlation for ejection fraction was better with contrast (r = 0.87 vs r = 0.70). Biases were smaller with contrast for all three parameters (end-diastolic volume, −16 ± 23 vs −36 ± 25 mL; end-systolic volume, −10 ± 16 vs −23 ± 18 mL; ejection fraction, −0.7 ± 5.5% vs −2.7 ± 8.1% of the mean measured values), reflecting improved accuracy. Also, measurement reproducibility was improved by contrast enhancement.


Contrast enhancement improves the visualization of RV endocardial borders, resulting in more accurate and reproducible 3D echocardiographic measurements of RV size and function. This approach may be particularly useful in patients with suboptimal image quality.

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