BIDMC Contrast Echo Policy
Contrast agents for echocardiography include agitated saline and gas-filled microbubbles
enclosed within a shell (e.g., Definity). The increased reflectivity of blood mixed with these
contrast agents provides for increased echogenicity of cardiac chambers. All current clinical
contrast echo applications are for intravenous administration. Patients should be informed
about all administrations. Written informed consent is not required.
Echo contrast is not routinely used for all studies. Saline contrast is typically used to
assess for a patent foramen ovale/atrial septal defect, intracardiac shunt, or to eccentuate a
tricuspid regurgitation jet. Definity echo contrast administration can be requested by the
sonographer who decides it is necessary to improve the image quality or information provided
by the test. This must then be approved by the staff echo attending or the cardiology fellow.
Agitated saline provides for somewhat larger microbubbles with more varied size. After
intravenous injection, the microbubbles pass through (opacify) the right atrium, the right
ventricle, and become lodged within the pulmonary capillaries where they are absorbed.
Multiple injections are often administered with studies are often performed at rest and with
maneuvers (Valsalva, cough)
Indications for Saline Contrast:
1. Identification/detection of an atrial septal defect
2. Identification/detection of an patent foramen ovale
1. routine in patients with ?cardiac source of embolism <65 yrs
2. Older patients if there is a specific history to suggest a paradoxical
3. Enhancement of tricuspid regurgitation velocity to facilitate quantification of
pulmonary artery systolic pressure
4. Identification/detection of an intrapulmonary shunt
1. A 21g or larger IV should be placed in the patients forearm or
i. Right arm is preferred.
ii. If a central line is in place, use the proximal port.
2. Attach a 10cc pre filled syringe with 10cc of normal saline to a 3-way
stop-cock and IV adapter. Attach an empty 10cc syringe with 1-cc of
air to the other port of the 3-way stop-cock.
3. Fill the 3-way stop-cock with normal saline from the filled syringe and
connect to the patient's IV (using alcohol prior to attachment)
4. Mix the saline and air rapidly back and forth, "bottoming out" the
syringe each time so as to create microbubbles. The mixture will turn
"grey" as the microbubbles are formed.
5. Administer 8-10cc of the agitated saline mixture with each IV push
Newer Generation Microbubbles (Definity):
Contrast agents for ultrasound are gas-filled microbubbles enclosed within a shell. These
microbubbles are often smaller than red blood cells and have the ability to traverse the
pulmonary capillary bed, thereby providing opacification of the left ventricular chamber and
enhancing endocardial border definition. There is growing evidence that when contrast is used
during echocardiography for these indications it has positive impact on accuracy, efficiency
and reproducibility. Currently, our agent of choice is Definity and all machine settings are
calibrated to that product.
The FDA has received reports of deaths and serious cardiopulmonary reactions following the
administration of DEFINITY. Four of the 11 reported deaths were caused by cardiac arrest
occurring during the infusion or within 30 minutes following the administration of DEFINITY.
Most of the serious, but non-fatal reactions also occurred in this time frame.
The FDA has requested that a Boxed Warning and other warnings emphasizing the risk for
serous cardiopulmonary reactions be added to the labeling for these products. Current (5/08)
WARNING: Serious Cardiopulmonary Reactions
Serious cardiopulmonary reactions, including fatalities, have occurred during or
following perflutren-containing microsphere administration.
- Assess all patients for the presence of any condition that precludes
DEFINITY Administration (see CONTRAINDICATIONS)
- In patients with pulmonary hypertension or unstable cardiopulmonary
conditions, monitor vital signs, electrocardiography and cutaneous
oxygen saturation during and for at least 30 minutes after DEFINITY
administration (see WARNINGS)
- Always have resuscitation equipment and trained personnel readily
Revised (5/08) CONTRAINDICATIONS:
DEFINITY is not to be used in the above situations
1. Right-to-left, bi-directional, or transient right-to-left cardiac shunts
2. Hypersensitivity to perflutren (see Warnings).
Serious Cardiopulmonary Reactions
Serious cardiopulmonary reactions, including fatalities have occurred during or following
perflutren-containing microsphere administration. The risk for these reactions may be
increased among patients with pulmonary hypertension or unstable cardiopulmonary
conditions (acute myocardial infarction, actue coronary artery syndromes, worsening or
unstable congestive heart failure, serous ventricular arrhythmias or respiratory failure,
including patients receiving mechanical ventilation). In these patients, monitor vital signs,
electrocardiogrpahy, and cutaneous oxygen saturation during and for at least 30minutes after
DEFINITY administration. In the absence of these underlying conditions, observe patients
closely during and following DEFINITY administration.
All decisions to use DEFINITY must be verbally approved by the echo staff attending or
the cardiology fellow.
Indications for Contrast Enhancement Imaging Agents:
1. Endocardial border definition in patients with technically suboptimal studies
2. Improved definition/evaluation of suspected intracardiac thrombi
3. Myocardial definition for planned septal ablation in HOCM
4. Enhancement of spectral Doppler signals, particularly for AS or TR jets (agitated
saline may be sufficient for the latter).
5. Endocardial border definition in patients with technically suboptimal studies
6. Improved definition/evaluation of suspected intracardiac thrombi, especially apical
Procedure for Cath Lab Ethanol Ablation/HOCM Protocol :
1. DEFINITY should be refrigerated prior to use
2. Mix in vial mixer for pre-set 45 seconds. Hand mixing is not adequate for this
3. Withdraw entire vial contents( 1.3cc) via a 3cc syringe and put in sterile basin
4. Add 8.7 ml of sterile normal saline to the sterile basin.
5. Stir gently
6. Change Application on machine to DEFINITY
7. Preset – automatically reduces MI, changes frequency to 1.7 mHz special slow
frame rate (bow-tie) ., number of beats acquired increased from 2 to 3-4,
And reduces compression/grey levels to increase contrast of image
8. Using a 1ml syringe, 0.5-1.0cc of the diluted Definity mixture is administered
by the interventional cardiologist to visualize septal anatomy..
Procedure for use of Definity in TTE scanning:
1. Definity should be refrigerated prior to use and activated by 45 second
shaking in desk top vial mixer. Hand mixing is not adequate for product
2. DEFINITY Bolus injection
a. Shake 1 bottle of Definity in the vial mixer for 45 sec
b. Get Definity pre-made injection kit from supply closet
2 alcohol swabs
3 saline filled syringes for flush
One 3cc syringe with safety spike
1 orange pkg lever lock cannula connector
c. Withdraw entire contents of vial via a 3cc syringe- - be
careful not to add any air to the vial
d. Hook up 3cc syringe to a 3-way IV stop cock-use the access port closest
to the vein to minimize tubing length . Avoid the port at right angles to the
vein- it creates too much turbulence on injection- use that port for the
e. Change ECHO machine to DEFINITY Preset via Application key.
f. Slowly inject 0.4-0.5cc bolus of DEFINITY
g. Immediately follow this injection with a slow push 10cc of
a. – begin recording as soon as contrast arrives in the LV and the
attenuation artifact has passed
h. If further views needed, re-inject, usually 0.4-0.5cc aliquots,
always followed by 10cc saline “chaser)
Note: If attenuation is seen, the injection rate may have been too rapid;
if swirling is seen, increase the volume of DEFINITY that is injected
3. DEFINITY Continuous Infusion
50cc saline bag
1 vial DEFINITY- activate by shaker mixer 45 sec
4 alcohol wipes
1 lever lock cannula
IV tubing (no filters) (continu-flo solution set)
One 10cc pre-filled saline syringe (to flush IV)
a. Withdraw the contents of 1 vial of activated DEFINITY into a 3cc
syringe and inject the entire contents into a 50cc bag of saline bag. Mix
well by gently squeezing bag
b. Flush existing IV to check line status/patency
c. Run solution through the IV tubing and then connect to patient's IV.
d. Start the initial drip at 4cc/min (1 drip/second)
If attenuation is seen, slow drip rate;
If swirling is seen, increase drip rate.
e. For RESTING echo studies
When ready, simply start drip at 1 drip/second. (Adjust if
necessary) Image. Once done, clamp tubing, detach, and discard
f. For STRESS echo studies:
Once opacification is achieved, clamp IV tubing to stop drip. When
you are ready to capture the next stage, unclamp tubing to re-start drip.
Repeat for each stage. By using this procedure you will not have to re-set
the infusion rate and you can ensure enough agent to complete the study.
This is more crucial for Pharmacologic stress since you only have 50cc and
4 stages to capture.
Alternative Diluted IV Bolus Injection Method
1.3 ml of activated ( shaken) Definity diluted with 8.7 ml saline in a 10 cc syringe.
Initial injection of up to 3cc , slow push
Subsequent injection of 1 to 2cc as needed