Usefulness of ultrasound contrast for image enhancement during stress echocardiography

Although stress echocardiography has been established as a diagnostic technique for the detection and assessment of ischemia, there are still a number of limitations to the technique. These are related to suboptimal image quality with poor visualization of endocardial borders. Because assessment of wall motion is fundamental to the diagnostic value of stress echocardiography (both pharmacologic and exercise), endocardial border visualization is of utmost importance. Furthermore, interinstitutional observer agreement of 100% in highest image quality patients to a cumbersome 43% in low image quality patients is present. Therefore, improvements of image quality during stress are essential. One of the recent improvements is harmonic imaging, which improves visualization of endocardial borders at rest and during dobutamine stress. However, there is room for improvement. Since the introduction of ultrasound contrast agents, contrast has been increasingly used for better endocardial border visualization. Data from centers with a large number of stress echocardiography tests have shown that the addition of contrast agents decreases the number of more redundant diagnostic testing. Data obtained in our center in a subset of patients administered with SonoVue, a new generation contrast agent made of stabilized microbubbles containing sulfur hexafluoride, an inert gas, showed an improvement in the number of evaluable segments with fundamental and harmonic imaging and in the endocardial border detection during dobutamine stress echocardiography. Contrast also enables future quantitative analysis using acoustic quantification (AQ), and color kinesis. These studies should be carried out now that contrast has been approved for introduction to the market.