Prolonged myocardial contrast echocardiography via peripheral venous administration of QW3600 injection (EchoGen): its efficacy and side effects

High-Frequency Ultrasound Activation of Perfluorocarbon Nanodroplets for Treatment of Glaucoma

Elevated intraocular pressure (IOP) is the most prevalent risk factor for initiation and progression of neurodegeneration in glaucoma. Ocular hypertension results from increased resistance to aqueous fluid outflow caused by reduced porosity and increased stiffness of tissues of the outflow pathway. Acoustic activation and resulting bioeffects of the perfluorocarbon (PFC) nanodroplets (NDs) introduced into the anterior chamber (AC) of the eye could potentially represent a treatment for glaucoma by increasing permeability in the aqueous outflow track. To evaluate the potential of NDs to enter the outflow track, 100-nm diameter perfluoropentane (PFP) NDs with a lipid shell were injected into the AC of ex vivo pig eyes and in vivo rat eyes. The NDs were activated and imaged with 18- and 28-MHz linear arrays to assess their location and diffusion. NDs in the AC could also be visualized using optical coherence tomography (OCT). Because of their higher density with respect to aqueous humor, some NDs settled into the iridocorneal angle where they entered the outflow pathway. After acoustic activation of the NDs at the highest acoustic pressure, small gas bubbles were observed in the AC. After two days, no acoustic activation events were visible in the AC of the rats and their eyes showed no evidence of inflammation.

Selective Enhancement of Swine Myocardium with a Novel Ultrasound Enhancing Agent During Transthoracic Echocardiography

Ultrasound enhancing agents are approved to delineate the endocardial border and opacify the left ventricle cavity (LVC). We present a nested phase change agent (NPCA) designed to enable selective myocardial enhancement without enhancing the LVC by employing a dual-activation mechanism dependent on sufficient ultrasound intensity and the microenvironment of the myocardium. Swine received bolus injections of NPCA while echocardiograms were collected and processed to determine background-subtracted acoustic intensities (AI) in the LVC and septal myocardium. At mechanical index (MI) ≥ 0.8, the NPCA enhanced the myocardium selectively (p < 0.001) while the LVC remained at baseline AI. A 5-mL bolus of NPCA enhanced swine myocardium and enhancement persisted for > 5 min at 1.4 MI, while hemodynamics and EKG remained normal. Our findings demonstrate that the NPCA enhances swine myocardium selectively without enhancing the LVC. The NPCA could have utility for functional and structural echocardiographic studies with clinical ultrasound using standard settings.

Therapeutic oxygen delivery by perfluorocarbon-based colloids

After the protocol-related indecisive clinical trial of Oxygent, a perfluorooctylbromide/phospholipid nanoemulsion, in cardiac surgery, that often unduly assigned the observed untoward effects to the product, the development of perfluorocarbon (PFC)-based O₂ nanoemulsions ("blood substitutes") has come to a low. Yet, significant further demonstrations of PFC O₂-delivery efficacy have continuously been reported, such as relief of hypoxia after myocardial infarction or stroke; protection of vital organs during surgery; potentiation of O₂-dependent cancer therapies, including radio-, photodynamic-, chemo- and immunotherapies; regeneration of damaged nerve, bone or cartilage; preservation of organ grafts destined for transplantation; and control of gas supply in tissue engineering and biotechnological productions. PFC colloids capable of augmenting O₂ delivery include primarily injectable PFC nanoemulsions, microbubbles and phase-shift nanoemulsions. Careful selection of PFC and other colloid components is critical. The basics of O₂ delivery by PFC nanoemulsions will be briefly reminded. Improved knowledge of O₂ delivery mechanisms has been acquired. Advanced, size-adjustable O₂-delivering nanoemulsions have been designed that have extended room-temperature shelf-stability. Alternate O₂ delivery options are being investigated that rely on injectable PFC-stabilized microbubbles or phase-shift PFC nanoemulsions. The latter combine prolonged circulation in the vasculature, capacity for penetrating tumor tissues, and acute responsiveness to ultrasound and other external stimuli. Progress in microbubble and phase-shift emulsion engineering, control of phase-shift activation (vaporization), understanding and control of bubble/ultrasound/tissue interactions is discussed. Control of the phase-shift event and of microbubble size require utmost attention. Further PFC-based colloidal systems, including polymeric micelles, PFC-loaded organic or inorganic nanoparticles and scaffolds, have been devised that also carry substantial amounts of O₂. Local, on-demand O₂ delivery can be triggered by external stimuli, including focused ultrasound irradiation or tumor microenvironment. PFC colloid functionalization and targeting can help adjust their properties for specific indications, augment their efficacy, improve safety profiles, and expand the range of their indications. Many new medical and biotechnological applications involving fluorinated colloids are being assessed, including in the clinic. Further uses of PFC-based colloidal nanotherapeutics will be briefly mentioned that concern contrast diagnostic imaging, including molecular imaging and immune cell tracking; controlled delivery of therapeutic energy, as for noninvasive surgical ablation and sonothrombolysis; and delivery of drugs and genes, including across the blood-brain barrier. Even when the fluorinated colloids investigated are designed for other purposes than O₂ supply, they will inevitably also carry and deliver a certain amount of O₂, and may thus be considered for O₂ delivery or co-delivery applications. Conversely, O₂-carrying PFC nanoemulsions possess by nature a unique aptitude for ¹⁹F MR imaging, and hence, cell tracking, while PFC-stabilized microbubbles are ideal resonators for ultrasound contrast imaging and can undergo precise manipulation and on-demand destruction by ultrasound waves, thereby opening multiple theranostic opportunities.

Blood-borne and brain-derived microparticles in morphine-induced anti-nociceptive tolerance

We hypothesized that elevations of microparticles (MPs) would occur with morphine administration to mice. Repetitive dosing to induce anti-nociceptive tolerance increases blood-borne MPs by 8-fold, and by 10-fold in deep cervical lymph nodes draining brain glymphatics. MPs express proteins specific to cells including neutrophils, microglia, astrocytes, neurons and oligodendrocytes. Interleukin (IL)-1β content of MPs increases 68-fold. IL-1β antagonist administration diminishes blood-borne and cervical lymph node MPs, and abrogates tolerance induction. Intravenous polyethylene glycol Telomer B, a surfactant that lyses MPs, and intraperitoneal methylnaltrexone also inhibit MPs elevations and tolerance. Critically, neutropenic mice do not develop anti-nociceptive tolerance, elevations of blood-borne or cervical node MPs. Immunohistochemical evidence for microglial activation by morphine does not correlated with the MPs response pattern. Neutrophil-derived MPs appear to be required for morphine-induced anti-nociceptive tolerance. Further, patients entering treatment for opioid use disorder exhibit similar MPs elevations as do tolerant mice.

Bubble Inflation Using Phase-Change Perfluorocarbon Nanodroplets as a Strategy for Enhanced Ultrasound Imaging and Therapy

Phase-change perfluorocarbon microdroplets were introduced over 2 decades ago to occlude downstream vessels in vivo. Interest in perfluorocarbon nanodroplets has recently increased to enable extravascular targeting, to rescue the weak ultrasound signal of perfluorocarbon droplets by converting them to microbubbles and to improve ultrasound-based therapy. Despite great scientific interest and advances, applications of phase-change perfluorocarbon agents have not reached clinical testing because of efficacy and safety concerns, some of which remain unexplained. Here, we report that the coexistence of perfluorocarbon droplets and microbubbles in blood, which is inevitable when droplets spontaneously or intentionally vaporize to form microbubbles, is a major contributor to the observed side effects. We develop the theory to explain why the coexistence of droplets and microbubbles results in microbubble inflation induced by perfluorocarbon transfer from droplets to adjacent microbubbles. We also present the experimental data showing up to 6 orders of magnitude microbubble volume expansion, which occludes a 200 μm tubing in the presence of perfluorocarbon nanodroplets. More importantly, we demonstrate that the rate of microbubble inflation and ultimate size can be controlled by manipulating formulation parameters to tailor the agent's design for the potential theranostic application while minimizing the risk to benefit ratio.

Fluorous-phase iron oxide nanoparticles as enhancers of acoustic droplet vaporization of perfluorocarbons with supra-physiologic boiling point

Perfluorocarbon emulsion nanodroplets containing iron oxide nanoparticles (IONPs) within their inner perfluorohexane (PFH) core were prepared to investigate potential use as an acoustically activatable ultrasound contrast agent, with the hypothesis that incorporation of IONPs into the fluorous phase of a liquid perfluorocarbon emulsion would potentiate acoustic vaporization. IONPs with an oleic acid (OA) hydrophobic coating were synthesized through chemical co-precipitation. To suspend IONP in PFH, OA was exchanged with perfluorononanoic acid (PFNA) via ligand exchange to yield fluorophilic PFNA-coated IONPs (PFNA-IONPs). Suspensions with various amounts of PFNA-IONPs (0-15% w/v) in PFH were emulsified in saline by sonication, using 5% (w/v) egg yolk phospholipid as an emulsifier. PFNA-IONPs were characterized with transmission electron microscopy (TEM), transmission electron cryomicroscopy (cryoTEM), and thermogravimetric analysis (TGA) with Fourier transform infrared spectroscopy (FTIR). IONP were between 5 and 10 nm in diameter as measured by electron microscopy, and hydrodynamic size of the PFH nanodroplets were 150 to 230 nm as measured by dynamic light scattering (DLS). Acoustic droplet vaporization of PFH nanodroplets (PFH-NDs) was induced using conversion pulses (100 cycle at 1.1 MHz and 50% duty cycle) provided by a focused ultrasound transducer, and formed microbubbles were imaged using a clinical ultrasound scanner. The acoustic pressure threshold needed for PFH-NDs vaporization decreased with increasing temperature and IONP content. PFH-NDs containing 5% w/v IONP converted to microbubbles at 42 °C at 2.18 MI, which is just above the exposure limits of 1.9 MI allowed by the FDA for clinical ultrasound scanners, whereas 10 and 15% emulsion vaporized at 1.87 and 1.24 MI, respectively. Furthermore, 5% IONP-loaded PFH-NDs injected intravenously into melanoma-bearing mice at a dose of 120 mg PFH/kg, converted into detectable microbubbles in vivo 5 h, but not shortly after injection, indicating that this technique detects NDs accumulated in tumors.

Myocardial Contrast Agents – Safety Considerations and Clinical Efficacy in Stress Echocardiography

Transthoracic echocardiographic examination is known to be a safe, non-invasive and reproducible method, used in every day clinical practice to obtain important information about cardiac structure and function. Unfortunately, a significant proportion of studies have highlighted the considerable technically difficultly in producing diagnostic images due to a poor acoustic window and more than 33% of patients undergoing stress echocardiography have suboptimal echocardiographic images. All these limitations have led to the use of contrast agents to improve the quality of standard ultrasound examination to provide a better delineation of left ventricle endocardial borders or to obtain information that cannot be achieved by using standard echocardiography, such as assessing myocardial microcirculation and therefore perfusion. This paper sought to review the clinical efficacy and safety of ultrasound contrast agents focusing on stress echocardiography.

Microparticles Impair Hypotensive Cerebrovasodilation and Cause Hippocampal Neuronal Cell Injury after Traumatic Brain Injury

Endothelin-1 (ET-1), tissue plasminogen activator (tPA), and extracellular signal-regulated kinases-mitogen activated protein kinase (ERK-MAPK) are mediators of impaired cerebral hemodynamics after fluid percussion brain injury (FPI) in piglets. Microparticles (MPs) are released into the circulation from a variety of cells during stress, are pro-thrombotic and pro-inflammatory, and may be lysed with polyethylene glycol telomere B (PEG-TB). We hypothesized that MPs released after traumatic brain injury impair hypotensive cerebrovasodilation and that PEG-TB protects the vascular response via MP lysis, and we investigated the relationship between MPs, tPA, ET-1, and ERK-MAPK in that process. FPI was induced in piglets equipped with a closed cranial window. Animals received PEG-TB or saline (vehicle) 30-minutes post-injury. Serum and cerebrospinal fluid (CSF) were sampled and pial arteries were measured pre- and post-injury. MPs were quantified by flow cytometry. CSF samples were analyzed with enzyme-linked immunosorbent assay. MP levels, vasodilatory responses, and CSF signaling assays were similar in all animals prior to injury and treatment. After injury, MP levels were elevated in the serum of vehicle but not in PEG-TB-treated animals. Pial artery dilation in response to hypotension was impaired after injury but protected in PEG-TB-treated animals. After injury, CSF levels of tPA, ET-1, and ERK-MAPK were all elevated, but not in PEG-TB-treated animals. PEG-TB-treated animals also showed reduction in neuronal injury in CA1 and CA3 hippocampus, compared with control animals. These results show that serum MP levels are elevated after FPI and lead to impaired hypotensive cerebrovasodilation via over-expression of tPA, ET-1, and ERK-MAPK. Treatment with PEG-TB after injury reduces MP levels and protects hypotensive cerebrovasodilation and limits hippocampal neuronal cell injury.

Carbon monoxide inhalation increases microparticles causing vascular and CNS dysfunction

We hypothesized that circulating microparticles (MPs) play a role in pro-inflammatory effects associated with carbon monoxide (CO) inhalation. Mice exposed for 1h to 100 ppm CO or more exhibit increases in circulating MPs derived from a variety of vascular cells as well as neutrophil activation. Tissue injury was quantified as 2000 kDa dextran leakage from vessels and as neutrophil sequestration in the brain and skeletal muscle; and central nervous system nerve dysfunction was documented as broadening of the neurohypophysial action potential (AP). Indices of injury occurred following exposures to 1000 ppm for 1h or to 1000 ppm for 40 min followed by 3000 ppm for 20 min. MPs were implicated in causing injuries because infusing the surfactant MP lytic agent, polyethylene glycol telomere B (PEGtB) abrogated elevations in MPs, vascular leak, neutrophil sequestration and AP prolongation. These manifestations of tissue injury also did not occur in mice lacking myeloperoxidase. Vascular leakage and AP prolongation were produced in naïve mice infused with MPs that had been obtained from CO poisoned mice, but this did not occur with MPs obtained from control mice. We conclude that CO poisoning triggers elevations of MPs that activate neutrophils which subsequently cause tissue injuries.

Microparticles initiate decompression-induced neutrophil activation and subsequent vascular injuries

Progressive elevations in circulating annexin V-coated microparticles (MPs) derived from leukocytes, erythrocytes, platelets, and endothelial cells are found in mice subjected to increasing decompression stresses. Individual MPs exhibit surface markers from multiple cells. MPs expressing platelet surface markers, in particular, interact with circulating neutrophils, causing them to degranulate and leading to further MP production. MPs can be lysed by incubation with polyethylene glycol (PEG) telomere B surfactant, and the number of circulating MPs is reduced by infusion of mice with PEG or antibody to annexin V. Myeloperoxidase deposition and neutrophil sequestration in tissues occur in response to decompression, and the pattern differs among brain, omentum, psoas, and leg skeletal muscle. Both MP abatement strategies reduce decompression-induced intravascular neutrophil activation, neutrophil sequestration, and tissue injury documented as elevations of vascular permeability and activated caspase-3. We conclude that MPs generated by decompression stresses precipitate neutrophil activation and vascular damage.

Current role of contrast echocardiography in the diagnosis of cardiovascular diseases

The use of contrast echocardiography (CE) in cardiovascular medicine has grown significantly over the last 15 years. Depending on the site of injection, contrast enhancement of the right- or left-sided cardiac chambers or myocardium now can be achieved. Contrast echocardiography can improve the evaluation of patients with valvular heart disease by enhancing the Doppler signal; CE also improves detection of intracardiac or intrapulmonary shunts. In patients with coronary artery disease, enhancement of the endocardial blood-tissue boundary allows for improved visualization of endocardial wall motion, assessment of wall thickening, and calculation of ejection fraction. Contrast echocardiography promises to delineate myocardial perfusion and has the potential for quantitating coronary flow and assessing myocardial viability. These applications may add important physiologic information to the anatomic information readily available from noncontrast echocardiography. Because it can be rapidly performed at the bedside, CE may be a valuable tool for use with inpatients with acute myocardial ischemia. When CE has been used after recanalization of occluded coronary arteries, the assessment of myocardial salvage conveys information concerning reflow, stunning, and prognosis, and in the case of an angioplasty it provides immediate information regarding the success of the procedure. Contrast echocardiography can also assess myocardial areas at risk of irreversible damage and the presence or absence of collateral flow. When performed with transesophageal or epicardial echocardiography in the operating room, CE is emerging as a valuable tool in the assessment of cardioplegia distribution and graft patency as well as in the delineation of the regional supply of each graft. With the continued development of newer contrast agents and refinement of ultrasound imaging equipment, the applications of CE will continue to grow.

Advances in myocardial contrast echocardiography and the role of adenosine stress

Advances in contrast echocardiography hold promise for the routine assessment of myocardial perfusion. Continued progress may ultimately position myocardial contrast echocardiography (MCE) as an imaging modality that can provide comprehensive cardiac assessment-anatomic, physiologic, and pathophysiologic. Vasodilator stress with adenosine can play an important role in conjunction with MCE, particularly as it relates to the noninvasive evaluation of myocardial perfusion and coronary blood flow reserve. Adenosine pharmacologic stress testing may provide improved test performance through perfusion detection when compared with traditional use of dobutamine assessments of regional wall motion abnormalities.

Influence of microbubble surface charge on capillary transit and myocardial contrast enhancement

OBJECTIVE

The goal of the study was to determine whether microbubble charge influences the microvascular retention of microbubble contrast agents.

BACKGROUND

Interactions between serum proteins and lipid membranes are greater with anionic compared with neutral membranes. These interactions may influence the microvascular behavior of anionic lipid microbubbles.

METHODS

Intravital microscopy of the cremaster muscle was performed in six wild-type mice and three C3-deficient mice during intravenous injection of lipid-shelled microbubbles with either a neutral or a negative charge. Both agents were prepared with and without a protective surface layer of polyethyleneglycol (PEG). Complement attachment to microbubbles was assessed by flow cytometry with flourescein isothiocyanate-conjugated anti-C3b monoclonal antibody. Myocardial contrast echocardiography was performed in six dogs to assess pulmonary and myocardial retention of microbubbles.

RESULTS

Size-independent capillary retention of microbubbles, occurring for a few seconds to >10 min, was frequently observed with anionic, but rarely with neutral, microbubbles (4.3 +/- 0.3 vs. 0.4 +/- 0.1 mm(-3), p < 0.01). Anionic microbubble retention was reduced by 70% by surface PEG and was also markedly reduced in C3-deficient mice (1.4 +/- 0.1 mm(-3), p < 0.05 vs. wild-type). Flow cytometry demonstrated complement attachment to only anionic microbubbles. Contrast echocardiography indicated both pulmonary and myocardial retention of only anionic microbubbles, the latter evidenced by persistent opacification >10 min after bolus intravenous injection.

CONCLUSIONS

Lipid microbubbles with a net negative charge can be retained within capillaries via complement-mediated attachment to endothelium. This property may be useful for the development of ultrasound contrast agents that can be imaged late after venous injection.

Microvascular rheology of Definity microbubbles after intra-arterial and intravenous administration

The microvascular rheology and extent of pulmonary retention of second-generation microbubble ultrasound contrast agents has not previously been well characterized. We assessed the microvascular behavior of Definity, a lipid-shelled microbubble agent containing perfluoropropane gas, using intravital microscopy of either rat spinotrapezius muscle or mouse cremaster muscle. Immediately after intra-arterial injection, which was performed to model pulmonary retention, larger microbubbles (> 5 microm) were entrapped within small arterioles and capillaries. The retention fraction of microbubbles was low (1.2% +/- 0.1%) and entrapment was transient (85% dislodged by 10 minutes), resulting in no adverse hemodynamic effects. Leukocyte or platelet adhesion at the site of entrapment was not seen. After intravenous injection, no microbubble entrapment was observed and the velocities of microbubbles in arterioles, venules, and capillaries correlated well with those of red blood cells. We conclude that after intravenous injection and pulmonary passage, the microvascular rheology of Definity microbubbles is similar to that of red blood cells. Microbubble entrapment within the pulmonary microcirculation after venous injection should be negligible and transient. These findings are important for establishing the safety of this agent.

Preliminary clinical experience in cardiology with sonazoid

Sonazoid (formerly NC100100) is a new ultrasound contrast agent for intravenous injection developed by Nycomed-Amersham. It consists of perfluorocarbon microbubbles that are stabilized with a surfactant and are within a well-defined size range (median diameter approximately 3 microm). Due to the low diffusibility and blood solubility of the gas, the controlled size distribution of the microbubbles, and the flexibility of the shell, Sonazoid is a free-flowing tracer capable of crossing the pulmonary capillary bed after peripheral intravenous injection. It is stable enough for the duration of the ultrasound examination and provides echo enhancement useful for clinical requirements. The preliminary clinical experience in cardiology indications, including its use in reducing the frequency of inadequate echocardiographic studies in patients with suboptimal echocardiograms, and its use as a myocardial perfusion agent in the setting of acute myocardial ischemia is briefly discussed.

Myocardial perfusion by contrast echocardiography: diagnosis of coronary artery disease using contrast-enhanced stress echocardiography and assessment of coronary anatomy and flow reserve

The advent of intravenous contrast agents, and newer ultrasound technology to enhance their detection, promises to improve and augment our conventional stress echocardiographic practice by improving diagnostic accuracy and providing novel information regarding myocardial perfusion and functional assessment of the coronary vasculature. The combination of intravenous contrast and harmonic stress echocardiography is a powerful tool for improved wall motion analysis through enhanced image quality, routinely permitting the evaluation of patients with suboptimal images. In this era of cost containment, we await studies in large populations addressing resource utilization and cost-effectiveness to determine if, indeed, all patients presenting with stress echocardiography should receive contrast. Myocardial perfusion can be observed using the technique, but the complex interactions of microbubbles and ultrasound in patients must be understood more fully before its implementation becomes routine practice. Non-invasive imaging of coronary arteries using contrast-enhanced transthoracic harmonic echo/Doppler promises to expand the field of diagnostic and experimental echocardiography, bringing new insight into the pathophysiology of ischemic and non-ischemic heart disease. The continued development of newer contrast agents and refinement of ultrasound imaging equipment ensures that the applications of contrast echocardiography in the assessment of CAD will continue to increase.

Contrast echocardiography: current and future applications

Recent updates in the field of echocardiography have resulted in improvements in image quality, especially in those patients whose ultrasonographic (ultrasound) evaluation was previously suboptimal. Intravenous contrast agents are now available in the United States and Europe for the indication of left ventricular opacification and enhanced endocardial border delineation. The use of contrast enables acquisition of ultrasound images of improved quality. The technique is especially useful in obese patients and those with lung disease. Patients in these categories comprise approximately 10% to 20% of routine echocardiographic examinations. Stress echocardiography examinations can be even more challenging, as the image acquisition time factor is critically important for accurate detection of coronary disease. Improvements in image quality with intravenous contrast agents can facilitate image acquisition and enhance delineation of regional wall motion abnormalities at the peak level of exercise. Recent phase III clinical trial data on the use of Optison and several other agents (currently under evaluation) have revealed that for approximately half of patients, image quality substantively improves, which enables the examination to be salvaged and/or increases diagnostic accuracy. For the "difficult-to-image" patient, this added information results in (1) enhanced laboratory efficiency, (2) a reduction in downstream testing, and (3) possible improvements in patient outcome. In addition, substantial research efforts are underway to use ultrasound contrast agents for assessment of myocardial perfusion. The detection of myocardial perfusion during echocardiographic examinations will permit the simultaneous assessment of global and regional myocardial structure, function, and perfusion-all of the indicators necessary to enable the optimal noninvasive assessment of coronary artery disease. Despite the added benefit in improved efficacy of testing, few data exist regarding the long-term effectiveness of these agents. Currently under evaluation are the clinical and economic outcome implications of intravenous contrast agent use for daily clinical decision making in a variety of patient subsets. Until these data are known, this document offers a preliminary synthesis of available evidence on the value of intravenous contrast agents for use in rest and stress echocardiography. At present, it is the position of this guideline committee that intravenous contrast agents demonstrate substantial value in the difficult-to-image patient with comorbid conditions limiting an ultrasound evaluation of the heart. For such patients, the use of intravenous contrast agents should be encouraged as a means to provide added diagnostic information and to streamline early detection and treatment of underlying cardiac pathophysiology. As with all new technology, this document will require updates and revisions as additional data become available.

Flow dynamics of QW7437, a new dodecafluoropentane ultrasound contrast agent, in the microcirculation: microvascular mechanisms for persistent tissue echo enhancement

OBJECTIVES

The purpose of this study was to test the hypothesis that a subgroup of QW7437 microbubbles, dodecafluoropentane-based ultrasound contrast microspheres, resides for prolonged periods in the microvasculature.

BACKGROUND

QW7437 produces echo enhancement in myocardium which may persist relatively longer than opacification in the left ventricular cavity. The mechanism for this persistent enhancement remains unknown.

METHODS

The transit of fluorescently labeled erythrocytes was examined by fluorescence intravital microscopy in the microvessels in five rat mesenteries. Ten rats were used to observe the behavior of fluorescently labeled QW7437 microbubbles in the mesenteric microcirculation.

RESULTS

There was no significant change in erythrocyte velocity in the arterioles and venules after the administration of QW7437 microbubbles (0.05 ml/kg) preactivated by negative hydrodynamic pressure. Of 552 microbubbles observed in four arterioles and five capillaries, 549 (99.5%) passed without stoppage (> or = 0.1 s stoppage); only one stopped transiently in arteriole and two in capillaries, each for <0.5 s. Sixty-five of 478 microbubbles (13.6%) observed in six postcapillary venules 11 to 30 microm in diameter and 24 of 408 microbubbles (5.9%) in four venules 31 to 50 microm in diameter stopped transiently (0.1 to 180 s) with an attachment to venular endothelium; the remaining microbubbles passed through the venules without stoppage.

CONCLUSIONS

Prolonged survival as microbubbles in the circulation and transient stoppage of a subgroup of microbubbles in the microvasculature, particularly in venules, are potential mechanisms for the persistent tissue echo enhancement by QW7437 microbubbles during contrast echocardiography.

Effects of tissue anisotropy and contrast acoustic properties on myocardial scattering in contrast echocardiography

In this study we explored the potential effects that tissue anisotropy, in conjunction with the acoustic properties of contrast, may have on quantitative measurements of myocardial perfusion with the use of ultrasonic contrast agents. We used a computer simulation of the parasternal short-axis view, based on previously measured values for the anisotropy of backscatter and attenuation of myocardium, to predict the backscattered energy from 18 specific regions within the heart before and after myocardial contrast perfusion. Results demonstrated a regional variation of contrast enhancement in the short-axis view and variations caused by incremental increases in contrast level for specific myocardial regions. Thus quantitative assessment of myocardial perfusion with contrast echocardiography is influenced by the anisotropic properties of the myocardium, and the resulting postcontrast image will depend on the interaction between tissue properties and contrast acoustic properties. The degree of myocardial enhancement caused by the presence of contrast may depend on the spatial position of the specific region investigated with respect to the transducer and the amount of contrast in the myocardium.

Persistent opacification of the left ventricle and myocardium with a new echo contrast agent

Echo contrast agents with long survival times open up new fields of application in the investigation of tissue perfusion and cardiovascular function. The purpose of this study was to characterize the time-course of the opacification of the heart cavities and myocardium with a new long-lasting second-generation, phospholipid-based echo contrast agent containing perfluoropentane (BY963-C5F12), and to compare its contrast potency with that of air-filled phospholipid monolayer (BY963-air). Doses of 0.03 mL/kg, 0.08 mL/kg and 0.16 mL/kg of BY963-air and BY963-C5F12 were administered intravenously to six conscious dogs weighing 25-36 kg. A transthoracic echocardiography was performed to evaluate peak intensity and area under the curve (AUC) from regions-of-interest placed in the right ventricle, left ventricle and left ventricular (LV) myocardium using acoustic densitometry. All injections were well tolerated, without wall-motion abnormalities or ECG changes. The LV cavity and myocardium were uniformly and well opacified for both echo contrast agents. However, at all administered doses, the contrast efficacy and duration were much more pronounced using BY963-C5F12 than with BY963-air. For the myocardium, the average peak intensity increased from 11.9+/-2.8 to 15.0+/-2.7 (not significant) following injection of BY963-air and from 12.8+/-3.2 to 18.7+/-2.8 (p < 0.01) following IV administration of BY963-C5F12; the latter corresponding to an increase in myocardial opacification of 46%. In conclusion, these results show the high myocardial opacification of BY963-C5F12 as compared to BY963-air. The simple incorporation of a perfluorocarbon gas into the phopholipid monolayer BY963 instead of air alters the acoustic properties of this contrast agent, resulting in qualitatively different application potentials for tissue opacification.

Clinical applications of transpulmonary contrast echocardiography

BACKGROUND

The recent development of new fluorocarbon-based echocardiographic contrast agents that are capable of opacification of the left-sided cardiac chambers after intravenous injection is a major new advance in diagnostic cardiac imaging.

METHODS AND RESULTS

This is a review article focusing on these novel contrast agents, new echocardiographic imaging techniques to optimize their efficacy, and their clinical applications. Specific clinical applications of these agents are (1) enhancement of endocardial border definition to improve assessment of regional and global left ventricular function, (2) myocardial perfusion imaging by intravenous contrast echocardiography, (3) augmentation of spectral and color flow Doppler images, and (4) tissue-specific targeting of microbubbles for delivery of therapeutic agents.

CONCLUSIONS

New intravenous contrast agents offer the possibility to assess myocardial perfusion echocardiographically. It is also possible to use these agents for delivery of therapeutic agents, including gene therapy.

New ultrasound contrast agents for left ventricular and myocardial opacification

Until recently, the use of contrast agents with 2-dimensional echocardiography has been limited to the detection of intracardiac shunts or abnormal venous connections. The advent of commercially available transpulmonary contrast agents and progress in imaging technology changed this situation. New indications for contrast echocardiography include improved assessment of ventricular function by endocardial border enhancement and the assessment of myocardial perfusion. The major advantage of novel contrast agents is their persistence in circulation, due to the content of a gas that is poorly soluble in plasma or a specific microcapsule wall composition. These features, in conjunction with advanced imaging techniques (intermittent harmonic imaging, harmonic power Doppler, pulse inversion Doppler) allow the detection of minute amounts of the agents in myocardium. There are more than 10 echocardiographic contrast agents undergoing clinical or late preclinical tests. Apart from commercially available Albunex, Levovist, Optison, such agents as EchoGen, Quantison, NC100100 and PESDA have been successfully used in humans. Initial clinical data demonstrating the feasibility of myocardial perfusion studies in patients have been presented for PESDA, Optison, Quantison and NC100100. Early attempts are being made for therapeutic applications of microbubbles, including ultrasound-intensified thrombolysis, tissue targeting and drug delivery. Rapid progress in microbubble technology and imaging techniques has raised a wide interest of the clinicians for contrast echocardiography, which may soon become an established technique for the evaluation of myocardial perfusion, competitive for radionuclide imaging.

New concept in echocardiography: harmonic imaging of tissue without use of contrast agent

BACKGROUND

Endocardial border detection is important for echocardiographic assessment of left-ventricular function. Second harmonic imaging of contrast agents enhances this border detection. We discovered that harmonic imaging improves tissue visualisation even before contrast injection. We therefore sought objectively to demonstrate the degree of enhancement of endocardial and myocardial visualisation.

METHODS

An ATL HDI-3000 scanner with software for contrast harmonic imaging was used to record short-axis images of the left ventricle in 27 patients with possible myocardial disease and 22 controls, in the fundamental mode and with harmonic imaging. A computer program measured the relative grey-scale values within six segments of the endocardium and myocardium. An Acuson Sequoia scanner equipped with software for tissue harmonic imaging was used to investigate the reproducibility of ejection-fraction calculations in 22 patients with ischaemic heart disease.

FINDINGS

Harmonic imaging produced brighter endocardium within each segment. Relative to the mean grey value of the total imaging sector, the values for harmonic and fundamental imaging were 171.5 vs 85.6% (p<0.0001) in end diastole and 194.1 vs 106.7% (p<0.0001) in end systole. Results for the myocardial segments were also significantly better for harmonic imaging. Structure enhancement of similar magnitude was seen among patients and healthy controls. Use of harmonic imaging reduced the proportion of unacceptable images by 14-46% in different views and improved the reproducibility of biplane ejection-fraction measurements.

INTERPRETATION

In comparison with fundamental imaging, the relative endocardial and myocardial brightness is enhanced by harmonic imaging.

Update on myocardial contrast echocardiography: a surgeon's perspective

The ability to evaluate myocardial perfusion and microvascular structural integrity can help surgeons predict the necessity for surgical intervention, the sequence of intraoperative interventions, the risk of perioperative infarction, the likelihood of successful surgical recovery, and the degree of long-term clinical benefit. The ability to directly assess perfusion intraoperatively may allow surgeons to reliably evaluate a patient's myocardial perfusion at any time during the operative procedure. As this article will discuss, surgeons may use myocardial contrast echocardiography intraoperatively to evaluate myocardial function and integrity, to determine the order of graft placement, to determine the success of bypass graft patency, and to help predict those patients who will experience successful cardiac function after recovering from surgery.

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms

OBJECTIVES

This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram.

BACKGROUND

The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration-approved active control.

METHODS

This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators.

RESULTS

Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92).

CONCLUSIONS

This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.

Three-dimensional myocardial contrast echocardiography: validation of in vivo risk and infarct volumes

OBJECTIVES

The aim of this study was to determine whether three-dimensional (3D) myocardial contrast echocardiography (MCE) could provide an accurate in vivo assessment of risk and infarct volumes.

BACKGROUND

MCE has been shown to accurately define risk area and infarct size in single tomographic slices. The ability of this technique to measure risk and infarct volumes by using three-dimensional echocardiography (3DE) has not been determined.

METHODS

Fifteen open chest dogs underwent variable durations of coronary artery occlusion followed by reperfusion. At each stage, MCE was performed by using left atrial injection of AIP201, a deposit microbubble with a mean diameter of 10 +/- 4 microm and a mean concentration of 1.5 x 10(7) x ml(-1). Images were obtained over a 180 degree arc with use of an automated rotational device and were stored in computer as a 3D data set. Postmortem risk area and infarct size were measured in six to eight left ventricular short-axis slices of equal thickness using technetium-99m autoradiography and tissue staining, respectively. MCE images corresponding to these planes were reconstructed off-line.

RESULTS

A close linear relation was noted between the volume of myocardium not showing contrast enhancement on 3D MCE during coronary occlusion and postmortem risk volume (y = 1.2x - 3.0, r = 0.83, SEE = 5.1, n = 15). The volume of myocardium not showing contrast enhancement on 3D MCE after reperfusion also closely correlated with postmortem infarct volume (y = 1.1x - 3.9, r = 0.88, SEE = 4.8, n = 11). No changes in systemic hemodynamic variables were noted with injections of AIP201.

CONCLUSIONS

When combined with AIP201, a deposit microbubble, 3D MCE can be used to accurately determine both risk and infarct volumes in vivo. This method could be used to assess the effects of interventions that attempt to alter the infarct/risk volume ratio.