title: The potential clinical value of contrast-enhanced echocardiography beyond current recommendations.
abstract: BACKGROUND
  Contrast agents are used in resting echocardiography to opacify the left ventricular (LV) cavity and to improve LV endocardial border delineation in patients with suboptimal image quality. If a wider use of contrast-enhanced echocardiography would be adopted instead of the current selective approach, diagnoses such as myocardial ischemia and LV structural abnormalities could potentially be detected earlier. The aim was therefore to retrospectively investigate if contrast-enhanced echocardiography beyond the current recommendations for contrast agent usage affects assessment of wall motion abnormalities, ejection fraction (EF) and detection of LV structural abnormalities. A secondary aim was to evaluate the user dependency during image analysis.
  
  
  METHODS
  Experienced readers (n = 4) evaluated wall motion score index (WMSI) and measured EF on greyscale and contrast-enhanced images from 192 patients without indications for contrast-enhanced echocardiography. Additionally, screening for LV structural abnormalities was performed. Repeated measurements were performed in 20 patients by the experienced as well as by inexperienced (n = 2) readers.
  
  
  RESULTS
  Contrast analysis resulted in significantly higher WMSI compared to greyscale analysis (p < 0.003). Of the 83 patients, classified as healthy by greyscale analysis, 55% were re-classified with motion abnormalities by contrast analysis. No significant difference in EF classification (≥55%, 45-54%, 30-44%, < 30%) was observed. LV structural abnormalities, such as increased trabeculation (n = 21), apical aneurysm (n = 4), hypertrophy (n = 1) and thrombus (n = 1) were detected during contrast analysis. Intra- and interobserver variability for experienced readers as well as the variability between inexperienced and experienced readers decreased for WMSI and EF after contrast analysis.
  
  
  CONCLUSIONS
  Contrast-enhanced echocardiography beyond current recommendations for contrast agent usage increased the number of detected wall motion and LV structural abnormalities. Moreover, contrast-enhanced echocardiography increased reproducibility for assessment of WMSI and EF.
authors.affiliation: Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Alfred Nobels Allé 10, SE-141 52, Huddinge, Sweden. malinl@sth.kth.se.
authors.forename: Malin K
authors.initials: MK
authors.lastname: Larsson
authors.affiliation: Department of Cardiology, Karolinska University Hospital, Hälsovägen B52-54, SE-141 86, Stockholm, Sweden. ctina.silva@gmail.com.
authors.forename: Cristina
authors.initials: C
authors.lastname: Da Silva
authors.affiliation: Department of Cardiology, Karolinska University Hospital, Hälsovägen B52-54, SE-141 86, Stockholm, Sweden. elif.gunyeli@karolinska.se.
authors.forename: Elif
authors.initials: E
authors.lastname: Gunyeli
authors.affiliation: Department of Cardiology, Karolinska University Hospital, Hälsovägen B52-54, SE-141 86, Stockholm, Sweden. ali.akebat-bin-ilami@stud.ki.se.
authors.forename: Ali Akebat Bin
authors.initials: AA
authors.lastname: Ilami
authors.affiliation: Department of Cardiology, Karolinska University Hospital, Hälsovägen B52-54, SE-141 86, Stockholm, Sweden. keszummer@yahoo.se.
authors.forename: Karolina
authors.initials: K
authors.lastname: Szummer
authors.affiliation: Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Alfred Nobels Allé 10, SE-141 52, Huddinge, Sweden. reidar.winter@ds.se.|Department of Cardiology, Karolinska University Hospital, Hälsovägen B52-54, SE-141 86, Stockholm, Sweden. reidar.winter@ds.se.
authors.forename: Reidar
authors.initials: R
authors.lastname: Winter
authors.affiliation: Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Alfred Nobels Allé 10, SE-141 52, Huddinge, Sweden. anna.bjallmark@sth.kth.se.|Department of Molecular Medicine and Surgery, Karolinska Institutet, K1 Klinisk fysiologi, N2:01, SE-171 76, Stockholm, Sweden. anna.bjallmark@sth.kth.se.
authors.forename: Anna
authors.initials: A
authors.lastname: Bjällmark
mesh_terms: D000368:Aged; D003287:Contrast Media; D025401:Echocardiography, Stress / Q000379:methods* / Q000592:standards; D005060:Europe; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods* / Q000592:standards; D007090:Image Interpretation, Computer-Assisted / Q000379:methods* / Q000592:standards; D008297:Male; D015588:Observer Variation; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013318:Stroke Volume; D014481:United States; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging*
chemical_list: D003287:Contrast Media