title: Quantification of perflutren microsphere contrast destruction during transit through an ex vivo extracorporeal membrane oxygenation circuit.
abstract: BACKGROUND
  Echocardiography is a key investigation in the management of patients on extracorporeal membrane oxygenation (ECMO). However, echocardiographic images are often non-diagnostic in this patient population. Contrast-enhanced echocardiography may overcome many of these limitations but contrast microspheres are hydrodynamically labile structures prone to destruction from shear forces and turbulent flow, which may exist within an ECMO circuit. This study sought to evaluate microsphere destruction (utilising signal intensity as a marker of contrast concentration) during transit through an ECMO circuit.
  
  
  METHODS
  Activated Definity® contrast was diluted to 50 ml with normal saline and infused into a crystalloid primed ex vivo ECMO with a Quadrox oxygenator at 150 ml/h. Imaging was performed on pre- and post-pump head/oxygenator sections of the circuit using a Philips iE33 scanner and S5-1 transducer. Five-millimetre regions of interest were placed in the centre of the ultrasound field. Average signal intensity (decibels) was calculated at speeds of 1000, 2000, 3000 and 4000 rpm and then repeated with an infusion rate of 300 ml/h. The oxygenator was then spliced out of the circuit and the measures repeated.
  
  
  RESULTS
  There was a significant reduction in contrast concentration during passage through the ECMO circuit at all speeds (with higher pump head speeds resulting in greater microsphere destruction). In a circuit with an oxygenator, relative decrease in signal intensity was 21.4 versus 5.2 % without an oxygenator. There was significant destruction of contrast microspheres during passage through the ECMO circuit at all pump head speeds. An oxygenator contributed to microsphere destruction at a significantly greater level than the pump head alone. There was no significant difference in mean signal intensity reduction in the circuit between an infusion of 150 or 300 ml/h (3.5 ± 3.2 versus 3.6 ± 2.5 dB, respectively, p = 0.79).
  
  
  CONCLUSIONS
  Flow of contrast through an ECMO circuit results in significant destruction of microspheres. Circuits with an oxygenator result in significantly greater levels of contrast destruction than by the pump head alone. Clinicians should be cognisant of the relationship between ECMO circuit configurations, pump head speed and contrast destruction when performing a contrast-enhanced echocardiogram in patients supported with ECMO.
authors.affiliation: Department of Echocardiography, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia. dgplatts@hotmail.com.|Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia. dgplatts@hotmail.com.|The University of Queensland, Brisbane, Queensland, Australia. dgplatts@hotmail.com.|Queensland Advanced Heart Failure and Cardiac Transplant Unit, Department of Echocardiography, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia. dgplatts@hotmail.com.
authors.forename: David G
authors.initials: DG
authors.lastname: Platts
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: Charles
authors.initials: C
authors.lastname: McDonald
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.|Adult Intensive Care Service, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: Kiran
authors.initials: K
authors.lastname: Shekar
authors.affiliation: Department of Echocardiography, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.|The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Darryl J
authors.initials: DJ
authors.lastname: Burstow
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.|Adult Intensive Care Service, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: Daniel
authors.initials: D
authors.lastname: Mullany
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.|Adult Intensive Care Service, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: Marc
authors.initials: M
authors.lastname: Ziegenfuss
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: Sara
authors.initials: S
authors.lastname: Diab
authors.affiliation: Critical Care Research Group, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.|The University of Queensland, Brisbane, Queensland, Australia.|Adult Intensive Care Service, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia.
authors.forename: John F
authors.initials: JF
authors.lastname: Fraser
keywords: Contrast echocardiography; Extracorporeal membrane oxygenation; Oxygenator