Event Rates for Commonly Performed Event Rates for Commonly Performed Cardiovascular ProceduresCardiovascular Procedures

Procedure Event Rate Event

CoronaryAngiography

1:1000 Death

Exercise TreadmillTesting

1:2500 MI or Death

SPECT Exam orRadionuclideVentriculography

1:1000 to1:10,000

Fatal Malignancy

ContrastEchocardiography

1:500,000 Death

Complete List of Contraindications to Complete List of Contraindications to Ultrasound Contrast AgentsUltrasound Contrast Agents

Right-to-left, bi-directional, or transient right-to-left Right-to-left, bi-directional, or transient right-to-left cardiac shuntscardiac shunts

Worsening or clinically unstable heart failureWorsening or clinically unstable heart failure Acute myocardial infarction or acute coronary syndromesAcute myocardial infarction or acute coronary syndromes Serious ventricular arrhythmias or high risk for Serious ventricular arrhythmias or high risk for

arrhythmias due to prolongation of the QT intervalarrhythmias due to prolongation of the QT interval Respiratory failure, as manifest by signs or symptoms of Respiratory failure, as manifest by signs or symptoms of

carbon dioxide retention or hypoxemiacarbon dioxide retention or hypoxemia Severe emphysema, pulmonary emboli or other Severe emphysema, pulmonary emboli or other

conditions that cause pulmonary hypertension due to conditions that cause pulmonary hypertension due to compromised pulmonary arterial vasculaturecompromised pulmonary arterial vasculature

Hypersensitivity to perflutrenHypersensitivity to perflutren

Complete List of Absolute Complete List of Absolute Contraindications to Cardiac Contraindications to Cardiac

CatheterizationCatheterization

“The only absolute contraindication to cardiac catherization is refusal of a

mentally competent patient to consent to the procedure”

Grossman W. Current practice standards. In: Baim DS and Grossman W, editors. Cardiac Catheterization, Angiography and Intervention. Baltimore, MD: Williams and Wilkins, 1996:9-16

PseudocomplicationPseudocomplication

Complications occurring after anyComplications occurring after any

medical pocedure may be attributable to medical pocedure may be attributable to the procedure itselfthe procedure itself progression of underlying disease state progression of underlying disease state

(pseudocomplication)(pseudocomplication)

PseudocomplicationPseudocomplication

Event -24 hour to cath Cath +72 hour

SAE 0.81% 0.81%

Death 0.24% 0%

Hildner et al. Pseudocomplications of cardiac catherization. Chest 1973;63:15-17

Serious adverse events are relatively common in patients who are “sick enough” to warrant invasive testing

ACC/AHA/ASE 2003 Guidelines Update for the ACC/AHA/ASE 2003 Guidelines Update for the Clinical Application of EchocardiographyClinical Application of Echocardiography

ACC/AHA/ASE 2003 Guidelines Update for the ACC/AHA/ASE 2003 Guidelines Update for the Clinical Application of EchocardiographyClinical Application of Echocardiography

“Echocardiographic contrast agents may improve diagnosis in free wall rupture and in identifying intracardiac thrombus.”

Contrast Echocardiography is Superior to Contrast Echocardiography is Superior to Tissue Harmonics for Assessment of Left Tissue Harmonics for Assessment of Left

Ventricular Function in Mechanically Ventricular Function in Mechanically Ventilated PatientsVentilated Patients

0

10

20

30

40

50

60

70

80

90

Harmonics Contrast

%

Conversion of non-diagnostic to diagnostic study

Kornbluth et al. Am Heart J 2000;140:291-6

Contrast Echocardiography is Superior to Tissue Contrast Echocardiography is Superior to Tissue Harmonics for Assessment of Left Ventricular Harmonics for Assessment of Left Ventricular Function in Mechanically Ventilated PatientsFunction in Mechanically Ventilated Patients

0102030405060708090

100

Fundamental Harmonics Contrast

%

1/5 of mechanically ventilated patients will require TEE if contrast contraindicated

Kornbluth et al. Am Heart J 2000;140:291-6

Wall motion scoring possible

Contrast Echocardiography Clarifies Contrast Echocardiography Clarifies Uniterpretable Wall Motion in Intensive Uniterpretable Wall Motion in Intensive

Care Unit PatientsCare Unit Patients

0

5

10

15

20

25

Fundamental Harmonic Contrast

%

% of patients with uniterpretable left ventricular function

Reilly JP et al. J Am Coll Cardiol 2000;35:485-90

Diagnostic Accuracy and Cost-Effectiveness of Diagnostic Accuracy and Cost-Effectiveness of Contrast Echocardiography on Evaluation of Cardiac Contrast Echocardiography on Evaluation of Cardiac Function in Technically Very Difficult Patients in the Function in Technically Very Difficult Patients in the

Intensive Care UnitIntensive Care Unit

0102030405060708090

100

Fundamental Harmonic Contrast TEE

%

Excellent or Adequate Endocardial Visualization

Yong et al. Am J Cardiol 2002;89:711-718

Complications of Transesophageal Complications of Transesophageal EchocardiographyEchocardiography

Seward JB et al. J Am Soc Echocardiogr 1992;5:228

Complications of Transesophageal Complications of Transesophageal EchocardiographyEchocardiography

Mortality rate = 1/10,000

Daniel WG et al. Circulation 1991;83:17-821