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Case
Studies
Explore Practical Applications for DEFINITY® Across Multiple Care Settings
Hypothetical patient cases.
The case studies presented herein are for informational purposes only and are not intended to serve as medical advice. Individual patient results and experiences may vary. The information provided is accurate and up to date to the best of our knowledge, and no warranty is made as to its accuracy or completeness.
Case Study: DEFINITY® in the Critical Care Unit
52-year-old man
Patient with diabetes mellitus and a history of drug abuse presented with altered mental status, nausea, and vomiting. He complained of chest discomfort for a few days and was found to have evolving anterior ST-segment changes on an electrocardiogram.
Cardiac enzyme testing showed a normal troponin T level and a slightly elevated CK-MB index suggestive of a recent myocardial infarction.
Case Study: DEFINITY® in the Emergent Care Setting
39-year-old man
Patient presented to the emergency department with chest pain. An electrocardiogram demonstrated an anterior and anterolateral ST-segment depression.
IV nitroglycerin and heparin were initiated, which significantly improved his pain and resolved the ST-segment.
Case Study: DEFINITY® in the Inpatient Setting
84-year-old woman
Patient was admitted to the hospital for congestive heart failure. She presented with chest and abdominal pain, progressive dyspnea, and nausea for 3 days.
Case Study: DEFINITY® in the Outpatient Setting
46-year-old woman
46-year-old woman with a history of hypertrophic cardiomyopathy, with poor cardiology follow-up. Presented with progressively worsening symptoms of congestive heart failure: dyspnea, lower extremity edema, palpitations.
An echocardiogram was performed to evaluate left ventricular wall motion, status post an acute myocardial infarction
Apical 4-chamber
See in High DEF(INITY)® DEF(INITY)®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical 2-chamber
DEFINITY®
Unenhanced
Unenhanced Echo
- Hypokinetic left ventricular segments with suspected thrombus in the apex with a high concern for embolic risk
DEFINITY® Echo
- Hypokinetic left ventricular segments with severely decreased systolic function
- Imaging findings were consistent with suspected thrombus
- DEFINITY® is not indicated for diagnosis or exclusion of left ventricular thrombus
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CK-MB=creatine kinase muscle and brain; LV=left ventricular; MRI=magnetic resonance imaging.
An echocardiogram was performed to evaluate left ventricular wall motion, status post an acute myocardial infarction
Conclusion
- The patient was started on systemic anticoagulation with intravenous heparin and medical therapy was initiated for congestive heart failure
- Contrast-enhanced echocardiography improved visualization of the LV cavity and supported further evaluation of findings suspicious for thrombus
- Cardiomyopathy confirmed the need for ischemic evaluation
- Surgical consultation was initiated for possible thrombolytic therapy vs surgical embolectomy
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CK-MB=creatine kinase muscle and brain; LV=left ventricular; MRI=magnetic resonance imaging.
An echocardiogram was performed STAT for assessment of acute chest pain
Apical 4-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical 2-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical Long Axis
DEFINITY®
Unenhanced
Unenhanced Echo
- Questionable wall motion abnormality in the inferolateral segment
DEFINITY® Echo
- Mid anterolateral, apical lateral, and anterior wall motion abnormalities identified
- Mid-to-distal inferolateral wall motion confirmed
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IV=intravenous; LAD=left anterior descending; PDA=posterior descending artery; PLV=posterolateral vessel; RCA=right coronary artery.
An echocardiogram was performed STAT for assessment of acute chest pain
Conclusion
- Proceeded with an invasive angiogram
- With DEFINITY®, a timely and critical management decision was made, providing the confidence that an invasive procedure was necessary and avoiding further testing and delay of treatment
Cardiac catheterization
- Significant 2-vessel coronary artery disease with 50% proximal stenosis of the LAD, 80% to 90% mid-vessel stenosis of the RCA, followed by 99% stenosis involving the bifurcation of the PDA and PLV
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IV=intravenous; LAD=left anterior descending; PDA=posterior descending artery; PLV=posterolateral vessel; RCA=right coronary artery.
An echocardiogram was performed to assess left ventricular function and to identify the source of the chest pain
Apical 4-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical 2-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical Long Axis
DEFINITY®
Unenhanced
Unenhanced Echo
- Unusual echogenic area within the apex, protruding into the left ventricle
- Ill-determined true nature of an apical abnormality
DEFINITY® Echo
- Left ventricular opacification with DEFINITY® demonstrated contrast filling within the lesion, supporting characterization as a mass and making thrombus less likely
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An echocardiogram was performed to assess left ventricular function and to identify the source of the chest pain
Conclusion
- Metastatic cardiac tumor identified
- Started on anticoagulation and rivaroxaban
- Further diagnostic testing was avoided, allowing for an immediate referral to oncology
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An echocardiogram was performed for congestive heart failure
Apical 4-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical 2-chamber
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Parasternal Long
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Parasternal Short
DEFINITY®
Unenhanced
Unenhanced
Enhanced with DEFINITY®
Apical Long Axis
DEFINITY®
Unenhanced
Unenhanced Echo
- Prominent left ventricular hypertrophy with hyperdynamic left ventricular function
- Asymmetric basal septal hypertrophy with systolic anterior motion of the anterior mitral valve leaflet and small pericardial effusion
DEFINITY® Echo
- Prominent septal left ventricular hypertrophy with hyperdynamic left ventricular function
- Normal lateral wall thickness compared to the unenhanced image
- Prominent basal septal hypertrophy is evident in the parasternal long axis view
- Short axis sweep reveals the geometry of hypertrophic cardiomyopathy, demonstrating a counterclockwise rotation from the basal anterior wall to the distal inferoapical segment
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An echocardiogram was performed for congestive heart failure
Conclusion
- Rare variant of spiral hypertrophic cardiomyopathy identified
- The patient was started on guideline-directed medical therapy to decrease left ventricular contractility and the outflow tract gradient
- An implantable cardioverter-defibrillator was placed due to risk for sudden cardiac death
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References:
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Kurt M, Shaikh KA, Peterson L, et al. Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort. J Am Coll Cardiol. 2009;53(9):802-810.
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Mulvagh SL, Rakowski H, Vannan MA, et al. American society of echocardiography consensus statement on the clinical applications of ultrasonic contrast agents in echocardiography. J Am Soc Echocardiogr. 2008;21(11):1179-1281.
INDICATION:
DEFINITY® is indicated, after activation, for use in adult and pediatric patients with suboptimal echocardiograms to opacify the left ventricular chamber and to improve the delineation of the left ventricular endocardial border.
IMPORTANT SAFETY INFORMATION
BOXED WARNING: SERIOUS CARDIOPULMONARY REACTIONS
Serious cardiopulmonary reactions, including fatalities, have occurred uncommonly during or following perflutren-containing microsphere administration. Most serious reactions occur within 30 minutes of administration.
Assess all patients for the presence of any condition that precludes DEFINITY® administration.
Always have resuscitation equipment and trained personnel readily available.
CONTRAINDICATIONS:
Contraindicated in patients with known or suspected hypersensitivity to perflutren lipid microsphere or its components, such as polyethylene glycol (PEG).
WARNINGS AND PRECAUTIONS:
Serious Cardiopulmonary Reactions have occurred during or following administration. The risk for these reactions may be increased among patients with unstable cardiopulmonary conditions (acute myocardial infarction, acute coronary artery syndromes, worsening or unstable congestive heart failure, or serious ventricular arrhythmias).
Serious Hypersensitivity Reactions have been observed during or shortly following administration including anaphylaxis, with manifestations that may include death. DEFINITY contains PEG and may increase risk of serious reactions including death in patients with prior hypersensitivity reaction(s) to PEG. Clinically assess patients for prior hypersensitivity reactions to products containing PEG. Monitor all patients for hypersensitivity reactions.
Systemic Embolization may occur in patients with a cardiac shunt. Assess patients with shunts for embolic phenomena following administration. DEFINITY is only for intravenous administration and must not be administered by intra-arterial injection.
There is a risk of Ventricular Arrhythmia Related to High Mechanical Index. Additionally, end-systolic triggering with high mechanical indices has been reported to cause ventricular arrhythmias. The maximum recommended mechanical index for use with DEFINITY is 0.8 in adult patients and 0.3 in pediatric patients.
Acute Pain Episodes in Patients with Sickle Cell Disease (SCD) shortly following administration have been reported. Discontinue DEFINITY in SCD patients experiencing new or worsening pain.
ADVERSE REACTIONS:
The most common adverse reactions (≥0.5%) are headache, back/renal pain, flushing, nausea, chest pain, injection site reactions, and dizziness.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch or call 1-800-FDA-1088.
Please see the accompanying full Prescribing Information and important safety information, including BOXED WARNING for serious cardiopulmonary reactions.
DEFINITY® Customer Service 1.800.299.3431
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