Contrast echocardiography using ultrasound enhancing agents (UEAs) has become an essential tool for improving diagnostic accuracy, especially when standard imaging is limited. By enhancing blood pool visualization and myocardial perfusion assessment, contrast studies help clinicians move from “limited study” to actionable information in real time.
For sonographers and echo labs, understanding when and how to use UEAs is critical for delivering high-quality cardiac imaging.

There are few moments in echocardiography more frustrating than knowing the answer is probably there… but you just can’t see it clearly. Poor endocardial definition. A hazy apex. A technically limited study that feels unfinished.
This is exactly where contrast echocardiography changes everything.
Ultrasound enhancing agents (UEAs) were designed to do one thing well: make blood visible. And when blood becomes visible, structure, function, and perfusion become easier to interpret. What was once a “limited exam” becomes a study you can confidently stand behind.

What are Ultrasound Enhancing Agents (UEAs)?
UEAs are microbubble-based contrast agents administered intravenously to enhance ultrasound signal within the cardiac chambers and myocardial vasculature.
Key characteristics:

• Remain intravascular (do not cross into interstitium)
• Reflect ultrasound strongly → brighter blood pool signal
• Improve visualization of:
  • Endocardial borders
  • LV cavity
  • Myocardial perfusion
  • Intracardiac masses or thrombus

Common uses include both left ventricular opacification (LVO) and myocardial contrast echocardiography (MCE).

What UEAs actually do
UEAs are microbubble-based agents given intravenously that stay within the vascular space. When exposed to ultrasound, these microbubbles reflect sound waves much more efficiently than blood alone, allowing the cardiac chambers to opacify and the endocardial borders to stand out.
Instead of guessing where myocardium ends and cavity begins, you see it. Cleanly. That clarity impacts everything—wall motion analysis, ejection fraction calculation, thrombus evaluation, and even myocardial perfusion assessment.

When contrast becomes essential
Many echo labs still think of contrast or UEA's as a “backup tool,” but in reality, it often transforms the quality of an exam.
Patients in the ICU, those on ventilators, individuals with challenging body habitus, and post-surgical patients frequently produce suboptimal baseline images. Without contrast, interpretation becomes cautious. With contrast, it becomes confident.
Left ventricular opacification is one of the most common uses. Once the cavity fills homogeneously, the endocardial border becomes unmistakable. Regional wall motion abnormalities become easier to identify. EF measurements become more accurate. And apical thrombus—often missed on non-contrast studies—becomes much more apparent. Echo contrast UEA's also allow us to move beyond anatomy into perfusion. Watching microbubbles replenish after a high-MI “flash” gives insight into microvascular blood flow—something standard echo simply cannot show.

The scanning experience: what it looks like in real time
Contrast imaging is as much about technique as it is about the agent itself.
When everything is optimized, the LV fills smoothly from base to apex. Borders become crisp. Wall motion becomes easier to follow. The study suddenly feels “complete.”
But when technique is off, the image tells you.
Swirling contrast usually means under-dosing or low-flow physiology. Overly bright, dense cavities with shadowing suggest overfilling or excessive gain. The goal sits in the middle: uniform opacification that enhances, not obscures.
Mechanical index plays a critical role here. Low MI preserves the microbubbles and allows continuous visualization. Brief high-MI impulses can intentionally destroy bubbles to evaluate myocardial replenishment. Understanding when to use each approach separates basic use from true contrast proficiency.

Why this matters clinically
Contrast echocardiography isn’t just about image quality—it’s about decision-making.
It helps confirm or rule out thrombus.
It improves EF accuracy.
It strengthens stress echo interpretation.
It reduces the need for additional downstream imaging.
And most importantly, it gives providers confidence in what they’re seeing.
For critically ill patients, that confidence can directly influence management.
For sonographers, it reduces the number of studies that feel incomplete.

Safety and comfort with use
UEAs have a strong safety profile and are used widely across clinical settings, from routine labs to high-acuity care environments. Like any medication, they require monitoring and adherence to protocols, but serious reactions are uncommon.
As familiarity grows, contrast becomes less intimidating and more integrated into routine workflow.

Common Pitfalls
​Overfilling the LV

• Causes attenuation
• Masks apex and far wall

Incorrect MI

• High MI destroys bubbles prematurely

Delayed imaging

• Misses optimal opacification window

Failure to adjust gain

• Leads to poor border definition despite contrast

Technique determines diagnostic value.

The evolution of contrast echo
Contrast echocardiography is no longer reserved for the most difficult studies. Its role continues to expand into myocardial perfusion imaging, structural heart evaluation, and even point-of-care applications. With advances in imaging technology and AI-assisted interpretation, the ability to assess both structure and perfusion at the bedside is becoming increasingly accessible. And for echo labs focused on quality, contrast has become a marker of advanced practice—not last resort imaging.

The real takeaway is that contrast/UEA doesn’t just make images brighter. It makes studies diagnostic. It makes interpretation more confident. It helps sonographers see what they suspected was there all along. Once you become comfortable with UEAs, you start to recognize how many patients benefit from them—and how many answers were previously just out of reach. In modern echocardiography, contrast isn’t an add-on. It’s a tool that helps you finish the story the image is trying to tell.

Download our Ultrasound Enhancing Agent Quick Guide for FREE!

Keep Scanning - 
​Lara Williams, BS, ACS, RCCS, RDCS, RVT, RDMS, FASE

Evaluating the fetal heart requires precision, pattern-recognition, and a deep understanding of normal cardiac anatomy as it evolves throughout gestation. Among the most essential components of any mid-trimester fetal echocardiogram are the Three-Vessel View (3VV) and the Three-Vessel–Trachea View (3VT). These upper mediastinal views provide powerful diagnostic insight, offering clues about outflow tract alignment, great vessel relationships, and congenital heart conditions that may otherwise remain undetected on the four-chamber view alone.
At All About Ultrasound and iHeartEcho™, our goal is to simplify these concepts so sonographers and providers can perform confident, high-quality assessments every time.

Why the 3VV & 3VT MatterWhile the four-chamber view evaluates intracardiac anatomy, the 3VV and 3VT look beyond the heart, assessing the spatial relationship of the pulmonary artery (PA), aorta (Ao), and superior vena cava (SVC). These vessels reveal alignment, caliber, and flow direction — key markers for congenital heart disease.
Abnormalities detected in the 3VV/3VT views often point toward:

• Outflow tract abnormalities
• Conotruncal anomalies
• Aortic arch abnormalities
• Abnormal situs
• Pulmonary artery flow or size abnormalities
• Dextrocardia or mediastinal shift

These views elevate the fetal echo exam from basic screening to true anatomic evaluation.

The Three-Vessel View (3VV)What You Should SeeThe classic normal 3VV demonstrates three vessels arranged from left to right:

1. Main Pulmonary Artery (largest and most anterior)
2. Ascending Aorta (medium size, centrally located)
3. Superior Vena Cava (smallest and rightmost)

Their descending order of size (PA > Ao > SVC) and their horizontal alignment across the upper mediastinum form the foundation of this view.
Normal Sonographic Appearance

• Cross-sectional appearance of each vessel
• Mild size reduction from PA to SVC
• Laminar forward flow on color Doppler
• A smooth “V-shape” taper of the PA transitioning into the ductal arch

The 3VV quickly alerts the sonographer to discrepancies in vessel size, position, or number — red flags for conditions such as transposition, truncus arteriosus, or right-sided aortic arch.

The Three-Vessel–Trachea View (3VT)After the 3VV, a slight cephalad sweep reveals the 3VT — the best view for evaluating the aortic and ductal arches.
What You Should SeeThe hallmark of a normal 3VT is the “V-sign”, where the:

• Aortic arch (Ao)
• Ductal arch (DA)

join and angle leftward, coursing just left of the trachea before descending into the thorax.
On ultrasound, this appears as:

• Two vessels converging into the descending aorta
• Both vessels left of the trachea
• Color Doppler showing uniform, forward flow through both arches

Clinical RelevanceSubtle deviations in the 3VT can indicate:

• Right-sided aortic arch
• Double aortic arch
• Coarctation of the aorta
• Interrupted aortic arch
• Aberrant subclavian artery
• Ductal-dependent lesions
• Tetralogy of Fallot or other conotruncal defects

The 3VT is often the earliest and most reliable clue for arch anomalies.

Common Abnormal Findings — What to Watch For1. Misalignment or Reverse Order of VesselsAorta larger than PA or positioned incorrectly? Think TGA, truncus, or severe outflow obstruction.
2. Absence of the “V-sign”Instead of converging structures, parallel vessels may indicate transposition.
3. Right-Sided Aortic ArchBoth vessels positioned right of the trachea.
4. Size DiscrepancyA significantly smaller aorta suggests coarctation; a small PA suggests pulmonary stenosis or atresia.
5. Additional or Enlarged VesselsMay represent a persistent left SVC, double arch, or venous anomalies.

Tips for Obtaining High-Quality Images

• Start from the outflow tracts and sweep superiorly to ensure continuous anatomic understanding.
• Optimize fetal lie — these views are easiest when the fetal spine is posterior or lateral.
• Use color Doppler judiciously to assess flow without artificially enlarging the vessels.
• Adjust angle and depth to bring the upper mediastinum into optimal focus.
• Review in cine loop to catch subtle dynamic findings.

Final Thoughts  - Mastering the 3VV and 3VT views empowers sonographers to detect congenital heart disease early and accurately. These views are not simply “optional extras” — they are essential components of a comprehensive fetal cardiac screening exam. At All About Ultrasound and iHeartEcho™, we believe that strong anatomical knowledge paired with consistent scanning technique leads to confident, high-quality fetal cardiac evaluation.
​
If your team needs deeper training, hands-on instruction, or fetal echo fundamentals, our educational programs, workshops, registry review and online learning modules are built to support your growth every step of the way. Plus grab FREE CME!

- ​Lara Williams, BS, ACS, RCCS, RDCS, RVT, RDMS, FASE

REFERENCES
Ling LH, Oh JK, Schaff HV et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999;100(13): 1380-6.
Myers RB, Spodick DH. Constrictive pericarditis: clinical and pathophysiologic characteristics. Am Heart J. 1999;138(2 Pt 1):219-32.
Mehta A, Mehta M, Jain AC. Constrictive pericarditis. Clin Cardiol. 1999;22(5):334-44.
Hancock EW. Differential diagnosis of restrictive cardiomyopathy and constrictive pericarditis. Heart. 2001;86(3): 343-9.
Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clinical usefulness. J Am Coll Cardiol. 1997; 29(6):1317-23.
Talreja DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108(15):1852-7.
Rajagopalan N, Garcia MJ, Rodriguez L, et al. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001;87(1):86-94.
Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994;23(1):154-62.
Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989;79(2):357-70.
Oh JK, Tajik AJ, Appleton CP, et al. Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation. Circulation. 1997; 95(4):796-9.
Sengupta PP, Mohan JC, Mehta V et al. Accuracy and pitfalls of early diastolic motion of the mitral annulus for diagnosing constrictive pericarditis by tissue Doppler imaging. Am J Cardiol. 2004;93(7):886-90.
Ha JW, Ommen SR, Tajik AJ, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol. 2004;94(3):316-9.
Garcia MJ, Rodriguez L, Ares M, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol. 1996;27(1):108-14.
von Bibra H, Schober K, Jenni R, et al. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein. Am J Cardiol. 1989;63(7):483-8.
Ha JW, Oh JK, Ling LH, et al. Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis. Circulation. 2001;104(9):976-8.
Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral 'annulus reversus' to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009;10(3):372-5.
Sengupta PP, Mohan JC, Mehta V et al. Doppler tissue imaging improves assessment of abnormal interventricular septal and posterior wall motion in constrictive pericarditis. J Am Soc Echocardiogr. 2005;18(3):226-30.
Sengupta PP, Krishnamoorthy VK, Abhayaratna WP, et al. Disparate patterns of left ventricular mechanics differentiate constrictive pericarditis from restrictive cardiomyopathy. JACC Cardiovasc Imaging. 2008;1(1):29-38.
Circ Cardiovasc Imaging. 2014 May;7(3):526-34. doi: 10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.
American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease (J Am Soc Echocardiogr 2013;26:965-1012.)

So, confused yet? Let's look at the grading parameters a little closer.

Patients that do not have a NORMAL EF, will have a degree of diastolic dysfunction and are evaluated based on filling pressures of the left atrium. Left atrial pressures can be somewhat normal in a patient with Grade 1 diastolic dysfunction, but will increased as this progresses. Patients with Grade 1 diastolic dysfunction will have reduced e' velocities and prolonged deceleration time. 

I can even remember one day when I had seven patients in a row with moderate to severe aortic stenosis. It can certainly be frustrating and time consuming for inexperienced sonographers to have to take additional images and to add on to our study time. Even experienced sonographers must sometimes take a step back and to remember that these patients need that extra time and attention to further the clinical decision making process for the treating physician and to bring answers and solutions to our patients. We are all human and it is easy to look at our schedules and our busy lives and get frustrated when something throws off our plans. However, treating every patient as though they are our own mothers, our fathers and our friends, will help to put our scanning protocols and requirements in the right perspective. This is the reason we do what we do.... patient care. Above all else, our imaging techniques, protocols and scanning skills should be sharpened and enhanced to further benefit the patients we serve. ​

Aortic stenosis is very common in populations over 65 years old and progression of the disease from sclerosis to critical stenosis can take less than 5 years. If you scan in an accredited echo lab, there may be many more additional protocol images to add when assessing aortic stenosis. However, with a few tips and tricks even a very new sonographer can master the art of imaging aortic stenosis and save the frustration of this very common pathology. This is the core of what we do, which is why this is included as a case study requirement for adult echocardiography accreditation through the Intersocietal Accreditation Commission. 

​So let's start with the basics... knowing the anatomy of the valve is important when using descriptions of aortic disease. The valve is comprised of three leaflets:
​• right coronary cusp
• left coronary cusp
​• ​non-coronary cusp

​Another core basic item in evaluation aortic stenosis is the Continuity Equation. Having an understanding of the hemodynamics is really the basis for an understanding of the disease process and echo evaluation of aortic stenosis. The Continuity Equation in it's most basic explanation is conservation of mass.... what goes in MUST come out. 

Also, due to the fact that the continuity equation squares the LVOT diameter, this can significantly introduce errors into the equation if that value is only slightly off or mis-measured. It is critical that the sonographer measure the LVOT very carefully and with attention to detail. According to the American Society of Echocardiography the LVOT should be measured with the following parameters and considerations:

•Inner edge to inner edge convention
•Mid-Systole with aortic valve leaflets open
•Parallel to the aortic valve plane
•Within 0.5–1.0 cm of the valve orifice
•Perpendicular to the axis of flow

Doppler angle and sample placement. What more can I say? This is critical to the mathematics. It is important to place the LVOT Doppler sample at approximately the same location as the LVOT diameter is measured from. The LVOT Doppler waveform should also not show significant valve clicks, otherwise Doppler sample placement is too far into the aortic valve.  ​

​It's important to ensure correct angle THROUGH the aortic valve orifice. In reviewing countless numbers of echo cases through the years for accreditation and quality review, I've seen many aortic valves evaluated incorrectly. 

It is important to place your continuous wave Doppler sample THROUGH the valve orifice and NOT across the valve leaflets. Simple hand maneuvers and tilting the transducer can open up the LVOT and allow for correct Doppler angle through the valve. ​

Now that you have the basics down, there are few extra steps we can do to evaluate aortic stenosis. Protocols should always include evaluation from the suprasternal notch view, and also evaluation with the Pedoff/dedicated continuous wave transducer. Additional Doppler attempts can also be performed in the subcostal view and the high right parasternal view (always ensuring that true valve clicks are obtained on continuous wave Doppler as this ensures the angle is positioned through the valve orifice).

While the pedoff transducer might be scary for some newer sonographers, once you get the hang of it, you'll realize it's really very simple. For the apical approach, start by beginning where you were able to obtain the best apical window of the aortic valve and LVOT. While observing the CW spectral display, listen to the blood flow and isolate one of the typical valve waveform patterns of either the mitral, aortic or tricuspid valves. Remember the aortic valve is in between the two atrioventricular valves so, keep that in mind when adjusting the probe.

When using the suprasternal notch approach, have the patient extend their neck and try to visualize the position of the ascending aorta and direct the face of the probe at a steep downward angle. One important thing to remember is that because there are no images, you must annotate the location on your images. This is required for accreditation and also just a good practice. ​

Let's not forget that high right parasternal view! The best patient positioning for this is right lateral decubitus. The patients' arm should be positioned up and out of the way. 

To STRAIN or not to STRAIN!?! That is the question.....

​So what is strain? There are three fundamental types of strain or deformation: Longitudinal, Radial and Circumferential. During systole, the left ventricle shortens along the longitudinal and circumferential axis, and it thickens in the radial dimension. Of the three, longitudinal strain has been proven to be the most reproducible. It has also been documented to correlate well with clinical outcomes. ​

In summary, strain imaging is a simple tool that can be put to everyday use within your echo lab. Protocols for establishing baseline global longitudinal strain are extremely valuable when evaluating chemo patients for left ventricular function. Strain imaging can be easily incorporated into your daily routine. 

Accreditation Updates: 
What's new with echocardiography accreditation?
The updated IAC Adult Echo Standards were published and went into effect on December 1st. So what do you need to know? The biggest operational change to the standards that will affect your scanning protocols and reporting methods is the requirement of evaluation of left ventricular diastolic function which now must be evaluated through a combination of PW and tissue Doppler techniques. In previous IAC Echo standards, this was an option. It is now a requirement for inclusion in echo scanning protocols. Diastolic function must now also be reported within the final echo report text.

While for some, this may be a significant change to protocols and reporting, for others, this has been incorporated in their daily operations for quite some time. Left Ventricular Diastology can be a hot topic with newly updated diagnostic criteria published in 2016. We have you covered for a quick assessment of diastology according to the updated criteria, use our FREE LV Diastology Analysis Tool. 

Echocardiography Accreditation can certainly be difficult to navigate when there are so many other aspects to running an echo lab that need your attention every day. If you are overwhelmed and need an easy method to simplify your accreditation process and improve quality within your lab, our DIY Accreditation Toolkit can help!

As sonographers, we've all been there... the referring physician enters vague orders because they are just trying to get an echo for their patient and you are left searching for an appropriate indication to perform the echocardiogram. This is unfortunately common place in echo labs across the country. Ultimately ensuring exam appropriateness lies on the shoulders of the sonographer, as we are the last stop before the exam is performed. This leaves the sonographer digging through H&P's trying to come up with something that might meet the criteria and calling the referring physician for clarification on orders. 

With Appropriate Use Criteria becoming a factor for pre-authorization and insurance payment, it is evident that education and ease of access to Appropriate Use Criteria is needed for referring physicians and sonographers. The published standards for appropriateness are detailed and thorough and cover just about every aspect of clinical care and exam indications you may encounter in your day to day routine schedule. However, it can be difficult to navigate the details of the standards and guidelines to quickly determine appropriateness with 7 STATS and 3 TEE's waiting when you walk in the door.

So that's where we come in. Our FREE (yes you read that correctly... FREE) Appropriate Use Criteria analysis tool helps referring physicians and cardiac sonographers quickly get the information they need to determine appropriateness. Just plug in your indications and we do the rest. The corresponding appropriateness level is displayed quickly and easily, saving you time and streamlining patient care.

Whether you need to search this quickly before ordering an echo or you are doing an Appropriate Use Criteria review for accreditation, this can save you time and simplify this once very tedious task. Our simple analysis search tool is free to use. You can find it HERE.

If your facility needs a more detailed report of AUC results for accreditation or internal tracking, our DIY Accreditation Toolkit includes this option with quick data entry and tracking. Also use our DIY Accreditation Toolkit to implement a Quality Improvement Program with tracking of employee and physician Quality Scores. Set a benchmark and track quality in the lab. Identify key areas for training and learning opportunities. Our detailed quality tools will help you set a standard of excellence for your lab.   Learn more about that or start your FREE 7 day trial HERE.

2011 Appropriate Use Criteria
2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease