Goal-Directed Fluid Therapy Guided by Cardiac Monitoring During High-Risk Abdominal Surgery in Adult Patients: Cost-Effectiveness Analysis of Esophageal Doppler and Arterial Pulse Pressure Waveform Analysis.

BACKGROUND: Several minimally invasive techniques for cardiac output monitoring such as the esophageal Doppler (ED) and arterial pulse pressure waveform analysis (APPWA) have been shown to improve surgical outcomes compared with conventional clinical assessment (CCA). OBJECTIVE: To evaluate the cost-effectiveness of these techniques in high-risk abdominal surgery from the perspective of the French public health insurance fund. METHODS: An analytical decision model was constructed to compare the cost-effectiveness of ED, APPWA, and CCA. Effectiveness data were defined from meta-analyses of randomized clinical trials. The clinical end points were avoidance of hospital mortality and avoidance of major complications. Hospital costs were estimated by the cost of corresponding diagnosis-related groups. RESULTS: Both goal-directed therapy strategies evaluated were more effective and less costly than CCA. Perioperative mortality and the rate of major complications were reduced by the use of ED and APPWA. Cost reduction was mainly due to the decrease in the rate of major complications. APPWA was dominant compared with ED in 71.6% and 27.6% and dominated in 23.8% and 20.8% of the cases when the end point considered was "major complications avoided" and "death avoided," respectively. Regarding cost per death avoided, APPWA was more likely to be cost-effective than ED in a wide range of willingness to pay. CONCLUSIONS: Cardiac output monitoring during high-risk abdominal surgery is cost-effective and is associated with a reduced rate of hospital mortality and major complications, whatever the device used. The two devices evaluated had negligible costs compared with the observed reduction in hospital costs. Our comparative studies suggest a larger effect with APPWA that needs to be confirmed by further studies.

Focused Cardiac Ultrasound in Place of Repeat Echocardiography: Reliability and Cost Implications.

BACKGROUND: Health care systems are increasingly moving toward models that emphasize the delivery of high-quality health care at lower costs. Rates of repeat echocardiography (two or more transthoracic echocardiographic studies performed within a short interval) are high and can contribute substantially to the cost of providing cardiovascular care. Certain findings from handheld ultrasound scans performed by echocardiographers have been shown to correlate well with findings on transthoracic echocardiography (TTE). It therefore may be feasible and cost effective to use expert focused cardiac ultrasound (eFCU) in place of repeat TTE for highly selected indications in certain settings. The aim of this study was to determine the reliability and cost implications of using eFCU in place of repeat TTE in selected inpatients. METHODS: Inpatients who underwent repeat TTE (prior TTE within 30 days) ordered for the assessment of ventricular function, pericardial effusion, or inferior vena cava collapse were prospectively enrolled. Subjects underwent eFCU in addition to TTE, and results were compared for correlation using the weighted κ statistic. The potential cost savings of using eFCU in place of TTE were modeled from the provider perspective (i.e., physicians and hospitals). RESULTS: Over 45 days, 105 patients were enrolled. The majority of scans were performed for assessment of left ventricular function and pericardial effusions. eFCU showed excellent correlation with TTE for most parameters, including left ventricular systolic function (κ = 0.80) and the presence and size of pericardial effusions (κ = 0.81) (P < .001 for both). Adoption of this eFCU protocol could save between $41 and $64 per study, or between $34,512 and $53,871 annually at the authors' institution. CONCLUSIONS: Findings from eFCU correlate well with those from TTE when used in the setting of repeat testing for assessment of ventricular function, pericardial effusion, and inferior vena cava collapse. The judicious use of eFCU in place of repeat inpatient TTE has the potential to deliver quality cardiac imaging at reduced cost.

Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition.

OBJECTIVES: The purpose of this study was to test the hypothesis that handheld ultrasound (HHU) provides a more accurate diagnosis than physical examination in patients with suspected cardiovascular abnormalities and that its use thus reduces additional testing and overall costs. BACKGROUND: Despite the limitations of physical examination and the demonstrated superiority of HHU for detecting cardiac abnormalities, it is not routinely used for the bedside diagnosis of cardiac conditions. METHODS: Patients referred for a standard echocardiogram for common indications (cardiac function, murmur, stroke, arrhythmias, and miscellaneous) underwent physical examination and HHU by different cardiologists, who filled out a form that also included suggestions for additional testing, if necessary, based on their findings. RESULTS: Of 250 patients, 142 had an abnormal finding on standard echocardiogram. Of these, HHU correctly identified 117 patients (82%), and physical examination correctly identified 67 (47%, p < 0.0001). HHU was superior to physical examination (p < 0.0001) for both normal and abnormal cardiac function. It was also superior to physical examination in correctly identifying the presence of substantial valve disease (71% vs. 31%, p = 0.0003) and in identifying miscellaneous findings (47% vs. 3%, p < 0.0001). Of 108 patients without any abnormalities on standard echocardiography, further testing was suggested for 89 (82%) undergoing physical examination versus only 60 (56%) undergoing HHU (p < 0.0001). Cost modeling showed that HHU had an average cost of $644.43 versus an average cost of $707.44 for physical examination. This yielded a savings of $63.01 per patient when HHU was used versus physical examination. CONCLUSIONS: When used by cardiologists, HHU provides a more accurate diagnosis than physical examination for the majority of common cardiovascular abnormalities. The finding of no significant abnormality on HHU is also likely to result in less downstream testing and thus potentially reduce the overall cost for patients being evaluated for a cardiovascular diagnosis.

Making the financial case for a surgeon-directed critical care ultrasound program.

BACKGROUND: We sought to demonstrate that a well-staffed, surgeon-directed, critical care ultrasound program (CCUP) is financially sustainable and provides administrative and educational support for point-of-care ultrasound. METHODS: The CCUP provides a clinical service and training as well as conducts research. Initial costs, annual costs (C), revenue (R), and savings (S) were prospectively recorded. Using data from the first 3 years, we calculated the projected C, R, and S at 5 years. We determined CCUP sustainability by C < R and C < R + S at 3 years and 5 years. RESULTS: During 36 months, the CCUP covered four surgical intensive care units (55 beds). Start-up costs included one basic and one cardiovascular device per 25 beds and a data storage system linking reports and images to the electronic medical record ($203,650). Billing increased threefold from Years 1 to 3, with a 21% increase between Years 2 to 3. Yearly costs included 0.5 full-time equivalent (FTE) sonographer and 0.2 FTE surgeon ($106,025); this was increased to 1 FTE and 0.25 FTE, respectively, for Years 4 and 5. The total 3-year cost was $521,725 and projected to be $863,325 by Year 5. The total 3-year revenue was $290,775 and projected to be $891,600 at 5 years. The total 3-year savings associated with the CCUP was $600,035 and is projected to be $1,194,220. With the use of the C < R, the CCUP meets operating expenses at Year 3 and covers overall cost at 5 years. If savings are included, then the CCUP is sustainable by its third year and is potentially profitable by Year 5. CONCLUSION: A surgeon-directed CCUP is financially sustainable, addresses administrative issues, and provides valuable training in point-of-care ultrasound.

The diversion of outpatient echocardiography from private offices to higher cost hospital facilities: an unanticipated effect of code bundling.

PURPOSE: In 2009, the add-on codes for spectral Doppler and color flow Doppler echocardiography were bundled into the code for primary transthoracic echocardiography. The relative value units for the new single code were substantially lower than the previous sum for the 3 codes. The purpose of this study was to see how this affected the distribution of outpatient echocardiographic studies between cardiology offices and hospital outpatient departments (HOPDs). METHODS: The 2005 to 2011 Medicare databases were used. All echocardiography Current Procedural Terminology codes were selected. Specialty codes identified those done by cardiologists (who do most echocardiographic studies). Place-of-service codes identified those done in offices and HOPDs. Procedure volumes and utilization rates per 1,000 were determined each year before and after bundling occurred in 2009. RESULTS: Cardiologists' office echocardiography utilization rate rose from 219.5 per 1,000 in 2005 to 257.1 in 2008 (+17%), then dropped to 100.0 in 2009 (-61%) because of bundling. Their HOPD echocardiography rate rose from 72.2 in 2005 to 76.5 in 2008 (+6%), then dropped to 35.0 in 2009 (-54%). From 2009 to 2011, cardiologists' office echocardiography rate dropped again from 100.0 to 88.8 (-11%), while their HOPD rate increased from 35.0 to 46.1 (+32%). CONCLUSIONS: Echocardiography code bundling produced the expected sharp drop in outpatient claims from cardiologists in 2009. But after bundling, office echocardiography rates continued to drop, while HOPD rates increased. It seems that in this instance, code bundling led to the closure of many cardiology offices and a resultant shift of echocardiography from that lower cost setting to the higher cost HOPD setting.

Diagnostic accuracy and cost-effectiveness of a pocket-sized transthoracic echocardiographic imaging device.

BACKGROUND: The recently introduced pocket-sized portable transthoracic echocardiography (pTTE) is accurate for measurement of cardiac chamber size and function as well as for assessment of valvular regurgitation. This study aimed to compare the diagnostic accuracy of the pocket-sized pTTE with the standard TTE (sTTE) and assess its cost-effectiveness. HYPOTHESIS: The use of pocket-sized pTTE, as an initial screening tool, may be feasible, accurate and cost-effective in the diagnostic strategy of cardiac abnormalities. METHODS: The study subjects were 200 patients scheduled for sTTE and an electrocardiogram (ECG). Each patient underwent pTTE examination with the Vscan (GE Medical Systems, Milwaukee, WI) immediately after sTTE. The findings of pTTE and the ECG were compared with the results of sTTE. Cost-effectiveness was calculated. RESULTS: There was a strong agreement in the detection of abnormal findings between pTTE and sTTE (agreement = 90%), whereas the agreement between the ECG and sTTE was 65%. When pTTE or the ECG was used as an initial screening tool prior to sTTE, similar cost reduction was obtained (approximately 30%) by reducing the number of referrals for sTTE. However, the negative predictive value of a diagnostic strategy with pTTE (92%) was superior to that with an ECG (67%). CONCLUSIONS: This study demonstrates that the pocket-sized pTTE provides accurate detection of cardiac structural and functional abnormalities beyond the ECG. In addition, the use of pTTE as an initial screening tool prior to sTTE is cost-effective, suggesting that the pocket-sized pTTE is poised to alter the current diagnostic strategy in clinical practice.

Sex-specific assessment of reduced coronary sinus flow in non-hypertensive patients with coronary artery disease at rest.

BACKGROUND: Access to data on the coronary flow in the coronary sinus (CS) can aid in the diagnosis of coronary artery disease (CAD). We tested the hypothesis that assessing the CS flow by transthoracic Doppler echocardiography (TTE) at rest can detect coronary artery stenosis in non-hypertensive patients. METHODS: The antegrade phase of coronary flow in the CS was analyzed and compared in 140 male and 135 female non-hypertensive subjects who had all undergone coronary angiography. RESULTS: There were statistically significant differences noted between males and females for the CS flow both in normal subjects and patients with CAD. Compared with normal subjects, patients with CAD had significantly lower blood flow in the CS both in males (196.6±174.31 vs. 367.65±168.04 ml/min, P<0.01) and females (183.04±65.46 vs. 244.13±135.43 ml/min P<0.01). For males, the diagnostic sensitivity, specificity, and accuracy of the cutoff value of the CS flow (206 ml/min) for predicting a significant coronary artery stenosis (>70%) were 91.67%, 81.25%, and 85.71%, respectively. For females, those of the cutoff value of the CS flow (195 ml/min) were 85.71%, 75%, and 80%, respectively. CONCLUSION: TTE can effectively detect coronary hemodynamically significant stenosis in non-hypertensive male and female patients at different cutoff values.

Evaluation of different strategies for identifying asymptomatic left ventricular dysfunction and pre-clinical (stage B) heart failure in the elderly. Results from 'PREDICTOR', a population based-study in central Italy.

AIMS: To evaluate the accuracy and cost-effectiveness of different screening strategies to identify systolic and/or diastolic asymptomatic LV dysfunction (ALVD), as well as pre-clinical (stage B) heart failure (HF), in a community of elderly subjects in Italy. METHODS AND RESULTS: A sample of 1452 subjects aged 65-84 years were chosen from the original cohort of 2001 randomly selected residents of the Lazio Region (Italy), as a part of the PREDICTOR survey. All subjects underwent physical examination, biochemistry/NT-proBNP assessment, 12-lead ECG, and Doppler transthoracic echocardiography (TE). Five strategies were evaluated including ECG, NT-proBNP, TE, and their combinations. Subjects older than 75 years, and with at least two additional risk factors, were defined as being high-risk for HF (435), whereas the remaining 1017 were defined at low risk. Screening characteristics and cost-effectiveness (cost per case) of the five strategies to predict systolic (EF <50% ) or diastolic ALVD and pre-clinical HF (stage B) were compared. NT-proBNP was the most accurate and cost-effective screening strategy to identify systolic and moderate to severe diastolic LV dysfunction without a difference between the high-risk and low-risk groups. Adding ECG to the NT-proBNP assessment did not improve the detection of pre-clinical LV dysfunction. TE-based screening was the least cost-effective strategy. In fact, all screening strategies were inadequate to identify stage B HF. CONCLUSIONS: In a community of elderly people, NT-proBNP is the most accurate and cost- effective pre-screening strategy to identify systolic and moderate to severe diastolic LV dysfunction.

[Left ventricular function in patients with chronic heart failure. Practical aspects on echocardiographic timing and structured reports in the out-of-hospital ultrasound laboratory]. / La funzione ventricolare sinistra nel paziente con scompenso cardiaco cronico Spunti di riflessione sulla tempistica e sulla refertazione minima essenziale nell'ambulatorio di ecocardiografia del territorio.

This review addresses some practical aspects of Doppler echocardiography and how to perform it in outpatients with heart failure, in an attempt to make the diagnostic protocols more effective and less expensive for the national healthcare system. This problem comes from the relevant percentage of redundant echocardiographic exams that are irrelevant for the appropriate clinical management. The most important echocardiographic indices to be used for making diagnosis of left ventricular systolic and/or diastolic dysfunction are also discussed. In order to warrant the best quality of the healthcare system, correct timing, performance and structured reports are encouraged even in out-of-hospital echocardiography laboratories, driven by solid scientific knowledge and international guidelines.

Echocardiography, dyssynchrony, and the response to cardiac resynchronization therapy.

Biventricular pacing or cardiac resynchronization therapy (CRT) has been a considerable advance in the therapy of chronic heart failure. However, it is clear that not all patients benefit either in terms of symptoms or cardiac function, and some may be worsened by CRT. In this review, we consider the arguments, both clinical and economical, in favour of improved selection of patients for CRT other than those in current guidelines. It also seems clear that the fundamental mechanism of CRT is correction of dyssynchrony, and we review the various methodologies available to detect dyssynchrony. Other factors are probably also important in determining outcomes such as lead position, the extent and form of myocardial damage, optimizing pacemaker performance, and clinical expertise. The potential costs of inappropriate CRT implantation are high to our patients and to the health economy, and it behooves the cardiology community to develop better selection criteria. The current guidelines can and should be improved.

Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients.

OBJECTIVES: To assess the effectiveness and cost-effectiveness of oesophageal Doppler monitoring (ODM) compared with conventional clinical assessment and other methods of monitoring cardiovascular function. DATA SOURCES: Electronic databases and relevant websites from 1990 to May 2007 were searched. REVIEW METHODS: This review was based on a systematic review conducted by the US Agency for Healthcare Research and Quality (AHRQ), supplemented by evidence from any additional studies identified. Comparator interventions for effectiveness were standard care, pulmonary artery catheters (PACs), pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. Data were extracted on mortality, length of stay overall and in critical care, complications and quality of life. The economic assessment evaluated strategies involving ODM compared with standard care, PACs, pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. RESULTS: The AHRQ report contained eight RCTs and was judged to be of high quality overall. Four comparisons were reported: ODM plus central venous pressure (CVP) monitoring plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs conventional assessment during surgery; and ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment postoperatively. Five studies compared ODM plus CVP monitoring plus conventional assessment with CVP monitoring plus conventional assessment during surgery. There were fewer deaths [Peto odds ratio (OR) 0.13, 95% CI 0.02-0.96], fewer major complications (Peto OR 0.12, 95% CI 0.04-0.31), fewer total complications (fixed-effects OR 0.43, 95% CI 0.26-0.71) and shorter length of stay (pooled estimate not presented, 95% CI -2.21 to -0.57) in the ODM group. The results of the meta-analysis of mortality should be treated with caution owing to the low number of events and low overall number of patients in the combined totals. Three studies compared ODM plus conventional assessment with conventional assessment during surgery. There was no evidence of a difference in mortality (fixed-effects OR 0.81, 95% CI 0.23-2.77). Length of hospital stay was shorter in all three studies in the ODM group. Two studies compared ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment in critically ill patients. The patient groups were quite different (cardiac surgery and major trauma) and neither study, nor a meta-analysis, showed a statistically significant difference in mortality (fixed-effects OR 0.84, 95% CI 0.41-1.70). Fewer patients in the ODM group experienced complications (OR 0.49, 95% CI 0.30-0.81) and both studies reported a statistically significant shorter median length of hospital stay in that group. No economic evaluations that met the inclusion criteria were identified from the existing literature so a series of balance sheets was constructed. The results show that ODM strategies are likely to be cost-effective. CONCLUSIONS: More formal economic evaluation would allow better use of the available data. All identified studies were conducted in unconscious patients. However, further research is needed to evaluate new ODM probes that may be tolerated by awake patients. Given the paucity of the existing economic evidence base, any further primary research should include an economic evaluation or should provide data suitable for use in an economic model.

A comparison of echocardiographic modalities to guide structural heart disease interventions.

Percutaneous techniques to treat structural heart disease are rapidly evolving based on innovative interventions and the considerable advancement in image guidance technology. While two-dimensional transthoracic and transesophageal echocardiography have been integral to procedural planning and execution, intracardiac and three-dimensional echocardiography supply unique visualization of target structures with a potential improvement in patient safety and procedural efficacy. The choice of image guidance modality is based on specific differences between imaging systems, as well as other variables including cost, patient safety, operator expertise, and complexity of procedure. We will compare the adjunctive imaging tools for structural heart disease interventions, with a focus on intracardiac echocardiography and real-time three-dimensional transesophageal echocardiography.

A comparison of cardiologist and noncardiologist use of echocardiograms: implications for containing health care costs.

Echocardiography enables physicians to examine the heart noninvasively and provides a comprehensive evaluation of the cardiovascular system. However, because it is a relatively expensive procedure compared to an ECG or X-ray, it is crucial that "echo" be utilized appropriately and judiciously. Using a retrospective chart review, we sought to determine whether there are differences in concordance between the diagnoses and echo findings of cardiologists and those of other physicians. Due to cardiologists' greater knowledge of cardiophysiology and echocardiography, cardiologists were expected to have a higher concordance between patient diagnosis and echocardiogram findings when compared to noncardiology physicians. Randomly, 500 echo reports were assessed for diagnosis, reason for the echo, and whether the echo findings agreed with the diagnosis. Other criteria that were studied included whether there were additional, unanticipated findings and whether these findings were of major or minor importance. Concordance between cardiologist pre-test diagnosis and echo findings was found in 95 out of 175 tests (54%). Noncardiologist pre-test diagnosis concordance with echo findings was found in 117 out of 325 tests (36%) (p<0.0001). Thus, the c ardiologists were found to have a significantly higher concordance between diagnosis and findings on echocardiogram when compared to noncardiologist physicians.

Comparative cost-effectiveness of B-type natriuretic peptide and echocardiography for predicting outcome in patients with congestive heart failure.

Two-dimensional echocardiographic and Doppler variables and B-type natriuretic peptide (BNP) can predict outcomes in patients with congestive heart failure (CHF). However, there is a paucity of data on the relative cost-effectiveness of these modalities in predicting outcome. One hundred sixteen patients hospitalized with CHF underwent simultaneous BNP and Doppler echocardiographic examinations once ready for discharge. The ability of these variables to determine the primary end point (cardiac death or rehospitalization for CHF) was determined. The cost-effectiveness ratios (CER) of 2-dimensional variables, Doppler indexes, and BNP were calculated for prediction of the primary end point. Follow-up was completed in 110 of 116 patients at a mean of 527 days after hospital discharge. Fifty-four patients (50%) reached the primary end point (37 rehospitalizations for CHF and 17 cardiac deaths). When added to a history of admission to the hospital in the preceding year for CHF, a comprehensive Doppler echocardiographic study predicted 52 of 54 events, with a CER of 729.10 dollars, whereas BNP predicted 47 of 54 events (CER 49.98 dollars; p < 0.001 for CER comparison). In patients admitted to hospitals with CHF, predischarge BNP is more cost-effective than comprehensive Doppler echocardiographic examination for the prediction of future cardiac death or rehospitalization for CHF.

Agitated colloid is superior to saline and equivalent to levovist in enhancing tricuspid regurgitation Doppler envelope and in the opacification of right heart chambers: a quantitative, qualitative, and cost-effectiveness study.

BACKGROUND: Doppler spectrum of tricuspid regurgitation (TR) is used to noninvasively assess right ventricular (RV) pressure. With mild TR, the native (Nat) TR envelope may not allow accurate pressure evaluation. Proprietary contrast agents, such as Levovist (Lev) can be used to augment TR Doppler and opacify right-sided heart chambers, but they are expensive, and their efficacy has not been objectively evaluated in patients with difficult baseline studies or compared with less expensive saline (Sal) or colloid solutions, such as Gelofusine (Gel). METHODS: Twenty-five consecutive patients with poor quality Nat TR envelopes on transthoracic echocardiogram were reexamined after serial intravenous injection of 3 contrast agents (Sal, Gel, and Lev). Doppler signals for each agent recorded on video and digitally on optical disk were assessed for signal quality, estimated RV pressure, interobserver and intraobserver variation, and longevity of signal. Quality of right ventricular-right atrial (RV-RA) opacification was also determined for Sal and Gel. Of the 25 patients, 9 underwent percutaneous right-sided heart catheterization. We used the pressures obtained from the catheterization to independently evaluate the pressure estimates from echocardiography. RESULTS: All 3 contrast agents significantly improved the mean quality grade (grades 0-5) of TR envelopes (Nat 1.12, Sal 1.97, Gel 2.56, Lev 2.41, P <.001), decreased the number of uninterpretable envelopes (grade 0) (Nat 49%, Sal 12%, Gel 4%, Lev 12%, P <.0001 for comparison of each agent relative to Nat), and improved the correlation between echocardiographic and catheter-derived RV-RA pressure measurements (Nat r = 0.65, Sal r = 0.75, Gel r = 0.90, Lev r = 0.88). The persistence of enhanced Doppler signals of interpretable quality (> grade 1) was greater for Lev (15.8 seconds) and Gel (15 seconds) than Sal (7.6 seconds) (P =.002). Opacification of RV and RA, measured as mean luminosity score during 2-dimensional harmonic imaging, was significantly higher for Gel than Sal (92.84 +/- 31.2 vs 56.06 +/- 25.6, respectively; P =.0003). Sal, Gel and Lev, respectively, cost $0.10, $2.50, and $75.00 per study. CONCLUSION: Agitated colloid is a novel, effective, and inexpensive alternative to proprietary agents and saline for the assessment of pulmonary systolic pressure and right-sided heart opacification.

[The best of echocardiography in 1999]. / L'essentiel de 1999 en échocardiographie.

As many techniques of medical investigation, echocardiography regularly benefits from technical innovations which, with application, prove to be extremely useful and, for some of them, even widen the field of investigation. The end of this decade has seen the introduction of major improvements. In daily practice, second harmonic imaging has been the most important technical advance with such improved quality of imaging that this mode has rapidly become the routine for transthoracic investigations in adults. All modern echocardiographs are, or can be, equipped at modest cost. Stress echocardiography, the diagnostic reliability of which is closely related to the quality of the imaging, has greatly benefited from this technique, to the point of obtaining equivalent results as nuclear medicine in the detection of myocardial ischaemia and cellular viability. The results are now sufficiently convincing for the technique to have a real prognostic value in myocardial ischaemia. Doppler tissue imaging is also a major advance but the clinical value is still under evaluation: the pulsed Doppler mode is quantifiable during the investigation, contrary to the calculation of transparietal velocity gradients which requires computerisation techniques not provided by all manufacturers. The regain in interest in contrast echocardiography is due to the development of agents which, injected intravenously, cross the pulmonary capillary barrier and opacify the left heart chambers. The reinforcement of the Doppler signal and improved detection of the endocardial echoes have justified the authorization of their commercialisation, but the essential point is their use in the investigation of myocardial perfusion which is under evaluation. Three-dimensional reconstruction has made great strides but its diffusion is still limited by the limited availability of the required powerful computers.