Contrast Echocardiography (Echo Contrast): Indications, Safety, and Technique

Types of Contrast

Available sources highlight two fundamentally different approaches to contrast echocardiography:

• Ultrasound contrast agents (UCA) based on microbubbles are used to enhance visualization of cardiac structure and function at rest and during stress echocardiography (British Society of Echocardiography, 2023). Microbubbles with a lipid shell are considered contrast agents for echocardiography with described interactions with ultrasound and a safety profile (ASE, cited Raisinghani et al.; Porter et al.).
• Agitated saline is used for detecting right-to-left shunts during transthoracic echocardiography (British Society of Echocardiography, 2026).

Indications

According to the BSE practical guideline (2023), contrast echocardiography is effective for improving the assessment of cardiac structure and function both at rest and during stress echocardiography. The use of UCA in routine echocardiography is recommended to be encouraged where indicated, through the implementation of protocols, training, and the creation of infrastructure for safe administration.

A separate indication is the detection of right-to-left shunts (including patent foramen ovale) using agitated saline (BSE, 2026). Exact diagnostic criteria and thresholds are not provided in the available fragments [to be clarified].

The safety and feasibility of contrast echocardiography for assessing patients with left ventricular assist devices (LVAD), including HeartMate 3, are also described (ASE, 2024, cited Fine et al.; Schinkel et al.).

Safety

The safety of contrast echocardiography with UCA is well documented (BSE, 2023). Safety issues of contrast echocardiography have been reviewed by the ASE committee (Bommer et al., cited in BSE, 2026). The safety and feasibility of the method are confirmed for specific clinical groups, including patients with LVAD (ASE, 2024). Specific contraindications to UCA administration and the frequency of adverse events are not provided in the available fragments [to be clarified].

Technique

Technical aspects of contrast imaging, including contrast-specific modes for Philips and GE systems, are described in the appendix to the BSE practical guideline (2023). Separate ASE recommendations for sonographers on performing contrast echocardiography are available (Porter et al., focused update, 2014). Detailed device setting parameters (mechanical index, modes) are not provided in the available fragments [to be clarified].

When using agitated saline for detecting right-to-left shunts, possible false-negative injections should be considered, characteristics of which are described for patients with patent foramen ovale (Johansson et al., cited in BSE, 2026).