Contrast-enhanced ultrasound to evaluate changes in renal cortical perfusion around cardiac surgery: a pilot study

Antoine G Schneider, Mark D Goodwin, Anthony Schelleman, Michael Bailey, Lynne Johnson, Rinaldo Bellomo, Antoine G Schneider, Mark D Goodwin, Anthony Schelleman, Michael Bailey, Lynne Johnson, Rinaldo Bellomo

Abstract

Introduction: Contrast-enhanced ultrasound (CEUS) is a new technique that might enable portable and non-invasive organ perfusion quantification at the bedside. However, it has not yet been tested in critically ill patients. We sought to establish CEUS's feasibility, safety, reproducibility and potential diagnostic value in the assessment of renal cortical perfusion in the peri-operative period in cardiac surgery patients.

Methods: We recruited twelve patients deemed at risk of acute kidney injury (AKI) planned for elective cardiac surgery. We performed renal CEUS with destruction-replenishment sequences before the operation, on ICU arrival and the day following the admission. Enhancement was obtained with Sonovue® (Bracco, Milano, Italy) at an infusion rate of 1 ml/min. We collected hemodynamic parameters before, during and after contrast agent infusion. At each study time, we obtained five video sequences, which were analysed using dedicated software by two independent radiologists blinded to patient and time. The main output was a perfusion index (PI), corresponding to the ratio of relative blood volume (RBV) over mean transit time (mTT).

Results: All 36 renal CEUS studies, including 24 in the immediate post-operative period could be performed and were well tolerated. Correlation between readers for PI was excellent (R2 = 0.96, P < 0.0001). Compared with baseline, there was no overall difference in median PI's on ICU admission. However, the day after surgery, median PI's had decreased by 50% (P < 0.01) (22% decrease in RBV (P = 0.09); 48% increase in mTT (P = 0.04), both suggestive of decreased perfusion). These differences persisted after correction for haemoglobin; vasopressors use and mean arterial pressure. Four patients developed AKI in the post-operative period.

Conclusions: CEUS appears feasible and well-tolerated in patients undergoing cardiac surgery even immediately after ICU admission. CEUS derived-parameters suggest a decrease in renal perfusion occurring within 24 hours of surgery.

Figures

Figure 1
Figure 1
Illustration of destruction-reperfusion sequence. During continuous infusion of the contrast agent, microbubble destruction is obtained by applying pulses at high mechanical index (high ultrasound intensity). Microcirculation replenishment is then observed. All images represent renal contrast-enhanced ultrasonography (CEUS), the left part of the image shows contrast-image mode imaging and the right part the standard (B-mode) image. (a) Immediately after the flash; (b) during replenishment (2 seconds after the flash); (c) at full replenishment (6 seconds after the flash); (d) sequence analysis with Sonotumor®: a region of interest was drawn (yellow line) in the largest possible area of renal cortex closer to the ultrasound probe. The software generates a time intensity curve. This curve is used to generate CEUS-derived parameters.
Figure 2
Figure 2
Bland-Altman plot for inter-observer agreement (perfusion indices). a.u., arbitrary units.
Figure 3
Figure 3
Perfusion indices: individual patients results indexed.
Figure 4
Figure 4
Overall results for perfusion indices.

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