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Objectives: The aim of this study was to evaluate the impact of echocardiographic contrast utilization on patient diagnosis and management. Background: Contrast echocardiography (CE) has improved visualization of endocardial borders. However, its impact on patient management has not been evaluated previously. Methods: We prospectively enrolled 632 consecutive patients with technically difficult echocardiographic studies who received intravenous contrast (Definity, Lantheus Medical Imaging, Billerica, Massachusetts). Quality of studies, number of left ventricular (LV) segments visualized, estimated ejection fraction, presence of apical thrombus, and management decisions were compared before and after contrast. Results: After CE, the percent of uninterpretable studies decreased from 11.7% to 0.3% and technically difficult studies decreased from 86.7% to 9.8% (p < 0.0001). Before contrast, 11.6 ± 3.3 of 17 LV segments were seen, which improved after CE to 16.8 ± 1.1 (p < 0.0001). An LV thrombus was suspected in 35 patients and was definite in 3 patients before CE. After contrast, only 1 patient had a suspected thrombus, and 5 additional patients with thrombus were identified (p < 0.0001). A significant impact of CE on management was observed: additional diagnostic procedures were avoided in 32.8% of patients and drug management was altered in 10.4%, with a total impact (procedures avoided, change in drugs, or both) observed in 35.6% of patients. The impact of contrast increased with worsening quality of nonenhanced study, the highest being in intensive care units. A cost–benefit analysis showed a significant savings using contrast ($122/patient). Conclusions: The utilization of CE in technically difficult cases improves endocardial visualization and impacts cardiac diagnosis, resource utilization, and patient management. [Copyright &y& Elsevier]