Objective Evidence of Inducible Ischemia in Patients with Ischaemic Heart Disease by Global Longitudinal Strain During Dobutamine Stress Echocardiography

Background: Operator dependent two-dimensional (2D) echocardiography is a noninvasive test to assess myocardial hypokinesia. Inter observer variability is more as it is subjective. Objective evidence of 2D global longitudinal strain (2D GLS) and strain rate imaging are getting popularity. Methods: This cross sectional study was done on 20 patients who came for dobutamine stress echo (DSE) in the department of cardiology of BSMMU, Dhaka from 1st February 2019 to 31st July 2019. 2D GLS was done before and just after DSE. Results: DSE findings revealed 6 patients had viable LAD, 9 had viable LCX and 6 had viable RCA, 9 had nonviable LAD, 2 had nonviable LCX and 3 had nonviable RCA territories. Difference in Post-systolic strain rate (SRps) in myocardial segments supplied by LAD at baseline peak stress in patients who had normal and nonviable LAD (-21% to. -23%, p=0.98) and (-6%to – 7%, p= 2.87) which were not significant. At peak exercise there was a trend towards greater SRps in viable territory of LAD in compared with baseline and peak stress (-1% to -16%, P = 0.05) which was significant. SRps in myocardial segments supplied by LCX at baseline and peak stress in patients who have normal and nonviable LCX (-20% to. -21%, p=0.82) and (-5%to – 5%, p=1.18) which had similar result as LAD territory. At peak exercise there was a trend towards greater SRps in viable territory of LCX compared with baseline and peak stress (-12% to -15%, P = 0.06). There was no significant difference in SRps in myocardial segments supplied by RCA at baseline and peak stress in patients who had normal and nonviable RCA (-23% to. -24%, p=1.72) and (-4%to – 5%, p=2.10). At peak exercise there was a trend towards greater SRps in viable territory of RCA compared with baseline and peak stress (-10% to -15%, P = 0.04). Conclusion: Results of subjective interpretation of DES has compared with objective evidence 2D GLS on peak stress which has similarity. It was a small study. Future large study is needed to establish these findings.

Real World Utility of Dobutamine Stress Echocardiography in Predicting Perioperative Cardiovascular Morbidity and Mortality after Orthotopic Liver Transplantation

BACKGROUND AND OBJECTIVES: Stress echocardiography is the current standard for cardiac risk stratification of patients undergoing orthotopic liver transplantation (OLT). We aim to evaluate the role of dobutamine stress echocardiography (DSE) in predicting perioperative major adverse cardiac event (MACE) in patients undergoing OLT. METHODS: This was a single-center retrospective study including 144 OLT patients. Of 144 patients, 118 had DSE. MACE included myocardial infarction (MI), heart failure (HF), cardiovascular and all-cause death 1 year after OLT. RESULTS: Our study cohort included 118 patients. The mean age was 57.3±8.2 years (range, 25–72 years). There were 85 men and 33 women, male to female ratio being 2.6:1. Of 118, 15 (13%) had positive DSE and 103 (87%) had negative DSE. Perioperative MACE incidence was 5.9% (95% confidence interval [CI], 2.6–12.3%). In predicting MACE, DSE had sensitivity of 5.6% (95% CI, 0.2–29.4%), specificity 86% (95% CI, 77.3–91.9%), positive predictive value 6.7% (95% CI, 0.3–33.4%), and negative predictive value (NPV) 83.5% (95% CI, 74.6–89.8%). Eighteen patients had MACE in first year post OLT (15%, 95% CI, 9.5–23.3%). Adverse events included cardiogenic shock (2/18), systolic HF (2/18), non-ST-elevated MI (7/18), cardiac mortality (3/18), and all-cause mortality (7/18). The overall complication rate of DSE was 17% (20/118). CONCLUSIONS: In our cohort, DSE had a low sensitivity but high NPV in predicting perioperative MACE post OLT. A similar trend was noted for DSE in predicting 1-year MACE post OLT. We reiterate the need of a better screening and risk stratification tool for OLT.

Eff ect of interventional therapy on chronic total occlusion by doubutamine stress echocardiography evaluation / 中国介入心脏病学杂志

Objective To evaluate the effect of percutaneous coronary intervention (PCI) on chronic total occlusion (OCT) by doubutamine stress echocardiography. Methods Forth-six CTO patients were categorized into the reopening group and failed-reopening group based on the results of PCI. All patients had undergoing low dose doubutamine stress echocardiography before PCI and at 6-month follow-up, measuring rest and stress wall motion score index (WMSI) with semi-quantitative method. Cardiac volumes and ejection fraction were measured with 3D full volume echocardiographic. Results The two groups showed no differences in general clinical data and all baseline echocardiography data before PCI. During follow-up, the reopening group was observed to have improvement in ejection fraction[(60.00±3.22)% vs.(62.65±3.58)%,P=0.017)],and WMSI in stress status[(1.42±0.37)vs.(1.32±0.36),P<0.001], compared with pre-PCI results. The reopening group showed improvement in ejection fraction[(62.65±3.58)% vs.(57.7±5.61)%,P=0.001)]and WMSI in stress status[(1.32±0.36)vs.(1.62±0.47),P<0.001)],when compared with the failed-reopening group. Conclusions Low dose doubutamine stress echocardiography can be nsed for evaluation of the eff ect of revascularization of CTO. The cardiac volumes and contractile function representing by wall motion in stress status were improved after recanalization of CTO.

Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women

BACKGROUND: Exercise-stress electrocardiography (ECG) is initially recommended for the diagnosis of coronary artery disease. But its value has been questioned in women because of suboptimal diagnostic accuracy. Stress echocardiography had been reported to have comparable test accuracy in women. But the data comparing the diagnostic accuracy of exercise-stress ECG and stress echocardiography directly are few. The aim of the study was to compare the diagnostic accuracy of exercise-stress ECG and dobutamine stress echocardiography (DSE) in Korean women. METHODS: 202 consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The diagnostic accuracy TET and DSE were calculated by the definition of > 50% or > 75% coronary artery stenosis (CAS). RESULTS: The sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CAS. The higher accuracy of DSE was maintained after exclusion of the patients who could not achieve over 85% age predicted heart rate before ischemia induction. DSE also showed greater diagnostic accuracy than TET by > 75% CAS criteria, and in subsets of patient with intermediate pretest probability. CONCLUSION: In the diagnosis of CAS, DSE showed higher accuracy than TET in female patients who presented with chest pain. As well as the test accuracy, adequate stress was more feasible with DSE than TET. These finding suggests DSE may be used as the first-line diagnostic tool in the detection of CAS in women with chest pain.

Assesment of Myocardial Ischemia by Combination of Tissue Synchronisation Imaging and Dobutamine Stress Echocardiography

BACKGROUND AND OBJECTIVES: Dobutamine stress echocardiography (DSE) is an important non-invasive imaging method for evaluating ischemia. However, wall motion interpretation can be impaired by the experience level of the interpreter and the subjectivity of the visual assessment. In our study we aimed to combine DSE and tissue syncronisation imaging to increase sensitivity for detecting ischemia. SUBJECTS AND METHODS: 50 patients with indications for DSE were included in the study. In 25 patients we found DSE positive for ischemia and in the other 25 patients we found it to be negative. The negative group was accepted as the control group. There was no significant difference in terms of risk factors and echocardiographic parameters between the two groups, except for wall motion scores. In both groups, left ventricular dyssychrony was accepted as the difference between time to peak systolic velocity (Ts) in the reciprocal four couple of non-apical segments at rest and during peak stress. Timings were corrected for heart rate. We compared the differences of the dyssynchronisation value at rest and during peak stress to determine the distinctions within the groups and between the groups of DSE positive and negative patients. RESULTS: We found that stress and ischemia did not create any significant difference over the left intraventricular dyssynchrony with DSE, although at the segmenter level it prolonged the time to peak systolic velocity (p<0.05). These alterations did not show any significant difference between positive and negative DSE groups. CONCLUSION: As a result, this segmenter dyssynchrony and the time to peak systolic velocity, which is corrected for heart rate, did not enhance any new value over DSE for detecting ischemia.

Preditores de viabilidade em pacientes com resposta negativa à ecocardiografia de estresse com dobutamina de baixa dose / Predictors of viability in patients with negative low-dose dobutamine stress echocardiograph / Predictores de viabilidad en pacientes con respuesta negativa a la ecocardiografía de estrés con dobutamina de baja dosis

FUNDAMENTO: A ecocardiografia de estresse com dobutamina de baixa dose é um teste específico para predizer disfunção de contratilidade reversível, mas mesmo assim, sua sensibilidade é menor do que ideal. OBJETIVO: Avaliar os preditores de recuperação miocárdica contrátil após a revascularização, em pacientes sem viabilidade na ecocardiografia de estresse com dobutamina de baixa dose. MÉTODOS: Trinta pacientes consecutivos foram selecionados consecutivamente, que apresentavam estenose coronária/oclusão significantes, tratáveis através de revascularização, anormalidade de motilidade de parede regional na distribuição da artéria afetada e ausência de viabilidade na ecocardiografia de estresse com dobutamina de baixa dose. Os pacientes foram submetidos a estudo de imagem com 99mTc-sestamibi em repouso e então submetidos à revascularização coronária bem sucedida. A ecocardiografia de seguimento foi realizada três meses depois. Os pacientes foram classificados em 2 grupos: grupo 1: com evidência de recuperação miocárdica contrátil após a revascularização na ecocardiografia de seguimento e grupo 2: sem evidência de recuperação miocárdica. Os dois grupos foram comparados em relação aos dados clínicos, ecocardiográficos e cintilográficos. RESULTADOS: A média da idade era 52,3 ± 5,9 anos e 97 por cento eram do sexo masculino. A porcentagem de captação total de 99mTc-sestamibi foi significantemente mais alta no grupo 1 quando comparado ao grupo 2 (p < 0,01) e foi o preditor independente mais forte de recuperação miocárdica contrátil no seguimento de 3 meses na análise de regressão multivariada. A curva ROC (Receiver Operating Characteristic) mostrou que um valor de corte da porcentagem de captação total do 99mTc-sestamibi uptake de 72 por cento, foi o melhor preditor da recuperação miocárdica contrátil, com uma sensibilidade de 100 por cento e especificidade de 95.7 por cento. CONCLUSÃO: Em pacientes sem evidência de viabilidade na ecocardiografia de estresse com dobutamina de baixa dose, a porcentagem de captação total do 99mTc-sestamibi prediz, de forma independente, a recuperação miocárdica contrátil após a revascularização coronária.

BACKGROUND: Low-dose dobutamine stress echocardiography is specific for predicting reversible contractility dysfunction, but its sensitivity is lower than ideal. OBJECTIVE: We sought to explore the predictors of myocardial contractile recovery following revascularization, in patients with no viability by low-dose dobutamine stress echocardiography. METHODS: We prospectively enrolled 30 consecutive patients with significant coronary stenosis/occlusion amenable for revascularization, regional wall motion abnormality in the distribution of the affected artery and absence of viability by low-dose dobutamine stress echocardiography. They underwent resting 99mTc-sestamibi imaging study, and then underwent successful coronary revascularization. Follow-up echocardiography was performed 3 months later. Patients were classified into 2 groups: group 1: with evidence of myocardial contractile recovery after revascularization at follow-up echocardiography and group 2: with no such evidence of recovery. The two groups were compared with respect to patients’ clinical, echocardiographic and scintigraphic data. RESULTS: The mean age was 52.3 ± 5.9 years, with 97 percent being males. The percentage of total 99mTc-sestamibi uptake was significantly higher in group 1 as compared to group 2 (p < 0.01), and it was the strongest independent predictor of myocardial contractile recovery at 3-month follow-up by multivariate regression analysis. Receiver operating characteristics curve revealed that a cutoff value of the percentage of total 99mTc-sestamibi uptake of 72 percent best predicted myocardial contractile recovery, with a sensitivity of 100 percent and specificity of 95.7 percent. CONCLUSION: In patients with no viability by low-dose dobutamine stress echocardiography, the percentage of total 99mTc-sestamibi uptake independently predicted myocardial contractile recovery following coronary revascularization.

FUNDAMENTO: La ecocardiografía de estrés con dobutamina de baja dosis es un test específico para predecir disfunción de contractilidad reversible, pero aun así, su sensibilidad es menor que lo ideal. OBJETIVO: Evaluar los predictores de recuperación miocárdica contráctil después de la revascularización, en pacientes sin viabilidad en la ecocardiografía de estrés con dobutamina de baja dosis. MÉTODOS: Treinta pacientes consecutivos fueron seleccionados consecutivamente, que presentaban estenosis coronaria/oclusión significantes, tratables a través de revascularización, anormalidad de motilidad de pared regional en la distribución de la arteria afectada y ausencia de viabilidad en la ecocardiografía de estrés con dobutamina de baja dosis. Los pacientes fueron sometidos a estudio de imagen con 99mTc-sestamibi en reposo y entonces sometidos a revascularización coronaria exitosa. La ecocardiografía de seguimiento fue realizada tres meses después. Los pacientes fueron clasificados en 2 grupos: grupo 1: con evidencia de recuperación miocárdica contráctil después de la revascularización en la ecocardiografía de seguimiento y grupo 2: sin evidencia de recuperación miocárdica. Los dos grupos fueron comparados en relación a los datos clínicos, ecocardiográficos y de cámara gamma. RESULTADOS: La media de edad era 52,3 ± 5,9 años y 97 por ciento eran del sexo masculino. El porcentaje de captación total de 99mTc-sestamibi fue significativamente más alto en el grupo 1 cuando fue comparado al grupo 2 (p <0,01) y fue el predictor independiente más fuerte de recuperación miocárdica contráctil en el seguimiento de 3 meses en el análisis de regresión multivariada. La curva ROC (Receiver Operating Characteristic) mostró que un valor de corte del porcentaje de captación total del 99mTc-sestamibi uptake de 72 por ciento, fue el mejor predictor de la recuperación miocárdica contráctil, con una sensibilidad de 100 por ciento y especificidad de 95.7 por ciento. CONCLUSIÓN: En pacientes sin evidencia de viabilidad en la ecocardiografía de estrés con dobutamina de baja dosis, el porcentaje de captación total del 99mTc-sestamibi predice, de forma independiente, la recuperación miocárdica contráctil después de la revascularización coronaria.

Dobutamine stress echocardiography for evaluating cirrhotic cardiomyopathy in liver cirrhosis / 대한간학회지

BACKGROUND/AIMS: The blunted ventricular systolic and diastolic contractile responses to physical and pharmacological stress in cirrhosis are termed cirrhotic cardiomyopathy (CCM). CCM has been known to involve multiple defects in the beta-adrenergic signaling pathway. The aim of this study was to determine whether cirrhotic patients have blunted cardiac responses to catecholamine stimulation through dobutamine stress echocardiography (DSE). METHODS: Seventy-one cirrhotic patients with normal left ventricular (LV) chamber size and ejection fraction were enrolled. The LV systolic and diastolic functions were evaluated by two-dimensional and Doppler echocardiography at rest and during peak dobutamine infusion (40 microg/kg/min). An abnormal response was defined as a decrease of less than 10% in LV end-diastolic volume, a decrease of less than 20% in end-systolic volume, and an increase of less than 10% in LV ejection fraction (EF) at peak dobutamine infusion, based on previously used criteria. The early/late diastolic flow (E/A) ratio and diastolic parameters were also measured. RESULTS: A blunted LV response to dobutamine was observed in 18 of 71 cirrhotic patients (25.4%). The baseline EF was significantly higher in 18 patients with a blunted DSE response than that of those with a normal DSE response (P<0.05). The baseline and peak E/A ratios, which are common diastolic dysfunction markers, were higher in the cirrhosis group than in the control group (P<0.001). No adverse events associated with DSE were observed. CONCLUSIONS: Blunted cardiac responses to dobutamine stimulation, which are implicated in defects in the beta-adrenergic signaling pathway, might contribute to the pathogenesis of CCM in patients with cirrhosis.

Comparison Study between Dobutamine Stress Echocardiography Using Real-Time Three Dimensional and Two Dimensional Echocardiography for Diagnosis of Coronary Artery Disease : Dobutamine Stress Echocardiography Using Real-Time Three Dimensional Echocardiogr

BACKGROUND AND OBJECTIVES: Dobutamine stress echocardiography (DSE) with 2D echocardiography (2DE) is one of the time-consuming procedures in the diagnosis of coronary artery disease (CAD). Moreover, the accuracy of DSE with 2DE depends on the operator's skill or bias during the image acquisition. This study was conducted to determine the feasibility and accuracy of DSE with real-time 3D echocardiography (RT3DE) for the diagnosis of CAD. SUBJECT AND METHODS: 62 patients (RT3DE: 36, 2DE: 26), suspected of angina pectoris and post-revascularization ischemia, underwent DSE and coronary angiography (CAG). Image acquisition was performed at the baseline, and at 4 times during the dobutamine infusion and recovery stages. The procedure time (from the baseline to the end of the peak dose stage) was recorded. Off-line analyses of the volumetric images acquired with RT3DE were performed using 3D computer software (TomTec, Co.). Digitized quad-screen images acquired with 2DE were analyzed using the 2DE review system (ProSolv 4.0). >50% luminal diameter stenosis of any coronary artery on CAG was defined as significant coronary artery stenosis. RESULTS: The procedure time of DSE with RT3DE was significantly shorter than that of DSE with 2DE (25+/-4 vs. 37+/-4 mins, p0.05) or specificity (p>0.05) between the two procedures. CONCLUSION: DSE with RT3DE seems to be a feasible and less time consuming diagnostic procedure, probably providing comparable sensitivity and specificity for the detection of coronary artery stenosis, than DSE with 2DE.

Usefulness of Dobutamine Stress Echocardiography for Detecting Restenosis after Coronary Artery Stenting

BACKGROUND AND OBJECTIVES: A noninvasive test with a high predictive value for detecting restenosis is needed to reduce the need for unnecessary coronary angiography. Recently, dobutamine stress echocardiography(DSE) has been shown to be highly sensitive, specific and accurate for the detection of coronary artery disease. No prior study, however, has evaluated its ability to detect restenosis after intracoronary stenting. The aim of this study was to determine the feasibility of DSE for detecting restenosis after intracoronary stenting. METHODS: To determine the feasibility of DSE for detecting restenosis after intracoronary stenting, the results of follow-up coronary angiography and DSE and treadmill exercise test(TMET) were examined in 36 patients(age, 61+/-6 yeas; 22 men) at least 4 months after angiographically successful intracoronary stenting. The DSE and TMET were performed at day 1. Dobutamine was infused with starting at a dose of 10 microgram/kg/min for 3 minutes, and increasing by 10microgram/kg/min every 3 minutes to a maximum of 40microgram/kg/min. In patients not achieving 85% of their age-predicted maximal heart rate, atropine (0.25mg intravenously, repeated up to maximum of 1mg if necessary) was added while the dobutamine infusion was continued. Positive findings for restenosis were defined as new or worsened wall motion abnormality at a previously dilated vascular territories. The coronary angiography was performed at day 2. Restenosis was defined as > or =50% lumen narrowing, determined by quantitative coronary angiography. RESULTS: Restenosis was angiographically demonstrated in 14 lesions(34.1%) of 41 lesions. The sensitivity and specificity of DSE for detecting restenosis was 50%(7/14) and 96.2%(26/27), and positive predictive value was 87.5%(7/8), negative predictive value was 78.8%(26/33), respectively. When restenosis was defined as > or =60% lumen narrowing, the sensitivity and specificity of DSE for detecting restenosis was 66.7%(6/9) and 96.9%(31/32), respectively. The target lesion revascularization rate(TLR) was 17%(7/41). The sensitivity of DSE for determining TLR was 85.7% (6/7) and specificity was 97.0%(33/34). CONCLUSION: It is concluded that DSE has a moderate sensitivity and high specificity for detecting restenosis after intracoronary stenting. DSE may be a useful diagnostic modality for determining target lesion revascularization of restenotic lesion but further studies are needed.

Significance of Left Ventricle Chamber Obliteration in Dobutamine Stress Echocardiography

BACKGROUND: LV chamber obliteration(COB) during dobutamine stress echocardiography indicates a vigorous inotropic response to dobutamine stress. This may suggest the absence of coronary artery disease, but a small LV cavity may also preclude recognition of wall motion abnormalities. METHODS: Chamber obliteration was defined by contact of the opposite walls in the apical 4 chamber views during dobutamine stress echocardiography. To detect of chamber obliteration and coronary artery disease, dobutamine stress echocardiography was performed in 132 patients with chest pain. To confirm of coronary artery disease, coronary angiography was performed in 64 patients among 132 patients. RESULTS: 1) Chamber obliteration during dobutamine stress echocardiography occurred in 37 patients(28%) among 132 patients. 2) Chamber obliteration during dobutamine stress echocardiography was more common in patients with hypertension(p<0.05) and left ventricular hypertrophy during baseline echocardiography(p<0.005). 3) Coronary angiography was performed in 64 patients(48 patients without chamber obliteration, 16 patients with chamber obliteration). The sensitivity of dobutamine stress echocardiography in the diagnosis of coronary artery disease was 88% in patients without chamber obliteration, 71% in patients with chamber obliteration. But, the difference of sensitivity of both groups was not significant. CONCLUSION: These results suggest that chamber obliteration during dobutamine stress echocardiography will not affect results of the sensitivity of dobutamine stress echocardiography in the diagnosis of coronary artery disease.

Comparison of Dobutamine Echocardiography and Thallium Scan in Assessment of Viable Myocardium After Acute Myocardial Infarction

BACKGROUND: It is clinically important to evaluate myocardial viability after acute myocardial infarction. There are several methods like dobutamine stress echocardiography (DSE) and thallium scan to identify viable myocardium. Thallium SPECT assesses cellular integrity and dobutamine stress echocardiography assesses contractile reserve of myocardium. METHODS: Between March and August 1995, 30 consecutive patients (27 men and 3 women; mean age 52+/-12years) within 3 weeks after acute myocardial infarction were admitted to Asan Medical Center. Each underwent two-dimensional echocardiography before and during dobutamine infusion 8.6+/-6.5 days after acute myocardial infarction and thallium scan with rest-redistribution or stress-redistribution-reinjection protocol 8.1+/-6.4 days after acute myocardial infarction. Viability myocardium was considered if there were improvement in regional wall motion during dobutamine infusion (5, 10mg/kg/min for 5min and 20, 30mg/kg/min for 3min), With thallium SPECT, myocardial viability was considered if regional wall motion was normal, if perfusion defect, were either completely or partial mildly reversible, or if myocardial perfusion decreasedly or moderately and if irreversible perfusion was defect. Follow-up echocardiography was performed 3+/-1 months after acute myocardial infarction. Recovery of regional function was identified when follow-up echocardiography showed improvement of wall motion. We evaluated the accuracy of dobutamine stress echocardiography and thallium scan by concordant interpretation in acute and follow-up studies. RESULTS: Among the enrolled 30 patients, 27 patients had Q-wave MI. Thrombolysis was performed in 17 patients (57%) and PTCA was done in 18 patients (60%). The location of myocardial infarction wall in 20 patients and the inferior and lateral wall in 10 patients. Dobutamine stress echocardiography was performed safely in 30 patients 8.6+/-6.5 days after acute myocardial infarction. Improved wall motion was apparent in 15 patients (50%) after follow-up echocardiography 3+/-1 months after acute myocardial infarction. The positive and negative predictive values of dobutamine stress echocardiography were 14/17 (82%) and 12/13 (92%), respectively. Thallium SPECT was done in 26 patients 8.1+/-6.4 days after acute myocardial infarction. Among these 26 patients, follow-up echocardiography showed improved wall motion in 12 patients. The positive and negative predictive values of thallium SPECT were 9/10 (90%) and 13/16 (80%), respectively. Positive dobutamine stress echocardiography (r=0.46, p=0.001), positive thallium SPECT (r=0.44, p=0.003), hypokinetic segments (p=0.01) and non-anterior MI (p=0.02) were associated with reversible postischemic dysfunction. CONCLUSION: Dobutamine stress echocardiography (DSE) can be safely performed early after acute myocardial infarction. Both dobutamine stress echocardiography and thallium SPECT are reliable and complementary methods to diagnose viable myocardium.

Hemodynamic Responses during Dobutamine Stress Echocardiography according to Stage Duration in Normals

BACKGROUND: The 3 minutes increment of dobutamine dose protocol is most commonly used method in dobutamine stress echocardiography (DSE). But the precise hemodynamic response to dobutamine dosage and its difference by extending stage duration have not been well elucidated. MATERIALS AND METHOD: Nineteen healthy voluntary subjects with a mean age of 23.9+/-4.7 years were included. All subjects underwent 3-minutes incremental and 5-minnutes incremental protocol of DSE at random order in a same day. Heart rate, blood pressure, stroke volume, fractional shortening, rate-pressure product and cardiac output were measured every 3 minutes in 3-min protocol of DSE. In 5-min protocol, same variables were measured at 3 minutes of each stage as well as at 5 minutes. RESULTS: 1) Heart rate did not increase until 10 microgram/kg/min dose and increased thereafter by increment of dobutamine dose. 2) Fractional shortening and stroke volume increased markedly from the 5 microgram/kg/min until 20 microgram/kg/min dose and showed slow increase or plateau at a higher dobutamine dose. 3) Systolic blood pressure, cardiac output and rate-pressure product increased continuously from initial dose to maximal dose. 4) Although by extending stage duration to 5 minute in 5-min protocol produced greater hemodynamic effects than those measured at 3 minutes of each stage, there were no significant difference in the results of 3-min and 5-min protocol of DSE. CONCLUSION: The increase of cardiac contractility most contributed to increase of cardiac output until 20microgram/kg/min dose and the increase of herat rate contributed dominantly thereafter, thus the hemodynamic variables showed different responses to increment of dobutamine dose. There were no significant difference in hemodynamic effects between the two protocols. So it is considered that 3-min protocol of DSE gives similar hemodynamic information as 5-min protocol and is more time-saving method.

Usefulness of Dobutamine Stress Echocardiography for Identification of Viable Myocardium in Acute Myocardial Infarction

BACKGROUND: In patients with acute myocardial infarction(MI), dysfunctional myocardium at rest after successful reperfusion may represent either necrotic or viable myocardium. And the latter can be recovered contractility after revascularization or medication. OBJECTIVE: To evaluate the efFectiveness of the dobutamine stress echocardiography(DSE) for identifying viable but dysfunctional myocardium in acute MI before revascularization. METHOD: Twelve patients with acute MI after thrombolytic therapy underwent Tc-99m-tetrofosmin dipyridamole myocardial SPECT(Single Photon Emission Computed Tomography) and DSE before coronary angiography in 7~12 hospital days, and they were followed up for recovery of contractile reserve by two-dimensional echocardiography after revascularization procedure or medication. Regional wall motion abnorrnality was scored from l(normal) to 4(dyskinesia). Dobutamine responsiveness was defined as irnprovement or aggravation of regional wall motion in dyssynergic segment during any stage of dobutamine infusion. Reversible ischemia by SPECT was defined as increased perfusion defect after dipyridamole and interpreted by radiologist. Dobutamine responsiveness on DSE and reversible ischemia on myocardial SPECT were matched and compared each other. RESULTS: Of 69 dyssynergic segments, 38(55%) recovered contractility during follow up echocardiography after revascularization or medication. In 30(79%, sensitivity) of these latter segments, regional wall motion had changed during dobutamine. However, 31(45%) did not recovered contractility and 25(81%, specificity) of thern had not changed during dobutamine. Of 36 dobutamine responsive dyssynergic segments, 30(83%, positive predictive accuracy) had recorved contractility. In 25(76%, negative predictive accuracy) of 33 dobutamine non-responsive segments had not recovered contractility. Reversible ischemia on myocardial SPECT showed less sensitive(67%) and specific(56%) for detection of potentially recoverable myocardium than DSE. And positive(68%) and negative predictive accuracy(56%) also showed significantly lower than DSE. CONCLUSION: DSE can identify dyssynergic but recoverable myocardial segement for risk stratification before intervention in acute MI. Dobutamine responsiveness of dyssynergic segment is superior to reversible ischemia on myocardial SPECT for prediction of wall motion improvement after MI irrespective of intervention or medical therapy.

Usefulness of Dobutamine Stress Echocardiography for Assessment of cardiac Risk before Noncardiac Surgery

BACKGROUND: Two-dimensional echocardiography performed during incremental infusion of dobutamine has been shown to be a safe and accurate method for detection of coronary artery disease in patients who are unable to undergo conventional exercise testing. A significant proportion of these patients are referred for evaluation before undergoing noncardiac surgery. METHOD: To assess the value of dobutamine stress echocardiography(DSE), for assessment of preoperative cardiac risk, 88 patients (male : 32, female : 56, mean age : 60 years) were evaluated. patients records were reviewed to determine the short-term outcome of surgery. significant cardiac events were defined as unstable angina, myocardial infarction and sudden cardiac death occurred before discharge. Intravenous dobutamine was infused in a graded fashion (10 to 45µg/kg/min in 3 minutes stages), with two-dimensional echocardiographic monitoring of segmental wall motion of left ventricle. RESULTS: 1) The major reasons underwent dobutamine stress echocardiography were abnormalities of ECG such as ST-T changes, abnormal Q wave(65% : 64 of 98 patients) and history of coronary artery disease(29% : 28 of 98 patients). 2) Of the 88 patients who underwent noncardiac surgery, 85(97%) patients were negative response in dobutamine stress echocardiography, and no patients had cardiac events, also 3(3%) patients who had positve response did not occur cardiac events. 3) No major adverse effects occurred with stress test in any patient. CONCLUSION: These results suggest that DSE is useful preoperative diagnostic method for predicting short-term surgical outcome in patients with suspicous coronary artery disease undergoing noncardiac surgery.

Diagnosis of Latent Hypertrophic Obstructive Cardiomyopathy with Dobutamine Stress Echocardiography

BACKGROUND: In latent type of hypertrophic obstructive cardiomyopathy, there is no pressure gradient at rest in left ventricular outflow tract(LVOT), but it develops with provocation. Dobutamine increase myocardial contractility and may inducce outflow tract obstruction. To evaluate the usefulness of dobutamine induced outflow tract obstruction as a provocation test, nine patients with latent obstructive cardiomyopathy were studied. METHOD: 680 cases of dobutamine stress echocardiography were reviewed. Nine patients developed late peaking outflow velocity pattern in response to dobutamine infusion(inducible group). Ten patients developed early peaking velocity pattern were included as control group. Left ventricular dimension, outflow tract diameter were measured, and pattern of septal hypertrophy was classified. Changes of peak velocity and acceleration time/ejection time ratio (AT/ET) were measured at rest and peak dose dobutamine. RESULTS: The peak outflow velocity at rest was not different in both groups(1.49±0.45, 1.18±0.11m/sec). Peak velocity and AT/ET ratio were significantly increased in inducible group(4.2±0.9m/sec, 0.66±0.17), but no significant changes were noted in control group. Patients with inducible group had greater septal thickness, smaller outflow tract diameter and greater prevalence of septal bulge morphology. CONCLUSION: These results suggest that dobutamine stress Doppler echocardiography could be a useful provocation test to diagnosis of latent obstructive cardiogyopathy.

Clinical and Echocardiographic Features of Mid-ventricualr Obstruction of the Left Ventricle

BACKGROUND: Mid-ventricular obstruction(MVO) of the left ventricle has been reported to be associated with mid-ventricular hypertrophy, papillary muscle hypertrophy, severe apical hypertrophy, elderly hypertension, and dobutamine stress echocardiography(DSE). The aim of this study is to determine the clinical and echocardiographic features of MVO. METHOD: MVO was defined as systolic hourglass narrowing of the left mid-ventricle in the apical long axis view with turbulent flow exceeding 1m/s. Fifteen patients were suvjected to this retrospective analysis. Baseline patients characteristics were mean age 56(range, 26-74)years, male gender 10(66%). Associated diseases were hypertrophic cardiomyopathy 9, aortic stenosis 1, hypertension without left ventricular hypertrophy(LVH) 1, old myocardial infarction with apical aneurysm 2, stable angina 1, and idiopathic 1. DSE was performed in 7 of 15 subjected patients to evaluate the chest pain. RESULTS: All patients had mild symptoms; chest tightness, palpitation, and weakness, without syncope nor hypotension. MVO was observed in 10 at rest, and 5 after provocation ; DSE 3, VPB 1, atropine 1. Observed peak velocity in the mid-ventricle ranged from 1.2 to 5.5m/s(mean ; 2.8±1.6m/s). Left ventricular outflow tract obstruction defined as the peak flow velocity exceeded 1.5m/s, was also present in 8. in 7 underwent to DSE, systolic blood pressure was changed from 144±15mmHg at rest to 175±28mmHg at peak, heart rate from 73±12/min to 108±23/min, left ventricular end diastolic dimension from 42±5mm to 37±4mm, ejection fraction from 66±10% to 80±6%, and peak flow velocity at the mid-ventricle from 1.0±0.6m/s to 3.3±1.7m/s. CONCLUSION: MVO can be observed in patients without LVH and may account for clinical symptoms of chest discomfort. The mechanism of MVO, at least in part, and be explained with increased ventricular contractility, increased heart rate, and small left ventricular cavity size.

Usefulness of Dipyridamole and Dobutamine Stress Echocardiography in Myocardial Infarction

BACKGROUND: The dipyridamole and dobutamine stress echocardiography have been studied as a non-invasive diagnostic test in coronary artery disease. Recently, some authors have extended the usefulness of these tests to predicting the prognosis of myocardial infarction patients. But as far as we know, there was no literature which tried boh tests to the same infarcted patients group. So, we performed both tests in the 23 infarcted patients to compare and evaluate both tests as predicting the prognosis in myocardial infarction. METHODS: Patients underwent (1) two-dimensional echocardiography under basal condition and after dipyridamole infusion for 4 minites at the dose of 0.14mg/kg/min, (2) another two dimensional echocardiography under basal and during dobutamine infusion at each dose of 5 to a maximum of 20microg/kg/min at 1 or 2 days after dipyridamole stress echocardiography, and (3) coronary and left ventricular angiography. Preinfusion and peak infusion images were analyzed independently by two different observers using Nova Micro Sonic soft were(DataVueII and ColorVue II analysis system). The segmental wall motions were scored as follows ; hyperkinetic : 1, normal : 2, hypokinetic : 3, akinetic : 4. THe test response was considered positive if abnormal wall motion and reduced myocardial thickening were observed during drug infusion at the vascular distributions except the akinetic infarcted segment identified during basal condition. The coronary angiography was analyzed by measuring the maximal luminal diameter stenosis with caliper and 50% or greater diameter narrowing was considered significant. The sensitivity and specificity were calculated by comparing echocardiographic prediction and angiographic findings. RESULTS: 1) Among 22 patients with sufficient image in dipyridamole stress echocardiography, 13 patients have myltivessel coronary disease without resting akinesia of non-infarcted segments. Only 5 patients showed positive findings in dipyridamole stress echocardiography(sensitivity, 38.4%). Among 9 patients who has single or minimal disease, 9 patients were negative finding(specificity, 100%). 2) Among 21 patients with sufficient image in dobutamine stress echocardiography, 12 patients have multivessel coronary disease without resting akinesia of non-infarcted segments. 7 patients showed positive finding in dobutamine stress echocardiography(sensitivity, 58.3%). Among 9 patients who has single or minimal disease, 8 patients showed negative finding(specificity, 88.8%). 3) In hemodynamic changes, dipyridamole stress echocardiography showed significant changes in heart rates and double products and dobutamine stress echocardiography showed significant changes in heart rates, systolic blood pressure and double products. 4) There was no significant side effect during both stress tests inacute and old myocardial infarction patients. CONCLUSION: 1) The dobutamine and dipyridamole stress echocardiography are safe and easy test for myocardial infarction patients. 2) The dobutamine stress echocardiography has higher sensitivity than dipyrdamole stress echocardiography for identifying multivessel coronary disease in myocardial infarction patients but the dose of both drugs were relatively small to get the adequate results. So the high dose of drugs must be tried in feature study.

Predicting Factors of Multivessel Coronary Artery Disease in Dobutamine Stress Echocardiography

BACKGROUND: Dobutamine stress echocardiography(DSE) is useful detection of coronary artery disease as a noninvasive test. The purpose of this study is to find predicting factors of multivessel disease (MVD) in DSE. METHODS: Sixty-five patients suspicious of coronary artery disease excluding myocardial infarction on clinical base had undergone DSE and coronary arteriography. We divided the patient group into normal group (22 patients), single vessel disease(SVD) group(25 patients) and multivessel disease (MVD) group (18 patients) according to the findings of the findings of coronary angiogram. DSE findings and hemodynamic change during stress were analyzed and compared in these groups. We defined MVD on DSE as findings of new or aggravating regional wall motion abnormalities in 2 or more coronary artery territories, and significant stenosis on coronary angiogram as stenosis of 50% or more. RESULTS: 1) The numbers of diseased vessel evaluated by DSE showed significant correlation with those evaluated by coronary angiogram. 2) Resting, low-dose and peak-dose wall motion scores were significantly different among 3 groups, being higher in MVD group than in SVD and normal group. 3) Total administered dose of dobutamine in MVD group was significantly lower than that of normal group. 4) Heart rate at peak-dose showed significant difference among 3 groups, but product of heart rate and systolic blood pressure at peak-dose was not significantly different. 5) Frequency of ST segment change was significantly higher in multicessel disease group CONCLUSION: DSE reflects severity of coronary artery disease. and frequency of resting regional wall motion abnormally. wall motion score in low-dose and paak stress seems to be useful as a predictor of multivessel disease. Value of total administered dose of dobutamine, hemodynamic changes and ST segment changes as a MVD remains to be proved.

Predicting Factors of Multivessel Coronary Artery Disease in Dobutamine Stress Echocardiography

BACKGROUND: Dobutamine stress echocardiography(DSE) is useful detection of coronary artery disease as a noninvasive test. The purpose of this study is to find predicting factors of multivessel disease (MVD) in DSE. METHODS: Sixty-five patients suspicious of coronary artery disease excluding myocardial infarction on clinical base had undergone DSE and coronary arteriography. We divided the patient group into normal group (22 patients), single vessel disease(SVD) group(25 patients) and multivessel disease (MVD) group (18 patients) according to the findings of the findings of coronary angiogram. DSE findings and hemodynamic change during stress were analyzed and compared in these groups. We defined MVD on DSE as findings of new or aggravating regional wall motion abnormalities in 2 or more coronary artery territories, and significant stenosis on coronary angiogram as stenosis of 50% or more. RESULTS: 1) The numbers of diseased vessel evaluated by DSE showed significant correlation with those evaluated by coronary angiogram. 2) Resting, low-dose and peak-dose wall motion scores were significantly different among 3 groups, being higher in MVD group than in SVD and normal group. 3) Total administered dose of dobutamine in MVD group was significantly lower than that of normal group. 4) Heart rate at peak-dose showed significant difference among 3 groups, but product of heart rate and systolic blood pressure at peak-dose was not significantly different. 5) Frequency of ST segment change was significantly higher in multicessel disease group CONCLUSION: DSE reflects severity of coronary artery disease. and frequency of resting regional wall motion abnormally. wall motion score in low-dose and paak stress seems to be useful as a predictor of multivessel disease. Value of total administered dose of dobutamine, hemodynamic changes and ST segment changes as a MVD remains to be proved.

A Case of Giant Coronary Arteriovenous Fistula with Coronary Steal Demonstrated by Dobutamine Stress Echocardiography and (99m)Tc-MIBI SPECT

We present a case of giant coronary arteriovenous fistula between left main coronary artery and pulmonary artery in a 60-year-old female who presented with anginal symptom. Dobutamine stress echocardiography and myocardial perfusion scan with (99m)Tc-MIBI revealed a reversible perfusion defect in the septal region. Coronary angiography demonstrated a giant coronary arteriovenous fistula origination from the left main coronary artery and draining into the pulmonary artery. This appears to be the first case in which dobutamine stress echocardiography and myocardial perfusion scan with (99m)Tc-MIBI demonstrated myocardial ischemia due to coronary steal in patient with a coronary arteriovenous fistula.