Preoperative dobutamine stress echocardiography versus cardiac arteriography for risk assessment prior to renal transplantation.

Because coronary artery disease is the leading cause of death in patients with end-stage renal disease, we prospectively studied the prognostic value of dobutamine stress echocardiography (DSE) compared to coronary angiography (CA) as an evaluative tool. Thirty-three patients at high risk for coronary artery disease were selected from a cohort of 133 renal transplant candidates and underwent both DSE and CA. In this study, the value of DSE was found to exist in its strong negative predictive value (92%). A negative DSE coupled with a negative clinical cardiac evaluation was found to practicably exclude the necessity for CA. DSE can thus serve as a non-invasive, low cost screening test.

Dobutamine stress echocardiography prior to aortic surgery: long-term cardiac outcome.

This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in predicting not only perioperative but also long-term cardiac events. One hundred fifty-nine patients who were evaluated for elective abdominal aortic surgery were screened preoperatively with DSE from January 1, 1992 to December 31, 1993. We concluded that DSE is useful for preoperative assessment of cardiac risk prior to elective aortic surgery to minimize the need for cardiac intervention and still maintain acceptable perioperative MI and death rates. A selective approach for coronary revascularization is justified by the higher mortality in the subgroup requiring sequential procedures. DSE also allowed us to identify those high-risk patients who are best excluded from aortic surgery. Patients with abnormal DSE results are at higher risk for late cardiac events, require cardiology follow-up, and may require late coronary intervention.

Dobutamine stress echocardiography for cardiac risk assessment before aortic surgery.

PURPOSE: This study evaluates dobutamine stress echocardiography (DSE) for perioperative cardiac risk assessment with elective aortic surgery. METHODS: Dobutamine stress echocardiography was used to evaluate 81 patients before infrarenal aortic surgery. Patients were placed into three groups. Group I (n = 31) had normal DSEs. Group II (n = 25) had resting wall motion abnormalities without dobutamine-induced changes of ischemia. Group III (n = 25) had evidence of dobutamine-induced ischemia. Patient analysis revealed that of 46 patients with clinical indicators of coronary artery disease (CAD), only 23 had DSEs with inducible ischemia. Two of 35 patients without clinical indicators of CAD had DSEs with inducible ischemia. RESULTS: The 56 patients in group I and II underwent aortic reconstruction without cardiac complications or death. Of the 25 patients in group III, surgery was deferred in five (two patients with claudication and three with aneurysms < or = 5 cm), and four underwent coronary artery bypass grafting. Outcome after coronary artery bypass grafting included one death from stroke, one aneurysm rupture, and two uncomplicated aortic reconstructions. The remaining 16 patients in group III underwent aortic surgery, with three postoperative myocardial infarctions (MI) and no deaths. CONCLUSIONS: Using DSE for preoperative assessment of cardiac risk allowed us to operate on 74 of 81 patients being considered for elective aortic reconstruction, with no operative deaths and a 4.1% rate of perioperative MI. Dobutamine stress echocardiography has the ability to identify patients with asymptomatic stress-induced ischemic myocardium and its increased risk for perioperative MI (p < 0.001). Equally important, for patients with clinical indicators of CAD but without DSE-inducible ischemia, no further cardiac evaluation is necessary.

Dipyridamole thallium imaging: use in preoperative cardiac risk assessment in vascular surgical patients.

BACKGROUND: The objective of this study was to determine whether routine performance of dipyridamole thallium imaging adds to the power of a careful clinical evaluation in the risk stratification of patients undergoing major vascular surgery. METHODS: In this retrospective study, 115 cases evaluated by dipyridamole thallium imaging before major vascular surgery were reviewed. Patients were assigned to a high-risk cohort if they had a history of congestive heart failure or evidence of previous myocardial infarction. RESULTS: Six (8%) patients from the high-risk cohort developed major cardiovascular complications. Reversible perfusion defects, present in 67% of the high-risk patients, did not predict complications. None of the patients in the low-risk cohort developed complications despite the presence of reversible perfusion defects in 33%. Patients in the high-risk cohort who underwent cardiac catheterization and selective coronary bypass grafting were uniformly free of perioperative complications. The extent and severity of fixed or reversible thallium perfusion did not predict the occurrence of cardiovascular complications. However, three patients were denied surgery following an unacceptable cardiovascular risk assessment based on clinical findings and multiple reversible thallium perfusion defects. CONCLUSION: In low-risk patients, screening with dipyridamole thallium can identify patients with redistribution defects whose risk of perioperative ischemic events can be reduced by intensifying perioperative anti-ischemic management. If the patient is in the high-clinical-risk subgroup, screening with dipyridamole thallium does not identify a cohort with negligible perioperative risk; thus, further evaluation of these patients by cardiac catheterization should be considered.

Abbreviated aortic insufficiency in aortic dissection caused by prolapse of the intimal flap.

Aortic insufficiency was identified in a patient with acute ascending aortic dissection. The aortic insufficiency was limited to the first half of diastole by prolapse of the intimal flap against the regurgitant orifice. This unusual pathophysiology was well demonstrated by two-dimensional and color flow Doppler echocardiography.

Effects of acute reperfusion on regional myocardial function: serial two-dimensional echocardiography assessment.

Serial two-dimensional echocardiography was performed in 23 patients with acute myocardial infarction who received intravenous thrombolytic therapy to evaluate the effect of acute reperfusion on regional wall motion abnormalities. Regional wall motion abnormalities improved in 4 of the 14 patients (29%) with successful reperfusion and in 1 of the 9 (11%) without successful reperfusion. In successfully reperfused patients, the main determinant of improvement in regional wall motion abnormalities was duration from the onset of chest pain to the time of reperfusion (3.3 vs. 6.3 h in successfully reperfused patients without recovery of regional wall motion abnormalities; P less than 0.001).

Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement.

Data from 1,156 patients greater than or equal to 30 years of age who underwent aortic valve replacement alone or with coronary artery bypass grafting from 1967 through 1976 (early series) and 227 similar patients operated on during 1982 and 1983 (late series) were reviewed. In the early series, 414 patients (36%) had preoperative coronary arteriography (group 1): group 1A (n = 224) did not have coronary artery disease, group 1B (n = 78) had coronary artery disease but did not undergo bypass grafting and group 1C (n = 112) had coronary artery disease and underwent bypass grafting. The 742 patients in group 2 did not have preoperative arteriography. Operative mortality rates (30 day) in groups 1A, 1B, 1C and 2 were 4.5, 10.3, 6.3 and 6.3%, respectively (p = NS). The 10 year survival in both groups 1 and 2 was 54%; in groups 1A, 1B and 1C it was 63, 36 and 49%, respectively (1A and 1B, p less than 0.01). In the late series, the 227 patients were divided into similar groups (group 1A, n = 73; 1B, n = 32; 1C, n = 99), and 90% had preoperative coronary arteriography. Operative mortality rates (30 day) for groups 1A, 1B and 1C were 1.4, 9.4 and 4.0%, respectively; that for group 2 (no preoperative arteriography, n = 23) was 4.3%. Definition of coronary anatomy by angiography seems important in most patients greater than or equal to 50 years old who are candidates for aortic valve replacement, and bypass grafting is recommended for those with significant coronary artery disease.