Contrast-enhanced Dobutamine Stress Echocardiography Research Articles

Coronary reserve in Dobutamine stress echocardiography: Feasibility study and determination of a pathological threshold for myocardial ischemia in the LAD territory

The evaluation of the coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD) during a Dobutamine stress echocardiography (DSE) is few realized in current practice. A threshold < 2 would be in favor of myocardial ischemia according to some studies. The main purposes of this study are to analyze the feasibility of the CFVR and to search for a pathological threshold in order to make it a complementary tool in the non-invasive detection for myocardial ischemia in the LAD territory. One hundred and ninety-six consecutive patients referred for detection of myocardial ischemia with contrast-enhanced DSE were evaluated in the GHPSJ from July 2017 to July 2018. CFVR was calculated as a ratio of the distal LAD diastolic peak velocity at rest and peak of stress. The result of the echocardiography was rendered only on the analysis of wall motion abnormalities as a standard reference. The feasibility of CFVR is 94.9%. The pathological threshold of CFVR is ≤ 2.1 (sensitivity of 84.2%, specificity of 70%). The CFVR is altered at 1.87 ± 0.52 in the positive DSE in the LAD territory vs. 2.67 ± 0.91 in the normal ones ( P < 0.001). No significant difference was found between the diabetic and non-diabetic populations ( P = 0.194). The coronary reserve is a non-invasive feasible technique in current practice, sensitive, allowing to add a quantitative criterion to the detection of a myocardial ischemia during a DSE even in non-echogenic patients who needed contrast agent. ( Figure 1 , Cut off value of CFVR).

Combination of contrast-enhanced wall motion analysis and myocardial deformation imaging during dobutamine stress echocardiography.

The combination of deformation analysis with conventional wall motion scoring (WMS) has been shown to increase the diagnostic sensitivity of dobutamine stress echocardiography (DSE). The feasibility and diagnostic power of WMS is largely improved by contrast agents; however, they are not used in combination with deformation analysis, as contrast agents are generally considered to render strain measurement unfeasible. To assess the feasibility of tissue velocity (TVI)- and 2D speckle tracking (ST)-based strain analysis during contrast-enhanced DSE; and to show whether there is an incremental value in combining deformation analysis with contrast-enhanced WMS. DS echocardiograms containing native, tissue Doppler, and contrast-enhanced loops of 60 patients were analysed retrospectively. The feasibility of WMS, TVI-, and ST-strain measurement was determined in 40 patients according to pre-defined criteria. The diagnostic ability of a combined protocol integrating data from contrast-WMS and TVI-strain measurement was then compared with contrast-WMS alone in all 60 patients, using coronary angiograms as a gold standard. Both TVI- and ST-based strain analysis were feasible during contrast-DSE (feasibility at peak stress: 87 and 75%). At the patient level, the diagnostic accuracy of the combined method did not prove superior to contrast-WMS (82 vs. 78%); a trend towards improved sensitivity and specificity for detecting coronary artery disease in the right coronary artery circulation (sensitivity: 85 vs. 77%, P = NS; specificity: 96 vs. 94%) was, however, observed. Both TVI- and ST-based myocardial deformation analysis are feasible during contrast-enhanced DSE, however, our results fail to demonstrate a clear diagnostic benefit of additional strain analysis over expert WMS alone.

New-Onset Seizure after Perflutren Microbubble Injection during Dobutamine Stress Echocardiography

Intravenous microbubble contrast agents are frequently used during ultrasound imaging to improve endocardial border detection, enhance Doppler signals, differentiate thrombi from tumors or define vascular anatomy. Dobutamine stress echocardiography (DSE) with or without addition of atropine is a standard technique for evaluation of coronary artery disease. Noncontrast or contrast-enhanced DSE is generally considered a safe procedure. We report what appears to be the first case of new-onset seizure activity following perflutren microbubble contrast injection during dobutamine-atropine stress echocardiography. On the basis of this single occurrence, we are only able to demonstrate a temporal, but not a causal relationship between the administration of microbubble echo contrast and onset of seizure. We do not suggest withholding administration of microbubble contrast when clinically indicated. However, increased vigilance in monitoring for seizure development in patients receiving microbubble contrast seems warranted.

Analysis of regional wall motion during contrast-enhanced dobutamine stress echocardiography: effect of contrast imaging settings

Myocardial contrast perfusion echocardiography (MCE) allows simultaneous assessment of perfusion and function. However, low frame rate during MCE may reduce the viewer's ability to discern contractile dysfunction. This study sought to compare MCE and left ventricular opacification (LVO) settings with regard to wall motion abnormalities (WMA) at rest and during dobutamine stress echocardiography (DSE). In 50 patients scheduled for coronary angiography and with poor baseline image quality, MCE and LVO were performed during DSE. Regional wall motion was assessed and inter-observer agreement was determined for each imaging modality. The endocardial border score index was similar for both modalities. The wall motion score index (WMSCI) at peak stress using MCE was well correlated with WMSCI obtained with LVO (r(2) = 0.9, P < 0.001). However, WMSCI at peak stress was underestimated by MCE (1.66 +/- 0.58 with DSE-LVO vs. 1.535 +/- 0.50 with DSE-MCE; P < 0.001). Inter-observer agreement on the presence of WMA was 0.65 for MCE and 0.67 for LVO at peak stress. Myocardial contrast perfusion echocardiography provides equal endocardial border delineation compared with LVO modality. Although the inter-observer agreement is slightly higher with LVO compared with MCE, it is not significantly different with MCE at peak stress. Despite the similar improvement in endocardial border delineation, LVO settings allow the detection of more WMA than MCE at peak stress, leading to a significantly higher accuracy for the detection of ischaemia in patients suspected of coronary artery disease when only wall motion is taken into account.

Effect of contrast application on interpretability and diagnostic value of dobutamine stress echocardiography in patients with intermediate coronary lesions: comparison with myocardial fractional flow reserve

Poor image quality remains a limitation of dobutamine stress echocardiography (DSE). This study aimed at investigating the effects of transpulmonary contrast application on endocardial border delineation and diagnostic yield of DSE in patients with intermediate coronary stenoses. The invasively measured fractional flow reserve (FFR) served as the reference standard. Seventy patients with an intermediate coronary stenosis entered the study. Cineloops were recorded during DSE before and after contrast application at rest and peak stress. Two observers blinded to angiography assessed wall motion. FFR was measured in the target vessel during repeat angiography and an FFR <or= 0.75 was considered pathological. Abnormal FFR findings were seen in 41% of the patients. Native DSE was abnormal in 36% and contrast-enhanced DSE in 50% of the patients. Luminal diameter narrowing measured by quantitative angiography was not significantly different between patients with normal and abnormal FFR. After contrast application, the number of non-interpretable segments [median (25-75th percentile)] decreased from 2 (1-3) to 0 (0-0) at rest and from 1 (0-3) to 0 (0-0) at stress (both P < 0.001). Compared with native imaging, sensitivity and accuracy increased with transpulmonary contrast from 48 [CI (confidence interval) 40-57%] to 83% (76-91%) and from 62 (CI 56-69%) to 77% (71-82%), respectively (both P = 0.05). Transpulmonary contrast application improves the interpretability and diagnostic yield of DSE in patients with intermediate coronary lesions.

Effects of Gender on Prognosis of Patients With Known or Suspected Coronary Artery Disease Undergoing Contrast-Enhanced Dobutamine Stress Echocardiography

Gender differences in the predictors of outcome among patients with known or suspected coronary artery disease (CAD) undergoing contrast-enhanced dobutamine stress echocardiography (CE-DSE) have not been completely determined. Follow-up (30+/-17 months) data for 581 men and 309 women with known or suspected CAD who underwent CE-DSE (mean age: 66 years) were obtained. Hard cardiac events included cardiac death and nonfatal myocardial infarction. Total cardiac events included hard cardiac events, unstable angina, congestive heart failure, and late revascularization (>3 months). Cardiac events occurred in 123 male and 50 female patients. Positive results for CE-DSE were associated with worse prognosis in both men and women (2-year total event free rate: 73.5% vs 88.2% in men, p<0.0001, 80.3% vs 91.3% in women, p<0.01). Addition of CE-DSE results, including abnormal left ventricular end-systolic volume response and left ventricular ejection fraction at peak stress <50%, to the clinical and rest echocardiography model provided incremental information for predicting total cardiac events (increase in chi-square value for the model from 60 to 72, p<0.001) in men and (increase in chi-square value for the model from 17 to 32, p<0.001) in women. CE-DSE provides incremental information for predicting future cardiac events in both men and women.

Mechanisms of regional wall motion abnormalities in contrast-enhanced Dobutamine Stress Echocardiography

In the diagnosis of coronary artery disease (CAD) with Dobutamine Stress Echocardiography (DSE), regional wall motion abnormalities (RWMA) are assumed to indicate a perfusion deficit. For a more particular examination of RWMAs, we compared simultaneous echo-contrast (Optisone)-enhanced DSE (0-40 microg/kg Dobutamine, 16-segment- model) and MiBi-SPECT in a prospective double-blinded study design in 69 non-selected consecutive patients (44 male, 25 female, age 64+/-12 years). Additionally, all patients were examined by coronary-angiography. The prevalence of significant CAD (stenosis >50% lumen diameter) was 52%. DSE had a sensitivity of 78% and a specificity of 66% for the detection of significant CAD with a positive and negative predictive value of 72 and 73%, respectively. Among 28 patients with significant CAD and positive DSE study (true positive), 78% displayed a corresponding perfusion deficit in MiBi-SPECT. Among 11 patients with a positive DSE study but no current significant coronary stenosis (false positive), 82% showed stress-induced RWMAs in the inferior/posterior region, 73% displayed left ventricular hypertrophy, 54% resting-ECG abnormalities and 45% resting-RWMA (3 previous MI, 2 previous CABG surgery). Among 8 patients with negative DSE study but significant coronary stenosis (false negative), 75% had a stenosis of the LCX, 63% displayed resting- WMA, 63% displayed left bundle branch block or ST-segment depression, 50% displayed only peripheral coronary stenosis, and DSE visualization was suboptimal in 38%. This prospective study in non-selected patients shows that the majority of RWMAs in DSE are matched to a perfusion deficit detectable by nuclear imaging. Nevertheless, pre-existing cardiac abnormalities may also lead to stress-induced RWMA not associated with a perfusion deficit or mask a perfusion deficit upon DSE. Particularly in patients with LV hypertrophy, resting-RWMA, bundle branch block or ST segment depression, the predictive value of DSE may, therefore, be limited.

Role of Contrast‐Enhanced Dobutamine Stress Echocardiography in Predicting Outcome in Patients with Known or Suspected Coronary Artery Disease

Although the application of intravenous contrast agents during stress echocardiography has been shown to improve diagnostic accuracy for detecting coronary artery disease, less information exists regarding its prognostic value. The aim of this study was to determine the role of contrast-enhanced dobutamine stress echocardiography (DSE) for predicting future cardiac events in patients with coronary artery disease (CAD). We studied 893 patients (mean age: 66, 581 men) with known or suspected CAD undergoing contrast-enhanced DSE. Positivity was defined as new/worsened wall motion abnormality or fixed abnormality during stress. All patients were followed for 15 +/- 10 months to evaluate hard cardiac events (cardiac death and nonfatal myocardial infarction) and total cardiac events (hard cardiac events, congestive heart failure, unstable angina, and late revascularization). Three patients were lost to follow-up, and 128 patients developed cardiac events, including 21 hard cardiac events. The 3-year event free survival rate was significantly lower in patients with positive DSE results than in those with negative DSE results. Stepwise Cox multivariate analysis revealed that positivity of DSE (P < 0.0001, Hazard ratio (HR): 2.48) and peak wall motion score index (WMSI) >1.5 (P < 0.0001, HR: 2.41) were independent predictors for total cardiac events. Considering hard cardiac events, the independent predictors were peak WMSI > 1.5 (P < 0.0001, HR: 6.65) and age > 70 years (P < 0.005, HR: 3.27). We conclude that contrast-enhanced DSE provides important prognostic information for future cardiac events.

Comparison of Contrast-enhanced Real-time Live 3-Dimensional Dobutamine Stress Echocardiography with Contrast 2-Dimensional Echocardiography for Detecting Stress-induced Wall-motion Abnormalities

Two-dimensional (2D) contrast-enhanced dobutamine stress echocardiography (DSE) is used clinically to diagnose stress-induced wall-motion abnormality (WMA). We hypothesized that contrast-enhanced real-time 3-dimensional (3D) DSE could improve the detection rate of WMA, because from a single full-volume acquisition, multiple segments can be visualized. We acquired both 2D and 3D DSE in 78 patients with known or suggested coronary artery disease (mean age: 65 years; 44 men). Dobutamine was infused using a standard protocol, and atropine added, if required. For 2D DSE, the intravenous contrast agent was injected at each stage and images displayed in a quadscreen format. For 3D DSE, contrast harmonic 3D data sets (full volumes) were acquired at baseline and peak stress. Using custom software, 3 short-axis views (from apex to base) were created, and wall motion scored using a wall-motion score index using a 16-segment model. A positive stress test was defined as new or worsened WMA or fixed abnormality during stress. Heart rate increased from 72 +/- 13 to 133 +/- 15/min (86 +/- 11% of age-predicted). A total of 1248 segments were analyzed at each stage for both modalities. A single segment at baseline and 5 segments at peak stress could not be assessed with contrast 2D DSE. In contrast, 88 segments at baseline and 39 segments at peak stress could not be assessed with contrast 3D DSE. With 3D DSE, the majority of uninterpretable segments were in the anterior and lateral walls. Significant correlations were noted between wall-motion score index by 2D and 3D DSE at baseline (r = 0.78) and peak stress (r = 0.83). The concordance rate (positive/negative findings) between modalities was 69% (54/78) on a patient basis and 88% (206/234) on a perfusion territory basis. When using 2D DSE results as the gold standard, sensitivity and specificity for detecting WMA by 3D DSE was 58% and 75%, respectively. Sensitivity and specificity values were 67% and 94% for the right coronary artery, 53% and 81% for the left anterior descending coronary artery, and 88% and 100% for the left circumflex coronary artery territory, respectively. Contrast-enhanced 3D DSE was feasible in the majority of patients. However, the moderate concordance between both modalities was a result of: (1) difficulties in visualizing the anterolateral segments because of the relatively large imprint of the transducer; and (2) lower frame rates with 3D DSE resulting in the erroneous diagnosis of dyssynchrony.

Quantitative Assessment of Left Ventricular Function During Contrast-Enhanced Dobutamine Stress Echocardiography Predicts Future Cardiac Events in Diabetic Patients

Non-invasive diagnosis and risk stratification of coronary artery disease are important for the selection and optimization of therapeutic interventions in diabetic patients, which may improve survival. The aim of this study was to determine the incremental value of contrast-enhanced dobutamine stress echocardiography (CE-DSE) for risk stratification. CE-DSE was performed in 326 patients with diabetes mellitus (mean age; 66 +/- 10 years, 223 men). All patients were followed up for a mean of 29 months (1-61 months). Dobutamine was infused in a standard protocol with an intravenous contrast agent. The primary endpoints for hard cardiac events included cardiac death and nonfatal myocardial infarction. The primary endpoints for total cardiac events included hard cardiac events, unstable angina pectoris, congestive heart failure, and late coronary revascularization (> 3 months). Cardiac events occurred in 74 patients. The addition of the CE-DSE results, including abnormal left ventricular end-systolic volume response and left ventricular ejection fraction at peak stress < 50%, to the clinical and rest echocardiography model provided incremental information in predicting total cardiac events (increase in chi-square value for the model from 17 to 24, p < 0.05) and hard cardiac events (increase in chi-square value for the model from 18 to 24, p < 0.05). Quantitative assessment of left ventricular function during CE-DSE provides incremental prognostic information in predicting cardiac events in diabetic patients.

Can Contrast Dobutamine Stress Echocardiography Be Performed with Standardized Imaging Settings for Everybody?

The objective was to assess a standardized imaging and contrast injection protocol for contrast-enhanced dobutamine stress echocardiography (DSE). A total of 102 patients underwent DSE with tissue harmonic imaging and a standardized protocol with contrast power modulation. Contrast intensities in the left ventricular cavity and the myocardium were evaluated by a visual score and quantitative analysis. Of the contrast studies, 98% were diagnostic without modification of the settings. Excellent endocardial border definition was found in 93% of the segments with contrast versus 53% with tissue harmonic imaging (P < .05). The interobserver agreement in assessing segmental wall motion improved from 71.5% to 85.9%. There were no differences between the myocardial segments' video intensity in the four- and three-chamber views. In the two-chamber view video intensity was lower in the basal segments compared with the other segments. Power modulation contrast imaging can be applied with a completely standardized protocol for DSE in the majority of patients with excellent endocardial border definition.

The validation of fractional flow reserve in patients with coronary multivessel disease: a comparison with SPECT and contrast-enhanced dobutamine stress echocardiography

Fractional flow reserve (FFR) is a new but well established parameter for the hemodynamic evaluation of coronary stenoses. A FFR below 0.75 was validated as functionally significant in coronary one or two vessel disease. This study was designed to prospectively define the best FFR cut off value (BCV) in patients with multivessel disease using two noninvasive tests, myocardial perfusion scintigraphy (SPECT) and contrast-enhanced dobutamine stress echocardiography (DSE) as reference methods. 47 symptomatic patients (29 male, mean age 64+/-10 yrs) with angiographically intermediate coronary lesions (50-75% diameter stenosis) entered the study. DSE (5-40 microg/min/kg dobutamine) was performed after intravenous injection of a second generation transpulmonary contrast agent. SPECT (Tc-99m-MIBI) was done at peak stress. All tests (DSE, SPECT and FFR) were performed within 4 weeks. SPECT yielded positive results in 15 and DSE in 16 patients, respectively. Mean FFR measured in the target lesion (RCA n=10; LAD n=22, RCX n=15) was 0.80+/-0.13. FFR was <0.75 in 15 patients. By performing a ROC analysis the BCV (highest sum of sensitivity and specificity) was found at 0.75. At this cut off value using both non-invasive tests as reference method, sensitivity and specificity were 83 and 77%. In patients with multivessel disease, a FFR <0.75 identifies a hemodynamically relevant lesion as compared to DSE and SPECT. This study underlines that FFR criteria are also applicable in patients with complex coronary artery disease.

Mechanisms of regional wall motion abnormalities in contrast-enhanced Dobutamine Stress Echocardiography

Mechanisms of regional wall motion abnormalities in contrast-enhanced Dobutamine Stress Echocardiography

Cardiac rupture during contrast-enhanced dobutamine stress echocardiography

Dobutamine stress echocardiography is widely used after myocardial infarction. This technique is safe and severe adverse reactions are uncommon. We report one case of cardiac rupture during contrast-enhanced dobutamine stress echocardiography.

Which is the better method in detecting significant left anterior descending coronary artery stenosis during contrast-enhanced dobutamine stress echocardiography: coronary flow velocity reserve or wall-motion assessment?

The diagnostic accuracy of dobutamine stress echocardiography (DSE) depends on wall-motion assessment. Coronary flow velocity reserve (CFVR) during DSE can be measured by transthoracic Doppler echocardiography. To investigate comparative diagnostic accuracy between wall-motion and CFVR assessment in the detection of significant left anterior descending coronary artery (LAD) stenosis, 274 patients underwent both contrast-enhanced DSE and coronary angiography. Intravenous contrast agent, Levovist, was injected to enhance left ventricular endocardial border delineation and coronary flow velocity in the LAD. Wall motion was assessed by standard technique, and CFVR was calculated as coronary flow velocity at peak dobutamine stress divided by baseline coronary flow velocity by transthoracic Doppler echocardiography. CFVR could be successfully obtained in 232 patients (feasibility, 85%). After excluding 14 patients with isolated diagonal stenosis, CFVR was significantly lower in 65 patients with significant LAD stenosis than it was in 153 patients without stenosis (1.62 ± 0.56 vs 2.72 ± 0.94, P < .001). CFVR ≤ 2.0 had a 75% sensitivity, a 81% specificity, and a 79% diagnostic accuracy for detecting significant LAD stenosis, and these values were comparable with those by wall-motion analysis (sensitivity, 78%; specificity, 89%; and diagnostic accuracy, 86%). The measurement of CFVR in the LAD during DSE was feasible and the diagnostic accuracy of CFVR was equivalent to wall-motion assessment in the detection of LAD stenosis.

Color kinesis during contrast-enhanced dobutamine stress echocardiography: feasibility and applicability.

Accurate interpretation of dobutamine stress echocardiography (DSE) needs expertise. Color kinesis (CK) allows objective assessment of wall motion (WM), and its feasibility and accuracy are enhanced under harmonic imaging with contrast agents. To explore its utility, CK was performed in 41 unselected patients during contrast-enhanced DSE. After bolus injection of Levovist, the CK image was acquired in the apical 4- and 2-chamber views at baseline and peak stress using the ultraharmonic mode. Quad screen format with second harmonic imaging after another injection of Levovist was also obtained as a reference. Regional WM (12 segments in the apical view) was independently assessed by both methods. Heart rate increased from 67 beats/min at baseline to 135 beats/min (88% of age predicted maximal heart rate) at peak stress. The CK image was successfully obtained in all patients at baseline and in 38/41 patients at peak stress. CK tracked endocardial motion accurately in 93% (456/492) of left ventricular segments at baseline and 87% (427/492) at peak stress. The concordance rate of normal and abnormal WM between the 2 methods was 86% (392/456, Kappa 0.61) at baseline and 85% (362/427, kappa 0.53) at peak stress. Among the 38 patients in whom both methods were completed, the standard quad screen display showed abnormal DSE results in 17 patients and 28/114 vascular territories. The sensitivity, specificity and diagnostic accuracy of CK for detecting abnormal findings were, respectively, 71% (12/17), 90% (19/21) and 82% (31/38) in patients and 57% (16/28), 97% (83/86) and 87% (99/114) in vascular territories. The application of CK was highly feasible during contrast-enhanced DSE and gave an objective assessment of WM. This method can be a valuable adjunct to the conventional interpretation of DSE.

Color kinetics during contrast-enhanced dobutamine stress echocardiography: its feasibility and applicability

Color kinetics during contrast-enhanced dobutamine stress echocardiography: its feasibility and applicability

Assessment of coronary flow velocity with transthoracic Doppler echocardiography during dobutamine stress echocardiography

OBJECTIVESThe purpose of this study was to evaluate the feasibility of measuring coronary flow velocity (CFV) by transthoracic Doppler echocardiography (TTDE) in the left anterior descending coronary artery (LAD) during contrast-enhanced dobutamine stress echocardiography (DSE). We also assessed the value of TTDE for detecting stress-induced myocardial ischemia in the LAD territory.BACKGROUNDNoninvasive assessment of both CFV and wall motion during DSE would enhance the diagnostic accuracy of DSE.METHODSOne hundred forty-four consecutive patients underwent CFV recording in the distal LAD by TTDE during contrast-enhanced DSE. Regional wall motion score index (WMSI) in the LAD territory and CFV ratio at peak stress (CFV ratio peak), defined as a ratio of CFV at peak stress to basal CFV, were obtained.RESULTSCoronary flow velocity was successfully recorded in 129 patients (90%) at baseline and during dobutamine infusion. Mean value of CFV ratio peak was 2.39 ± 0.83 (range: 0.84 to 4.40). There was good correlation between WMSI at peak stress and CFV ratio peak (r = 0.62, p < 0.001). Coronary flow velocity ratio peak was significantly lower in patients who developed stress-induced wall motion abnormality (WMA) in the LAD territory than it was in those patients without WMA (1.51 ± 0.51 vs. 2.76 ± 0.65, p < 0.001). A CFV ratio peak <2.1 had a sensitivity of 92% and a specificity of 86% for detecting the presence of stress-induced WMA.CONCLUSIONSAssessment of CFV in the distal LAD during DSE is feasible in the majority of cases and provides a CFV ratio for detecting stress-induced myocardial ischemia in the LAD territory.