Dobutamine Stress Echocardiography Research Articles

THE ROLE OF MULTIPARAMETRIC EVALUATION PRIOR TO L–VAD IMPLANT IN RIGHT VENTRICLE DISFUNCTION: A CASE REPORT

Abstract Background Right ventricular failure is the most common post–operative complication after L–VAD implant and it represents an important cause of mortality in these patients. Pre–existing right ventricular disfunction is considered an absolute contraindication to L–VAD implant, though in some cases right ventricular hypokinesia could be the expression of elevated pressure in the pulmonary circulation secondary to high left heart filling pressures. Numerous clinical, echocardiographic and hemodynamic parameters have been proposed for the evaluation of L–VAD eligibility. Among these Michigan right ventricle failure score, rest and dobutamine stress echocardiography (TAPSE, S wave peak, right wall longitudinal strain) and right heart catheterization parameters showed an adequate correlation with L–VAD implant outcome. Case Report A 67 yo patient affected by advanced heart failure secondary to ischemic dilatative cardiomyopathy was referred to our unit for frequent exacerbations of heart failure despite optimal medical therapy. Echocardiography detected severe left ventricle disfunction, severe mitral regurgitation and a hypokinetic right ventricle that was not present at a previous evaluation showing only a mild disfunction. We therefore performed a dobutamine stress echocardiography to assess right ventricular contractile reserve, which demonstrated an adequate systolic response at hight dose of dobutamine (20 y/Kg/min). These data were confirmed by right heart catheterization, which allowed the evaluation of hemodynamic predictors of post L–VAD RV failure. After Heart Team discussion the L–VAD was successfully implanted. The patient was extubated at day 1 PO and weaned from inotropes at day 4, he did not present any clinical and hemodynamic signs of RV failure and is currently undergoing post–surgical rehabilitative care. Conclusions Our experience strengthen the importance of a standardized multiparametric assessment in patients affected by advanced heart failure proposed for L–VAD and showing right ventricle contractile impairment.

Current awareness and use of transthoracic echocardiography in evaluation of valvular heart disease in Kumamoto Prefecture -a report from the Kumamoto cardiovascular echocardiography standardization project.

There are few reports on transthoracic echocardiography (TTE) for the evaluation of valvular heart disease in a specific area or region. This cross-sectional questionnaire-based survey was conducted in 2023 in Kumamoto Prefecture, where 106 hospitals provide cardiology services. Ninety-three (88%) of the hospitals completed questionnaires regarding TTE. The severity of low flow/low gradient AS was evaluated by dobutamine stress echocardiography in only 7% of hospitals and exercise stress echocardiography for asymptomatic mitral regurgitation in only 5%. Multivariate logistic regression analysis revealed that participation in remote multi-institutional echocardiographic meetings and use of the Kumamoto Prefecture echocardiographic manual were significantly associated with the use of a multi-window approach (P < 0.05). In Kumamoto Prefecture, echocardiographic measurements are performed according to the recommendations at a relatively low rate. Dissemination of recommendations through remote meetings and the use of the echocardiographic manual may increase the likelihood of TTE being performed according to the recommendations.

Characteristic of Clinical Likelihood Chronic Coronary Syndrome patients with Significant Coronary Lesion in RSUP dr. Mohammad Hoesin Palembang

Chronic coronary syndrome (CCS) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. Significant Coronary artery disease (CAD) is defined by invasive coronary angiography as &gt;50% stenosis of the left main stem, &gt;70% stenosis in a major coronary vessel, or 30% to 70% stenosis with fractional flow reserve ?0.8. This study aimed to identify the characteristics of clinical likelihood CCS patients with site of significant coronary lesion based on pre-test probability (PTP) from demographic characteristics; risk factors; laboratory and echocardiography findings. This is a retrospective cohort study. We reviewed 60 medical records of clinical likelihood chronic coronary syndrome patients with positive inducible ischemia area from dobutamine stress echocardiography and significant CAD lesion from coronary angiography. The incidence of significant CAD in this population was 56.1%. There was a significant relationship between age &gt; 65 years with the incidence of significant LAD lesion (23.3%, p = 0.019); significant LCx lesion (20%, p = 0.043). There was a significant relationship between PTP score ? 16% with significant LAD lesion (55.0%, p = 0.001); significant LCx lesion (45.0%, p = 0.031); and significant RCA lesion (40.0%, p = 0.050). Patients with age &gt; 65 years have a higher incidence of significant LAD and LCx lesions. Patients with pre-test probability score ? 16% have a higher incidence of significant lesions across coronary branches, predominantly in the LAD.

The diagnostic value of stress echocardiography with limited myocardial ischemia in high-risk patients

BackgroundThe diagnostic value of limited myocardial ischemia in DSE is not well known. ObjectivesWe investigated whether myocardial ischemia during dobutamine stress echocardiography (DSE) in 1 apical segment of any of the ventricular walls of the left ventricle relates to the anatomical and functional stenosis of the suppling coronary artery. MethodsOur observational, prospective study enrolled 212 patients, symptomatic or asymptomatic, with newly diagnosed limited myocardial ischemia on DSE. Almost 25% of them had already known CAD, while the rest were divided into low-risk and high-risk groups, integrating 1-2 and ≥3 classical cardiovascular risk factors, respectively. After DSE, all patients underwent invasive coronary angiography (ICA) and were followed up for one year. In coronary arteries distributing ischemic area, the calculated stenosis ≥50% and FFR<0.8 were considered anatomically and functionally significant, respectively. In the latter cases, the patients underwent coronary revascularization. ResultsSignificant anatomical and functional stenosis of the supplying coronary artery was common among patients with already known CAD (62.5% and 44.5%, respectively) or those without CAD but a high-risk profile (60.2% and 25.6%, respectively). In logistic regression analysis, CAD revascularization was independently determined by an already known CAD, diabetes mellitus, and high-risk profile. During follow-up, 24 patients experienced ACS or new angina episodes, which were associated with diabetes and smoking in univariate analysis. ConclusionLimited myocardial ischemia may implicate significant anatomical and functional coronary stenosis among individuals with a history of CAD or those without known CAD but a high-risk profile. The prognostic value of our findings requires further investigation.

Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease.

Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings. Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and t-test or Wilcoxon rank-sum test for continuous variables. Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002]. Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.

Is dobutamine stress echocardiography a good screening tool for coronary artery disease in breast cancer patients that underwent treatment with radiotherapy?

Abstract INTRODUCTION Accelerated atherosclerosis has been described in breast cancer patients receiving cardiac exposure from adjuvant radiotherapy (RT). As a result of multidisciplinary care, breast cancer cure rates have improved in recent decades. Therefore, evaluating radiation-induced heart disease (RIHD), especially coronary artery disease (CAD), is essential. The 2022 cardio-oncology European Society of Cardiology (ESC) guidelines recommend screening patients 5 to 10 years after RT for CAD according to cardiovascular risk factors. This screening is generally recommended with exercise stress echocardiography since it can assess the physiological functional performance. Until now, it is unknown if dobutamine stress echocardiography (DSE) is an equal screening tool and if it can predict major adverse cardiovascular events (MACE) (myocardial infarction, stroke, cardiac death, revascularization). PURPOSE Evaluate if DSE is an adequate tool to stratify and predict MACE in post-radiotherapy patients. Methods A retrospective, descriptive cohort study was conducted. Patients who had chest RT for breast cancer and underwent DSE from 2000 to 2022 were included. A bivariate analysis, including Kruskal Wallis and Pearson Chi-Squared test, was done to identify variables associated with a positive DSE. A multivariable Cox Model for MACE and a time-to-event curve for MACE were also performed. Results We identified 163 patients that underwent DSE after a median time of 5.8 years from the end of RT. The median age was 74 years, 98.2% were female, 50% had left and 45% right breast cancer, 81% had hypertension, 41% diabetes mellitus, 71% dyslipidemia, 34% were smokers, and 19% had a prior myocardial infarction. The average dose of photon RT to the chest was 55Gy in the cohort, and 40% received chemotherapy before RT. Patients were divided into two groups: positive and negative DSE. A positive DSE was seen in 19.6%. The median (Q1, Q3) regional wall motion abnormalities (RWMA) of patients with a positive DSE was 1 (1, 1.015) at baseline and 1.280 (1.190, 1.520) at peak stress, and for a negative DSE, was 1 (1, 1) at baseline and peak stress. 88.2% of negative DSE and 87.5% of positive DSE achieved the target heart rate of 85%. HTN, dyslipidemia, and prior MI were significantly associated with a positive DSE (p &amp;lt;0.023). The cumulative incidence of MACE was higher in the group of positive DSE (p&amp;lt;0.001), even after adjusting for hypertension, diabetes mellitus, dyslipidemia, smoking, and prior myocardial infarction, with a hazard ratio of 2.500 (1.51 – 4.13) and a p&amp;lt; 0.001. Similar results were observed regardless of RT laterality. Conclusions In breast cancer survivors that received adjuvant radiotherapy as part of multidisciplinary care, a positive DSE was an independent predictor of MACE compared to a negative result. These results support the usefulness of dobutamine stress echocardiography as a screening tool in breast cancer survivors.Kaplan-Meier Curve for MACE

Dobutamine stress echocardiography remains indispensable for the diagnosis of low-flow low-gradient severe aortic stenosis

Abstract Background In patients with low-gradient aortic stenosis (AS) and low transvalvular flow, current guidelines recommend dobutamine stress echocardiography (DSE) to determine valve stenosis severity. Additionally, aortic valve calcification (AVC) scores are also used with this intent. Previous studies have determined cut-off values of ≥2000AU for men and ≥1200AU for women to distinguish between true severe AS and pseudosevere AS. Purpose To assess the relationship between AVC and DSE in low-flow low-gradient aortic stenosis. Methods We performed a multicenter international registry study including patients that underwent DSE to determine AS severity and multi-slice computed tomography (MSCT) of sufficient quality to determine AVC scores. Severe AS was diagnosed when resting peak aortic valve velocity was ≥4.0 m/s, or stress aortic valve area (AVA) remained &amp;lt;1.0cm2 at peak dobutamine stress levels; moderate AS was diagnosed when resting AVA was ≥1.0cm2 and peak velocity was &amp;lt; 4.0m/s or stress AVA exceeded 1.0cm² at peak stress. Using the previous cut-off values, MSCT-AVC scores were compared to DSE-derived AS diagnoses to determine sensitivity and specificity of AVC, and the positive and negative predictive values of high and low scores. Subsequently, we performed a receiver-operating characteristics (ROC)-curve analysis for men and women separately. Results We included 271 patients from 8 centers, of which 231 patients had sufficiently interpretable DSE and MSCT. Median age was 79 years (Interquartile range (IQR): 71-84), median BMI was 26.4 kg/m2 (IQR: 24.1-30.0) and median BSA was 1.9 m2(IQR: 1.8-2.1). Left ventricular ejection fraction was reduced (&amp;lt;50%) in 209 (90.5%) patients. Bicuspid valve morphology was present in 20 patients (8.7%). DSE confirmed severe AS in 103 patients, 4 of whom already had resting peak aortic valve velocity ≥4.0m/s. Moderate AS was diagnosed in 128 patients, of which 76 had a resting AVA ≥ 1.0cm2. Characteristics of these patients are summarized the table. Of the patients with severe AS, 49 (47.6%) had a high AVC score (≥2000 for men or ≥1200 for women) and of patients with moderate AS, 75 (58.6%) had an AVC score below those cut-off values. This corresponds to a sensitivity of 47.6%, a specificity of 58.4% and positive and negative predictive values of 53.5% and 51.6%, respectively. The ROC-curves are shown in the figure; the area under the curve was 0.55 for men and 0.52 for women, signifying poor discriminative performance. Conclusion In this multicenter international registry we found that aortic valve calcification scores correlated poorly with AS severity and therefore DSE remains the preferred technique to assess borderline AS severity.Table.Patient characteristicsFigure.ROC curve

Dobutamine stress echocardiography in low-gradient aortic stenosis

Abstract Background Dobutamine stress echocardiography (DSE) is recommended to distinguish between true-severe and pseudo-severe aortic stenosis (AS) in patients with low flow low-gradients and left ventricular ejection fraction (LVEF) &amp;lt;50%. However, DSE has mostly been tested in the setting of LVEF&amp;lt;35%. Purpose The purpose of this study was to examine the diagnostic accuracy of DSE according to aortic valve calcification (AVC) score, in patents with low-flow, low-gradient AS across a wide range of LVEF. Methods Patients with aortic mean gradient &amp;lt;40 mmHg, aortic valve area (AVA) &amp;lt;1.0 cm2, and stroke volume index (SVi) ≤35 mL/m2 undergoing DSE were identified from three prospectively collected patient cohorts, and stratified according to LVEF; &amp;lt;35%, 35-50% and &amp;gt;50%. Severe AS was defined as AVC score ≥2000 AU among men, and ≥1200 AU for women. Recommendation for severe AS according to DSE, are an AVA &amp;lt;1.0 cm2 combined with an aortic mean gradient ≥40 mmHg or peak velocity ≥4 m/s. Receiver operating characteristic curves for DSE-derived AVA, mean gradient and Vmax were used to identify optimal cut-off points for each LVEF subgroup. Results Of the 221 patients included in the study, 78 (35%) presented with LVEF &amp;lt;35%, 67 (30%) with LVEF 35-50%, and 76 (34%) with LVEF &amp;gt;50%. Baseline characteristics are presented in the table. Based on AVC, severe AS was present in 102 (46%) of patients. Using recommended thresholds for severe AS for AVC and DSE, led to a sensitivity of 49%, a specificity of 84% and an accuracy of 67% for DSE for all patients with LVEF &amp;lt;50%, but with significant heterogeneity between groups figure. AVA performed rather uniformly across LVEF subgroups; (AUC =0.68 vs 0.62 vs 0.54, p=0.36) LVEF&amp;lt;35%, LVEF 35-50%, LVEF&amp;gt;50% respectively and displayed a rather uniform optimal cut-off (1.0 cm2 vs 0.9 cm2 vs 0.8 cm2). However, mean gradient and Vmax during DSE, both showed significantly diagnostic heterogeneity across LVEF groups (AUC= 0.90 vs 0.67 vs 0.65, p=&amp;lt;0.001 and AUC= 0.90 vs 0.66 vs 0.60, p=&amp;lt;0.001) with different optimal thresholds (30 mmHg &amp; 3.8 m/s, 45 mmHg &amp; 4.3 m/s and 37mmHg &amp; 4 m/s, LVEF&amp;lt;35%, LVEF 35-50%, LVEF&amp;gt;50%, respectively). Conclusion Our study shows, that the association between DSE gradients and AS severity assessed by AVC demonstrates important heterogeneity depending on LVEF. While DSE had the highest accuracy in patients with LVEF&amp;lt;35% both patients with LVEF 35-50%, and patients with LVEF&amp;gt;50% showed significantly less concordance between DSE and AVC.

Randomized study for the optimal treatment of symptomatic patients with low gradient severe aortic valve stenosis and preserved left ventricular ejection fraction (ROTAS trial)

Abstract Background the best management of symptomatic patients with low gradient (LG) severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) has not been established in randomized controlled trials. The ROTAS trial aimed to assess the superiority of aortic valve replacement (AVR) versus optimized medical therapy (OMT) in symptomatic patients with LG severe AS and preserved LVEF. Methods and Results Fifty-two patients (age 79±7 years; males 46%, mean aortic gradient: 31±5 mmHg; aortic surface: 0.8±0.1 cm², LVEF 61±8%) were randomized 1:1 to AVR or OMT. The stroke volume index (SVi, cut-off 35 ml/m²) was considered for randomisation so that the same percentage of patients with reduced SVi was present in the two groups. The follow-up lasted 14±7 months. An early interruption of the study occurred in 2021 because of the extremely low inclusion rate during the COVID-2019 pandemic and the large tendency to already implant TAVI in patients with severe LG AS with preserved LVEF. In all patients, a multimodality approach, including dobutamine stress echocardiography and/or aortic calcium score was applied to confirm AS severity. The primary end-point (a composite of overall death and heart failure hospitalisation) occurred in 13 (25%) patients. Patients receiving OMT did not experience worse survival compared to patients receiving AVR (HR=1.57, 95% CI:0.51-4.83, p=0.4275). Kaplan-Meier curves showed similar event-free survival (log-rank p=0.4236) among the 2 groups (Figure 1). Conclusions In the randomized ROTAS trial, AVR was not associated with a better prognosis in symptomatic patients with LG severe AS and preserved LVEF.Figure 1

Prognostic value of transvalvular flow rate in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study.

There are limited data on the clinical relevance of transvalvular flow rate (Qmean ) at rest (Qrest) and at peak stress (Qstress ) during dobutamine stress echocardiography (DSE) in patients with low-gradient severe aortic stenosis (LG-SAS). We retrospectively analyzed the clinical data of patients with LG-SAS who underwent DSE. LG-SAS was defined as an aortic valve (AV) area index of<.6 cm2 /m2 and a mean AV pressure gradient (AVPG) of<40mm Hg. The primary endpoint included all-cause death and heart failure hospitalization. Of 100 patients (mean age 79.5±7.3 years; men, 45.0%; resting left ventricular ejection fraction [LVEF] 52.1%±15.9%; resting stroke volume index 35.8±7.7mL/m2 ; Qrest 171.8±34.9mL/s), the primary endpoint occurred in 51 patients during a median follow-up of 2.84 (interquartile range 1.01-5.21) years. When the study patients were divided into three subgroups based on Qrest and Qstress , the multivariate analysis showed that Qrest<200mL/s and Qstress ≥200mL/s (hazard ratio 3.844; 95% confidence interval 1.143-12.930; p=.030), as well as Qrest and Qstress<200mL/s (hazard ratio 9.444; 95% confidence interval 2.420-36.850; p=.001), were significantly associated with unfavorable outcomes with Qrest and Qstress ≥200mL/s as a reference after adjusting for resting LVEF, resting mean AVPG, chronic kidney disease, New York Heart Association functional class III/IV, and AV replacement. Flow conditions based on the combination of Qrest and Qstress are helpful for risk stratification in LG-SAS patients.

Abstract 14203: Speckle Tracking Analysis During Dobutamine Stress Echocardiography in Patients Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion

Background: Dobutamine stress echocardiography (DSE) is often used as a non-invasive diagnostic modality for detection of myocardial ischemia and viability. A “biphasic response” in DSE can occur, in which contractility improves in dysfunctional segments with low dose stage and then becomes dysfunctional again at higher doses due to ischemia. We investigated if speckle tracking analysis during DSE can evaluate patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Methods: DSE was performed one day before CTO-PCI in consecutive 30 patients (18 female, age=71±11 years). Since 27 patients had 1 vessel, and 3 patients had 2 vessel CTO lesions, total of 33 regions were analyzed. Global (GLS) and regional longitudinal strain (RLS) were calculated as an averaged value of peak longitudinal strain in the apical 4-, 2-chamber, and long axis views at baseline echo, at low-dose, at high-dose DSE, and 6 months after CTO-PCI using available software (QLAB, Philips Medical Systems). Results: CTO-PCI was successfully done in all patients. GLS and RLS were feasible in all regions. Overall, GLS (-15.5±2.8 at baseline v.s. -17.3±3.8, p&lt;0.001) and left ventricular ejection fraction (LVEF) (56±6% v.s. 58±7%, p&lt;0.01) significantly improved 6 months after CTO-PCI. There was also significant improvement of RLS for the obstructed CTO regions (-13.8±3.6 v.s. -16.5±4.2, p&lt;0.005). Although in 24 patients (26 regions) with biphasic response during DSE (Figure), GLS (-15.7±2.5 v.s. -17.9±3.6, p&lt;0.01), LVEF (54±6% v.s. 56±7%, p&lt;0.05), and RLS (-13.8±3.5 v.s. -16.8±4.0, p&lt;0.01) improved significantly, GLS (-14.9±4.2 v.s. -15.8±5.0, p=n.s.), LVEF (59±3% v.s. 60±3%, p=n.s.), and RLS (-13.9±4.5 v.s. -15.5±5.7, p=n.s.) didn’t change in 6 patients (7 regions) without biphasic response. Conclusion: Speckle tracking analysis is feasible during DSE. CTO-PCI may improve both global and regional cardiac functions in patients with myocardial viability.

Abstract 15667: The Transvalvular Pressure Gradient to Valve Area Ratio: A Novel, Simple Doppler Echocardiographic Parameter to Adjudicate Low-Gradient Aortic Stenosis Severity

Background: In patients with low-gradient (LG) aortic stenosis (AS), dobutamine stress echocardiography (DSE) or aortic valve calcium scoring (AVCS) by computed tomography is required to confirm AS severity and the indication for intervention. Hypothesis: We hypothesized that the mean transvalvular gradient to effective orifice area ratio (MG/EOA, in mmHg/cm 2 ) measured during rest echocardiography predicts true-severe AS (TSAS) and clinical outcomes in LG-AS patients. The present study aimed to assess the diagnostic accuracy and prognostic value of the MG/EOA ratio in LG-AS patients. Methods: The diagnostic accuracy of the MG/EOA ratio to predict TSAS was assessed in: i) an in vitro dataset obtained in a circulatory model, and ii) an in vivo dataset collected in 198 patients recruited in the prospective observational cohort TOPAS study (NCT01835028), using receiver operating characteristic (ROC) curve analysis. The prognostic value of this parameter was assessed using spline curve analysis and multivariate Cox regression, using a composite of aortic valve replacement or all-cause mortality at 2-years as clinical endpoint. Results: The MG/EOA ratio at rest predicted TSAS with an area under the ROC curve of 0.99 [0.98-1.00] in the in vitro dataset and 0.92 [0.87-0.95] in the in vivo dataset of LG-AS patients. In the in vivo dataset predominantly composed of patients with a low flow state, the optimal cut-off of MG/EOA ratio was 29 mmHg/cm 2 with a normal flow state (percentage of correct classification: 95%) and 25 mmHg/cm 2 with a low flow state (85%). In LG-AS patients, a MG/EOA ratio ≥ 23 mmHg/cm 2 was associated with increased risk of the composite endpoint (unadjusted HR=2.16 [1.58-3.06], p&lt;0.001; adjusted HR=2.80 [1.94-4.03], p&lt;0.001). The net reclassification index (NRI) of the resting parameter MG/EOA was 0.57 (p&lt;0.001), which was similar to projected EOA (NRI=0.61, p&lt;0.001) measured by DSE. Conclusion: We propose a new, easily obtainable parameter from standard echocardiography that outperforms other rest echocardiographic parameters and is non-inferior to DSE with respect to diagnostic accuracy and prognostic value. The MG/EOA ratio can be useful in LG-AS to confirm AS severity and may thus avoid the use of additional tests such as DSE or AVCS.

Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery.

Major vascular surgery is associated with ahigh perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment. The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of adedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of astepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30days. The secondary endpoint was acute renal failure and severe bleeding. In total, 77patients (mean age 68.1 ± 8.1years, 70% male) were included: 39underwent standard and 38underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups. Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

S1537 A Novel Use of Stress Index and Pulse Pressure Change in Dobutamine Stress Echocardiography in Acute Alcohol Associated Hepatitis vs Chronic Liver Disease

S1537 A Novel Use of Stress Index and Pulse Pressure Change in Dobutamine Stress Echocardiography in Acute Alcohol Associated Hepatitis vs Chronic Liver Disease

Diagnostic capabilities of echocardiographic indicators of acceleration time and the ratio of acceleration time to total left ventricular ejection time in the assessment of severe aortic stenosis in patients with reduced left ventricular ejection fraction

Objectives: 1) to evaluate the diagnostic capabilities of AT and AT/ET in determining severe AS in patients with reduced LV EF and low stroke volume.2) to determine the threshold values for AT and AT/ET in the diagnosis of severe AS in patients with low stroke volume and low transaortic gradient.Materials and methods. This is prospective single center study included 70 patients with low transaortic pressure gradient, reduced LV ejection fraction was and severe aortic stenosis. All patients have been examined from 2017 to 2022. Inclusion criteria for the study are: isolated AV stenosis with, reduced LV RF, low transaortic pressure gradient. Severity of AS was identified based on dobutamine stress echocardiography and aortic valve area (AVA). Severe stenosis was defined as AVA&lt; 1 cm2.Result. A statistically significant and high negative correlation was found between the AVA and AT/ET ratio, (r = 0.77, p &lt; 0.001) and weak correlation with the AT indicator (r = 0.41, p = 0.01). The RoC-analysis showed the greatest predictive ability in the differential diagnosis of severe AS for the ratio AT/ET (AUC = 0.84 ± 0.54, p &lt; 0.001) and the lower predictive ability for the indicator AT (AUC = 0.63 ± 0.72, p &lt; 0.02). The optimal threshold value for determining severe AS for the AT / ET &gt; 0.32 (sensitivity of 92%, specificity of 70%), for AT &gt; 99 (sensitivity of 81%, specificity of 88%). Multiple logistic regression analysis revealed that the AT/ET ratio is the only echocardiographic parameter that has a significant impact on the differential diagnosis of severe AS in patients with reduced LV EF (OR 1.5; 95% CI 1.2–1.9, p = 0.001). There was low interobserver variability in measurements of AT score (intraclass correlation coefficient was 0.93 [95% CI, 0.80-0.97] and AT/ET ratio (intraclass correlation coefficient was 0.88 [95% CI, 0.75–0.95]).Conclusions.In patients with AS and reduced LV stroke volume the AT/ET ratio is highly sensitive and well reproducible in the diagnosis of severe AS. The AT index has a weak diagnostic ability of severe AS in that patients.The threshold value of AT/ET &gt;0.32 can diagnose severe AS with a high degree of probability in patients with reduced LV stroke volume and reduced transaortic gradients with reduced LV EF.

The Utility of Low-Dose-Dobutamine Stress Echocardiography in Patients with Heart Failure with Reduced Ejection Fraction: An Update.

Despite significant advancements in medical therapy, heart failure with reduced ejection fraction (HFrEF) continues to be a significant cause of death and disability. Reversible ischaemic left ventricular dysfunction due to viable myocardium is one such contributing factor. In these cases, coronary revascularization has shown promise in improving left ventricular function and prognosis. For patients with HFrEF and wide QRS, cardiac resynchronization therapy (CRT) is an effective option to address electromechanical dyssynchrony. However, approximately 30% of patients do not respond positively to CRT, highlighting the need to refine candidate selection for this treatment. In some patients with reduced HFrEF, there is a condition known as classical low-flow, low-gradient aortic stenosis (AS) that may be observed. This condition is characterized by a low transaortic flow, which leads to reductions in both the transaortic mean gradient and aortic valve area. Decision-making regarding revascularization, CRT, and pharmacological treatment play a crucial role in managing HFrEF. Cardiac imaging can be valuable in guiding decision-making processes and assessing the prognosis of patients with HFrEF. Among the imaging modalities, dobutamine stress echocardiography has come a long way in establishing itself as a feasible, safe, effective, relatively cheap non-invasive technique. The aim of this review is to explore the current literature on the utility of low-dose stress echocardiography in diagnosing and prognosticating patients with HFrEF.

Diagnosis of cardiovascular disease in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) are at high risk of cardiovascular disease (CVD) and cardiovascular death. Identifying and monitoring cardiovascular complications and hypertension is important for managing patients with CKD or kidney failure and transplant recipients. Biomarkers of myocardial ischaemia, such as troponins and electrocardiography (ECG), have limited utility for diagnosing cardiac ischaemia in patients with advanced CKD. Dobutamine stress echocardiography, myocardial perfusion scintigraphy and dipyridamole stress testing can be used to detect coronary disease in these patients. Left ventricular hypertrophy and left ventricular dysfunction can be detected and monitored using various techniques with differing complexity and cost, including ECG, echocardiography, nuclear magnetic resonance, CT and myocardial scintigraphy. Atrial fibrillation and other major arrhythmias are common in all stages of CKD, and ambulatory heart rhythm monitoring enables precise time profiling of these disorders. Screening for cerebrovascular disease is only indicated in asymptomatic patients with autosomal dominant polycystic kidney disease. Standardized blood pressure is recommended for hypertension diagnosis and treatment monitoring and can be complemented by ambulatory blood pressure monitoring. Judicious use of these diagnostic techniques may assist clinicians in detecting the whole range of cardiovascular alterations in patients with CKD and enable timely treatment of CVD in this high-risk population.

Aortic Valve Calcium Score in Addition to Dobutamine Stress Echocardiography for Low-Flow, Low-Gradient Aortic Stenosis Assessment

Aortic Valve Calcium Score in Addition to Dobutamine Stress Echocardiography for Low-Flow, Low-Gradient Aortic Stenosis Assessment

Complications of exercise and pharmacologic stress echocardiography.

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

Epicardial adipose tissue volume, plaque vulnerability and myocardial ischemia in non-obstructive coronary artery disease

BackgroundEpicardial adipose tissue (EAT) accumulation has been associated with inflammation, atherosclerosis and microvascular dysfunction. Whether increased EAT volume is associated with coronary plaque vulnerability and demand myocardial ischemia in patients with non-obstructive coronary artery disease (CAD) is less explored. MethodsIn 125 patients (median age 63[58, 69] years and 58% women) with chest pain and non-obstructive CAD, EAT volume was quantified on non-contrast cardiac CT images. EAT volume in the highest tertile (>125 ml) was defined as high EAT volume. Total coronary plaque volume and plaque vulnerability were quantified by coronary CT angiography (CCTA). Demand myocardial ischemia was detected by contrast dobutamine stress echocardiography. ResultsHigh EAT volume was more common in men and associated with higher BMI, hypertension, increased left ventricular mass index (LVMi), C-reactive protein (CRP) and positive remodelling (all p < 0.05). There was no difference in age, coronary calcium score, total and non-calcified plaque volume or presence of demand myocardial ischemia between groups (all p ≥ 0.34). In a multivariable model, obesity (p = 0.006), hypertension (p = 0.007) and LVMi (p = 0.016) were independently associated with high EAT volume. Including plaque vulnerability in an alternative model, positive remodelling (p = 0.038) was independently associated with high EAT volume. ConclusionIn non-obstructive CAD, high EAT volume was associated with cardiometabolic risk factors, inflammation and plaque vulnerability, while there was no association with demand myocardial ischemia or coronary plaque volume. Following our results, the role of EAT volume as a biomarker in non-obstructive CAD remains unclear.