During Dobutamine Stress Echocardiography Research Articles

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.

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.

Comparison between Visual Assessment and Longitudinal Strain during Dobutamine Stress Echocardiography.

The relationship between visual assessment and longitudinal strain during dobutamine stress echocardiography (DSE) remains poorly investigated. This study assessed wall motion segments visually graded as normokinetic, hypokinetic, and akinetic at baseline and the peak of DSE and compared with longitudinal strain between segments with and without induced impaired contractility and improved contractility during DSE. This study included 112 patients examined by DSE, consisting of 58 patients referred for diagnostic study and 54 patients referred for viability study. Regional left ventricular (LV) contractility was assessed visually and longitudinal strain was measured using echocardiography transthoracic. At baseline, the strain of LV segments was -16.33 ± 6.26 in visually normokinetic, 13.05 ± 6.44 in visually hypokinetic, and -8.46 ± 5.69 in visually akinetic segments. During peak dose, the strain of LV segments was -15.37 ± 6.89 in visually normokinetic, -11.37 ± 5.11 in visually hypokinetic, and -7.37 ± 3.92 in visually akinetic segments. In segments with visually observed impaired contractility, the median longitudinal strain was significantly lower than in segments without impaired contractility. For segments with visually observed improved contractility, the median longitudinal strain was significantly higher than for segments without improved contractility. In diagnostic study, sensitivity of visual assessment for absolute decrease of >2% longitudinal strain was 77%, respectively. In the viability study, the sensitivity was 82% for an absolute decrease of ≥2% longitudinal strain. There is good association between strain analysis value and visually assessed wall motion contractility.

Pulmonary Arterial Pressure Changes Under Dobutamine Stress Echocardiography in Non-Anemic Iron Deficient COPD Subjects.

PurposeNon-anemic iron deficiency (NAID) is common in COPD, and could induce functional/structural changes in the pulmonary vascular bed. Thus, we aimed to study, during resting and ambient oxygen conditions, the systolic pulmonary arterial pressure (sPAP) changes during dobutamine stress echocardiography (DSE) for NAID+ compared to NAID- subjects with COPD.Patients and MethodsWe analyzed 24 patients with COPD and evaluated their clinical parameters, including lung function and serum iron profile, followed by the changes in the sPAP under DSE.ResultsTen subjects with NAID+ were compared with fourteen NAID- subjects for sPAP measurement. At baseline, only left atrial volume was significantly different between groups (30±4 vs 23±5 mL*m2), respectively (p-value=0.002). For the right side, tricuspid annular plane systolic excursion (TAPSE) was similar between-groups (22±2 vs 20±4, p-value >0.05), at baseline. The sPAP (mmHg) changes were also not significantly different between groups (pre 32±14 vs peak 48±14 for NAID+ and pre 29±7 vs peak 43±10 for NAID-, Group p-value=0.400, Time p-value <0.0001, and Interaction p-value=0.606).ConclusionCOPD subjects with NAID do not show increased sPAP responses during DSE, compared with iron-replete subjects.

The effect of atropine used in dobutamine stress echocardiography on pupil diameter.

The use of atropine during dobutamine stress echocardiography (DSE) is contraindicated in persons with narrow angle glaucoma though there is limited evidence that low doses of intravenous atropine do not cause pupillary dilation. The aim of this study is to investigate whether atropine when administered in persons without glaucoma during dobutamine stress echocardiography causes pupillary dilation. Out of 144 patients without a history of glaucoma referred for DSE for clinical indications, 105 patients received intravenous atropine doses ranging from 0.1 mg to 1.25 mg (most patients received 0.25-0.75 mg). Pupil diameter of both eyes was measured under the same light conditions before and after the DSE using a CP-30 Optical Digital PD Ruler. For the total of 210 examined eyes pupil diameter remained unaltered after each DSE test (3.65 ± 0.799 mm before vs 3.63 ± 0.766 mm after, p = .737). Similarly, pupil diameter remained unchanged when left and right eyes were assessed separately (right eye: 3.770 ± 0.812 before vs 3.752 ± 0.745 mm after, p = .821 and left eye: 3.521 ± 0.770 before vs 3.499 ± 0.770 mm after, p = .806). Diameter of right and left pupil were also unaltered after grouping patients by sex and iris pigmentation. Age, weight, atropine dose and propranolol dose were not correlated with changes in pupil diameter. Intravenous atropine in usual doses administered in DSE does not cause mydriasis in adults without glaucoma. Future studies need to confirm our findings and expand the investigation regarding safety of atropine use during DSE in patients with narrow angle glaucoma.

Abstract 14281: Comparative Visualization of Left Ventricular Segments With and Without Intravenous Contrast During Dobutamine Stress Echocardiography in Class III Obese Patients

Introduction: Concern exists regarding adequacy of visualization of stress echocardiograms performed without intravenous contrast (IVC) enhancement in patients with Class III obesity (body mass index ≥ 40 kg/m 2 ). Hypothesis: Use of (IVC) enhancement will significantly improve visualization and interpretability for ischemia of left ventricular (LV) segments during dobutamine stress echocardiography (DSE) at baseline and at peak stress compared to non-use of IVC enhancement. Methods: DSE was performed on 128 candidates for bariatric surgery with class III obesity without chest pain or pre-existent coronary artery disease. DSE without IVC was initially performed on 62 patients with class III obesity, then was subsequently was performed with IVC on 66 patients with class III obesity. LV regional wall motion was assessed at baseline and peak stress using the 16-segment model. Results: In the IVC group 1046 of 1056 LV segments studied (99.1%) were well-visualized and interpretable at baseline and 1044 of 1056 LV segments studied (98.9%) were well-visualized and interpretable at peak stress. In the non-IVC group 905 of 992 LV segments studied (91.2%) were well-visualized and interpretable at baseline and 886 of 992 LV segments studied (89.3%) were well-visualized and interpretable at peak stress. A significantly greater number of LV segments were well-visualized and interpretable in the IVC group compared to the non-contrast group, at baseline and at peak stress (p &lt; 0.00001 for both). DSE was positive for ischemia in 1 patient. All patients eventually underwent bariatric surgery without cardiovascular complications. Six months after surgery, all patients were alive; none developed cardiovascular events. Conclusion: The use of IVC enhancement during DSE significantly improves visualization and interpretability of lLV segments in patients with class III obesity and relatively low cardiovascular risk.

Feasibility of Real-Time Myocardial Contrast Echocardiography to Detect Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients

Cardiac allograft vasculopathy (CAV) is an important adverse prognostic factor for pediatric heart transplant (HT) recipients. Invasive coronary angiography (ICA) is the gold standard for CAV detection but lacks sensitivity for early microvascular changes and cumulative radiation exposure is of concern. Real-time myocardial contrast echocardiography (RTMCE) using ultrasound enhancing (contrast) agents performed during dobutamine stress echocardiography (DSE) can assess myocardial function, perfusion, and microvascular integrity. The objective of this study was to determine the safety and feasibility of RTMCE during DSE to detect CAV in a pediatric HT population. HT patients 10-21years of age were recruited to undergo DSE with RTMCE to determine technical feasibility, test tolerability and adverse event rate, and detection of perfusion defects compared with ICA-detected CAV. Thirty-six patients from two centers were enrolled, with a mean age 13.5±4.3years; 21 (58%) were male. Wall motion and myocardial perfusion were qualitatively assessed and compared with ICA findings of CAV. Myocardial blood flow (MBF) at rest and peak stress was quantified, and myocardial blood flow reserve (MBFR) was defined as the ratio of peak to rest MBF. Five (14%) patients had CAV by ICA, two with obstructive disease and three with mild CAV. Real-time myocardial contrast echocardiography was feasible in 32 (89%) patients. Three patients had wall motion defects, including one with a mixed defect and two with fixed defects. A perfusion abnormality was present in five patients, two of whom had obstructive CAV and one with mild CAV. Sensitivity and specificity of RTMCE for CAV detection were 60% and 94%, respectively, and diagnostic accuracy was 89%. MBFR assessment was feasible in 20 (63%) patients. The mean MBFR was 3.4±0.7. Patients with CAV had lower MBFR than those without (2.0±0.2 vs 3.7±0.8; P<.01). There were no serious adverse events related to RTMCE. Dobutamine stress RTMCE appears to be safe and feasible for the assessment of CAV in pediatric HT recipients. Further assessment is warranted to determine whether this noninvasive technique could provide a reliable alternative to ICA.

Longitudinal Strain by Speckle Tracking during Dobutamine Stress Echocardiography in Suspected Coronary Arteries Disease

&#x0D; Background. Speckle tracking echocardiography (STE) provides valuable information about global and regional myocardial function. STE during dobutamine stress-echocardiography (DSE) enables more reliable ischemia diagnosis.&#x0D; The aim of the study was to evaluate STE feasibility as a DSE visualization method and its accuracy compared to coronary angiography (CAG) in the patients with moderate-to-high coronary arteries disease (CAD) risk.&#x0D; Methods. We prospectively examined 140 patients (84 [60.0%] men and 56 [40.0%] women) with suspected CAD in order to verify diagnosis and evaluate myocardial viability and coronary reserve.&#x0D; Results. Mean left ventricular ejection fraction (LVEF) was 54.4±15.8%. All the patients had normal blood pressure (BP) and heart rate (HR) during the test. There were no significant hemodynamics alterations during the test. There were no significant complications during DSE with only 15 (12.9%) cases of different relatively low grade supraventricular and ventricular arrhythmia, mainly transitory without interventions. There were 116 (82.9%) positive DSE results, of which 2 (1.72%) were false-positive. In 2 (8.3%) patients with negative DSE results, CAG revealed 1-vessel insignificant (50– 70%) lesions with developed collaterals (false-negative results). According to DSE and CAG results, 96 (82.3%) patients underwent revascularization interventions: 86 (89.6%) percutaneous coronary interventions (PCIs) and 10 (10.4%) coronary artery bypass grafting (CABG) surgery. Sensitivity and specificity of DSE with STE for primary CAD diagnosis according to the “golden standard” CAG results were 98.3% and 91.7%, respectively, with identical positive and negative predictive values and very high overall accuracy of the method (AUC = 0.98; OR = 627.0, p&lt;0.0001). Sensitivity and specificity of DSE with STE for defining indications for intervention and revascularization were 97.9% and 91.7%, respectively, with high overall accuracy (AUC = 0.95; OR = 564.0, p&lt;0.0001). Combined quantification of ΔGLS and ΔWMSI for primary CAD diagnosis showed significantly lower sensitivity 86.2%(p=0.0002)andspecificity80.4%(p=0.0064)withsignificantlylowerintegralmethodaccuracy(AUC0.83,p&lt;0.0001).&#x0D; Conclusions. DSE with STE as a visualization method is a safe and optimal method for ischemia diagnosis and evaluation of myocardial viability and coronary reserve in patients with suspected CAD. Given the lower ΔGLS and ΔWMSI accuracy compared to integral DSE with STE result evaluation, as well as frequent GLS growth in significant number of patients with definite positive test result, authors recommend evaluating integral test result rather than strain value.

Quantitative assessment of contractile reserve of systemic right ventricle in post-Senning children: Incorporating speckle-tracking strain and dobutamine stress echocardiography.

The systemic load on the right ventricle (RV) after Senning atrial switch leads to ventricular dysfunction. Quantitative assessment of RV contractile reserve is mandatory to anticipate the need for anti-fibrotic treatment. We aimed to quantitatively assess RV contractile reserve in Senning children by estimating speckle-based global longitudinal strain (GLS) during dobutamine stress echocardiography (DSE). This prospective study compared thirty-one post-Senning children (group I) and thirty controls (group II). In post-Senning children, echocardiographic RV systolic function using one-plane ejection fraction (RVEF), RV fractional area change (RVFAC), tricuspid annulus plane systolic excursion (TAPSE), its Z-score, and RVGLS were recorded at rest and peak DSE. Contractile reserve was defined as improvement >5% in RVEF, >2% in GLS, and/or to near normal TAPSE. RVEF, RVFAC, TAPSE, and TAPSE Z-score were significantly lower in patients than controls [RVEF:40.13±2.93% vs 53.17±3.17% (P<.001*), RVFAC: 21.17±2.37% vs 37.23±2.13% (P<.001*), TAPSE:13.81±1.26 vs 17.45±2.93mm (P<.001*), TAPSE Z-score: -3.47±0.46 vs -2.09±0.48 (P<.001*)]. Also, RVGLS was significantly impaired in Senning children than controls[ (-11.89±2.31% vs -22.35±6.73% (P<.001*)]. At peak DSE, contractile reserve was not evident as measured by RVEF which increased none significantly to 42.47±2.80% (P=.063). However, RVGLS improved significantly to -15.78±0.93% (P<.001*) and discovered the masked contractile reserve in Senning children. The 19(61.29%) children who showed masked contractile reserve (improvement in RVGLS>2%) underwent continuation of anti-fibrotic medications. Despite systemic RV function in post-Senning children was impaired at rest and during DSE, RVGLS was useful in quantitative assessment of masked contractile thus promoted continuing anti-fibrotic treatment.

Dobutamine Stress Echocardiography with B-Mode Speckle Tracking in Patients after Acute Coronary Syndromes: Diagnostic and Prognostic Value

&#x0D; Background. Speckle tracking echocardiography (STE) provides valuable data on myocardial function. STE during dobutamine stress echocardiography (DSE) allows reliable myocardial ischemia diagnosis.&#x0D; Aim. To evaluate STE during DSE in patients with coronary artery disease (CAD) after acute coronary syndrome (ACS) and its accuracy in ischemia diagnosis, assessment of myocardial viability and coronary reserve. Methods. We examined 58 patients (55 [94,8 %] men and 3 [5,2 %] women) men) with CAD after ACS admitted to our Institute for defining indications for coronary interventions. All the patients underwent DSE with STE for longitudinal strain quantification.&#x0D; Results. Mean left ventricular ejection fraction (LVEF) was 52.4±5.8%. Significant CAD according to coronary angiography (CAG) prior to DSE was proved in 38 (65.5%) patients. All the patients had a history of ACS up to 12 years before the examination (38 [65.5%] patients after percutaneous coronary intervention (PCI), including 18 [31.0%] primary PCI; 9 [15.5%] patients after coronary artery bypass grafting (CABG); 3 [5.2%] after graft PCI, 1 [1.72%] patient after aortic valve replacement (AVR) with dilated cardiomyopathy (DCM) phenotype). There were no significant complications during DSE: 5 (8.6%) cases of relatively low grade transient arrhythmia with no need for intervention. As per DSE results, we performed 35 (60.3%) revascularization interventions: 31 (58.6%) PCI’s and 4 (6.9%) CABG procedures with good outcomes. It was shown that DSE with STE sensitivity and specificity were 89.7% and 94.7% (AUC 0.92), respectively, with positive and negative predictive values of 97.2% and 81.8%, respectively, with extremely high OR 157.5, p&lt;0.0001. Combined quantification of ΔGLS and ΔWMSI showed insignificantly lower sensitivity (86.3% [p=0.57]) and specificity (87.8% [p=0.19]) vs. integral semiquantitative ischemia markers with significantly lower overall method accuracy (AUC 0.79, p=0.047).&#x0D; Conclusions. DSE with STE as a visualization method is a safe and optimal method for ischemia diagnosis, as well as for myocardial viability and coronary reserve assessment in patients with CAD after ACS with the aim of risk stratification and defining indications for interventions and myocardial revascularization.

Additional diagnostic accuracy of global longitudinal strain at peak dobutamine stress in patients with moderate pretest probability of coronary artery disease.

Previous studies confirmed the feasibility of 2D speckle tracking echocardiography (2D STE) during dobutamine stress echocardiography (DSE) in assessing myocardial ischemia in patients with previous myocardial infarction. It is unknown whether it improves the diagnostic accuracy in young patients with intermediate pretest probability for coronary artery disease (CAD) and no prior cardiovascular events. We prospectively studied 101 patients by DSE and STE, followed by coronary angiography within 1month. Significant CAD was defined as diameter stenosis≥50%. Receiver operating characteristic analysis obtained global longitudinal strain (GLS) cutoff values of significant area under the curve (AUC). Mean age: 53±8years, 56% females, 49 had significant CAD (group 1) and 52 had normal/mild CAD (group 2); no significant baseline differences except more males in group 1 (P: .002). DSE sensitivity and specificity for CAD were 79.6% and 92.3%, respectively, positive predictive value (PPV): 90.6%, negative predictive value (NPV): 82.7%, and diagnostic accuracy: 86%. At peak stress, all strain parameters were significantly lower in group 1. However, GLS had the highest AUC: 0.88, P: <.001. GLS cutoff value≤-20.5 had 89.8% sensitivity, 84.6% specificity, 84.6% PPV, 89.8% NPV, and 87% diagnostic accuracy. Combining GLS cutoff with DSE had higher AUC than either alone (0.9, P<.001): 95.9% sensitivity, 84.6% specificity, 85.5% PPV, 95.7% NPV, and 90% diagnostic accuracy. 2D-STE-derived GLS increases DSE precision to detect CAD in intermediate pretest probability patients: It improves DSE sensitivity, NPV, and accuracy. It is reproducible and has comparable specificity.

A head-to-head comparison of wall motion score index, force, strain, and ejection fraction for the prediction of SYNTAX and Gensini coronary scores by dobutamine stress echocardiography.

Predicting the severity of coronary artery disease (CAD) may be possible during dobutamine stress echocardiography (DSE) with various indices of left ventricular function. We assessed the relative value of ejection fraction (EF), force, global longitudinal strain (GLS), and wall motion score index (WMSI) in predicting SYNTAX and Gensini scores in patients with known or suspected CAD. We prospectively enrolled 223 patients (120 men; mean [SD] age, 62 [9] years) and assessed the following indices: 1) EF (with triplane imaging); 2) force, calculated as the ratio of systolic blood pressure to left ventricular end‑systolic volume; 3) GLS; 4) WMSI. All patients underwent coronary angiography within 12 weeks with SYNTAX and Gensini scores evaluation. The correlation of SYNTAX and Gensini scores was highest with peak WMSI (SYNTAX, rho = 0.591; Gensini, rho = 0.612; P<0.001), intermediate with peak force (SYNTAX, rho = -0.346; Gensini, rho = -0.377; P<0.001) and GLS (SYNTAX, rho = -0.205; P = 0.002 and Gensini rho = -0.216; P = 0.001), and the weakest for EF (SYNTAX, rho = -0.149; P = 0.03 and Gensini, rho = -0.191; P = 0.006). The similar hierarchy of variables was detected for changes during DSE. In the subgroup after myocardial infarction (n = 66 [27%]), GLS outperformed the force. In patients with CAD at DSE peak, theWMSI and force were better predictors of the coronary SYNTAX and Gensini scores and CAD severity than GLS or EF. However, in patients after myocardial infarction, the GLS correlation with coronary scores improved and got closer to the visual assessment.

FLOW RESERVE ASSESSED BY FLOW RATE BUT NOT BY STROKE VOLUME PREDICTS MORTALITY IN LOW-FLOW, LOW-GRADIENT AORTIC STENOSIS

Flow reserve i.e. an increase in stroke volume >20% (Δ20%SV) during dobutamine stress echocardiography (DSE), has been used to predict mortality following surgical aortic valve replacement (AVR) in patients with classical low-flow, low-gradient aortic stenosis (CLF-AS). We hypothesized that mean

Stress cardiomyopathy induced during dobutamine stress echocardiography.

Background:Catecholamines play a central role in pathogenesis of stress cardiomyopathy (SC). We aimed to review the clinical characteristics, procedural details and outcomes of patients with SC during dobutamine stress echocardiography (DSE).Methods/Results:A total of 20 adults [age 64±15 years, 80% women, 67% hypertension, 20% diabetes, 33% hypercholesterolemia, 19% chronic kidney disease, 13% known anxiety disorder] with SC during DSE were identified from local digital archives of our laboratory (n=3) or reports in English literature (n=17). Indication for DSE was suspected coronary artery disease (CAD) in all patients. Left ventricular (LV) ejection fraction was normal at baseline. SC developed at a blood pressure of 154±47/86±24 mmHg, heart rate of 130±17 bpm (88±10% predicted maximum) and peak rate-pressure product of 20559±3898 mmHg*bpm. ST segment elevation was seen in 65%. SC occurred at peak dobutamine infusion rate of 38±6 μg/kg/min in 85% and during recovery in 15%. Atropine [0.7±0.6 (0.25-2) mg] was given to 7 patients. LV ejection fraction dropped to 30±6% with apical (40%), apical and mid (45%) or basal and mid (10%) circumferential LV ballooning. One patient (5%) had a mixed pattern of wall motion abnormality. LV outflow tract obstruction developed in 15%. Major adverse cardiac events occurred in 7 (35%) and included death (n=1), congestive heart failure (n=2), hypotension (n=3) and atrial fibrillation with heart failure (n=1). At a mean follow up duration of 19±19 days, complete or partial recovery of LV wall motion abnormality was seen in 18 and 1 patient, respectively.Conclusion:SC uncommonly occurs during DSE. However, death and other adverse events (hypotension, heart failure and atrial fibrillation) may occur and require urgent attention. Once managed, complete recovery is expected in most patients.

P314 The functional effects of intramural course of coronary arteries by two-dimensional speckle-tracking dobutamine stress

Abstract Background Intramural course of a coronary artery is a common anatomic variant, especially in the left anterior descending coronary artery (LAD). However, its effect on the myocardial function during stress remains still unclear. Purpose We compared regional myocardial strain measured by speckle tracking during dobutamine stress echocardiography (DSE) in patients with or without intramural course of the LAD. Methods Fifty patients (63 ±7 years) were prospectively enrolled and underwent DSE, computed tomography angiography (CTA), quantitative 15-Oxygen water positron emission tomographic perfusion imaging (PET), and invasive angiography. Patients with superficial (&amp;gt;1 mm) or deep (&amp;gt;2 mm) intramural course in the LAD were identified using CTA. Regional longitudinal strain and strain rate (LS, LSr), circumferential strain and strain rate (CS, CSr), as well as radial strain and strain rate (RS, RSr) were measured at rest, at a dobutamine dose of 20 mg/kg/min, at peak stress, and at early recovery (1 min after stress). Obstructive coronary artery disease (CAD) was defined as &amp;gt;75% stenosis or 40% to 75% stenosis combined with either fractional flow reserve &amp;lt; 0.80 or ischemia on PET. Results Intramural course of the LAD was detected in 17 patients. Of these, 8 patients had obstructive CAD and were excluded. Thus, 9 patients with intramural course and 11 controls without intramural course or obstructive CAD in the LAD were included. Myocardial strain and strain rate in the myocardial territory distal to intramural segment were similar to those in controls at rest, dobutamine stress and early recovery (Figure). Furthermore, there were no significant differences, at all time points, between the regional strain values of the myocardial segments those distal to the superficial and deep intramural course. In the myocardium distal to an intramural coronary segment, regional myocardial flow measured by PET during adenosine stress correlated with the regional LS (r = 0.80, p = 0.004), LSr (r = 0.66, p = 0.03), and CS (r = 0.69, p = 0.02) and RS (r = 0.53, p = 0.07) at the peak dobutamine stress. However, there was no correlation between flow and strain at rest. Conclusions Myocardial strain is not consistently affected in patients with intramural course of the LAD during dobutamine stress as assessed by speckle tracking echocardiography. Larger studies are warranted to evaluate whether certain anatomical variants cause abnormalities in systolic myocardial strain. Abstract P314 Figure.

The Value of Regional 2D Longitudinal Strain Analysis during Dobutamine Stress Echocardiography in Detecting the Culprit Coronary Territory

Aim: To evaluate the diagnostic value of analyzing the regional longitudinal strain by 2D speckle tracking modality during dobutamine stress echocardiography (DSE) in detecting the culprit disease in either coronary circulation. Methodology: Prospectively 101 symptomatic patients at intermediate pretest probability for CAD were studied within one month by DSE, followed by coronary angiography. The 3 standard apical views were acquired both at rest and peak stress at an average frame rate of 70/sec. The following indices: longitudinal peak systolic strain (LS), longitudinal peak systolic strain rate (LSRs), and longitudinal early diastolic strain rate (LSRd) were obtained from each segment of the 17 segment model. Regional strain was calculated as the mean of strain parameters of all 10 segments representing the anterior coronary circulation and of the 7 segments representing the posterior coronary circulation separately. Coronary stenosis ≥ 50% was considered significant. Results: 52 patients had normal or mild CAD , the 49 patients with significant CAD were classified into ACC group n-21, and PCC group n=22. Those with mixed territory disease (n=17) were excluded from final analysis. At rest, LS &amp; LSRs were significantly lower in PCC than ACC group (-19.462.6 vs -21.762.5, p: 0.007 and -1.2360.17 vs -1.4960.33, p: 0.015 respectively). At peak stress, all strain parameters were significantly different between the two groups regardless of the involved territory. In Receiver Operator Characteristics analysis, peak stress LS in either ACC and PCC territories showed the largest area under the curve: 0.9 (p&lt;0.001) and 0.88 (p&lt;0.001) respectively. The mean LS at cutoff value of -21% &amp; -20% had 90.5% sensitivity and 88.5% specificity for detecting significant ACC disease, and 81.8% sensitivity and 79% specificity for detecting significant PCC disease respectively Conclusion: Baseline regional strain analysis has the potential to detect significant CAD in PCC territory. At peak stress the longitudinal systolic strain can detect significant disease in either coronary territory with high sensitivity and specificity.

P1503Decrement of vortex formation time during dobutamine stress echo

Abstract Background Vortex Formation Time (VFT) is a novel index of systolic and diastolic function which may be also affected by left ventricular geometry, but has never been evaluated during dobutamine stress echocardiography (DSE) protocols. We sought to investigate the changes in VFT during DSE protocol. Methods DSE was performed in 50 consecutive patients. Patients with poor acoustic window, atrial fibrillation, cardiac valve disease or pacemaker were excluded. Apical four and apical two chamber views were acquired and the following parameters were calculated off- line without knowledge of DSE result both at rest and at peak: left ventricular end-diastolic and end-systolic volume, stroke volume, ejection fraction, stroke work, e and a wave peak velocity and VTI, TDI-derived mitral annular early diastolic velocity at the lateral wall and mitral valve diameter. VFT calculated according to the following equation: VFT = [4 *(1 − β) * α3 * EF]/π, where α = (LVEDV/α3)(1/3) and is affected by ventricular geometry and β = VTIa-wave/(VTIe wave + VTIa-wave) reflecting the atrial filling fraction. Results Median age of the study population was 61 [53–72], 38 men (76%) and 13 (26%) had an old myocardial infarction. Fifteen patients (30%) were positive for myocardial ischemia during DSE. At rest, median LVEDV was 121.5ml (101.8–148.0), median EF (%): 59.9 [54.4–64.1], median atrial filling fraction: 0.43 [0.40–0.48], median mitral valve diameter (cm): 2.8 [2.6–3.0] and median VFT: 2.44 [1.74–3.10]. At peak, median LVEDV was 102.0ml [86.4–122.3] median EF (%) 65.7 [58.8–69.8], median atrial filling fraction: 0.67 [0.59–0.73], median mitral valve diameter (cm): 2.7 [2.5–2.9] and median VFT: 1.45 [1.05–1.88]. VFT decreased in the whole population (Wilcoxon rank test, p&lt;0.001) (figure 1A) and when patients were stratified according to test result. Median VFT decrease was significantly higher in patients with a positive DSE (50%) than in patients with negative DSE (39%) (Mann- Whitney U test, p=0.048) (figure 1B). Figure 1 Conclusion The VFT decreased significantly during DSE and most prominently in patients with ischemic response. This may indicate the deterioration of left ventricular diastolic or systolic function as well as change in left ventricular geometry during DSE protocol.

The effect of cardiac shock wave therapy on myocardial function and perfusion in the randomized, triple-blind, sham-procedure controlled study

BackgroundRecent triple-blind sham procedure-controlled study revealed neutral effects of the cardiac shock wave therapy (CSWT) on exercise tolerance and symptoms in patients with stable angina. Current data about the effects of CSWT on global and regional myocardial contractility and perfusion is limited. Hereby we report the results of an imaging sub-study that evaluated the capacity of CSWT to ameliorate myocardial ischemia induced during dobutamine stress echocardiography (DSE) and cardiac single photon emission computed tomography (SPECT).MethodsProspective, randomized, triple-blind, sham procedure-controlled study enrolled 72 adult subjects who complied with defined inclusion criteria. The subjects were assigned to the OMT + CSWT and the OMT + sham procedure study groups with 1:1 ratio. Application of the CSWT covered all segments of the left ventricle. Imaging ischemia tests were performed in 59 study patients: DSE and SPECT before the CSWT treatment and after 6 months, with DSE carried out additionally at 3 months after randomization. Co-primary endpoints of the study were: change in wall motion score index (WMSI), representing the stress-induced impairment of regional myocardial function, and change in summed difference score (SDS), representing the amount of perfusion defect.ResultsOMT + CSWT and OMT + sham procedure study groups included 30 and 29 patients, respectively. Regional myocardial contractility during DSE significantly improved at 3 months follow-up in OMT + CSWT group compared to baseline as shown by WMSI at stress (1.4 ± 0.4 vs 1.6 ± 0.4, p = 0.001), but not in OMT + sham procedure group (1.5 ± 0.3 vs 1.6 ± 0.4, p = 0.136). The difference in stress DSE results between both study groups disappeared after 6 months. SPECT results demonstrated a significant reduction of inducible ischemia in OMT + CSWT group compared to OMT + sham procedure group at 6 months follow-up (SDS dropped from 5.4 ± 3.7 to 3.6 ± 3.8 vs 6.4 ± 5.9 to 6.2 ± 5 respectively, p = 0.034).ConclusionsCardiac shock wave treatment showed the ability to reduce stress-induced myocardial ischemia, as assessed by wall motion abnormalities and perfusion defects, compared to sham procedure.Trial registrationClinicaltrials.gov (NCT02339454). The trial was registered retrospectively on 12 January 2015.

Quantitative assessment of the rotation and twist of the left ventricle during dobutamine stress echocardiography: a comparison of patients with and without significant coronary artery disease.

The rotation and twist of the left ventricle (LV) have been comprehensively evaluated at rest. However, little is known about rotational mechanics during dobutamine stress echocardiography (DSE). We aimed to quantify and compare the basal and apical rotation and twist of the LV at rest as well as at the peak and recovery stages of DSE in patients with and without coronary artery disease (CAD). We enrolled 91 patients, including 48 patients with CAD and 43 patients without CAD (mean [SD] age, 62 [9] years and 61 [10] years, respectively). Coronary artery disease was defined as the presence of stenoses of 50% or more in the left main coronary artery and/or stenoses of 70% or more in other epicardial arteries. Rotation was measured by 2‑dimensional speckle‑tracking echocardiography, and twist was calculated as the difference between the basal and apical rotation. Neither rotation nor twist differed between patients with and without CAD at rest, although apical rotation was significantly greater in the CAD group at peak DSE (mean [SD], 5.43° [3.45°] vs 3.71° [3.52°], P = 0.01) and at recovery (mean [SD], 5.05° [3.65°] vs 2.87° [2.73°], P <0.01). On the contrary, the absolute value for basal rotation at recovery was higher in patients without CAD (mean [SD], 3.87° [3.37°] vs 2.63° [2.43°], P = 0.03). In both groups, the rotation and twist did not change significantly during the dobutamine challenge. During DSE, we observed differences in LV rotation between patients with and without CAD, revealing the effect of ischemia on deformation parameters.

Predictive Value of Left Ventricular Myocardial Deformation for Left Ventricular Remodeling in Patients With Classical Low-Flow, Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is an alternative treatment in surgically intermediate- or high-risk patients with classical low-flow, low-gradient (LFLG) aortic stenosis (AS). The objective of this study was to investigate whether two-dimensional (2D) speckle-tracking echocardiography (STE) can predict left ventricular (LV) flow reserve during dobutamine stress echocardiography (DSE) and remodeling after TAVR in patients with LFLG AS. Seventy-five symptomatic patients with severe LFLG AS were recruited (mean age, 77.6±8.4years). Patients underwent a complete clinical evaluation, standard echocardiography, 2D STE, and DSE. Echocardiographic analysis was performed before and 6months after TAVR using global longitudinal strain (GLS) measured on 2D STE. All patients received self-expanding transcatheter prosthetic valves. Six months after TAVR, LV GLS (12.8±3.2% vs 16.3±4.2%, P<.0001) significantly increased. In a multivariate analysis, LV GLS before TAVR (P<.0001) was an independent predictor of LV flow reserve during DSE. By receiver operating characteristic curve analysis, a cutoff value for LV GLS of ≤12% well distinguished patients without significant flow reserve and with lack of positive remodeling after TAVR at follow-up. These results support the hypothesis that myocardial analysis by 2D STE at baseline can be useful for the identification of patients with LFLG AS whowould benefit from TAVR. The results of this study underline the predictive value of LV GLS on flow reserve during DSE and on global LV remodeling after TAVR in patients with LFLG AS. Cutoff values for LV GLS could be used to identify patients responding better to TAVR.