Specificity Of Dobutamine Stress Echocardiography Research Articles

Comparison of Coronary Artery Calcium Scoring with Dobutamine Stress Echo for Detection of Coronary Artery Disease Before Liver Transplantation.

BackgroundDobutamine stress echocardiography (DSE) is commonly used for cardiovascular assessment before orthotopic liver transplantation (OLT). The coronary artery calcium score (CACS) is a useful screening tool for coronary artery disease (CAD). We aimed to compare the sensitivity and specificity of DSE and CACS for CAD in OLT candidates.Material/MethodsA total of 265 of the 1589 patients who underwent OLT at our center between 2008 and 2019 had preoperative coronary angiography (CAG). Of these, 173 had DSE and 133 had a CT scan suitable for CACS calculation within 1 year of OLT. Patients with a nondiagnostic DSE were excluded (n=100). Two reviewers evaluated CACS on CT scans. The sensitivity/specificity of DSE and CACS for detection of angiographically significant CAD were calculated for patients with both tests (n=36).A separate analysis compared the sensitivity/specificity of a diagnostic DSE (n=73) and CACS (n=133) against CAG for all patients with either test.ResultsSensitivity and specificity were 57.1% and 89.7%, respectively, for DSE, compared with 71.4% and 62.1% for CACS at ≥100 Agatston score. For the analysis of all patients with either test, the sensitivity/specificity of DSE for detection of CAD and CACS were 30.8% and 85.0% and 80.0% and 62.8%, respectively. On ROC analysis, CACS was a satisfactory predictor of obstructive CAD (AUC, 0.76±0.06, 95% CI, 0.66–0.87; P<0.001).ConclusionsCACS may be an important tool for cardiovascular assessment in patients undergoing OLT. DSE was nondiagnostic in a large percentage of OLT candidates, limiting its use in this population.

Pneumatic Lower Extremity Compression During Dobutamine Stress Echocardiography

Afterload is expected to increase with pneumatic compression of the lower extremities. There are left ventricular (LV) wall stress, which is the most important factor determining myocardial oxygen demand, will also increase, leading to an increase in the sensitivity of dobutamine stress echocardiography (DSE) or a shortened time to a positive response. In 40 patients who underwent DSE and were anticipating undergoing coronary angiography (CAG), the imaging was repeated with pneumatic compression (100 mmHg) of the lower extremities (DSEcomp) prior to CAG. The sensitivity and specificity of DSE and DSEcomp were determined based on the CAG findings. All patients tolerated pneumatic compression of the lower extremities during the tests. LV end-systolic volume (p=0.042) and end-systolic wall stress (p=0.036) were significantly greater with DSEcomp than with DSE. In 3 patients with false-negative results for DSE, DSEcomp gave a positive response, demonstrating a significant increase in sensitivity from 75% to 94% (p=0.045). Only 1 patient with a true negative result for DSE was interpreted as showing a positive response for DSEcomp, resulting in a decrease in specificity from 88% to 83% (p=NS). In 10 of 12 patients with true positive results for both DSE and DSEcomp, positive responses were seen at least 1 stage earlier with DSEcomp than with DSE. Pneumatic compression of the lower extremities increases the sensitivity of DSE and shortens the time to a positive response.

Instructions for Obtaining Journal CME Credit

Anesthesiology's journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.The American Society of Anesthesiologists designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading this article, participants should have a better understanding of emerging approaches to evaluating patients and determining their risk for cardiac complications after surgery.Authors – Ronit Lavi, M.D., Shahar Lavi, M.D., Elena Daghini, M.D., and Lilach O. Lerman, M.D., Ph.D. Grants or research support: Supported in part by grant Nos. HL77131 and DK73608 from the National Institutes of Health, Bethesda, Maryland. Consultantships or honoraria: NoneQuestion Writers – Peter L. Bailey, M.D., and Leslie C. Jameson, M.D. Drs. Bailey and Jameson have no grants, research support, or consultant positions, nor do they receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Lavi et al. entitled “New frontiers in the evaluation of cardiac patients for noncardiac surgery” in the December issue of Anesthesiology, choose the one correct answer for each question: http://content.wkhealth.com/linkback/openurl?issn=0003–3022&amp;volume=107&amp;issue=6&amp;spage=1018∂=fulltext1. Which of the following statements concerning perioperative cardiac risk is most likely true?A. The lower limit of functional capacity consistent with an adequate cardiac reserve is 7 metabolic equivalents.B. Congestive heart failure does not predict increased perioperative cardiac complications.C. Type of surgical procedure does not influence cardiac risk.D. The outcomes used to quantify cardiac risk are cardiac death and nonfatal myocardial infarction.2. Which of the following statements concerning the evaluation of coronary arteries by computed tomography is most likely true?A. Its negative predictive value is too low for clinical use.B. Respiratory movement does not reduce image quality.C. Coronary stents can result in imaging artifacts.D. It cannot be used to detect coronary artery graft problems after bypass surgery.3. Which of the following statements concerning echocardiography and the evaluation of patients for cardiac conditions is most likely true?A. It is not recommended for the preoperative evaluation of suspected aortic stenosis.B. The specificity of dobutamine stress echocardiography is excellent (&gt; 95%).C. Quality of dobutamine stress echocardiography is operator dependent to a significant degree.D. Its cost relative to other cardiac tests is high.4. Which of the following statements concerning myocardial nuclear studies and the evaluation of patients with suspected cardiac conditions is most likely true?A. Testing with myocardial single-photon emission computed tomography with thallium dipyridamole is the best predictor of postoperative adverse cardiac events.B. Positron emission tomography with F-18 fluorodeoxyglucose can predict functional recovery of viable myocardium.C. Positron emission tomography scanning is very cost effective.D. Single-photon emission computed tomography technetium-99m imaging is not a useful preoperative assessment tool.5. Which of the following statements about cardiac computed tomography scanning is most likely true?A. It is associated with less risk than coronary angiography.B. It has been demonstrated to be a cost-effective strategy in reducing perioperative risk.C. It is not useful for assessing left ventricular function.D. It is not useful for assessing coronary plaques.

Abstract 2086: Usefulness of Pneumatic Lower Extremity Compression During Dobutamine Stress Echocardiography

Background Afterload is expected to increase with pneumatic compression of the lower extremities. Therefore, left ventricular (LV) wall stress which is the most important factor determining myocardial oxygen demand will also increase, leading to an increase in sensitivity of dobutamine stress echocardiography (DSE) or shortened time to positive response.The purpose of this study was to evaluate the effect of pneumatic compression of lower extremities on the diagnostic accuracy of DSE. Methods In 40 patients who underwent DSE and were anticipating coronary angiography, DSE was repeated with the pneumatic compression (100mmHg) of lower extremities (DSEcomp) prior to coronary angiography. Sensitivity and specificity of DSE and DSEcomp were determined based on the coronary angiographic finding. Results All patients tolerated pneumatic compression of the lower extremities during the tests. LV end-systolic volume (p=0.042) and end-systolic wall stress (p=0.036) were significantly greater in the DSEcomp than DSE. In 3 patients with false negative results in DSE, DSEcomp showed positive responses, demonstrating a significant increase in sensitivity from 75% to 94% (p=0.045). Only 1 patient with true negative result in DSE was interpreted as showing positive response in DSEcomp, resulting in a decrease in specificity from 88% to 83% (p=NS). In 11 of 13 patients with true positive results both in DSE and DSEcomp, positive responses were seen at least 1 stage earlier in DSEcomp compared to DSE. Conclusions Pneumatic compression of lower extremities increases the sensitivity of DSE and shortens the time to positive response.

Automated coupled-contour and robust myocardium tracking in stress echocardiography

Dobutamine stress echocardiography is a commonly used imaging modality for the diagnosis of coronary artery disease and the detection of myocardial viability. The major limitations are that it is operator dependent and that the analysis is subjective and qualitative resulting in interobserver variability. It is also tedious and time consuming. Consequently, several quantitative approaches have been proposed, such as acoustic quantification and color kinesis but none of these has proved to be fully quantitative. In this manuscript we describe the development of a new, quantitative technique based on tracking of both endocardium and epicardium providing information of endocardial excursion and myocardial thickening, a crucial parameter of wall function evaluation. Preliminary data indicate that the method is practical and feasible, but clinical trials are required to prove whether it will improve the sensitivity and specificity of dobutamine stress echocardiography.

Stress Imaging in Renal Transplant Candidates

To the Editor: I read with interest the recent paper published by De Lima et al.1 A recent meta-analysis by Rabbat et al2 casts doubt on one conclusion of De Lima et al, as Rabbat et al found that noninvasive stress imaging was predictive of acute myocardial infarction and cardiac death in renal transplant candidates. De Lima et al’s findings regarding the accuracy of dipyridamole single-photon emission computed tomography (SPECT) thallium for prediction of coronary anatomy are generally concordant with previous publications (with the notable exception of Dahan et al,3 who employed a novel stress protocol utilizing combined dipyridamole and exercise thallium imaging in hemodialysis patients). The findings of De Lima et al regarding dobutamine stress echocardiography are difficult to accept in the context of conventional clinical practice. Specifically, the authors in the present study did not administer atropine to augment the heart rate response during the administration of dobutamine. It would be helpful for …

Comparison of pressure measurement, dobutamine contrast stress echocardiography and SPECT for the evaluation of intermediate coronary stenoses. The COMPRESS trial

DSE and SPECT are two well-established methods to non-invasively investigate the functional significance of coronary artery stenoses in patients with coronary artery disease. The measurement of Fractional Flow Reserve has emerged a new invasive reference standard for lesion specific quantification of coronary artery stenoses. The objective of our prospective study was to compare sensitivity and specificity of Dobutamine Stress Echocardiography (DSE) and Single Photon Emission Computer tomography (SPECT) with the pressure derived Fractional Flow Reserve (FFR) for the identification of hemodynamic relevant coronary lesions in patients with predominately coronary multivessel disease and angiographically intermediate stenoses. Inclusion criteria were a coronary lesion of 50-75% diameter stenosis by visual assessment in patients with known or suspected CAD. SPECT, DSE and FFR testing was performed within one week of coronary angiography. The study comprised 48 consecutive symptomatic patients. In 41 cases, a coronary multivessel disease was present. Mean FFR was 0.80 +/- 0.13 (0.41-1.0). Overall sensitivity of DSE and SPECT was 67% and 69% whereas specificity reached 77% and 87%. However, sensitivity was significantly reduced if the target lesion was located distally. DSE showed poor results if the lesions were located in the circumflex artery or if a history of prior myocardial infarctions was present. DSE and SPECT are both useful methods for the non-invasive assessment of coronary artery disease. DSE showed reasonable combination of sensitivity and specificity even in patients with multivessel disease. Although use of noninvasive stress tests is only limited in patients with prior myocardial infarctions and invasive stress testing should be preferred in these patients.

Does real-time perfusion have any incremental value for the sensitivity and specificity of dobutamine stress echocardiography?

Does real-time perfusion have any incremental value for the sensitivity and specificity of dobutamine stress echocardiography?

Effect of intravenous contrast for left ventricular opacification and border definition on sensitivity and specificity of dobutamine stress echocardiography compared with coronary angiography in technically difficult patients

Background The study evaluates whether Optison used during dobutamine stress echocardiography (DSE) will improve endocardial border definition and whether this will translate to an improvement in sensitivity and specificity of the test in patients with poor echocardiographic windows. DSE is extremely valuable in the workup of patients with coronary artery disease. The test is limited in patients with suboptimal endocardial border visualization. Frequent studies have demonstrated improved endocardial border visualization with intravenous contrast agents at rest. Methods and Results We studied 229 patients: 112 had good rest echocardiography with no contrast and 117 had poor rest echocardiography with Optison injection during DSE. Percentage of endocardial border visualization, wall thickening, sensitivity, and specificity were compared in both groups, as was interobserver variability. Both groups were matched with respect to age, percentage of previous myocardial infarctions, resting wall motion abnormality, percentage of coronary stenosis, and number of diseased coronary arteries. Optison significantly improved endocardial border visualization, especially at peak stress. The ability to measure wall thickening was significantly higher in the contrast DSE group with suboptimal images versus the noncontrast group with optimal images (89% ability to measure wall thickening vs 71%, P =.01). This resulted in a comparable sensitivity (79% vs 71%, P = not significant [NS]), specificity (76% vs 82%, P = NS), and diagnostic accuracy (80% vs 76%, P = NS). Agreement on test interpretation was higher among 3 observers in contrast DSE versus noncontrast DSE groups (79% vs 69%, P =.01). Conclusions In patients with poor echocardiographic windows, the use of Optison during DSE improves endocardial border visualization, which translates to a comparable sensitivity and specificity to noncontrast DSE tests in patients with good echocardiographic windows. (Am Heart J 2001;142:908-15.)

Comparison of simultaneous dobutamine echocardiography and thallium-201 stress-reinjection single-photon emission computed tomography in predicting improvement of chronic myocardial dysfunction after revascularization

Previous studies have shown that ultrasonic integrated backscatter is valuable in characterizing stunned myocardium. Recent investigations have demonstrated that resting cardiac cycle-dependent variation of integrated backscatter closely paralleled the contractile reserve in patients with chronic left ventricular ischemic dysfunction. The purpose of this study was to validate whether ultrasonic tissue characterization (UTC) compared with dobutamine stress echocardiography (DSE) and thallium-201 stress-reinjection single-photon emission computed tomography (Tl-SPECT) could predict reversible myocardial dyssynergy in patients with chronic coronary artery disease. Forty-eight patients with stable coronary artery disease underwent UTC, DSE, and Tl-SPECT simultaneously before successful coronary revascularization and were followed up with echocardiograms at rest >3 months later. Among the 58 investigated segments, the weighted amplitude, a composite parameter derived from the integrated backscatter power curve, was larger for those groups with greater functional recovery (p <0.001). For the persistent akinetic segments, the weighted amplitudes were small with large deviations of the nadir ratios that represented the asynchrony between the intramural contractile events and the global systole. Using the cut-off value 2.0 of the weighted amplitude, the sensitivity and specificity for predicting functional improvement after revascularization were both 82.8% (κ = 0.66) and comparable to the sensitivity and specificity of DSE and Tl-SPECT. UTC, delineating the myocardial physical state and intramural contraction, can be a novel approach in predicting functional improvement of chronic dyssynergy after revascularization.

Optimal criteria for the diagnosis of coronary artery disease by dobutamine stress echocardiography

The diagnosis of coronary artery disease (CAD) on the basis of inducible ischemia in ≥2, rather than ≥1, segments was suggested to improve specificity of dobutamine stress echocardiography (DSE). However, the impact of using these criteria on the sensitivity and accuracy of DSE was not studied. We studied the accuracy of DSE (up to 40 μg/kg/min) for the diagnosis of CAD in 290 patients with suspected myocardial ischemia using the criteria of ≥1 and ≥2 ischemic segments. Ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model. Among the 85 patients without previous myocardial infarction, significant CAD was detected in 51 (60%). Sensitivity, specificity, and accuracy of DSE using ≥1 ischemic segment were 73%, 85%, and 78%, respectively. Those using ≥2 segments were 67%, 94%, and 78%, respectively (p = NS). Regional specificity improved by using ≥2 segments (91% vs 96%, p <0.05) at the expense of an equivalent reduction in regional sensitivity (60% vs 44%, p <0.05), whereas the regional accuracy was similar (80% vs 79% for ≥1 and ≥2 segments, respectively). In the 205 patients with previous myocardial infarction, the criterion of ischemia in ≥1 segment had a higher sensitivity and accuracy for overall diagnosis of CAD (75% vs 64%, p <0.05; 77% vs 68%, p <0.05), infarct-related CAD (64% vs 47%, p <0.005; 70% vs 57%, p <0.01), and remote CAD (74% vs 57%, p <0.005; 78% vs 69%, p <0.05) than the criterion of ≥2 segments, respectively. It is concluded that in patients without previous myocardial infarction, the use of ≥2 ischemic segments by DSE for the diagnosis of CAD does not improve the accuracy of DSE compared with the criterion of ≥1 ischemic segment. Conversely, in patients with previous infarction the use of ≥2 segments reduces the overall and regional sensitivity and accuracy without a significant improvement in specificity.

Dobutamine stress echocardiography for assessing coronary artery disease after transplantation in children

Objectives. The purpose of this study was to determine the feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography (DSE) for evaluating posttransplant coronary artery disease (TxCAD) in children, and to determine the frequency of selected cardiac events after normal or abnormal DSE.Background. Posttransplant coronary artery disease is the most common cause of graft loss (late death or retransplantation) after cardiac transplantation (CTx) in children. Coronary angiography, routinely performed to screen for TxCAD, is an invasive procedure with limited sensitivity. The efficacy of DSE for detecting atherosclerotic coronary artery disease is established, but is unknown in children after CTx.Methods. Of the 78 children (median age 5.7 years, range 3 to 18) entered into the study, 72 (92%) underwent diagnostic DSE by means of a standard protocol, 4.6 ± 1.9 years after CTx. The results of coronary angiography performed in 70 patients were compared with DSE findings. After DSE, subjects were monitored for TxCAD-related cardiac events, including death, retransplantation and new angiographic diagnosis of TxCAD.Results. No major complications occurred. Minor complications, most often hypertension, occurred in 11% of the 72 subjects. The sensitivity and specificity of DSE were 72% and 80%, respectively, when compared with coronary angiography. At follow-up (21 ± 8 months), TxCAD-related cardiac events occurred in 2 of 50 children (4%) with negative DSE, versus 6 of 22 children (27%) with positive DSE (p < 0.01).Conclusions. DSE is a feasible, safe and accurate screening method for TxCAD in children. Positive DSE identifies patients at increased risk of TxCAD-related cardiac events. Negative DSE predicts short-term freedom from such events.

The value of dobutamine stress echocardiography for the detection of coronary artery disease in women

To determine whether there were any gender-based differences in the detection of coronary artery disease by dobutamine stress echocardiography, we examined 288 patients (187 men and 101 women) who underwent coronary angiography within 8 weeks of dobutamine stress testing. Abnormal test results were indicated by left ventricular wall motion abnormalities at rest, which did not improve or worsen, or inducible wall motion abnormalities in two or more segments with dobutamine. Overall, dobutamine stress echocardiography showed a high sensitivity, specificity, and accuracy in both men and women: 85%, 96%, and 88% and 90%, 79%, and 86%, respectively. The sensitivity in detecting significant coronary artery disease in our population was not influenced by gender. However, the sensitivity of the test was influenced by the extent and location of coronary disease and the pattern of left ventricular hypertrophy. The sensitivity was 80% in patients with single-vessel disease, whereas the sensitivity was 91% in patients with multivessel disease. In addition, patients with single-vessel disease had lower sensitivity when the abnormality was located in the left circumflex coronary artery territory (59% versus 86% in the left anterior descending and right coronary territories). Our data indicated that there is no gender-based difference in the sensitivity and specificity of dobutamine stress echocardiography in detecting coronary artery disease and that the limitations of the test should be attributed to the extent and location of coronary disease. (J Am Soc Echocardiogr 1997;10:811-17.)

Dobutamine stress echocardiography in the detection of coronary artery disease in a clinical practice setting

In this prospective study, patients referred for coronary angiography for detection of disease underwent dobutamine stress echocardiography to define its value in a clinical practice setting. Results: Of 219 patients studied, 170 (78%) had significant coronary artery disease. The overall sensitivity and specificity of dobutamine stress echocardiography for coronary artery disease were 82 and 65%, respectively. The sensitivity was 88% for detection of triple-vessel disease, 83% for double-vessel disease, and 74% for single-vessel disease. Positive and negative predictive values for coronary artery disease were 89 and 51%, respectively. Dobutamine stress echocardiography correctly identified only 72 of 138 patients with significant stenosis of the left anterior descending coronary artery. In 219 patients, 345 of 657 major epicardial vessels had significant disease. Dobutamine stress echocardiography could only correctly identify the vessel involved in 188. Triple-vessel disease was present in 65 patients. Dobutamine stress echocardiography correctly categorised 18% ( n=12) of these. The remainder were incorrectly classified as having double-vessel disease or single-vessel disease ( n=45), or no disease at all ( n=8). Conclusion: Dobutamine stress echocardiography performs well. However, lower specificity may lead to unwarranted referrals for coronary angiography, and the low NPV give false reassurance as to the absence of disease.

The use of dobutamine stress echocardiography for the determination of myocardial viability.

Determining the presence of viable myocardium has prognostic and therapeutic implications in the treatment of ischemic heart disease. Dobutamine stress echocardiography (DSE) is one possible technique to help identify both hibernating and stunned but viable myocardium. Low-dose dobutamine infusion has an increased inotropic effect, while higher doses cause both inotropic and chronotropic effects. Thus, at lower doses cardiac augmentation occurs, and at higher doses regions of ischemia may be produced in the presence of significant coronary artery disease. This is manifested echocardiographically as changes in segmental wall motion. In theory, therefore, areas of viable myocardium should show improved wall motion at low doses, and areas of irreversible myocardial damage will remain akinetic. Five studies have investigated DSE for determining viability in the setting of acute myocardial infarction, thus looking for stunned but viable myocardium. DSE was shown to compare favorably with positron emission tomography and was highly sensitive and specific for predicting functional myocardial recovery. Five additional studies examined DSE for determining the presence of hibernating myocardium. The sensitivity and specificity of DSE were found to range from 71 to 92% and from 73 to 93%, respectively. The benefits of DSE include lower cost, convenience to both patient and physician, additional ancillary information, and determination of the possible need for urgent revascularization. Limitations of DSE include occasional technical difficulty in obtaining and interpreting studies and the need for larger volumes of viable myocardium to detect changes predictive of functional recovery. Larger trials are currently underway to confirm DSE as a reliable technique for determining myocardial viability.

Dobutamine stress echocardiography for detection of coronary artery stenosis in children with Kawasaki disease

This study was designed to assess the feasibility and diagnostic accuracy of dobutamine stress echocardiography for detection of coronary artery stenosis in children with Kawasaki disease. Dobutamine stress echocardiography is valuable as an alternative test for detection of coronary artery disease in adult patients; however, its usefulness for children has been demonstrated only in limited cases. Dobutamine stress echocardiography (up to 30 microgram/kg body weight per min) was performed in 50 patients at the convalescent stage of Kawasaki disease, including 26 patients with coronary sequelae documented by previous coronary angiography (sequelae group, 3 to 15 years old) and 24 patients with normal coronary arteries documented by echocardiography (normal group, 7 to 16 years old), who underwent quantitative coronary angiography on a separate day. Left ventricular regional wall motion divided into 16 segments was assessed in relation to the extent of coronary artery disease. A positive test response was defined as a new or worsened wall motion abnormalities. Significant coronary artery disease (> or = 50% diameter stenosis of major vessels) was present in 21 patients in the sequelae group. There was no significant difference in the maximal dose of dobutamine between the sequelae and normal groups ([mean +/- SD] 22.4 +/- 5.1 vs. 24.2 +/- 2.5 microgram/kg per min). Heart rate and systolic blood pressure were significantly increased (p < 0.01) at maximal dose of dobutamine compared with values at rest in both groups; consequently, the rate-pressure product exceeded 20,000 in 20 (40%) of the 50 patients during dobutamine infusion. Ten patients had self-limiting side effects; however, there were no serious complications from stress-induced ischemia. New wall motion abnormalities corresponding to the extent of coronary artery disease were detected in 19 of 21 patients in the sequelae group, whereas no wall motion abnormalities were detected in the normal group. Thus, the sensitivity and specificity of dobutamine stress echocardiography for the detection of coronary artery disease were 90% and 100%, respectively. We conclude that dobutamine stress echocardiography is a safe and accurate diagnostic method for detection of coronary artery stenosis in Kawasaki disease. Moreover, this is a possible alternative method for patients unable to exercise adequately, even if they are small children.

Dobutamine stress echocardiography in orthotopic heart transplant recipients

Objectives. This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation.Background. After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography.Methods. We enrolled 41 patients, a mean (±SD) of 40 ± 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 μg/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner.Results. Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses >50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses (<50%), and four had minor diffuse coronary irregularities. Dobutamine stress echocardiography showed hypokinesia in five of these seven patients despite nonsignificant lesions at coronary angiography. The respective overall sensitivity and specificity of dobutamine stress echocardiography were 86% and 91%. At follow-up, 2 of the 37 patients had an acute myocardial infarction. Both had abnormal findings on dobutamine stress echocardiography: One had normal coronary angiographic results, and one had significant coronary lesions.Conclusions. Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

974-43 Influence of Resting Left Ventricular Ejection Fraction on the Predictive Accuracy of DobutamlneStress Echocardlography

Dobutamine Stress Echocardiography(DSE) is widely used as a non-invasive test to screen for the presence of coronary artery disease ICAD). Its ability to accurately separate patients (pts) with limited vessel (0 or 1 vessel) disease (LVD) from high risk multi-vessel 12 or 3) disease (MVD) pts, in the presence of decreased resting left ventricular ejection fraction (LVEF) is unknown. Accordingly, we analyzed the results from 136 consecutive pts who underwent both coronary angiography and DSE. DSE was performed with graded dobutamine infusion of 5,10,20,30, and 40 μg/kg/min in 5 min stages, and WMA was graded using a 16 myocardial segment model. DSE was considered indicative of MVD when there were at least two abnormal contiguous segments in two different coronary distributions. CAD was considered significant when &gt; 50% luminal area narrowing was present. There were 27 pts with O-V, 52 with 1-V, 40 with 2-V, and 17 with 3V CAD. The data from 59 of 136 (42%) pts who had an LVEF ≤ 40% were compared to the 79 pts with an LVEF &gt;40%: Parameters EF &gt; 40% (N = 79) EF &lt; 40% (N = 57) 0–1 V 2–3 V 0–1 V 2–3 V Sensitivity % 70 67 14 86 Specificity % 67 70 86 26 In pts with LVEF &gt; 40% DSE had similar accuracy in identifying LVD and MVD. In contrast. the specificity of DSE in separating LVD from MVD was poor in patients with decreased LVEF. These results suggest that 11) DSE in an adequate screening test for MVD and (2) baseline LVEF contributes importantly to the overall interpretation of DSE in predicting MVD.

Effect of dobutamine stress echocardiography on mitral regurgitation

Objectives. This study was performed to examine the effect of dobutamine stress echocardiography on mitral regurgitation and to test the hypothesis that mitral regurgitation will increase in patients with an ischemic response.Background. New or worsening mitral regurgitation during stress testing has been proposed as a marker of ischemia. However, it is unclear whether ischemia induced by dobutamine is associated with mitral regurgitation because the hemodynamic effects of dobutamine may vary with regard to mitral regurgitation, depending on left ventricular function and maximal dose attained.Methods. Dobutamine stress echocardiography was performed in 102 consecutive patients with suspected or known coronary artery disease. Color flow Doppler was used to determine the presence and change in mitral regurgitation at baseline and peak dobutamine infusion (up to 40 μg/kg body weight per min). The mitral regurgitation color flow Doppler area was semiquantitatively graded as mild (<4 cm2), moderate (4 to 8 cm2) or severe (>8 cm2). Patients were assigned to ischemic and nonischemic groups according to the dobutamine stress echocardiographic results.Results. The two groups achieved the same maximal dose and demonstrated similar blood pressure and heart rate responses to dobutamine infusion. Only two patients developed new mitral regurgitation during dobutamine infusion, and both had a normal dobutamine echocardiographic result. More patients without ischemia had no mitral regurgitation compared with patients with ischemia. There was an insufficient number of patients with coronary angiographic data to determine the effects of mitral regurgitation on the sensitivity and specificity of dobutamine stress echocardiography. Of 23 patients with a rest ejection fraction <50%, 61% had an improvement in mitral regurgitation grade compared with 25% of patients with a rest ejection fraction ≥50% (p < 0.02).Conclusions. These data indicate that although dobutamine infusion often improves mitral regurgitation in patients with left ventricular dysfunction during stress echocardiography, it does not induce or worsen mitral regurgitation in those who demonstrate an ischemic response. Future studies are necessary, with larger numbers of patients, to determine the effects of mitral regurgitation on the sensitivity and specificity of dobutamine stress echocardiography.

False positive dobutamine stress echocardiograms: Characterization of clinical, echocardiographic and angiographic findings

Objectives. This study was designed to characterize the clinical, echocardiographic and angiographic findings in patients who have regional wall motion abnormalities predictive of coronary artery disease on dobutamine stress echocardiograms, although coronary angiography reveals no critical stenoses.Background. The specificity of dobutamine stress echocardiography has been reported to be lower than its sensitivity; the sources of false positive findings on dobutamine stress echocardiograms have not been previously defined.Methods. Clinical and echocardiographic characteristics were retrospectively reviewed for patients who had both a dobutamine stress echocardiogram indicate of coronary artery disease on the basis of wall motion abnormalities and <50% stenoses reported on coronary angiography performed within 6 weeks of the echocardiogram. A 16-segment model was used to perform wall motion scoring. Angiograms were independently reviewed, and stenosis severity was quantified with the use of digital calipers.Results. Thirty-nine (11.4%) of 342 studies met criteria for false positive test results, which occurred predominantly in women (72%, p < 0.601). Regional wall motion abnormalities were evident more often in the posterior circulation (62%), and 65% of them were limited to the basal segments. Twelve (28%) of 43 wall motion abnormalities were associated with coronary stenoses of at least intermediate grade (lumen diameter 40.3% to 68.1%). Abnormalities confined to basal segments of the posterior circulation were unlikely to have associated coronary lesions (p = 0.03).Conclusions. False positive findings on dobutamine stress echocardiograms tend to involve small wall motion abnormalities that are frequently located in basal segments of the posterior myocardial circulation. Approximately one third of false positive results occurred in patients with intermediate-grade coronary stenoses, and these studies may reflect true inducible ischemia. Additional sources of false positive study results may include poor endocardial visualization and abnormal motion dye to tethering to the fibrous skeleton of the heart. Altered echocardiographic diagnostic criteria may be appropriate for small wall motion abnormalities confined to basal segments of the posterior circulation.