Stress Echocardiography In Patients Research Articles

P207 Adjunctive application of handgrip exercise associated with rapid pacing stress echocardiography in patients with implanted pacemakers

Abstract The aim Assessment of safety, diagnostic, and prognostic value of a stress echocardiography protocol based on rapid pacing in patients with implanted permanent pacemakers and concomitant handgrip dynamometer method. There are no data in the literature on this type of modification of the stress test. Methods Rapid pacing stress echo tests with further handgrip were performed in 54 patients (33 females, aged 49-88, mean 72 +/- 8 years), using previously implanted permanent pacemakers. Left ventricular segmental contractility was assessed at rest, during 3 minutes pacing at the rate of 100/minutes, over 5 minutes at 85% of maximal age-predicted heart rate and then further at peak stage per 1 minute with the addition of a handgrip (compression of the dynamometer with a force equal to half the maximum strength of the patient measured before the test). The test was performed using only VVI pacing mode in 16 patients in whom atrial pacing was not possible. In the remaining 38 patients AAI/DDD pacing mode was initially used. Results No severe adverse effects were observed. Significant increase in heart rate comparing to baseline was achieved [74/minutes vs. 127/minutes (P < 00001)]. Wall motion score index increased significantly (from 1.07 vs. 1.15, p < 00001). During the handgrip stage, both systolic (p < 0.0005) and diastolic (p < 0.0001) blood pressure significantly increased. Among all surveys, 18 (33%) were considered positive, 36 (67%) negative. All the examinations were diagnostic. In 35 patients coronary angiography was performed (15 pts with test positive and 20 pts with test negative). Sensitivity, specificity, accuracy, positive, and negative predictive values for significant coronary stenosis were respectively: 61.6%, 68.2%, 65.3%, 53.3%, and 75%. For patients with DM2 the above values were: 83.3%, 85.7%, 84.6%, 83.3%, 85.7%. No statistical differences were observed depending on the type of the device or the use of beta blockers In patients with LMA stenosis test sensitivity was - 100%, with LAD – 62.5%, with CX - 75% and with RCA was 71.5%. Revasculization was required in 8 patiens with test positive and 3 with test negative (p = 0.01). During 6-moth follow-up there was no cardiac death, myocardial infarction or stroke . Conclusions The sensitivity and specificity of the stress test using the pacemaker and the handgrip method for all patients proved to be lower than the values obtained in other stress tests. However, the use of the handgrip method during stimulation caused an increase in mean systolic and diastolic blood pressure. Such an extension makes the pacing stress echo test more physiological. Moreover the stress test using pacemaker and handgrip method proved to be safe and well-tolerated by patients. The prognostic value of the negative result of the study research using stimulation from the patient"s pacemaker and the handgrip method was high in the 6 month follow-up

P1553 Regional peak systolic longitudinal strain during dipyridamole stress echocardiography in patients with normokinetic response determined by visual assessment

Abstract OnBehalf on behalf of the Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) Background Regional wall motion (RWMA) remains the cornerstone of stress echocardiography (SE) and its evaluation is still based on visual assessment by 2D. Regional longitudinal peak systolic strain (LPSS) provides a quantitative, operator-independent assessment of RWMA. Aim To compare 2D (qualitative) versus strain (quantitative) assessment of RWMA during dipyridamole SE. Methods In a prospective study we recruited 17 patients (mean age 69 ± 7 years, 11 women) with known or suspected CAD referred for accelerated high dose (0.84 mg/kg in 6") dipyridamole SE. We included patients with normokinesis at rest and with normal SE response. A 17-segment model was used to assess RWMA and strain (LPSS and global longitudinal strain, GLS). Ejection fraction (EF) was measured with Simpson"s biplane method. LPPS and GLS were measured using Automated Function Analysis (AFI). Results 289 segments could be assessed head-to-head with the 2 methods (2D and Strain). Heart rate was 61 ± 8 bpm at rest and rose to 86 ± 19 at peak stress (p = 0.0001) EF increased from 66 ± 7% (rest) to 73 ± 5% (peak stress, p = 0.0006 vs rest). GLS increased from -17.9 ± 3.4% at rest to -19.8 ± 2.4% at peak stress (p = 0.0074). Stress-rest (Δ) changes in EF did not correlate with Δ-GLS (r = 0.2, p = ns). LPSS was -18.2 ± 5.2% at rest and on average increased to -19.7 ± 5.8 % (p < 0.0001 vs rest), with heterogeneity of regional contractile reserve, highest in apical segments 13-17 (n = 85, LPSS rest= -20.3 ± 4.9 vs stress = - 22.5 ± 4.3, p = 0.0002), intermediate in mid-segments 7-12 (n = 102, LPSS rest= -18.5 ± 5.0 vs stress = -19.8 ± 5.6, p= 0.0166) and lowest in basal segments 1-6 (n = 102, LPSS rest= -16.1 ± 5.0 vs stress = - 17.3 ± 6.1, p= =0.0518= ns), see figure. At individual segment analysis, 50 segments (17.3%) showed an unmatched response, with normal visual response and LPSS reduction (stress ≤ rest at least 15%), observed especially in basal segments, see Table, unmatched 2D strain segments. Conclusions DSE allows a simultaneous qualitative and quantitative assessment of regional wall motion and global function by 2D and advanced strain-based indices. Strain-SE is feasible and may corroborate the results of trained naked eye interpretation with quantitative support, but degree of changes in regional strain is related to specific position of segment in basal, mid or apical part of left ventricle, with unmatched results between visual and strain not infrequent, especially in basal segments. Unmached 2D strain segments Basal (1-6), n = 102 Mid (7-12), n = 102 Apical (13-17), n = 85 P value Basal vs Mid P value Mid vs Apical P value Basal vs Apical 24 (23.5%) 18 (17.6%) 8 (9.4%) ns ns =0.0185 Number and proportion of segments with LPSS worsening ≥15% in basal, mid and apical portion of left ventricle. Abstract P1553 Figure. Changes of regional LPSS during DSE

The predictive value of speckle tracking during dobutamine stress echocardiography in patients with chronic stable angina

ObjectiveEvaluation of the diagnostic value of speckle tracking echocardiography (STE) at rest and during dobutamine stress in predicting the presence and severity of coronary artery disease (CAD) in patients with chronic stable angina. MethodsA total of 100 patients with chronic stable angina were evaluated using STE at rest and during dobutamine stress to detect the presence, severity, and number of affected coronary arteries. Then, the correlation with the SYNTAX score (SS) was analyzed. ResultsSTE at stress showed better agreement with coronary angiography (CA) than dobutamine stress echocardiography (DSE) in detecting the presence of coronary artery stenosis (Kappa = 0.819, p < 0.001). STE at stress suggested involvement of the left anterior descending artery (LAD) with excellent agreement with CA (Kappa = 0.816, p < 0.001). For right coronary artery, STE at rest and stress showed good agreement with the CA results (Kappa = 0.775 and 0.858, respectively, p < 0.001), whereas for left circumflex artery, STE at rest and stress showed a fair agreement with the CA results (Kappa = 0.556 and 0.583, respectively, p < 0.001). Resting global longitudinal peak systolic strain (GLPSS) ≥ −15.2% had the best diagnostic accuracy (sensitivity = 61.8%; specificity = 93.5%) in predicting SS > 22. Stress GLPSS ≥ −12.5% had the best diagnostic accuracy (sensitivity = 82.4%; specificity = 78.3%) in predicting SS > 22. ConclusionSpeckle tracking during DSE has high sensitivity and specificity for predicting the presence of CAD. It provides quantitative diagnostic information that decreases the false positive and false negative results of DSE.

P1789 Stress echocardiography in patients with pulmonary arterial hypertension - a pilot study

Abstract INTRODUCTION Pulmonary arterial hypertension (PAH) is a rare, progressive disease with poor prognosis. Stress echocardiography (SE) gives an important data on hemodynamic response to exercise. In patients with PAH SE may be useful for the diagnosis and risk assessment but data are lacking. AIM OF STUDY The aim of the study was to analyze exercise-induced response of right heart function and pulmonary artery pressure in patients with PAH. MATERIALS AND METHODS Study group consisted of 15 hemodynamically stable patients, 9 women, aged 22-73 (median- 50), diagnosed with PAH treated at Cardiology Department. The patients were subjected to stress echocardiography on supine cycloergometer and underwent assessment before and at peak-exercise. Moreover the standard parameters of clinical assessment: NT-proBNP, WHO functional class, and 6-minute walk test were analyzed. RESULTS Nine patients were in WHO class III, 4 of them- WHO class II and 2- WHO class I. The median NT-proBNP concentration was 169.3 (IQR 151.2-989.5) pg/ml. 6-Minute Walk Test distance was 455 (428-489) meters. The median workload was 75 (IQR 50-100) Watts and it was the median 54% (IQR 37-62%) of predicted. The echocardiographic parameters assessed in SE at rest and shortly after peak-exercise revealed that RV systolic volume did not significantly differ: 70 (49.8-112.3) vs 71.5 (36.6-110) ml, p = 0.3. Right atrial area decreased from median 21.9 (17.4-27.3) to 19.8 (16.4-22.1) cm2, p = 0.05, whereas right atrial volume did not significantly changed - 80 (47.5-99.5) vs 68 (47.3-78.8) ml, p = 0.13. Further, shortly after exercise tricuspid regurgitation peak gradient (TRPG) significantly increased - 43 (25-76.5) vs 71 (50.5-102) mmHg, p = 0.002. CONCLUSIONS In stable PAH patients supine SE is feasible. Even in advanced WHO functional classes patients were able to exercise. Among echocardiographic parameters TRPG reflecting systolic pulmonary artery pressure showed the biggest difference between baseline and peak-exercise values. SE and seems to be a valuable tool in PAH patients’ assessment.

1680 Left ventricular filling pressure assessment with exercise stress echocardiography in patients with non-valvular atrial fibrillation

Abstract Background Noninvasive parameters of LV filling pressure (E/e’) and pulmonary pressures (RVSP) by Doppler echocardiography correlate with functional capacity and outcome in sinus rhythm (SR). Their role in AF is less clear. Elevated left ventricular filling pressures (E/e’) and pulmonary artery systolic pressures (PASP) by Doppler stress echocardiography correlate with impaired functional capacity in patients in sinus rhythm (SR). However, there is limited data in atrial fibrillation (AF). Purpose The aim of this study was to delineate the characteristics of patients with AF referred for exercise stress echocardiography and determine the prevalence and significance of E/e’ and PASP elevations in AF. Methods Subjects were patients referred for exercise treadmill stress echocardiography (n= 14,937) and underwent regional wall motion assessment, Doppler assessment of mitral inflow (E) and early tissue relaxation (e’) velocities and PASP at rest and immediately following maximum symptom limited exercise. Exclusion criteria included significant valvular heart disease (moderate or greater stenosis and/or regurgitation of any cardiac valve or previous valve repair or replacement) (1%), congenital heart disease (&amp;lt;1%) or refusal to participate in research (&amp;lt;1%). Results Patients with AF (n = 310, 2%) were older (71 ± 10 vs 59 ± 13 years, p &amp;lt; 0.001). While resting blood pressure was similar, resting heart rates were higher in AF (80 ± 17 bpm vs 73 ± 13 bpm, p &amp;lt; 0.0001). AF patients achieved lower workloads (6.4 ± 2.4 METS vs 9 ± 2.4 METS, p &amp;lt; 0.001) with lower peak double products (22336 ± 6677 vs 25148 ± 5438, p &amp;lt; 0.001). Rates of resting (27% vs 10%, p &amp;lt; 0.0001) and exercise-induced (37% vs 20%, p &amp;lt; 0.0001) regional wall motion abnormalities were higher in AF. Mean E/e’ was higher in AF at rest (12 ± 5 vs 9 ± 3, p &amp;lt; 0.001) and with exercise (12 ± 5 vs 10 ± 4, p &amp;lt; 0.001), with a higher percentage of patients in AF having E/e’ ≥15 at rest (20% vs 6% in SR, p= &amp;lt;0.001) and with exercise in (23% vs 8%, p &amp;lt; 0.001). PASP was higher in AF at rest (33 ± 8 mm Hg vs 28 ± 6 mm Hg, p &amp;lt; 0.001) and with exercise (48 ± 12 vs 42 ± 11, p &amp;lt; 0.001) compared to SR. E/e’ correlated with exercise capacity in AF and in SR, with an E/e’ cutoff of 11.7 that was best predictive of impaired functional capacity (&amp;lt; 5 METS in women and &amp;lt; 7 METS in men). Conclusions Abnormalities of E/e’ and PASP are more prevalent in patients with AF and correlate with impaired functional capacity. In patients with AF, a medial E/e’ ratio of ≥ 12 immediately following exercise is best associated with impaired functional capacity.

P943 Added value of quantification of dobutamine stress echocardiography in patients with suspected coronary artery disease

Abstract Background Patients with chest pain and suspected coronary artery disease (CAD) frequently undergo dobutamine stress echocardiography (DSE) which is based on visual wall motion analysis. Purpose In this prospective study, we investigated accuracy and clinical utility of quantification of DSE. Methods In 81 consecutive patients scheduled for DSE, standard test was performed in 35 patients, while in the remaining 46 DSE was quantified. Visual assessment of wall motion abnormalities (WMA) was compared to speckle tracking–derived longitudinal strain parameters – global longitudinal strain (GLS) and mechanical dispersion (MD) at different stages of DSE. Reliable tracking was impossible at high-dose DSE in most patients. Results In most patients, it was impossible to obtain reliable speckle tracking analysis at high-dose DSE due to high heart rates. New WMA were observed in 23 patients (28%). Patients with dobutamine-induced WMA had similar values of GLS and MD at rest and during low-dose DSE as those without WMA (p &amp;gt; 0.05 for both). However, during the recovery phase, patients with new WMA at high dose DSE showed a greater amount of MD than those without (52 ± 16 vs. 40 ± 14 ms, p &amp;lt; 0.05). Both MD ≥60 ms and GLS ≤-16% during recovery phase had a low sensitivity (20% for both) but high specificity (90% for GLS and 92% for MD) for the detection of WMA during DSE. (Table). Conclusions Patients with WMA during DSE exhibit a lower GLS and a greater extent of mechanical dispersion («ischemic memory») during recovery phase. Clinical utility of strain-based quantification of DSE is limited due to inability to define effective cutoff values of strain parameters. Abstract P943 Figure.

P6483Predictors of contractile reserve on dobutamine stress echocardiography in patients with classical low-flow, low-gradient aortic stenosis

Abstract Background There is a lack of information on factors that influence contractile reserve (CR) on dobutamine stress echocardiography (DSE) in patients with classical low-flow, low-gradient aortic stenosis (LFLG-AS). Purpose This study sought to evaluate the predictors of CR in patients with LFLG-AS. Methods Prospective study including 43 consecutive LFLG-AS patients (aortic valve area [AVA] ≤1.0 cm2, mean transaortic gradient &lt;40 mmHg, left ventricular ejection fraction [LVEF] &lt;50%) with true severe aortic stenosis. All patients underwent dobutamine stress echocardiography and T1-mapping cardiac magnetic resonance (CMR). CR was defined as an increase ≥20% in the left ventricular stroke volume at peak stress. Patients with pseudo-severe aortic stenosis were excluded. Results All of the patients in the study had degenerative aortic stenosis, with a median age of 67 [60–74] years, most of them being male (83.7%). A high prevalence of comorbidities was found, highlighted by diabetes (42%), hypertension (70%), atrial fibrillation (25%) and coronary artery disease (38%). Mean transaortic gradient was 25 [20–33] mmHg, AVA was 0.88 [0.68–0.95] cm2, LVEF was 35 [28–43]% and 32.6% had moderate/severe functional mitral regurgitation. CMR myocardium extracellular volume fraction (ECV) was 28.8 [26.3–33.0] %, indexed ECV was 35.4 [25.0–41.2] ml/m2, 32.6% had positive transmural delayed-enhancement images and 25.6% had positive mesocardial delayed-enhancement images. On DSE, 30 patients (69.7%) had CR and 13 patients (30.3%) had no CR. Global longitudinal strain was 10 [7–12] %, Δ indexed flow rate was 25 [3–38] ml/m2.seg and Δ mean gradient was 10 [3–16] mmHg. By multivariate analysis, moderate/severe functional mitral regurgitation (HR 0.122, 95% CI 0.020–0.759, p=0.024) and AVA (HR 0.606, 95% CI 0.396–0.925, p=0.020 [for each increase of 0.05 cm2]) were the only factors associated with CR. ECV, indexed ECV and positive transmural or mesocardial delayed-enhancement images were not associated with CR in the univariate analysis. Conclusions In our study, the absence of moderate/severe functional mitral regurgitation and AVA were predictors of CR on DSE in patients with LFLG-AS. As AVA was smaller in patients with CR, our finding contradicts the hypothesis that more severe aortic stenosis could also contribute to the lack of CR. Other possible factors that are surrogate of myocardium fibrosis, as ECV, indexed ECV and positive delayed-enhancement images, were not associated with the absence of CR. Acknowledgement/Funding FAPESP

P1511Promising prognostic value of negative stress echocardiography in patients with incomplete revascularization after successful primary PCI

Abstract Background The specific role of non-invasive functional testing in a risk stratification of patients with incomplete revascularization after primary percutaneous coronary intervention (pPCI) still needs to be evaluated. The aim of our study was to assess negative prognostic value of stress echocardiography (SECHO) after successful pPCI and incomplete revascularization of non-culprit lesions. Methods Our study consisted of 202 patients (mean age 59±10 years, male 142) successfully treated with pPCI, who performed SECHO according to Bruce protocol in order to assess residual ischemia in coronary artery with non-culprit lesion. Duke treadmill score, functional capacity (Metabolic Equivalents - METs), achieved target heart rate (THR), heart rate recovery (HRR), wall motion score index (WMSI) and ejection fraction were interrogated in all patients. Slow HRR was defined as ≤18 beats/min. Median follow-up of the patients was 70 months (IQR 55–83 months) for the occurrence of cardiovascular death and non-fatal myocardial infarction. We also assessed the independent predictors for the occurrence of the adverse events. Results Out of 202 patients, 42 (20.8%) had positive SECHO test, 4 patients (1.98%) had died due to non-cardiac causes and 7 patients (3.5%) were lost to follow-up. From the remaining 149 patients with negative SECHO, 13 (8.7%) had an adverse event (7 cardiovascular deaths and 6 non-fatal MI). Negative predictive value of SECHO test was 91.3%. Univariate predictors of adverse events were slow HRR (HR 4.343 [95% CI 1.473–14.011], p=0.008), and not achieved THR (HR 0.322 [95% CI 0.105–0.985], p=0.047). By multivariate analysis, only slow HRR remained independent predictor of adverse events (HR 3.324 [95% CI 1.013–10.906], p=0.048). Conclusion SECHO test has excellent negative prognostic value in patients with incomplete revascularization of non-culprit lesions after successful pPCI. Still, particular care should be taken to the patients with slow HRR and negative SECHO due to increased risk for the occurrence of adverse events. Acknowledgement/Funding Ministry of Education and Science of the Republic of Serbia (Grant No III41022)

P1504Impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block

Abstract Background/Introduction ECG has always provided very useful information that can be used to diagnosis, treatment and prevention of cardiovascular events, but ECG changes is not useful to the detection of myocardial ischemia in patients with left bundle branch block (LBBB). QT dispersion (QTd) is a measure of inhomogeneous repolarization of myocardium. Abnormally high QTd has been correlated with risk of cardiac death in coronary patients. Purpose The aim of this study was to establish the impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block. Methods The study involved 123 patients with LBBB, average age 52.7 years. In all subjects clinical examination, standard ECG and exercise stress echocardiography, were performed. The criterion for myocardial ischemia was the appearance of transient segmental wall motion abnormality. The first ECG was done before the exercise stress echocardiography and the second one was done immediately after exercise, with calculation of corrected QT dispersion (QTdc). Results During exercise stress echocardiography, in 45 (36.6%) subjects wall motion abnormality occurred (group with myocardial ischemia: MI), and 78 (63.4%) subjects were without ischemia (group without myocardial ischemia: NMI). Before starting the exercise stress echocardiography, MI group patients had significantly higher values of QTdc (61.2±17.6 vs 43.6±15.4 ms; p&lt;0.001) in comparison to NMI group patients. During the exercise stress echocardiography, the QTdc significantly increased in MI group from 61.2±17.6 to 87.4±20.3 ms (p&lt;0.001). In the NMI group there were no significant changes in the values QTdc during exercise stress echocardiography (from 43.6±15.4 to 46.5±19.8 ms (p - NS). Conclusions Significant increase of QT dispersion is associated with the occurrence of myocardial ischemia during exercise stress echocardiography in patients with LBBB. This new diagnostic approach, of using QT dispersion, significantly improves the clinical usefulness of exercise stress echocardiography in detecting myocardial ischemia in patients with LBBB.

The Added Value of Exercise Stress Echocardiography in Patients With Heart Failure

Doppler echocardiography can provide reliable and repeatable measures of cardiac index (CI), whereas lung ultrasound (LUS) represents a quantitative approach to assess pulmonary congestion. We tested the hypothesis that simultaneous assessment of CI and LUS during exercise stress echocardiography (ESE) may define heart failure (HF) outpatients with different risk of adverse outcome. Standard transthoracic echocardiography and LUS (B-lines) evaluation were assessed during semisupine ESE. CI and B-lines were measured at baseline and peak exercise. Resting plasma B-type natriuretic peptide levels were also evaluated. We enrolled 105 HF patients (87 males; age 62 ± 11 years; New York Heart Association class I to III) with reduced left ventricular ejection fraction (30 ± 7%). Patients were classified into 4 profiles: (1) peak CI ≥4.0 l/min/m2 and peak B-lines <15 (no evidence of congestion or hypoperfusion, n = 47); (2) peak CI ≥4.0 l/min/m2 and peak B-lines ≥15 (congestion with adequate perfusion, n = 23); (3) peak CI <4.0 l/min/m2 and peak B-lines <15 (hypoperfusion without congestion, n = 13); and (4) peak CI <4.0 l/min/m2 and peak B-lines ≥15 (congestion and hypoperfusion, n = 22). There were 21 cardiovascular deaths and 18 hospitalizations for worsening HF during a median follow-up of 29 months. Multivariate predictors of the combined end point were peak hemodynamic profiles (hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.19 to 2.21; p = 0.002), B-type natriuretic peptide (HR 1.00, 95% CI 1.00 to 1.01; p = 0.001), and rest E/e' (HR 1.09, 95% CI 1.03 to 1.15; p = 0.002). Survival analysis showed a worse survival in patients with ESE-derived D profile, followed by patients with C, B, and A profile (log-rank: chi-square = 40.5; p <0.0001). In conclusion, dual evaluation of CI and LUS during ESE is useful for risk stratification of HF patients with reduced ejection fraction. Evidence of pulmonary congestion and low CI at peak ESE identifies a subgroup with a very high risk of adverse outcome.

Prognostic value of exercise stress echocardiography in patients with secondary mitral regurgitation: a long-term follow-up study.

Secondary mitral regurgitation (MR) remains a challenging problem in the diagnosis and treatment of patients with heart failure. Although it is well known that secondary MR is dynamic, the impact of the severity of MR during exercise on long-term outcome has not been fully evaluated. The aim of the present study was to investigate the prognostic value of exercise stress echocardiography (ESE) in patients with secondary MR. This prospective study included 118 consecutive patients with secondary MR and left ventricular dysfunction (mean ejection fraction at rest: 38 ± 14%) who underwent semi-supine ESE. Their major cardiovascular events (MACE) including cardiac death were followed up for a median of 41.7 (range: 6-128) months. MR significantly increased from rest to exercise (effective regurgitant orifice: 0.18 ± 0.09 vs. 0.25 ± 0.12cm2, P < 0.001). The prevalence of severe MR was higher during exercise than those at rest (37% vs. 56%, P < 0.001). During follow-up, MACE occurred in 49 patients (41.5%) including 12 cardiac deaths. Cox proportional-hazard multivariate analysis revealed that older age and MR severity during exercise were significantly associated with increased risk of MACE (hazard ratio: 1.04 and 8.4, respectively, both P < 0.05). ESE provides prognostic information in patients with secondary MR that is useful for predicting long-term outcome.

Preoperative dobutamine stress echocardiography in patients undergoing orthotopic liver transplantation.

Coronary artery disease (CAD) is associated with increased mortality in patients who undergo orthotopic liver transplantation (OLT). Chronic vasodilatory state and poor exercise tolerance in patients with end-stage liver disease make dobutamine stress echocardiography (DSE) preferred for preoperative evaluation of CAD prior to OLT. We studied the incidence of positive DSE results and the association between DSE results and perioperative and longer-term events. DSE results pre-OLT will predict short and long term outcomes. We studied 460 patients who underwent DSE within 1 year prior to OLT between 2004 and 2011. Primary events included death and MI at 30 days post-OLT. We also recorded longer-term deaths. Four patients (0.9%) had an ischemic response to DSE, 360 (78%) were normal, and 96 (21%) were nondiagnostic. Fourteen patients (3%) had a primary event at 30 days following OLT (13 deaths and 1 NSTEMI), and there were 108 (24%) deaths at 4.6±2 years of follow-up. No patient with ischemia on DSE had a 30-day event. The accuracy, sensitivity, specificity, and positive and negative predictive values of DSE that was not normal (ie, ischemic or nondiagnostic response) to predict 30-day post-OLT events were 76%, 14%, 78%, 2%, and 97%, respectively. On Cox survival analysis, only baseline left ventricular ejection fraction (HR: 0.90, 95% CI: 0.85-0.96, P < 0.001) was associated with longer-term deaths. Patients undergoing pre-OLT DSE have very low incidence of an ischemic response on DSE, and it has no association with 30-day events.

Integration of Wall Motion, Coronary Flow Velocity, and Left Ventricular Contractile Reserve in a Single Test: Prognostic Value of Vasodilator Stress Echocardiography in Patients with Diabetes

Coronary flow velocity reserve (CFVR) and left ventricular contractile reserve (LVCR) have demonstrated prognostic importance in patients with diabetes. The aim of this study was to investigate the prognostic contribution of combined evaluation of CFVR and LVCR in patients with diabetes with nonischemic stress echocardiography. Three hundred seventy-five patients with diabetes (mean age, 68±9years) with nonischemic dipyridamole stress echocardiography underwent assessment of CFVR of the left anterior descending coronary artery (prospectively) and LVCR with left ventricular force (retrospectively) in a multicenter study. On receiver operating characteristic analysis, LVCR ≤ 1.1 was the best prognostic predictor and was considered an abnormal value. CFVR was abnormal (≤2) in 139 patients (37%), LVCR in 156 (42%), neither in 157 (42%), and both in 77 (21%). During a median follow-up period of 16months, 86 major adverse cardiac events occurred: 16 deaths, 13 myocardial infarctions, and 57 revascularizations. Multivariate prognostic indicators were CFVR ≤ 2 (P<.0001), age (P=.03), and LVCR≤1.1 (P=.04). The 3-year rate of major adverse cardiac events was 63% in patients with both abnormal CFVR and LVCR, 42% in those with abnormal CFVR only, 19% in those with abnormal LVCR only, and 10% in patients with both normal CFVR and LVCR. The 3-year hard event rate was 3% in patients with both normal CFVR and LVCR, fivefold higher in patients with abnormal CFVR or LVCR only, and ninefold higher in patients with both abnormal CFVR and LVCR. Patients with diabetes with nonischemic dipyridamole stress echocardiography may still have significant risk in presence of abnormal CFVR and/or LVCR, which assess the underlying, largely unrelated, microvascular and myocardial components of coronary circulation.

The safety, efficacy and cost-effectiveness of stress echocardiography in patients with high pretest probability of coronary artery disease

ObjectiveIn this study, we assess the clinical and cost-effectiveness of stress echocardiography (SE), as well as the place of SE in patients with high pretest probability (PTP) of coronary artery...

Exercise stress echocardiography in hypertrophic cardiomyopathy.

In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.

When to use stress echocardiography in the evaluation of patients with valvular heart disease

Stress testing and stress echocardiography are firmly established diagnostic tests in the evaluation of patients with suspected or known coronary artery disease, but less established in the evaluation of patients with valvular heart disease. However, there is emerging data supporting the incremental benefit of stress testing and stress echocardiography in patients with known valvular heart disease. Particular applications include hemodynamic assessment of valve function and pulmonary response during exercise induced or chemically-induced stress to correlate with the patient’s exertional symptoms. In addition, stress testing affords the opportunity for functional assessment of ventricular systolic function for prognostication and planning for surgery.

Stress echocardiography in patients who experienced mechanical ventilation weaning failure

IntroductionCritically ill patients may suffer varying degrees of temporary myocardial dysfunction during respiratory weaning that could play an important role in weaning failure. ObjectivesIn this study, we tried to assess the existence of temporary diastolic dysfunction during respiratory weaning. MethodsInclusion period is from 2006 to 2015. In this study, we included 181 ventilated patients with cardiogenic shock that were being weaned from mechanical ventilation. Twenty of those patients were successfully weaned from mechanical ventilation, and the rest (161) experienced complications in their weaning process. All patients had a left ventricular ejection fraction >0.45 and E/E′ ratio≤8, did not require vasoactive drugs at that time, and did not have remaining significant ischemic disease. We divided our patients into 3 groups, as follows: A, patients who could not tolerate a T-tube and required pressure-support ventilation (82); B, patients who successfully tolerated a T-tube period (20); and C, patients who could not tolerate spontaneous breathing modes of mechanical ventilation and remained on assisted mechanical ventilation.We performed stress echocardiography for the last two groups; using dobutamine to assess diastolic function and using ephedrine to evaluate functional mitral regurgitation (MR). We estimated pulmonary capillary wedge pressure through the E/E′ ratio and the flow in the pulmonary veins. ResultsIn group A (ie, those patients who could not tolerate a T-tube trial), we observed an increase in the E/E′ ratio (6.32±0.77 vs 15.2±6.65; P=.0001) and a worsening of strain (S) and strain rate (SR) (−13.6±1.80 vs −11.88±5.6, P=.0001; and −1.3±1.28 vs −0.95±0.38, P=.0001; respectively). We did not observe a change in the E/E′ ratio during stress echocardiogram on those patients with successful weaning from mechanical ventilation (7.41±0.43 vs 8.38±4.57, P=.001). However, we did see in this group an increased peak velocity of the S wave and of SR (−16.11±08.72 vs −19.89±5.62 and −1.48±0.23 vs −1.59±0.21, P=.001; respectively).In 42 weaning failure patients, the dobutamine echocardiography showed an increased E/E′ ratio (7.41±0.43 vs 15.98±7.98; P=.0001) and deterioration of S (−15.41±09.56 vs −12.72±6.55; P=.0001) and SR (−1.41±0.78 vs −1.22±0.65; P=.0001). In 37 patients without systolic or diastolic impairment and functional MR grade >2, ephedrine echocardiography showed an increase of effective regurgitant volume (29.56±11.32 mL vs 46.56±0.13 mL, P=.0001) and effective regurgitant orifice area (0.19±0.09 cm2 vs 0.31±0.09 cm2, P=.0001). ConclusionsStress echocardiography may be helpful in detecting silent diastolic and systolic dysfunction or severe MR that could have a major impact on respiratory weaning.

Prognostički značaj stresne ehokardiografije kod bolesnika sa inkompletnom revaskularizacijom nakon primarne perkutane koronarne intervencije

Prognostički značaj stresne ehokardiografije kod bolesnika sa inkompletnom revaskularizacijom nakon primarne perkutane koronarne intervencije

Rapid Fire Abstract: Coronary artery disease: the crucial role of imaging369Left ventricular longitudinal strain is superior to blood biomarkers in prediction of poor exercise capacity in patients with a first-ever STEMI370Early identification of STEMI patients treated with pPCI at risk to develop heart failure during follow-up: speckle tracking echocardiographic study371The clinical and cost effectiveness of stress echocardiography in patients with

Rapid Fire Abstract: Coronary artery disease: the crucial role of imaging369Left ventricular longitudinal strain is superior to blood biomarkers in prediction of poor exercise capacity in patients with a first-ever STEMI370Early identification of STEMI patients treated with pPCI at risk to develop heart failure during follow-up: speckle tracking echocardiographic study371The clinical and cost effectiveness of stress echocardiography in patients with

Coronary artery spasm and dobutamine stress echocardiography in patients without known coronary disease: prevalence, predictors and outcomes

Background and objective Given its high diagnostic and prognostic value and good safety profile, dobutamine stress echocardiography (DSE) is widely used in patients with known or suspected coronary artery disease (CAD); it may however, occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence of dobutamine-related coronary spasm in patients without known CAD, to determine the potential predictors of spasm amongst those with positive DSE and to assess mid-term clinical outcomes.Methods 3,952 patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or a positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE and significant coronary lesions at angiograms but no history of CAD.Results Twenty-nine patients with DSE-related vasospasm (19.4% of positive DSE without known CAD) were compared with 64 patients with significant coronary lesions. They were significantly younger (56 vs 67.7 years; P < 0.001), had less frequently hypertension (27.6% vs 64.1%; P = 0.01) and diabetes mellitus (31% vs 68.8%; P = 0.01); conversely they had more frequently dyslipidaemia (79.3% vs 53.1%; P = 0.021); they also had a lower ischaemic area at peak DSE (< 4 involved segments) at 79.3% vs 48.4% (P = 0.006). On multivariate analysis, dyslipidaemia (HR = 21.3; 95% CI = [3.45-131.7]; P = 0.001), and less than 4 ischaemic segments at peak DSE (HR = 4.3; 95% CI = [1.14-16.23]; P = 0.034) were found to be independent predictors of coronary spasm rather than significant coronary lesions. Conversely, hypertension, DM and age > 60 were predictors of significant coronary lesions rather than spasm. Long-term actuarial survival free from adverse events was significantly higher in the group of patients with coronary spasm at 93% versus 70% (log rank P = 0.037) in patients with significant coronary disease.Conclusion DSE-induced coronary spasm is an important condition associated with a good mid-term prognosis; dyslipidaemia and lower ischaemic area at peak DSE predicted spasm rather than significant stenoses in patients with positive DSE and no history of CAD.