Transesophageal Dobutamine Stress Echocardiography Research Articles

Usefulness of an accelerated transoesophageal stress echocardiography in the preoperative evaluation of high risk severely obese subjects awaiting bariatric surgery

BackgroundSevere obesity is associated with an increased risk of coronary artery disease (CAD). Bariatric surgery is an effective procedure for long term weight management as well as reduction of comorbidities. Preoperative evaluation of cardiac operative risk may often be necessary but unfortunately standard imaging techniques are often suboptimal in these subjects. The purpose of this study was to demonstrate the feasibility, safety and utility of transesophageal dobutamine stress echocardiography (TE-DSE) using an adapted accelerated dobutamine infusion protocol in severely obese subjects with comorbidities being evaluated for bariatric surgery for assessing the presence of myocardial ischemia.MethodsSubjects with severe obesity [body mass index (BMI) >40 kg/m2] with known or suspected CAD and being evaluated for bariatric surgery were recruited.ResultsTwenty subjects (9M/11F), aged 50 ± 8 years (mean ± SD), weighing 141 ± 21 kg and with a BMI of 50 ± 5 kg/m2 were enrolled in the study and underwent a TE-DSE. The accelerated dobutamine infusion protocol used was well tolerated. Eighteen (90%) subjects reached their target heart rate with a mean intubation time of 13 ± 4 minutes. Mean dobutamine dose was 31.5 ± 9.9 ug/kg/min while mean atropine dose was 0.5 ± 0.3 mg. TE-DSE was well tolerated by all subjects without complications including no significant arrhythmia, hypotension or reduction in blood arterial saturation. Two subjects had abnormal TE-DSE suggestive of myocardial ischemia. All patients underwent bariatric surgery with no documented cardiovascular complications.ConclusionsTE-DSE using an accelerated infusion protocol is a safe and well tolerated imaging technique for the evaluation of suspected myocardial ischemia and cardiac operative risk in severely obese patients awaiting bariatric surgery. Moreover, the absence of myocardial ischemia on TE-DSE correlates well with a low operative risk of cardiac event.

201 The role of transesophageal dobutamine stress echocardiography in patients qualification towards severe ischemic mitral regurgitation cardiosurgical treatment

201 The role of transesophageal dobutamine stress echocardiography in patients qualification towards severe ischemic mitral regurgitation cardiosurgical treatment

530 The role of transesophageal dobutamine stress echocardiography in patients qualification towards severe ischemic mitral regurgitation cardiosurgical treatment

530 The role of transesophageal dobutamine stress echocardiography in patients qualification towards severe ischemic mitral regurgitation cardiosurgical treatment

Preoperative evaluation for bariatric surgery using transesophageal dobutamine stress echocardiography.

Bariatric surgery is an effective option for weight control in morbid obesity. The goal of this study was to assess cardiac risk prior to bariatric surgery using transesophageal-dobutamine stress echocardiography (TE-DSE). 7 morbidly obese patients (mean BMI 67.7 +/- 15.6) were prospectively evaluated by TE-DSE prior to bariatric surgery. All patients underwent TE-DSE without complications. 6 of 7 patients had no evidence of ischemia on TE-DSE. One patient had abnormal TE-DSE showing inferior ischemia and was treated with beta-blockers and nitrates prior to surgery and had no complications. All patients underwent surgery without cardiac complications. 1 patient died at 18 days of sepsis. Over a mean follow-up period of 11 months, the 6 surviving patients have not experienced any cardiac events. Their average weight loss is 58.2 kg. TE-DSE is a valuable noninvasive technique for predicting cardiac risk in morbidly obese patients undergoing bariatric surgery.

727 Value of transesophageal dobutamine stress echocardiography in patient qualification towards ischaemic mitral insufficiency cardiosurgical treatment

727 Value of transesophageal dobutamine stress echocardiography in patient qualification towards ischaemic mitral insufficiency cardiosurgical treatment

Transesophageal Dobutamine Stress Echocardiography With Tissue Doppler Imaging for Detection and Assessment of Coronary Artery Disease

BackgroundTransesophageal dobutamine stress echocardiography (T-DSE) has been shown to be a sensitive and specific technique for the detection of myocardial ischemia. A major limitation of echocardiographic study interpretation, however, is...

Identification of hemodynamically significant restenosis after percutaneous transluminal coronary angioplasty in acute myocardial infarction by transesophageal dobutamine stress echocardiography and comparison with myocardial single photon emission computed tomography.

Beside thrombolysis, percutaneous transluminal coronary angioplasty (PTCA) has become a well-established treatment for acute myocardial infarction. However, restenosis occurs in approximately 15%-40% of patients. Despite a frequently occurring infarct-related regional systolic dysfunction at rest, the identification of hemodynamically relevant restenosis seems important in terms of risk stratification, adequate treatment, and possible improvement of prognosis in these patients. This study was designed to assess the role of transesophageal dobutamine stress echocardiography and myocardial scintigraphy for identification of hemodynamically significant restenosis after PTCA for acute myocardial infarction. Multiplane transesophageal stress echocardiography (dobutamine 5, 10, 20, 30, and 40 micrograms/kg per min) studies and myocardial single photon emission computed tomography (SPECT) studies were performed in 40 patients, all of whom underwent PTCA in the setting of acute myocardial infarction > or = 4 months prior to the test. Repeated coronary angiography was performed in all study patients who showed stress-induced perfusion defects or wall-motion abnormalities, or both. Significant restenosis (> or = 50%) was angiographically found in 15 (37.5%) of 40 patients. Of these 15 patients, transesophageal dobutamine stress echocardiography identified restenosis in 12 (80%) and myocardial SPECT in 14 (93%), yielding diagnostic agreement in 70% of patients. Echocardiographic detection of restenosis was based mainly on a biphasic response to increasing doses of dobutamine. Sensitivity and specificity for identification of hemodynamically relevant restenosis in individual patients was 80% and 92%, respectively for dobutamine stress echocardiography versus 93% and 68% for myocardial SPECT. Both transesophageal dobutamine stress echocardiography and myocardial SPECT were highly sensitive in identifying significant restenosis after PTCA for acute myocardial infarction. Therefore, either test, as a single diagnostic tool or especially if performed together, are clinically valuable alternatives to coronary angiography for the detection of restenosis after PTCA for acute myocardial infarction.

Value of transesophageal dobutamine stress echocardiography in assessing coronary artery disease

The introduction of digital echocardiography has significantly enhanced our ability to select the best set of frames for analysis. However, despite the beneficial attributes of transthoracic dobutamine stress echocardiography, poor quality 2-dimensional images continue to be a significant limiting factor in patients with chest deformities, severe chronic obstructive lung disease, marked obesity, and previous chest surgery. Transesophageal echocardiography provides a new window to monitor left ventricular contractility without the interference of bone and air-filled structures of the thoracic cage. The transesophageal dobutamine stress test is a logical but poorly explored modality to image/stress the heart in certain patients with known or suspected myocardial ischemia. Overall sensitivity (≤85%) and specificity (≤95–100%) of transesophageal dobutamine stress echocardiography appear to be similar to that of previous transthoracic studies, although no direct comparison has been accomplished between transthoracic and transesophageal stress images. False negative transesophageal dobutamine stress echocardiography results have been described in patients with single-vessel disease in whom ischemic regions may not have been visualized throughout the entire study. False positive study results may be present in patients with hypertension and myocardial hypertrophy that may have signs and symptoms of myocardial ischemia in absence of obstructive disease of the epicardial coronary arteries, presumably related to either microvascular disease or impaired vasodilatory reserve. The proportion of patients with coronary artery disease who need a transesophageal examination for reliable assessment of echocardiographic response to stress varies depending on the operators’ skills, the interpreters’ experience, and the use of videotape or digitizing systems for image analysis. Although clinically useful in its present transthoracic and transesophageal form, a major limitation of dobutamine stress echocardiographic study is the subjective visual interpretation of endocardial motion and wall thickening, which is only semiquantitative. Color kinesis and tissue Doppler imaging (TDI) are 2 novel echocardiographic techniques that color code endocardial motion and myocardial velocity online and have the potential to objectively quantify regional left ventricular function. Quantitative standardization of transthoracic and transesophageal data interpretation, such as establishing endocardial motion by color kinesis or velocity thresholds by TDI for an abnormal segmental response to stress, has the potential to decrease interobserver variability and increase interinstitutional agreement.

Transesophageal Dobutamine Stress Echocardiography in the Evaluation of Myocardial Ischemia in Morbidly Obese Subjects

The evaluation of chest pain or suspected coronary artery disease (CAD) in morbidly obese subjects is limited by the inability of routine diagnostic techniques to adequately image these individuals. Morbidly obese subjects are therefore often inadequately treated or inappropriately treated for presumed CAD. We prospectively evaluated 23 morbidly obese patients with chest pain using transesophageal dobutamine stress echocardiography (TE-DSE). The mean (+/- SD) weight was 164 +/- 8 kg (range, 118 to 215 kg). We identified nine patients with abnormal TE-DSE findings. Five of these patients subsequently had cardiac catheterization with confirmation of CAD in the regions identified by TE-DSE. Over a follow-up period of 18 +/- 6 months, three cardiac events (non-Q-wave myocardial infarction) occurred in the same group, including two patients without confirmatory cardiac catheterization data. Thus, seven of nine patients with positive results of TE-DSE had objective confirmatory evidence of CAD. No cardiac events were observed in the group with normal TE-DSE over the same follow-up period. TE-DSE is a safe and potentially useful technique for the evaluation of suspected CAD in morbidly obese subjects.

Complicaciones de la ecocardiografía de estrés transesofágica con dobutamina

The transesophageal echocardiographic approach improves the diagnostic power of transthoracic stress echocardiography. However, it is a seminvasive test and its safety is not well established. Our objective was to compare the incidence of complications of transesophageal and transthoracic dobutamine echocardiography. We collected data from 63 patients with inadequate transthoracic window, who underwent transesophageal dobutamine echocardiography and were compared with 100 patients in whom the transthoracic approach was diagnostic. Baseline blood pressure and heart rate were higher in the first group. There were no differences in those parameters at the end of the test. Neither were atropine administration and side effects more frequent in any of the groups. There were no cases of ventricular fibrillation, ventricular tachycardia, acute myocardial infarction, intractable angina or intolerance to the probe. Side effects were equally present in both groups. Transesophageal dobutamine stress echocardiography is a safe test that can be used in patients with coronary artery disease and poor transthoracic window.

Prognostic value of negative transesophageal dobutamine stress echocardiography in men at high risk for coronary artery disease

Recently published reviews have called into question the sensitvity of transthoracic stress echocardiography to predict cardiac events, especially when the test is negative, compared with myocardial perfusion imaging studies. To our knowledge there are a lack of data assessing the prognostic value of transesophageal echocardiography–dobutamine stress echocardiography (TEE-DSE) in predicting cardiac events. Because TEE-DSE has been reported to be highly accurate for detecting ischemia in patients with suspected coronary artery disease, we tested the hypothesis that a negative TEE-DSE can identify a low-risk group in a population with a high likelihood of coronary artery disease. Between October 1996 and December 1997, 46 high-risk patients with negative TEE-DSE were identified. Annualized pretest risk for all cardiac events using the Framingham model was 4% based on risk factors. Mean age was 64 years. Mean follow-up time was 16.2 months. There were no cardiac deaths. There were 6 soft and 1 hard cardiac event. The annualized combined ischemic cardiac event rate was 3.8%, and for hard cardiac events it was 1.1%. By Kaplan-Meier analysis, 97% of the population remained free of any ischemic event at the end of 1 year and 93% were free at 22 months. We conclude that optimal image quality and enhanced endocardial definition for assessing wall motion changes with TEE translates into better prognostication and approaches that of myocardial perfusion imaging for negative studies. Advances in ultrasound medicine such as contrast enhancement of myocardial definition, which improve diagnostic accuracy of DSE, should translate into better prognostication.

Transesophageal dobutamine stress echocardiography with tissue doppler imaging for detection and assessment of coronary artery disease

Transesophageal dobutamine stress echocardiography with tissue doppler imaging for detection and assessment of coronary artery disease

Improved Specificity of Transesophageal Dobutamine Stress Echocardiography Compared to Standard Tests for Evaluation of Coronary Artery Disease in Women Presenting with Chest Pain

Improved Specificity of Transesophageal Dobutamine Stress Echocardiography Compared to Standard Tests for Evaluation of Coronary Artery Disease in Women Presenting with Chest Pain

Improved Specificity of Transesophageal Dobutamine Stress Echocardiography Compared to Standard Tests for Evaluation of Coronary Artery Disease in Women Presenting With Chest Pain

The detection of coronary artery disease (CAD) by noninvasive methods has been hindered in women by the high rate of false–positive results. To determine the feasibility and accuracy of transesophageal dobutamine stress echocardiography for identification of CAD in women, we studied 84 patients (age 51 ± 11 years) who underwent symptom-limited exercise treadmill testing, exercise thallium-201 scintigraphy, and coronary angiography for evaluation of anginal chest pain. Of the 84 patients, 62 had normal coronary arteries or nonsignificant coronary lesions, and 22 had significant stenosis of ≥1 major coronary artery. During treadmill exercise, repolarization changes were observed in 16 of 21 patients with CAD and in 19 of 60 patients with normal coronary arteries. With thallium scintigraphy, a reversible defect was observed in 19 of 22 patients with CAD and in 12 of 60 patients with normal coronary arteries. Regional wall motion abnormalities during dobutamine infusion developed in 18 of 22 patients with CAD and in none of the 62 patients with normal coronary arteries. All 3 tests had similar sensitivity for detection of CAD (76% for exercise treadmill test, 86% for thallium scintigraphy, and 82% for transesophageal dobutamine stress echocardiography). However, transesophageal dobutamine stress echocardiography had significantly higher specificity than the other 2 tests (100% vs 68% for exercise treadmill test and 80% for thallium scintigraphy; p = 0.0001). Thus, transesophageal dobutamine stress echocardiography is accurate for evaluation of CAD among women presenting with chest pain; its use should be considered when more conventional tests are equivocal or technically suboptimal.

Investigation of the Mechanism of Chest Pain in Patients With Angiographically Normal Coronary Arteries Using Transesophageal Dobutamine Stress Echocardiography

Objectives. The present study sought to determine whether myocardial contractile abnormalities accompany the development of chest pain in patients with normal coronary angiograms.Background. The mechanism of chest pain in patients with angina despite a normal coronary arteriogram is controversial. Although previous studies postulated the existence of coronary microvascular dysfunction, others failed to find evidence of myocardial ischemia, and recent studies have demonstrated abnormal cardiac sensitivity in these patients that can lead to chest pain on a nonischemic basis.Methods. Seventy patients (26 men and 44 women, mean age 49 ± 10 years) with angina-like chest pain and angiographically normal coronary arteries underwent exercise treadmill testing, radionuclide angiography at rest and during exercise, thallium stress testing and transesophageal dobutamine stress echocardiography. The results of exercise treadmill testing and stress echocardiography were compared with those obtained in 26 normal control subjects (19 men and 7 women, mean age 56 ± 7 years).Results. Abnormalities consistent with myocardial ischemia were noted in 31% of the patients during exercise treadmill testing, in 16% during exercise radionuclide angiography and in 18% during thallium stress testing. The findings of the radionuclide studies were not concordant with one another and were not related to the presence of repolarization changes during exercise testing. During infusion of dobutamine, chest pain developed in 59 patients (84%) and in none of the control subjects (p < 0.0001); repolarization changes occurred in 22 patients (34%) and in 2 control subjects (8%) (p < 0.04). None of the patients or the control subjects developed regional wall motion abnormalities with dobutamine. The quantitative myocardial contractile response to dobutamine was similar in patients and control subjects, with an 80% power to detect a 25% difference in systolic wall thickening at the maximal dose of dobutamine.Conclusions. There was no agreement in the results of noninvasive tests in our patients. Despite the frequent provocation of chest pain and electrocardiographic abnormalities with dobutamine, the patients demonstrated a quantitatively normal myocardial contractile response without development of wall motion abnormalities. These observations strongly suggest that myocardial ischemia is not the cause of chest pain in patients with a normal coronary arteriogram.(J Am Coll Cardiol 1997;29:293–301)

Cardiovascular technology

Transesophageal dobutamine stress echocardiography uses ultrasonic imaging of the myocardium from the esophagus and stomach during the infusion of incremental doses of dobutamine. Given the semi-invasive nature of the procedure, the nurse who assists the physician plays an essential role in the successful completion of the test. This method is useful for the evaluation of patients with coronary artery disease and for investigations based on ultrasound imaging of the myocardium. Its expanding applications emphasize the relevance of a nursing collaboration and thereby create an opportunity to increase nurses' participation in echocardiography laboratories.

Transesophageal dobutamine stress echocardiography in the evaluation of coronary artery disease

The goal of this study was to determine the feasibility, safety, sensitivity and specificity of transesophageal dobutamine stress echocardiography for the detection of coronary artery disease. Dobutamine stress echocardiography has been shown to be an extremely sensitive and specific noninvasive technique for the detection of myocardial ischemia. However, inadequate transthoracic images preclude the use of dobutamine stress echocardiography in a small but significant group of patients. Transesophageal echocardiography provides better resolution than that obtained with routine transthoracic imaging. Patients scheduled for routine cardiac catheterization underwent transesophageal dobutamine stress echocardiography. All patients underwent coronary arteriography within 48 h of the study, and lesion severity was determined by quantitative coronary angiography. Significant coronary obstruction was defined as stenosis > 50%. Fifty-one male patients were enrolled in the study; six were excluded for technical reasons. There were no adverse outcomes or complications. Of 27 patients with significant coronary artery disease, 22 had positive study results (sensitivity 82%). Of 13 patients without significant obstructive coronary disease, 1 had a false positive study result (specificity 93%). In patients with a minimal lumen diameter < 1.25 mm, sensitivity was > 80%, and in patients with a minimal lumen diameter > 1.5 mm, sensitivity was < 70%, suggesting that lesions with a minimal lumen diameter < 1.25 mm are more likely to be physiologically significant. Transesophageal dobutamine stress echocardiography is a feasible, safe and accurate technique for the detection of myocardial ischemia. There are inherent limitations to this technique in that transesophageal echocardiography must be performed. Transesophageal dobutamine stress echocardiography may allow extension of dobutamine stress testing to patients with inadequate transthoracic echocardiographic imaging and may provide an opportunity for further research applications.

909-3 Transesophageal Dobutamine Stress Echocardiography for Detection of Coronary Artery Disease in Women Presenting with Chest Pain: Comparison with Other Standard Tests

Non-invasive identification of coronary artery disease (CAD) in women is hindered by a relatively high incidence of false positive studies. We have shown that transesophageal dobutamine stress echocardiography (TEDSE) is a useful technique for assessment of CAD in a predominantely male population. To determine the accuracy of TEDSE for detection of CAD in women in relation to other standard non-invasive tests, we studied 49 women (age 51 ± 10 years, range 33–78) who underwent cardiac catheterization, exercise treadmill test (ETT) and stress thallium scintigraphy (TI) for evaluation of chest pain and suspected CAD. Transesophageal echocardiography was performed using a biplane (13 patients) or an omniplane probe (36 patients), and dobutamine was infused in stepwise increments up to 40 μg/kg/min. Ten women had CAD (≥ 70% stenosis of ≥ 1 major coronary artery) and 39 had normal coronary angiograms. During TEDSE, chest pain developed in 8 of 10 (80%) women with CAD and in 31 of the 39 (79%) with normal coronary arteries (p = NS). Of the 10 women with CAD, 7 had ST segment depression during ETT, 8 had reversible TI defects, and 8 developed new or worsening wall motion abnormalities during TEDSE (sensitivity: 70%, 80%, and 80%, respectively; p = NS). Of the 39 women without CAD, 12 had ST segment depression during ETT, 8 had reversible Tl defects, and none developed new or worsening wall motion abnormalities during TEDSE (specificity: 69%,79%, and 100%, respectively; p &lt; 0.002). The overall accuracy was 69% for ETT, 80% for TI, and 96% for TEDSE (p &lt; 0.003). Thus, TEDSE is an accurate test for detection of CAD among women presenting with chest pain which, by virtue of its high specificity, compares favorably with other standard methods.

764-3 Transesophageal Dobutamine Stress Echocardiography for the Evaluation of Patients with Chest Pain and Normal Coronary Arteries

Demonstration of myocardial ischemia with noninvasive testing has been inconsistent in patients with chest pain and normal coronary arteries (CPNCA), thus raising doubts about the ischemic nature of their symptoms. We have shown that transesophageal dobutamine stress echocardiography (TEDSE) accurately reveals inducible myocardial ischemia in coronary artery disease (CAD) patients. Accordingly. to determine whether patients with CPNCA have similar evidence of myocardial ischemia during TEDSE. we studied 52 patients with CPNCA (17 men; age 49 ± 9 years). 16 (31%) of whom had ischemic-appearing ECG responses to treadmill exercise. Their results were compared to those of 62 CAD (≥70% stenosis of ≥1 coronary artery) patients (54 men; age 61 ± 10 years) and 21 normal volunteers (NV) (15 men; age 56 ± 7 years). Dobutamine was infused in stepwise increments up to 40 μ g/kg/min. TEDSE induced chest pain in 44(85%) patients with CPNCA, in 31 (50%) CAD patients. and in none of the NV (p &lt; 0.001). Ischemic-appearing ECG changes developed in 17 (33%) patients with CPNCA. in 32 CAD patients (51%), and in only 1 15%) NV (p &lt; 0.001). New or worsening wall motion abnormalities occurred in none of the patients with CPNCA. in 55 (89%) CAD patients. and in none of the NV Thus. despite successful provocation of chest pain and/or ECG changes, patients with CPNCA do not have evidence of myocardial ischemia during TEDSE. Therefore. TEDSE appears as a useful method for the identification of patients with chest pain of non-ischemic origin.

Transesophageal dobutamine stress echocardiography for evaluation of patients with coronary artery disease

Objectives. The present study was undertaken to determine the safety, feasibility and diagnostic accuracy of transesophageal dobutamine stress echocardiography for the evaluation of patients with known or suspected coronary artery disease.Background. Dobutamine stress echocardiography has proved to be a valuable method for detecting and prognosticating ischemic heart disease, In addition, it may provide accurate information about myocardial viability in patients with systolic dysfunction. However, in some patients the technique may be limited by poor myocardial imaging with the conventional transthoracic approach.Methods. Seventy-six patients (62 men, 14 women; mean age ± SD 60 ± 10 years) who underwent coronary angiography were included in the study. Transesophageal stress echocardiograms were performed after withdrawal of antianginal medications for ≥ 48 h. Dobutamine was infused at a starting dose of 2.5 μg/kg body weight per min and was increased by 5-μg/kg per min increments every 5 min to a maximum of 40 μg/kg per min. Two-dimensional views were acquired at each stage and digitized for subsequent analysis. The left ventricle was divided into 16 segments, and each segment was assigned to a major coronary artery with the use of a model of regional distribution of coronary perfusion.Results. Sixty-two of the 76 patients had angiographic evidence of coronary artery disease. New or worsening regional wall motion abnormalities developed during dobutamine infusion in 55 of these 62 patients and in none of the 14 patients with normal coronary arteries (sensitivity 89%, specificity 100%, overall accuracy 91%). Regional wall motion abnormalities in the distribution of more than one major coronary artery were seen in 3 of the 25 patients with single-vessel coronary artery disease and in 30 of the 37 patients with multivessel disease (p < 0.0001). The test was successfully completed in 73 (96%) of the 76 patients; it was discontinued in the remaining 3 patients because of intolerance to the probe. No major complications occurred in any patient. Minor complications developed in seven patients but did not affect the diagnostic accuracy of the test.Conclusions. Transesophageal dobutamine stress echocardiography is a safe, feasible and accurate method for assessing coronary artery disease. Its use should be considered in patients who have a suboptimal ultrasound window, and it provides an excellent tool for clinical investigations based on ultrasound imaging of the myocardium.