José L. Andrade

Safety of Dobutamine-Atropine Stress Echocardiography: A Prospective Experience of 4033 Consecutive Studies ☆ ☆☆

Dobutamine-atropine stress echocardiography (DASE) is an established method and has been shown to be accurate for the detection of coronary artery disease. Still, there are few large clinical studies that analyze the safety of DASE in general or the safety of performing it on an ambulatory basis. Most studies use a target heart rate as the primary end point regardless of whether asymptomatic ischemia occurs. Such studies have shown a serious cardiac event rate of approximately 0.3%. We prospectively studied 4,033 consecutive patients on an ambulatory basis and in the hospital with the use of DASE from July 1991 to December 1998. All tests were performed by an experienced physician, and all clinical and DASE data were stored in a large database organized at the beginning of the study. Dobutamine was infused in scalar doses of 5, 10, 20, 30, and 40 microg/kg per minute in 3-minute stages. Development of a new wall motion abnormality, achievement of 85% of target heart, and end of the DASE infusion protocol were used as an end point. If 85% of the target heart rate was not achieved, atropine was infused up to 1 mg in the absence of myocardial ischemia, which was used in 1,280 studies. There were 3,645 diagnostic tests, and 388 (10%) were found to be nondiagnostic. This result was due to poor image quality in 115 (3%), end of protocol in negative-submaximal examinations in 124 (3%), and limiting side effects in 149 (4%). Thirty-seven percent of the tests showed positive results for myocardial ischemia. Major test-related cardiac complications occurred in 10 (0.25%) patients and included 1 ventricular fibrillation, 1 case of myocardial infarction, and 8 cases of sustained ventricular tachycardia. Atropine poisoning was observed in 5 (0.12%) patients. No deaths occurred as a direct or indirect consequence of DASE. We conclude that dobutamine-atropine stress echocardiography is a reasonably safe method for detection of coronary artery disease in the hospital or in an ambulatory basis. The use of new wall motion abnormality as 1 of the end points may prevent further ischemia-related complications.

Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study☆

Valvular function, assessed by Doppler technique, has not been extensively investigated during normal pregnancy. To prospectively study this feature, 18 normal pregnant women were followed during their pregnancies and puerperium, with serial clinical and pulsed-continuous Doppler echocardiographic examinations. In four gestational periods and the puerperium, we analysed: (a) ventricular and atrial dimensions, as well as valve annular diameters; (b) prevalence and characteristics of trivial valvular regurgitations. During pregnancy, slight but significant increases of the four cardiac chamber dimensions and valve annular diameters were observed, except for the aortic ring. The prevalence of physiologic valvular regurgitation in early pregnancy (mitral, 0%; tricuspid, 38.9%; pulmonary, 22.2%; aortic, 0%), was similar to a control group of 18 healthy non-pregnant women. As pregnancy evolved, there was a progressive and significant increase of multivalvular regurgitation, maximal at full-term (mitral, 27.8%; tricuspid, 94.4%; pulmonary, 94.4%, P < 0.05 vs. early pregnancy). Aortic regurgitation was not detected in any stage of pregnancy. In the puerperium, mitral regurgitation resolved, but tricuspid and pulmonary regurgitation were still significantly prevalent (83.3% and 66.7%, respectively, P < 0.05 vs. early pregnancy). It is concluded that physiologic multivalvular regurgitation is frequent in pregnancy, mainly involving right-sided valves in late gestational periods, occasionally persisting in the early puerperium. Chamber enlargement, valve annular dilatation, and increased prevalence of trivial valve regurgitation are time-related events during normal pregnancy, resulting from a reversible cardiac remodeling process induced by physiologic volume overload. These aspects should be considered for a correct interpretation of Doppler echocardiographic findings in pregnant women with suspected heart disease.

Repeated echocardiographic examinations of patients with suspected infective endocarditis

Objective: To study the diagnostic contribution of repeated transthoracic (TTE) and transoesophageal echocardiography (TOE) among patients with suspected infective endocarditis. Methods: 262 patients with 266 episodes of suspected infective endocarditis were referred for TTE and TOE over three years in a 423 bed university cardiology hospital. Patients were a mean (SD) of 47.6 (17.9) years old. 139 (52.3%) episodes occurred in men and 127 (47.7%) in women. The diagnostic information obtained from repeated TTE and TOE examinations was evaluated relative to the diagnosis of endocarditis. Results: TTE examinations were repeated in 192 (72.2%) and TOE examinations were repeated in 49 (18.4%) of 266 episodes. A mean of 2.4 TTE and 1.2 TOE examinations were performed for each episode of suspected endocarditis. The second and third TTEs added diagnostic information in 34 (26.7%) and the second and third TOEs added diagnostic information in 25 (19.7%) of 127 episodes with definite endocarditis. After the third TTE or TOE no additional diagnostic information was obtained. Conclusions: The diagnostic contribution of repeated TTE or TOE for the diagnosis of endocarditis decreased as the number of repetitions increased. In this setting, the data do not substantiate more than three TTE or TOE examinations as an efficient strategy to increase the diagnostic yield for all but selected patients with suspected endocarditis.

Value of rapid beta-blocker injectionat peak dobutamine-atropine stressechocardiography for detection of coronary artery disease

OBJECTIVES We studied the value of a rapid beta-blocker injection at peak dobutamine-atropine stress echocardiography (DASE) for the detection of coronary artery disease (CAD). BACKGROUND The presence of tachycardia and hyperdynamic wall motion may make it difficult to recognize a new wall motion abnormality (NWMA) at peak stress. METHODS We studied 101 patients (mean age 58.2 +/- 9.8 years) who underwent effective DASE and coronary angiography. All patients received a rapid intravenous injection of metoprolol immediately after peak DASE image acquisition. Positivity in combined peak plus post-metoprolol images was defined when there was only peak NWMA, maintenance of peak NWMA, or NWMA detected only after metoprolol injection. Significant CAD was defined as >or=50% stenosis by quantitative angiography. RESULTS There were 37 patients without and 64 with CAD. The sensitivity, specificity, accuracy, and positive and negative predictive values for the detection of CAD at peak stress were 84%, 92%, 87%, 95%, and 77%, respectively. Five patients with CAD had negative peak images that became positive only after metoprolol. Extension of peak NWMA during metoprolol was observed in 14 patients, and multivessel CAD was detected in 10 of them. The sensitivity, specificity, accuracy, and positive and negative predictive values for peak plus metoprolol images were 92%, 89%, 91%, 94%, and 87%, respectively. CONCLUSIONS The use of metoprolol injected at peak of dobutamine infusion improved the detection of CAD by DASE.

Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography.

BACKGROUND Transesophageal echocardiography (TEE) plays an important role in evaluating cardioembolic sources of emboli. The identification of a patent foramen ovale (PFO) is reportedly improved with TEE compared with transthoracic echocardiography (TTE), but the Valsalva maneuver during TEE may be difficult or suboptimal. The aim of this study was to assess the efficacy of the Valsalva maneuver for PFO diagnosis using TEE compared with TTE by evaluating patients with ischemic stroke referred for echocardiography. METHODS Only patients able to perform the Valsalva maneuver during TTE were included; efficacy was defined by a 20 cm/sec decrease in transmitral E velocity. A PFO was judged present when microbubbles of agitated intravenous saline were seen in the left chambers within three cycles after right atrial opacification. RESULTS Of 108 patients (mean age, 55 ± 15 years; 61 men), 48 (44%) were judged to have PFOs by TEE and/or TTE. In 36 patients (33% of the total, 75% of those with PFOs), microbubbles were observed both by TEE and TTE, in seven patients only during TTE, and in five patients only during TEE. In patients able to satisfactorily perform the Valsalva maneuver during TEE, 22 PFOs were found, and two shunts (9%) were missed, whereas in patients unable to perform this maneuver, 26 PFOs were observed, with five shunts missed (19%) (P < .05). When a PFO was missed by TTE, either the echocardiographic window was suboptimal or the shunt was small. CONCLUSIONS An adequate Valsalva maneuver is crucial for diagnosis of PFO; most patients with stroke may be screened using TTE with contrast and the Valsalva maneuver, with TEE indicated in case of suboptimal transthoracic images.

Endocardial Border Delineation during Dobutamine Infusion Using Contrast Echocardiography

Background: A significant percentage of pharmacologic stress echocardiograms produce suboptimal images despite the use of second harmonic imaging. Intravenous continuous infusion of myocardial ultrasound contrast may enhance endocardial border delineation during dobutamine‐atropine stress echocardiography (DASE), improving wall‐motion analysis. Patients and Methods: We prospectively studied 68 patients (41 males and 27 females), mean age 58 years, with DASE during intravenous infusion of contrast using second harmonic imaging. Dobutamine was infused in scalar doses of 5 μg/kg/min to 40 μg/kg/min, and atropine was administered in doses of up to 1 mg. We diluted 0.1 mL of perfluorocarbon‐exposed sonicated dextrose albumin (PESDA) microbubbles into 80 mL of saline solution, which was used for continuous intravenous infusion. Blinded reviewers used a 16‐segment model at rest and peak DASE to analyze segmental wall delineation in two sets of images for each patient, with and without contrast. An endocardial delineation score of 0–3 (nondelineated to excellent delineation) was given to each segment. An endocardial delineation score index (EDSI), the number of endocardial delineation scores for each set of images divided by 16, was created. Results: The analysis of the mean EDSI for the 2176 segments was 1.46 (± 0.43) at rest and 1.30 (± 0.48) at peak for noncontrast images and 2.22 (± 0.52) and 2.29 (± 0.52) for contrast images. Complete left ventricle opacification was obtained in all patients, with a mean dose of 4 mL/min, although in 15 (22%) patients, signs of apical bubble destruction occurred. There were 1768 (81%) of 2176 segments delineated without contrast enhancement and 2057 (95%) of 2176 with enhancement (P < 0.05). Conclusion: Continuous infusion of myocardial ultrasound contrast improves endocardial border delineation using second harmonic imaging in patients undergoing DASE.

Contrast Echocardiography Can Save Nondiagnostic Exams in Mechanically Ventilated Patients

Patients in an intensive care unit (ICU) under mechanical ventilation (MV) are very difficult to image by transthoracic echocardiography, diminishing the beneficial information that could be obtained by this noninvasive approach. The objective of this study is to assess whether the addition of a contrast agent to fundamental imaging (FI) can improve or change the initial diagnosis in cardiac postoperative patients under mechanical ventilation by enhancing endocardial border delineation and Doppler flow signal. Thirty mechanically ventilated post–cardiac surgery patients (20 men, mean age 61 ± 13 years) were evaluated with FI before and after intravenous injection of contrast. Left ventricular endocardial border delineation score index (EBDSI), estimated left ventricular ejection fraction (LVEF), and color and spectral Doppler were analyzed. The use of contrast resulted in a significant increase in the number of well‐delineated segments, with a salvage rate of 77% of nondiagnostic studies. EBDSI was 1.62 ± 0.61, before contrast, increasing to 2.05 ± 0.53 after it (P < 0.001). There was a change in the LVEF estimation in 5 exams, and a new wall motion abnormality was detected in other 4 exams, after the use of contrast. Moreover, a significant change was observed in the quantification of mitral regurgitation in 5 patients, in the aortic transvalvular peak gradient in 1 patient, and measurement of tricuspid regurgitation peak flow velocity in 8 patients. It is concluded that in cardiac postoperative patients under mechanical ventilation, intravenous injection of a contrast agent using FI resulted in a high salvage rate of studies and changed the initial diagnosis in a significant number of patients.

Hand-carried ultrasound performed at bedside in cardiology inpatient setting – a comparative study with comprehensive echocardiography

BackgroundHand-carried ultrasound (HCU) devices have been demonstrated to improve the diagnosis of cardiac diseases over physical examination, and have the potential to broaden the versatility in ultrasound application. The role of these devices in the assessment of hospitalized patients is not completely established. In this study we sought to perform a direct comparison between bedside evaluation using HCU and comprehensive echocardiography (CE), in cardiology inpatient setting.MethodsWe studied 44 consecutive patients (mean age 54 ± 18 years, 25 men) who underwent bedside echocardiography using HCU and CE. HCU was performed by a cardiologist with level-2 training in the performance and interpretation of echocardiography, using two-dimensional imaging, color Doppler, and simple calliper measurements. CE was performed by an experienced echocardiographer (level-3 training) and considered as the gold standard.ResultsThere were no significant differences in cardiac chamber dimensions and left ventricular ejection fraction determined by the two techniques. The agreement between HCU and CE for the detection of segmental wall motion abnormalities was 83% (Kappa = 0.58). There was good agreement for detecting significant mitral valve regurgitation (Kappa = 0.85), aortic regurgitation (kappa = 0.89), and tricuspid regurgitation (Kappa = 0.74). A complete evaluation of patients with stenotic and prosthetic dysfunctional valves, as well as pulmonary hypertension, was not possible using HCU due to its technical limitations in determining hemodynamic parameters.ConclusionBedside evaluation using HCU is helpful for assessing cardiac chamber dimensions, left ventricular global and segmental function, and significant valvular regurgitation. However, it has limitations regarding hemodynamic assessment, an important issue in the cardiology inpatient setting.

Subclinical right ventricle systolic dysfunction in childhood-onset systemic lupus erythematosus: insights from two-dimensional speckle-tracking echocardiography.

Objective The objective of this article is to evaluate right ventricle strain imaging by two-dimensional speckle-tracking (2DST) in childhood-onset systemic lupus erythematosus (c-SLE). Methods Thirty-five c-SLE patients with no signs or symptoms of heart failure and 33 healthy volunteers were evaluated by standard echocardiogram and 2DST. Conventional parameters included tricuspid annular plane systolic excursion (TAPSE), RV tissue-Doppler-derived Tei index and systolic pulmonary artery pressure. Global peak longitudinal systolic strain (PLSS) and strain rate (PLSSR) of RV were obtained by 2DST. Demographic/clinical features, SLEDAI-2K/SLICC/ACR-DI and treatment were also assessed. Results The median current age was similar in patients and controls (14.75 vs. 14.88 years, p = 0.62). RV PLSS was significantly reduced in c-SLE (−24.5 ± 5.09 vs. −27.62 ± 3.02%, p = 0.003). Similar findings were observed after excluding patients with pulmonary hypertension (−24.62 ± 4.87% vs. −27.62 ± 3.02%, p = 0.0041). RV PLSS was positively correlated with TAPSE (r = +0.49, p = 0.0027) and negatively correlated with Tei index (r = −0.34, p = 0.04) in c-SLE. RV PLSSR was not different comparing patients and controls (−0.65 s−1 ± 0.47 vs. −1.87 ± 0.49 s−1, p = 0.07). Further analysis of c-SLE patients revealed higher frequencies of neuropsychiatric manifestations (39% vs. 0%, p = 0.007) and antiphospholipid antibodies (55% vs. 18%, p = 0.035) in those with RV PLSS ≤ −23.7% vs >−23.7%. No differences were evidenced in demographic data, disease activity/damage or treatments (p > 0.05). Conclusions The present study, using a new and more sensitive technique, revealed subclinical RV systolic dysfunction in c-SLE patients that may have future prognostic implications. The novel association of asymptomatic RV dysfunction with neuropsychiatric manifestations and antiphospholipid antibodies may suggest common physiopathological pathways.

Detection of Functional Recovery Using Low-Dose Dobutamine and Myocardial Contrast Echocardiography After Acute Myocardial Infarction Treated with Successful Thrombolytic Therapy

Objective: We studied the value of low‐dose dobutamine stress echocardiography (LDDE) and myocardial contrast echocardiography (MCE) in early prediction of left ventricular functional recovery (LVFR) after acute myocardial infarction (AMI) treated with successful thrombolysis. Design: LDDE and MCE using second‐harmonic intermittent imaging were performed in first week after AMI. LVFR was defined as an absolute ≥5% increase in ejection fraction, from early to 6 months of follow‐up by Technetium‐99m‐Sestamibi single‐photon emission computed tomography. Patients: Out of 50 patients studied, 19 evolved with LVFR (group 1) and 31 without LVFR (group 2). Regional dysfunction was detected in 103 (37%) infarcted‐related segments in group 1 and in 173 (63%) segments in group 2. Results: Sensitivity, specificity, positive, and negative predictive values and accuracy for detecting LVFR by LDDE were 94.7% (18/19), 87.1% (27/31), 81.8% (18/22), 96.4% (27/28), and 90% (45/50), respectively, and by MCE were 94.7% (18/19), 51.6% (16/31), 54.5% (18/33), 94.1% (16/17), and 68% (34/50). In group 1, functional improvement was observed in 86.9% (53/61) of segments with contractile reserve by LDDE and in 65.8% (52/79) of segments with microvascular perfusion by MCE. In group 2, functional improvement was observed in 78.3% (18/23) of segments with contractile reserve by LDDE and in 25.5% (25/98) of segments with microvascular perfusion by MCE. All segments without perfusion by MCE evolved without functional recovery. Conclusion: LDDE was an accurate predictor of late left ventricular function recovery after AMI, while MCE was sensitive and has a high negative predictive value demonstrating that microvascular perfusion is essential for LVFR.