Transcript PHARMACOLOGICAL STRESS ECHO_ DR PRADEEP

DR PRADEEP SREEKUMAR
SENIOR RESIDENT
DEPT. OF CARDIOLOGY
GOVT. MEDICAL COLLEGE CALICUT
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Stress echocardiography was introduced in
the early 1980s
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Reliable and cost effective method for both
the diagnosis and risk stratification of
patients with suspected or known CAD.
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Use has increased exponentially worldwide
and is continuing to expand.
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Stress echocardiography may be performed
in conjunction with dynamic exercise
(treadmill or bicycle).
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In patients who are unable to exercise,
pharmacological agents may be used, such
as dobutamine or dipyridamole.
Indications :
• Diagnosis of ischemia
• Risk stratification before major non-cardiac
surgery, especially vascular
• After AMI:
– Early wall motion abnormality predicts new event.
– Remote wall motion abnormality predicts
multivessel disease.
– Viability of akinetic area:
• Sustained improvement: Good prognosis
• Biphasic response: Good prognosis with revascularisation,
poor without
Indications :
• Before PCI / CABG:
Significance of stenosis. (NB: only most severe
stenosis usually responsive).
Viability
• Assess aortic stenosis with poor LV function.
Generally low gradient and low area. With low
dose Dobutamine:
– Increase in gradient: significant AS,
– increase in aortic valve area: poor hemodynamics
and non-significant AS.
Stress modalities
• Exercise
Sitting bicycle
Supine bicycle
Threadmill
• Pharmacological
Dipyridamole – vasodilating
Adenosine – vasodilating
Dobutamine-Contractility and HR
increase
Contraindications:
• Dobutamine
Uncontrolled hypertension: >220/120
(resting)
hypertrophic obstructive cardiomyopathy.
Malignant ventricular arrhythmia.
• Dipyridamole:
AV-block
COPD
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With any form of stress testing
echocardiographic images are first acquired
digitally during rest in parasternal and apical
views.
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Subsequently, stress images are acquired
during low, intermediate, and peak stress.
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Rest and stress images are interpreted for
global and regional left ventricular (LV) size,
shape, and function.
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A normal response is when, during stress,
the LV size becomes smaller compared to
rest, while the shape is maintained and there
is increased endocardial excursion and
systolic wall thickening
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Dobutamine, which is a sympathomimetic
agent, is particularly useful in patients with an
existing resting wall thickening abnormality.
Low doses of dobutamine increases
myocardial perfusion, recruits potentially
contractile myocardium, and hence increases
myocardial contractility in dysfunctional
myocardium if there is sufficient contractile
reserve (viability).
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At high dose, however, dobutamine increases
myocardial oxygen demand and in the
presence of flow limiting stenosis will result in
demand/supply mismatch leading to
myocardial ischaemia, resulting in
deterioration of regional function (biphasic
response).
Thus, dobutamine at low doses depicts the
presence of myocardial viability, while at high
doses uncovers myocardial ischaemia .
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Dipyridamole may be used as an alternative
to dobutamine but it produces infrequent
wall thickening abnormalities even in the
presence of significant flow limiting coronary
stenosis
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Stress echocardiography is based on the
fundamental causal relationship between
induced myocardial ischemia and left ventricular
regional wall motion abnormalities.
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Mason and colleagues used M-mode
echocardiography to study 13 patients with
coronary artery disease and 11 age-matched
control subjects during supine bicycle exercise
Tennant and Wiggers observed the relationship
between systolic contraction and myocardial blood
supply to the left ventricle.
With the induction of ischemia, these investigators
demonstrated the rapid and predictable development
of systolic bulging (or dyskinesis).
This observation established the link between
induced ischemia and transient regional myocardial
dyssynergy, recorded echocardiographically as the
development of wall motion abnormality after the
application of a stressor
In the absence of a flow-limiting coronary
stenosis, physiologic stress results in
Increase in
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Heart rate
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Contractility
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Systolic wall thickening
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Endocardial excursion
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Global contractility
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Ejection fraction
Decrease in end-systolic volume
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Blunted in the setting of
advanced age
hypertension
beta-blocker therapy
Absence of the hypercontractile state in
response to stress should be considered an
abnormal response.
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In the presence of a coronary stenosis, the
increase in myocardial oxygen demand that
occurs in response to stress is not matched by
an appropriate increase in supply.
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If the supply-demand mismatch persists, a
complex sequence of events known as the
ischemic cascade develops.
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After the development of a regional perfusion
defect, a wall motion abnormality will occur,
characterized echocardiographically as a
reduction in systolic thickening and
endocardial excursion.
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The severity of the wall motion abnormality
(hypokinesis versus dyskinesis) will depend on
several factors like
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Magnitude of the blood flow change
Spatial extent of the defect
The presence of collateral blood flow
Duration of ischemia.
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Deterioration in regional wall motion,is a
specific and predictable marker of regional
ischemia
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Once the stressor is eliminated, myocardial
oxygen demand decreases and ischemia
resolves.
Normalization of wall motion may occur
rapidly, although typically the complete
recovery of normal function takes 1 to 2
minutes-depends on the severity and
duration of ischemia.
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Stunned myocardium is the term applied
when functional abnormalities persist after
transient ischemia for a longer period.
Although a reversible process, stunning may
last days or even weeks if the ischemia is
severe and prolonged.
Wall Motion Abnormalities at Rest
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Myocardial Infarction
Cardiomyopathy
Myocarditis
Hibernating myocardium
Stunned myocardium
Postoperative state
Left bundle branch block
Hypertension
Right ventricular volume/pressure overload
Wall Motion Abnormalities during Stress
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Ischemia
Rate-dependent bundle branch block
Dobutamine is a synthetic catecholamine that causes
both inotropic and chronotropic effects through its
affinity for β1, β2, and α receptors in the myocardium
and vasculature.
 Because of differences in affinity, the cardiovascular
effects of dobutamine are dose dependent, with
augmented contractility occurring at lower doses
followed by a progressive chronotropic response at
increasing doses.
 Peripheral effects may result in either predominant
vasoconstriction or vasodilation, so changes in
vascular resistance (i.e., blood pressure) are
unpredictable.
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The net effect of these interactions is a
combined increase in contractility and heart
rate with an associated increase in
myocardial oxygen demand.
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If coronary flow reserve is limited,
myocardial oxygen demands will
eventually exceed supply and ischemia will
develop.
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The change in venous return that typically
accompanies leg exercise is less pronounced
with dobutamine.
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In addition, the autonomic nervous system
mediated changes in systemic and pulmonary
vascular resistance are different with
exercise compared with dobutamine
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Heart rate response is less important with
dobutamine compared with exercise, and ischemia
can often be induced even if target heart rate is not
attained.
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The lower heart rate achieved during dobutamine but
produces greater augmentation in contractility.
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Thus, the two modalities produce ischemia by
different mechanisms.
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As a result, the parameters that define an adequate
level of stress are also different.
Digital images are acquired at baseline (these loops are
displayed and used as reference throughout the infusion).
Continuous electrocardiogram and blood pressure
monitoring are established.
 Dobutamine infusion is begun at a dose of 5 (or 10)
µg/kg/min. The infusion rate is increased every 3 minutes to
doses of 10, 20, 30, and 40 µg/kg/min.
 The echocardiogram, electrocardiogram, and blood pressure
are monitored continuously. Low-dose images are acquired
at either 5 or 10 µg/kg/min (at the first sign of increased
contractility).
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Atropine 0.5 to 1.0 mg can be given during
the mid- and high-dose stages to augment
the heart rate response.
Mid-dose images are acquired at either 20 or
30 µg/kg/min. Peak images are acquired
before termination of the infusion.
Post-stress images are recorded after return
to baseline. The patient is monitored till
return to baseline status
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Exceeding target heart rate of 85% age-predicted
maximum
 Development of significant angina
 Recognition of a new wall motion abnormality
 A decrease in systolic blood pressure >20 mm Hg
from baseline
 Arrhythmias such as atrial fibrillation or
nonsustained ventricular tachycardia
 Limiting side effects or symptoms
Because of the short half-life of dobutamine, inducible ischemia can be
readily reversed through termination of the infusion.
In severe cases or when the ischemic manifestations persist, a short-acting
intravenous beta-blocker (such as metoprolol or esmolol) is effective.
Symptoms
palpitations
anxiety.
Arrhythmias seen include:
premature ventricular contractions
atrial arrhythmias
Nonsustained ventricular tachycardia (3% )of patients
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In one series of 1,118 patients referred for
dobutamine stress echocardiography, there
were no incidents of death, myocardial
infarction, or sustained ventricular
tachycardia or fibrillation (Mertes et al.,
1993).
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No absolute contraindications to dobutamine stress testing.
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Dobutamine echocardiography has been safely performed
in patients with recent myocardial infarction, extensive left
ventricular dysfunction, abdominal aortic aneurysm,
syncope, aortic stenosis, hypertrophic cardiomyopathy,
history of ventricular tachycardia, and aborted sudden
death.
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Safe in patients with bronchospastic lung disease.
Unlike dobutamine, Adenosine works by creating a
maldistribution phenomenon by preventing the
normal increase in flow in areas supplied by stenotic
coronary arteries.
 In more extreme cases, flow may actually be
diverted away from abnormal regions (so-called
coronary steal), resulting in true ischemia.
 Adenosine is a potent and short-acting direct
coronary vasodilator. Dipyridamole is slower acting
and its effects result from inhibition of adenosine
uptake.
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The development of a wall motion
abnormality is predicated on the ability to
create sufficient maldistribution of regional
blood flow to result in an ischemia-induced
wall motion abnormality.
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Compared with dobutamine, these changes
are more subtle and short-lived
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Redistribution of regional blood flow can occur
without an associated wall motion abnormality.
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Vasodilator stress agents may be better suited
to imaging techniques that rely on relative
changes in perfusion rather than the
development of a wall motion abnormality.
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Dipyridamole and adenosine have been
commonly used with nuclear imaging
techniques
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Analyzed based on a subjective assessment of regional wall
motion, comparing wall thickening and endocardial excursion
at baseline and during stress.
The rest or baseline echocardiogram is first examined for the
presence of global systolic dysfunction or regional wall
motion abnormalities .
Subtle abnormalities at baseline, such as hypokinesis of the
inferior wall, may occur in the absence of coronary artery
disease and represent a cause of false-positive results.
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Limitation of interpretation is the subjective and
nonquantitative nature of wall motion analysis.
Calculation of the ejection fraction at rest and during stress, is
technical challenging and rarely performed in routine
practice.
A more practical approach involves the estimation of left
ventricular volume changes during stress.
The normal response to stress includes a decrease in both endsystolic and end-diastolic volume that can be visually
appreciated using side-by-side inspection of images.
Failure of the end-systolic size to decrease is an abnormal
response. An increase in volume with stress often indicates
severe and extensive (i.e., multivessel) disease.
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Relies on tissue Doppler imaging to quantify
myocardial deformation in response to applied
stress.
Strain is the change in length of a segment of tissue
that occurs when force is applied.
Strain rate is how strain changes over time.
When assessed using the Doppler technique, strain
rate can be measured as the difference in velocity
between two points normalized for the distance
between them.
Strain and strain rate have been examined as
objective, quantifiable markers of ischemia during
stress testing.
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One approach involves determining the
myocardial velocity gradient, which is the
difference between the systolic velocities of
the endocardium versus the epicardium
(normalized for wall thickness).
Normally, the endocardium has a higher
velocity than the epicardium, and this
difference is frequently diminished with
ischemia
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One approach (endorsed by the American Society
of Echocardiography) divides the left ventricle into
16 segments and then grades each segment on a
scale from 1 to 4 in which
1 normal,
2 hypokinesis,
3 akinesis,
4 dyskinesis.
Wall motion is analyzed at baseline, and a wall
motion score index is generated according to the
formula
Hypokinesis is the mildest form of abnormal wall
motion.
 It is defined as the preservation of thickening and
inward motion of the endocardium during systole but
less than normal.
 It has been defined arbitrarily as less than 5 mm of
endocardial excursion
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Hypokinesis is most likely to be truly abnormal if it is
limited to a region or territory that corresponds to
the distribution of one coronary artery and is
associated with normal (or hyperdynamic) wall
motion elsewhere.
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Tardokinesis – a form of hypokinesis.
delayed, sometimes postsystolic, inward motion or
thickening.
Akinesis is defined as the absence of systolic
myocardial thickening and endocardial excursion.
 Dyskinesis is the most extreme form of a wall
motion abnormality and is defined as systolic
thinning and outward motion or bulging of the
myocardium during systole.
 A left ventricular segment that is thin and/or highly
echogenic indicates the presence of scar.
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Segments that are abnormal at rest and remain
unchanged with stress are generally best interpreted as
showing evidence of infarction without additional
ischemia.
Hypokinetic areas that worsen during stress are usually
labeled ischemic. These may represent a combination of
previous nontransmural infarction and induced
ischemia.
Segments that are akinetic or dyskinetic at baseline,
even if wall motion worsens during stress, are best
interpreted as indicating infarction, and the ability to
detect additional ischemia in such segments is limited.
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An abnormal exercise echocardiogram generally
identifies patients at increased risk of cardiac
events.
The echocardiographic findings that have been
correlated with risk include a new wall motion
abnormality, rest and exercise wall motion score
index, and end-systolic volume response.
In most series, echocardiographic evidence of
ischemia was the most potent marker of highrisk status and has consistently been a better
discriminator than other variables, such as
exercise-induced ST-segment depression
Most series applying stress echocardiography to the patient
before noncardiac surgery have used dobutamine stress. The
majority of patients in the published literature were evaluated
before major peripheral vascular surgery and therefore included
patients who frequently are unable to exercise.
 In this high-risk subset, dobutamine stress echocardiography has
consistently demonstrated value and the presence or absence of
an inducible wall motion abnormality has been the most potent
determinant of relative risk.
 The absence of an inducible wall motion abnormality confers a
very favorable prognosis, with a negative predictive value of 93%
to 100%.
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Meta-analysis examining the value of dipyridamole thallium
and dobutamine echocardiography before vascular surgery
(Shaw et al., 1996), the presence of an inducible wall motion
abnormality on echocardiography provided the greatest
ability to discriminate between high- and low-risk status
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The limitations of the stress ECG in this population have led
some investigators to recommend an imaging stress test in
most if not all circumstances.
Several series have examined the role of both exercise and
dobutamine stress echocardiography in this large patient
subset.
The majority of these studies have demonstrated that wall
motion analysis increases both the sensitivity and the
specificity of the test.
Most series report a sensitivity of 80% to 90% and a
specificity of 85% to 90%.
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The term viable is commonly used to refer to
myocardium that has the potential for functional
recovery
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Refers to either stunned or hibernating myocardium
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The use of dobutamine echocardiography is based
on the observation that viable myocardium will
augment in response to adrenergic stimulation,
whereas nonviable myocardium will not.
The biphasic response, augmentation at low dose followed
by deterioration at higher doses, is most predictive of the
capacity for functional recovery after revascularization.
 Dobutamine echocardiography has been tested in two
clinical scenarios.
 In most series, sensitivity (for predicting functional recovery)
has ranged from 80% to 85% with slightly higher specificity
(85%-90%).
 Amount of myocardium identified as viable correlates fairly
well with the degree of improvement in global function after
revascularization and with long-term outcome.
 When compared with nuclear techniques, dobutamine
echocardiography provides generally concordant results
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Nuclear techniques will identify significantly more segments
(and patients) as viable.
 In most series, sensitivity favors nuclear methods, but
dobutamine echocardiography is consistently more specific.
Thus, all the methods appear to provide a similar positive
predictive value. That is, evidence of viability by any of the
techniques is predictive of the potential for functional
recovery after revascularization.
 However, the negative predictive value varies widely among
the different modalities.
 In many series, dobutamine echocardiography is favored.
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The presence of viability identifies patients in whom
revascularization is associated with a significant survival
advantage compared with medical management (Fig. 16.41).
 Absence of viability is associated with no significant outcome
advantage, whether medical or surgical therapy is implemented.
These results were confirmed in a meta-analysis that included
more than 3,000 patients studied with either echocardiographic or
nuclear methods (Allman et al., 2002).
 Among patients with viability, surgical revascularization improved
prognosis compared with medical therapy. In patients without
viability, outcome was similar regardless of treatment .
 This is in contrast to the results of a multicenter registry in which
medically treated patients with viability had a better prognosis
than patients without viability (Picano et al., 1998).
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The application of contrast echocardiographic
techniques to stress testing falls into two distinct
categories: left ventricular opacification for border
enhancement and myocardial perfusion imaging.
 The concept of using an intravenous contrast agent
to improve left ventricular border detection is
predicated on its ability to cross the pulmonary
circuit and provide sufficient left-sided chamber
opacification
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By improving endocardial border detection, the accuracy
with which systolic function and wall motion analysis can be
ascertained is increased.
Studies have confirmed, in properly selected patients, that
the use of contrast for left ventricular opacification improves
the reproducibility and accuracy of wall motion analysis
A perfusion defect must precede the development of a wall
motion abnormality so a method to assess myocardial perfusion
should increase the sensitivity of the test to detect ischemia.
 After intravenous injection, the distribution of the contrast agent
parallels blood flow and can be visualized (the contrast effect) as it
traverses the microvasculature of the tissue, generating a timeintensity curve.
 Thus, perfusion can be assessed as a relative change (rest versus
stress), a regional difference (e.g., lateral wall versus septum), or
more quantitatively based on changes in the rate of flow or blood
volume.
 An echocardiographic test that combines wall motion assessment
with the simultaneous ability to evaluate perfusion changes in
response to stress would have considerable utility
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Stress Echocardiography in
Valvular Heart Disease
Exercise testing clearly has no role, and is
contraindicated in patients with definite cardiac
symptoms or symptoms that are highly
suspicious
 some patients,may ignore or not report mild
dyspnea and fatigue, which are difficult to
differentiate from the effects of aging or
deconditioning.
 The principal role of exercise testing is to
unmask symptoms or abnormal blood pressure
responses in patients withAS who claim to be
asymptomatic.
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Patients with anatomically severe AS and LV systolic
dysfunction (ejection fraction <40%) often present
with a relatively low-pressure gradient, such as a
mean gradient of 30 to 40 mm Hg or less.
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Difficult to differentiate them from a primary
cardiomyopathic process and a thickened but
nonstenotic aortic valve producing an outflow
murmur-pseudosevere AS
In true severe AS, the small and relatively fixed AVA
contributes to an increase in afterload, a decrease in ejection
fraction, and a reduction stroke volume.
 In pseudosevere AS, the predominant factor is myocardial
disease, and the severity of AS is overestimated on the basis
of AVA because there is incomplete opening of the valve
caused by reduction in the opening force generated by the
weakened ventricle.
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In both situations, the low-flow state and lowpressure gradient contribute to a calculated
AVA that meets criteria for severeAS at rest
(1.0 cm2)
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The resting echocardiogram does not
distinguish between these 2 situations
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Distinction is essential because patients with
true severe AS and poor LV function will
generally benefit significantly from AVR.
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Patients with pseudosevere AS will not and
may also have a higher risk of perioperative
mortality.
The results of dobutamine stress echocardiography
aid in decision making in patients with low-flow aortic
stenosis (AS) when dobutamine elicits contractile
reserve. Management decisions are more difficult
when contractile reserve is absent.
 Contractile reserve is defined as an increase in stroke
volume (SV) 20% using the criteria of Nishimura et al.
and Monin et al.
 When contractile reserve is elicited, patients with true
severe AS manifest an increase in transvalvular
pressure gradient (P) with a low calculated aortic
valve area (AVA).
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The main objective of dobutamine stress
echocardiography in the context of low-flow
AS is to increase the transvalvular flow rate
while not inducing myocardial ischemia.
Side effects are not infrequent with full-dose
dobutamine in unselected patients with
normal or moderately reduced LV ejection
fraction and can occur in up to 20% of
patients with low-flow, low-gradientAS
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The dobutamine stress approach is based on the concept that
patients who have pseudosevere AS will show an increase in the
AVA and little change in the transvalvular gradient in response to
the increase in transvalvular flow rate
The changes in gradient and AVA during dobutamine stress
depend largely on the magnitude of the flow augmentation
achieved, which may vary considerably from one patient to
another.
 Therefore, the AVA and gradient are measured at flow conditions
that may differ dramatically from one patient to another, and the
use of these indexes, which are not normalized with respect to the
flow increase, may lead to misclassification of stenosis severity in
some patients.
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To overcome this limitation, the investigators of the TOPAS
(Truly or Pseudo Severe Aortic Stenosis) multicenter study
(30) have proposed a new echocardiographic parameter: the
projected AVA at a standardized normal flow rate.A
projected AVA 1.0 cm2 is considered an indicator of true
severe stenosis.
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Patients identified as having true severe AS and functional
reserve, defined as the ability to increase stroke volume with
dobutamine by 20% or more (25), have a much better
outcome with AVR than with medical therapy (26,27).
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Patients with a lack of LV functional reserve have been
shown to have a poor prognosis with either medical or
surgical management (25), but as a group they may also
benefit from AVR (27,31).
25. Monin JL, Monchi M, Gest V, Duval-Moulin AM, Dubois-Rande JL, Gueret P. Aortic stenosis with severe
left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low dose
dobutamine echocardiography J Am Coll Cardiol 2001;37:2101-2107
26. Monin JL, Quere JP, Monchi M, et al. Low-gradient aortic stenosis: operative risk stratification and
predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics
Circulation 2003;108:319-324.[
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Once true severe AS has been documented, AVR might be
reasonable even in the absence of LV functional reserve,
although decisions in these high-risk patients must be
individualized in the absence of clear guidelines
The other potential role of dobutamine stress
echocardiography in patients with AS and impaired LV
function is the detection of underlying CAD, because
infarcted or hibernating myocardium may be responsible in
large part for the contractile dysfunction in many patients. In
such patients, revascularization has the potential to improve
LV function and clinical outcomes (32,33). However, this
situation can represent a diagnostic challenge in patients
with AS because multivessel CAD may induce global LV
dysfunction, and conversely, regional wall motion
abnormalities may occur in the absence of CAD (34).
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lack of contractile reserve on dobutamine stress echocardiography
may also be related to LV afterload mismatch, independent of the
presence of CAD.These factors may explain why an important
proportion of patients with no contractile reserve nonetheless
show an improvement in LV ejection fraction after aortic valve
replacement with or without revascularization (27). The specificity
of stress-induced ST-segment changes and reversible perfusion
abnormalities for predicting epicardial coronary artery stenosis is
very low in patients with AS because alterations in coronary flow
reserve linked to LV hypertrophy and microvascular disease may
be present independent of CAD at the epicardial level (35). Thus, in
these complex patients coronary angiography (invasive or
noninvasive) remains the diagnostic standard.
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As with patients with AS, exercise testing may elicit
symptomatic responses in patients with AR who are
apparently asymptomatic based on the medical history, thus
identifying candidates for surgery. In addition, pre-operative
exercise capacity in patients with AR and LV systolic
dysfunction, together with duration of pre-operative LV
dysfunction, is helpful in predicting survival and recovery of
function after AVR
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The observed magnitude of change in ejection fraction or
stroke volume from rest to exercise is related not only to
myocardial contractile function but also to severity of
volume-overload and exercise-induced changes in preload and peripheral resistance (1). The validity of stress
echocardiography in predicting outcome of patients with
asymptomatic AR is limited by the small number of
available studies (39,40) compared with the more
extensive and consistent experience with exercise
radionuclide angiography (41–44). With the sparse data
supporting the incremental prognostic value of stress
echocardiography, this specific application is not
recommended for routine clinical use (1).
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In asymptomatic patients with severe MS (mean gradient
>10 mm Hg and mitral valve area [MVA] <1.0 cm2), or
symptomatic patients with moderate MS (mean gradient of
5 to 10 mm Hg and MVA of 1.0 to 1.5 cm2), the measurement
of pulmonary artery pressures (measured from the tricuspid
regurgitant velocity) during exercise or dobutamine stress
echocardiography can help distinguish those who could
benefit from valvuloplasty or valve replacement from those
who should be maintained on medical therapy
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Patients with reduced atrioventricular compliance show a more
pronounced increase in pulmonary arterial pressure during
exercise or dobutamine than those with normal compliance
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Hence, in some patients determined to have only moderate MS at
rest, the physiologic effects of heart rate sensitivity and
atrioventricular compliance can produce exercise-induced
pulmonary hypertension and exertional dyspnea.
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The resting values of transmitral gradient and pulmonary arterial
pressure do not necessarily reflect the actual severity of the
disease, stress echocardiography is useful for assesing the
severity of MS, assessing its hemodynamic impact, and explaining
exercise-induced symptoms.
The current ACC/AHA guidelines have given a Class I
recommendation (Level of Evidence: C) for stress
echocardiography in patients with MS and discordance
between symptoms and stenosis severity (1).
 The threshold values proposed by the ACC/AHA guidelines
(1) for consideration for intervention are a mean transmitral
pressure gradient >15 mm Hg during exercise or a peak
pulmonary artery systolic pressure >60 mm Hg during
exercise (Fig. 2).
 In patients with pulmonary artery pressures or valve
gradients above these values, percutaneous balloon
valvotomy or surgical intervention is recommended, even for
patients with apparently moderate MS at rest (1,7,9).
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Asymptomatic patients with severe MR, exercise stress
echocardiography may help identify patients with
unrecognized symptoms or subclinical latent LV dysfunction.
In symptomatic patients in whom the severity of MR is
estimated to be only mild at rest, exercise echocardiography
may be useful in elucidating the cause of symptoms by
determining whether the severity of MR increases or
pulmonary arterial hypertension develops during exercise
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worsening of MR severity, a marked increase in pulmonary
arterial pressure, impaired exercise capacity, and the
occurrence of symptoms during exercise echocardiography
can be useful findings for identifying a subset of apparently
asymptomatic patients at higher risk who may benefit from
early surgery.
A pulmonary artery systolic pressure >60 mm Hg during
exercise has been suggested as a threshold value above
which asymptomatic patients with severe MR might be
referred for surgical valve repair (1,8).
This application of stress echocardiography is rated as a Class
IIa recommendation .

Stress echocardiography -valuable in confirming or
excluding the presence of hemodynamically significant
prosthetic valve stenosis or PPM, especially when there is
discordance between the patient's symptomatic status and
the prosthetic valve hemodynamics measured at rest

In contrast to a normally functioning and well-matched
prosthesis (including a bileaflet mechanical valve with a
localized high gradient at rest), a stenotic prosthetic valve is
generally associated with a marked increase in gradient
with exercise
A disproportionate increase in transvalvular gradient (>20
mm Hg for aortic prostheses or >12 mm Hg for mitral
prostheses) generally indicates severe prosthesis dysfunction
or PPM
 High resting and stress gradients occur more often with
smaller (21 for aortic and 25 for mitral) rather than largersized prostheses, and mismatched rather than non
mismatched prostheses.

THANK
YOU……