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1 Stress Echocardiography: Illustrative Cases Sunil Mankad, MD, FACC, FCCP, FASE Associate Professor of Medicine Mayo Clinic College of Medicine Director, Transesophageal Echocardiography Associate Director, Cardiology Fellowship Mayo Clinic, Rochester, MN
2 DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None
3 Dobutamine Echo and Prediction of LV Recovery % Sensitivity Specificity Biphasic Any improvement Qureshi: Circ, 2/4/97 DSE
4 Improvement Throughout Study with Dobutamine
5 Biphasic Response with Dobutamine
6 Cases 1. Soccer coach receives a red card 2. Let Lord Murphy Reign 3. Bigger is not always better 4. Very Tight 5. Two for the price of one 6. Go With the Flow
7 Case: 51 yo male, soccer coach New onset chest pain while biking No CV risk factors Referred for Exercise Echo 12 minutes on Bruce Protocol 118% FAC 13 METS Fatigue Positive ECG Flat BP response: 158/92 to 160/84 mmhg
8 Exercise Echo Rest Exercise 4ch LV LV 2ch
9 Exercise Echo Rest Exercise 5ch LV LV SA
10 What does the Exercise Echo show? 1. Normal 2. Inferior ischemia 3. Circumflex ischemia 4. LAD ischemia 5. Multivessel disease
11 Catheterization Post stent
12 Case: 67 yo male Referred for pre-op clearance for 7 cm Thoracic Aortic Aneurysm repair No cardiac hx (no CP, no dyspnea) HTN, hyperlipidemia, obesity, ex-smoker Sedentary lifestyle exercise involves getting up from sofa to get TV remote controller Referred for dobutamine stress echo
13 Dobutamine Stress Echo 4 Ch View Baseline 10 mcg/kg/min LV LV LV LV
14 Dobutamine Stress Echo 3 Ch View Baseline 10 mcg/kg/min LV LV LV LV
15 Dobutamine Stress Echo 2 Ch View
16 Dobutamine Stress Echo Short Axis View
17 What does the DSE show? 1. Normal 2. Inferior, Inferolateral Ischemia 3. Anterior ischemia 4. Apical ischemia
18 Cx Cath
19 67 yo male pre-op for TAA repair Multivessel CAD, diffuse disease Medical Rx TAA repair 28-mm woven Hemashield graft Rocky post-op course; delayed extubation, afib, elevated troponin, worsening of inferolateral RWMA on echo d/c d after 16 day hospitalization 1 yr later: dx d with metastatic stomach CA Hospice
20 70 year old male with dyspnea on exertion PMH DM HTN Hyperlipidemia Referred for exercise echo
21 Exercise Echocardiogram 5ch Rest Rest 4ch 5ch Immediately Postexercise Stress 4ch SA 2ch SA 2ch
22 What does the DSE show? 1. Normal 2. RCA ischemia 3. Circumflex ischemia 4. Mutlivessel ischemia
23 Exercise Echocardiogram 5ch Rest Rest 4ch 5ch Immediately Postexercise Stress 4ch SA 2ch SA 2ch LVEF: 60 to 50% LV size: Dilatation
24 High grade stenosis of the left anterior descending and 1st diagonal coronary arteries
25 40 Year Old Executive Male Heartburn and eructation with exertion HTN Hyperlipidemia Smoker Referred for exercise echo 6 minutes on Bruce Protocol heartburn and positive EKG changes
26 Exercise Echocardiogram LV LV
27 Exercise Echocardiogram
28 What does the DSE show? 1. Normal 2. RCA ischemia 3. Circumflex ischemia 4. LAD ischemia
29 Cath
30 Cath: Post Stenting
31 64 yo male, engineer from Bagdad with chest pain Hx PTCA, DES to D1 and LAD ASA, Plavix, Cardiac rehab Returns 1 yr later; asymptomatic, but sedentary, wants ex echo? Medication compliance
32 64 yo male, engineer, Hx stent to D1/LAD
33 64 yo male, engineer with chest pain
34 What does the DSE show? 1. Normal 2. RCA ischemia 3. Circumflex ischemia 4. LAD/D1 ischemia 5. Non-diagnostic study
35 What does the cath show?
36 Case 70 year old male PMH: Anteroapical MI, CABG after MI ICD placed: NSVT, EF 30% Asymptomatic for 5 years Now presents with CHF, NYHA class III Physical Exam: Grade 3/6 late peaking SEM Diminished carotid upstroke Single component S2
37 2D Echo: Severe LV Dysfunction EF: 20%
38 Aortic Valve Parasternal Long-Axis Parasternal Short-Axis
39 Aortic Valve Gradient Pk Gr = 27 mmhg Mn Gr = 14 mmhg AVA = 0.8 cm2
40 Coronary Angiogram Patent LIMA Patent SVG to OM1 Occluded LAD 90% proximal Left Circumflex stenosis No significant disease in RCA Viability Study: Apical scar, all other areas viable
41 Question What would you do next? A. Aortic valvuloplasty B. Refer to CT Surgery for AVR C. Dobutamine stress study D. Prayer
42 Dobutamine in Low Gradient- Low EF Aortic Stenosis True severe AS SV, transvalvular gradient; No change in calculated AVA remains in severe range Pseudo severe AS SV and AVA; No significant transvalvular gradient
43 Baseline Pseudo Aortic Stenosis Dobutamine AVA 0.8 cm cm 2 Stroke volume TVI 8 cm TVI 16 cm cc Mean gradient TVI 42 cm Dimensionless Index = 0.19 TVI 51 cm Dimensionless Index = mmhg Eleid M, Mankad S et al. Heart Fail Rev. 2012
44 True Low Gradient/Low EF Aortic Stenosis Baseline Dobutamine Stroke volume cc Frederick-04-still.jpg Mean gradient mmhg Dimensionless Index = 0.22 Dimensionless Index = 0.23 AVA = 0.7 cm 2 Eleid M, Mankad S et al. Heart Fail Rev. 2012
45 Yes 15 patients 21 pt AVR Contractile reserve Increase in SV >20% Periop mortality 7% 12 survive Class I-II 2 late deaths Non-cardiac
46 Yes 15 patients 21 pt AVR Contractile reserve No 6 patients In pt with LV systolic dysfunction and AS with a Periop low output and a low MG, dobutamine Periop mortality challenge 7% may aid in selecting mortality those 33% who would benefit from an AV operation. 2 late deaths 2 late deaths Circulation Non-cardiac 2002; 106: CHF 12 survive Class I-II 2 survive Class I-II Nishimura: Circulation, 2002
47 Low Gradient Aortic Stenosis Monin et al - Circulation 2003; 108: AS pt - AVA 0.7, MG 29 mmhg LV contractile reserve assessed by DSE Present in 92 (Group I) Absent in 44 (Group II)
48 Kaplan-Meier Survival Estimates by Group and Treatment Operative Mortality 5% Group I Valve replacement Pt survival (%) Operative Mortality 32% Group II Valve replacement Group I Medical treatment Group II Medical treatment Follow-up (mo)
49 Case: Results of Dobutamine Stress Echo V1 TVI (cm) V2 TVI (cm) AVA (cm2) Baseline /14 5 mcg/kg/min dobutamine 10 mcg/kg/min dobutamine 20 mcg/kg/min dobutamine / / /17 Peak/Mean AV Gradient (mmhg) * No significant change in EF during study
50 Change in LVEF after AVR Severe AS with low EF Contractile Reserve No Contractile Reserve % Before AVR After AVR Quere, J.-P. et al. Circulation 2006;113:
51 Influence of Contractile Reserve in Low-gradient AS Absence of CR related to operative mortality, but it does not predict the absence of LVEF recovery in pt surviving AVR These data further support the concept that surgery should not be contraindicated on the basis of absence of CR alone Quere, J.-P. et al. Circulation 2006;113:
52 Take Home Points Dobutamine stress testing is helpful in low gradient-low EF AS Importance of contractile reserve True AS vs Pseudo AS Absence of contractile reserve substantially increases operative mortality with AVR in low EF-low gradient AS But if patients survive, EF improves and outcome good
53 Thank You! Acknowledgements: Dr. Sharon Mulvagh
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