Dobutamine Stress testing In Low Flow, Low EF, Low Gradient Aortic Stenosis Case Studies
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1 Dobutamine Stress testing In Low Flow, Low EF, Low Gradient Aortic Stenosis Case Studies Mitral Regurgitation The New ASE Guidelines: Role of 2D/3D and CMR William A. Zoghbi MD, FASE, MACC Professor and Chairman, Department of Cardiology Elkins Family Distinguished Chair in Cardiac Health Houston Methodist Hospital Flow dependence of Velocity, Gradients, & Valve Motion/Orifice 1
2 Aortic Stenosis AHA & ACC Guidelines Indicator Mild Moderate Severe Jet velocity < 3.0 m/s > 4.0 m/s Mean gradient < 25 mmhg > 40 mmhg Valve area > 1.5 cm < 1.0 cm 2 In Normal or High flow Conditions (SV > 35 ml/m 2 ) Nishimura R. et al. JACC 2014 Low Flow, Low EF, Severe AS Is It? LVOT TVI 16 cm SV 45 ml V 2.7 m/s Mean Gr 30 mmhg AVA 0.7 cm2 2
3 Dobutamine Stress ECHO Protocol in Low Flow, Low EF, Severe AS Baumgartner H, et al. Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr Apr;30(4): Dobutamine Stress ECHO Protocol 3 types of responses SV & LVEF Gradient AVA Implication Severe AS AS not severe Severe CM /?Severe AS 3
4 Case 1 Clinical Presentation 87 yo male with CAD s/p CABG, aortic stenosis, systolic HF EF 30-35%, HTN, DM, CKD III, TIA, paroxysmal AF presents with dyspnea and decompensated HF, NYHA III Exam: 124/59, HR 63, BMI 23 kg/m2 CV: RRR, +S3, II/VI SEM LSB Echocardiogram Parasternal Short Axis Aortic Valve LVOT 1.9 cm Vitals: BP 112/56 mmhg, HR 71 bpm 4
5 Dobutamine Stress ECHO Parasternal Apical 4 Chamber Dobutamine Stress ECHO 2 Chamber Short Axis LVEF 30-34% LVEF 35-39% 5
6 Doppler LVOT TVI 16 cm LVOT SV 45 ml LVOT TVI 23 cm LVOT SV 66 ml 2.7 m/s Mean 30 mmhg AVA 0.7 cm2 Consistent with low-flow low-gradient severe aortic stenosis 4 m/s Mean 43 mmhg AVA 0.8 cm2 Case 2 Clinical Presentation 86 yo M with CAD s/p CABG, aortic stenosis, systolic HF EF 25% s/p CRT-D, COPD presents with dyspnea, NYHA IV Exam: 108/51, HR 79, 3L O2 93%, BMI 21 kg/m2 CV: RRR, II/VI systolic murmur RUSB, +JVD (12 cm), decreased breath sounds, 1+ edema 6
7 Echocardiogram Parasternal Short Axis Aortic Valve LVOT 2.2 cm Vitals: BP 100/53 mmhg, HR 85 bpm Dobutamine Stress ECHO Parasternal Apical 4 Chamber 7
8 Dobutamine Stress ECHO 2 Chamber Short Axis LVEF 25-29% LVEF 30-34% Doppler LVOT TVI 12 cm LVOT SV 44 ml Dobutamine LVOT TVI 20 cm LVOT SV 76 ml 2.7 m/s Mean 16 mmhg AVA 0.9 cm2 Consistent with pseudo-severe aortic stenosis Mild aortic stenosis 3 m/s Mean 23 mmhg AVA 1.4 cm2 8
9 Case 3 Clinical Presentation 78 yo M with CAD, aortic stenosis, systolic HF EF 40%, COPD, CKD presents with dyspnea, NYHA III Exam: 127/51, HR 70, BMI 21 kg/m2 CV: RRR, II/VI systolic murmur RUSB, +wheezing, 2+ edema, +JVD Echocardiogram Parasternal Short Axis Aortic Valve LVOT 2 cm Vitals: BP 166/71 mmhg, HR 59 bpm 9
10 Dobutamine Stress ECHO Parasternal Apical 4 Chamber Dobutamine Stress ECHO 2 Chamber Short Axis LVEF 40-44% LVEF 50-54% 10
11 Doppler LVOT TVI 17 cm, LVOT SV 54 ml Dobutamine LVOT TVI 23 cm, LVOT SV 73 ml Consistent with moderate aortic stenosis 3.2 m/s Mean 21 mmhg AVA 0.8 cm2 3.8 m/s Mean 27 mmhg AVA 1 cm2 75M with AS & NYHA Class III Heart Failure Is DSE Needed? VTI=12.8cm SV = 40 ml Mn Gr = 46 mmhg AVA = 0.40cm 2 VTI=100cm 4m/s 11
12 Case 72 yr old man with NYHA class III heart failure Systolic ejection murmur The aortic valve was calcified LV dilated with an EF of 20%. 72M With Class III Heart Failure D=2.0 EF = 20% VTI=10.3 V = 2.2m/s Mean Grad = 11mmHg SV = 32 ml AVA = 32/47 = 0.69cm VTI=47 12
13 72M With Class III Heart Failure Dobutamine infusion at 20mcg/kg/min Pulsed Doppler- LVO CW Aortic Valve TVI = m/s Dobutamine V = 2.2m/s Mean Grad = 11mmHg SV = 32 ml AVA = 32/47 = 0.69cm 2 V = 2.8 m/s Mean Grad = 14 mmhg SV = 35 ml AVA = 35/52 = 0.69cm 2 13
14 Dobutamine Echo in AS with Depressed LVEF & Low Gradient 3 types of responses SV & LVEF Gradient AVA Implication Severe AS AS not severe Severe CM /?Severe AS Low Flow, Low EF, Low Gradient Severe AS Low Flow Low Gradient Severe AS MG < 40 mmhg, AVA < 1 cm 2, LVEF < 50%, SV < 35ml/m 2 Low Dose Dobutamine Stress Echo MGr 40 mmhg MGr < 40 mmhg & AVA 1 cm 2 MGr < 40 mmhg & AVA > 1 cm 2 True Severe AS Assess Δ in flow/gr/ava Is SV still reduced? How close to cutoff of Severe AS? Contour of AS Jet Ca Score of AV (1200 W, 2000 M) Pseudo Severe AS 14
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