Disclosures. Stress Echocardiography 2010 Appropriate Use & Further Applications. Stress Echo Clinical Utility 9/8/10

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Augustine Briggs
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1 2010 & Further Applications Disclosures None Geoffrey A. Rose, MD FACC FASE Director, Cardiac Ultrasound Laboratory Sanger Heart & Vascular Institute Clinical Utility and Event-free Survival Cortigiani, L. et al. J Am Coll Cardiol 1998;32: Fragasso et al. JACC 1999;34:441-7 and Cardiac Mortality and Cardiac Mortality Influence of WMSI Sicari, R. et al. J Am Coll Cardiol 2003;41: Yao, S.-S. et al. J Am Coll Cardiol 2003;42:

2 and Survival Influence of LVEF Clinical utility established Ability to predict survival Ability to risk stratify patients How to ensure appropriate use? Yao, S.-S. et al. J Am Coll Cardiol 2003;42:

3 : Uncertain Indications Inappropriate Indications 3

Inappropriate Indications Limitations Dependence on Image Quality - Improved by use of Contrast

64 year old man s/p CABG 4 years ago Vague chest wall chest pain while mowing lawn Minor ST-T

Images: Limited Quality Clinical Case 5:30 min standard Bruce protocol Normal HR/BP response to

4 Inappropriate Indications Limitations Dependence on Image Quality - Improved by use of Contrast Qualitative Image Assessment - High degree of interobserver variability Clinical Case Example 64 year old man s/p CABG 4 years ago Vague chest wall chest pain while mowing lawn Minor ST-T wave s on ECG (his baseline) No resting symptoms Added on mid-morning to office whil ing Images: Limited Quality Clinical Case 5:30 min standard Bruce protocol Normal HR/BP response to exercise Vague chest wall/left arm pain ECG w/o ischemic changes Images... Stress Images: Worse Quality 4

5 Baseline Stress Clinical Case What do we do now? Can t do nuclear today. Can do cath, but should we? CTA? Admit? Reassure? Consider contrast stress echo. Contrast Enhancement in Limitations of Conventional - Interpretation dependent on image quality 43% agreement amongst experts when evaluating lowest quality images - Nondiagnostic images in ~30% of pts Hoffman et al. JACC 1996; 27:330-6 Marwick et al. JACC 1992; 19:74-81 Contrast Enhancement in Factors influencing image quality Body habitus Respiration/excessive cardiac motion Lung disease Prior CABG LV Opacification (LVO) and Endocardial Border Definition (EBD) challenged Benefit of Contrast LVO and EBD Benefit of Contrast LVO and EBD Microbubble radius changes asymmetrically in response to symmetric change in acoustic pressure Reflected sound wave from microbubbles contains non-linear components Uniform Change Non-uniform response Results in higher harmonics, allowing differentiation from tissue Tissue behavior: Linear >> nonlinear components (at lower MI) Uniform Change Non-uniform response 5

Contrast Enhancement of LVO and EBD Low mechanical index (MI) imaging - Peak acoustic intensity / transmit frequency - MI < 0.

JACC 1994; 23:1440-3 Increased improvement the worse the baseline images - Improved visualization (both LVO + EBD) - Improved reader confidence - Accuracy?

than 24 hours apart, one with and one without contrast in random order - 92 pts underwent coronary angiography within 30 days Plana et al.

6 Contrast Enhancement of LVO and EBD Low mechanical index (MI) imaging - Peak acoustic intensity / transmit frequency - MI < 0.2 Allows detection w/o disruption of microbubbles Linear scatterers (tissue) canceled out Clinical Utility of Contrast in LVO and EBD - Porter et al. JACC 1994; 23: Increased improvement the worse the baseline images - Improved visualization (both LVO + EBD) - Improved reader confidence - Accuracy? Clinical Utility of Contrast in Utility of Echocontrast Visualization of Segments at Peak Stress OPTIMIZE Trial pts underwent 2 DSE studies no more than 24 hours apart, one with and one without contrast in random order - 92 pts underwent coronary angiography within 30 days Plana et al. JACC Img 2008;1: Plana et al. JACC Img 2008;1: ility of EchocontrastAccuracy at Peak S of EchocontrastVisualization of Segments a Plana et al. JACC Img 2008;1: Plana et al. JACC Img 2008;1:

Incremental Value of Contrast in Utility of Echocontrast Visualization of Segments at

of agent less reimbursement - Cost of other supplies/storage - Additional nurse and

- Reduction of further testing Dolan et al.

Utility of Echocontrast Visualization of Segments at Peak Stress Dolan et al.

7 Incremental Value of Contrast in Utility of Echocontrast Visualization of Segments at Peak Stress Value = Quality / Cost Cost Considerations (Direct; Negative Impact) - Cost of agent less reimbursement - Cost of other supplies/storage - Additional nurse and sonographer time - Physician review time Cost Considerations (Indirect; Positive benefit) - Reduction of further testing Dolan et al. JACC 2009;53:32-36 Utility of Echocontrast Visualization of Segments at Peak Stress Utility of Echocontrast Visualization of Segments at Peak Stress Dolan et al. JACC 2009;53:32-36 Dolan et al. JACC 2009;53:32-36 Utility of Echocontrast Visualization of Segments at Peak Stress Dolan et al. JACC 2009;53:32-36 Baseline Stress 7

Incremental Value of Contrast in Contrast stress echo vs.

JASE 2002; 15:1334-45 Incremental Value of Contrast in Role in Non-Ischemic Heart Disease ASE/ACC Appropriateness Guidelines - Use of

echocontrast w/ stress echo in physician office setting - C8929; C8930: use in hospital outpt setting Similar diagnostic accuracy ~30% reduction in

8 Incremental Value of Contrast in Contrast stress echo vs. Nuclear perfusion imaging Similar diagnostic accuracy ~30% reduction in costs over 3 months Baseline Stress Tardif et al. JASE 2002; 15: Incremental Value of Contrast in Role in Non-Ischemic Heart Disease ASE/ACC Appropriateness Guidelines - Use of echocardiographic contrast agents is recommended when 2 or more endocardial segments cannot be adequately visualized New Codes: : use of echocontrast w/ stress echo in physician office setting - C8929; C8930: use in hospital outpt setting Similar diagnostic accuracy ~30% reduction in costs over 3 months Valvular Heart Disease - Functional assessment in Aortic Stenosis - Assessment of RVSP in Mitral Regurgitation Cardiomyopathy - LVOT gradient HCM - Exercise MR in HCM - Pseudostenosis in AS/ LVEF Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy < 2 m/s 8

9 Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy > 4 m/s w/ Supine Bicycle Exercise w/ Supine Bicycle Exercise Hypertrophic Cardiomyopathy Ao Stenosis and Depressed LVEF Monin et al. JACC 2001 w/ Supine Bicycle Exercise Group I: Contractile Reserve Group II: No Contractile Reserve Pseudostenosis and Depressed LVEF Future Directions Baseline: EF 36% Mean Ao gradient: 21 mmhg LVOT VTI: 14 cm LVOT: 2.0 cm AVA: 0.9 sq cm 20 mcg/kg/min Dob >15% Role of real-time 3D in visual assessment of regional wall motion assessment Contrast perfusion imaging Quantification of regional wall motion Role of strain imaging? 9

10 9/8/10 Potential Role of Quantitative Echo 6 y.o. boy with Stress Kawasaki disease Aneurysm of RCA on 2D echo Occluded dominant RCA on angio with R Rcollateral flow Nonobstructive disease by angio elsewhere Inferior/Inferolat WMA Quantitative Quantitative Peak Peak Quantitative Peak 10

11 9/8/10 Quantitative Peak Quantitative Global 2D strain: -21% Peak Global 2D strain: -24% 11

ECHO HAWAII. Role of Stress Echo in Valvular Heart Disease. Not only ischemia! Cardiomyopathy. Prosthetic Valve. Diastolic Dysfunction

ECHO HAWAII. Role of Stress Echo in Valvular Heart Disease. Not only ischemia! Cardiomyopathy. Prosthetic Valve. Diastolic Dysfunction Role of Stress Echo in Valvular Heart Disease ECHO HAWAII January 15 19, 2018 Kenya Kusunose, MD, PhD, FASE Tokushima University Hospital Japan Not only ischemia! Cardiomyopathy Prosthetic Valve Diastolic