Stress Echocardiography in VHD: is myocardial contrac8on a reliable marker for ischemia?
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1 Stress Echocardiography in VHD: is myocardial contrac8on a reliable marker for ischemia? Rosa Sicari CNR, Ins8tute of Clinical Physiology, Pisa, Italy Milano 8 maggio 2012
2 Stress Echo and Cardiac death 1,0 Cardiac mortality (%),9,8 92% DET - P = % DET+, Follow-up (months) Sicari et al. JACC 2003
3 Stress Echo and Extent of Ischemia Delta WMSI < % 81.4 % DET 92% - DET - Delta WMSI > % P< P P = = % 71.2% DET + DET+ Sicari et al. JACC 2003
4 Ischemia vs. Anatomy Sicari et al. JACC 2003
5 Prognostic value of stress echocardiography 50 6,214 Hypertensives Known CAD 50 5,328 Normotensives Suspected CAD Events % Events % Subjects at risk Follow-up (years) Follow-up (years) SE (+) RWMA (+) SE (+) RWMA (-) SE (-) RWMA (+) SE (-) RWMA (-) Cortigiani L and Sicari R Eur Heart J 2011
6
7 Myocardial Ischemia The direct observa8on of a developing systolic dysfunc8on combined with a post- systolic shortening indicates acute myocardial ischemia. However, the lack of clinical trials does not allow recommending specific parameters for differen8a8ng various states of acute and chronic ischemia when baseline data are not available
8 School of Athens in the stress echo lab Contrac8lity Systolic thickening: quick and dirty Pressure Volume loops: Beau0ful and impossible Regional wall func8on
9 Stress echo lab: contrac8lity me too? Peak systolic pressure = cuff sphygmomanometer (r=.92) Slutsky R et al. Peak systolic blood pressure/end- systolic volume ra8o: assessment at rest and during exercise Am J Cardiol, : 813 Force = SP/ESVIndex Suga H, Sagawa K, Shoukas AA. Load independence of the instantaneous pressure- volume ra8o of the canine let ventricle and effects of epinephrine and heart rate on the ra8o. Circ Res, 1973 Mar;32:314
10 Contrac8lity in stress echo lab: simplify for success Systolic Blood Pressure + 1/ End - systolic volume = Contrac0lity SP + ESV = Contrac8lity SP + = ESV = Contrac8lity =/ SP + /= ESV = Contrac8lity
11 Time sequence during stress upsloping ESP/ESVI biphasic flat Cri8cal heart rate HR Cri8cal heart rate is the heart rate beyond which ESP/ESVI declines by 5%. Inagaki et al. Circula8on 1999 Mulieri AL in Heart Metabolism in Failure RA Howart Ed. 1997
12 Subepicardial flow : beyond regional wall mo0on Gallagher KP, Ross J Jr et al. Am J Physiol 1084 Lower LV volumes for any given pressure increase (Sabbah, Marzilli. Am J Physiol 1981) Possible an0- arrhythmic and an0- remodeling effect of subepicardium (Kaul S. Circula0on 1995)
13 Inotropic reserve in the stress echo lab EXERCISE DOBUTAMINE PACEMAKER Contrac=lity Inotropic reserve Bowditch treppe User- friendly Requisites Capability to exercise Intravenous line Permanent pacemaker JASE 2003 EHJ 2005 Eur J Heart Failure 2004
14 Force- Frequency Rela8onship (nega8ve normal) HF = 80 bmp HF = 115 bmp HF = 130 bmp HF = 140 bmp ESV = 30 ml ESV = 25 ml ESV = 23 ml ESV = 16 ml SBP = 140 mmhg SBP = 170 mmhg SBP = 190 mmhg SBP = 210 mmhg SBP/ESV = 4.6 SBP/ESV = 6.8 SBP/ESV = 8.2 SBP/ESV = Delta SBP/ESV = 13 / 4.6 = 2.8
15 Force- Frequency Rela8onship (nega8ve abnormal) HF = 60 bmp HF = 80 bmp HF = 100 bmp HF = 120 bmp ESV = 120 ml ESV = 100 ml ESV = 81 ml ESV = 95 ml SBP = 110 mmhg SBP = 120 mmhg SBP = 130 mmhg SBP = 140 mmhg SBP/ESV = 0.9 SBP/ESV = 1.2 SBP/ESV = 1.6 SBP/ESV = Delta SBP/ESV = 1.5 / 0.9 = 1.6
16 Contractility and Prognosis in Negative Stress Testing Bombardini T et al. Int J Cardiol, 2007
17 Chronic Mitral Insufficiency: the role of LV func8on Predictors of LV dysfunc8on Indexed End- Systolic Volume during exercise > 25 ml/m2 Ejec8on Frac8on <68% Increment of EF <4% during exercise Leung DY et al JACC 1996
18 Exercise Echocardiography predicts LV dysfunc8on in asymptoma8c AR Medically treated Valve Replacement Marwick T et al. Heart 2000
19 Probability of Survival in Low Flow/Low Gradient Aor8c Stenosis Pa8ents Without CR on DSE Tribouilloy et al. JACC 2009
20 Coronary flow reserve improves ater aor8c valve replacement for aor8c stenosis Hildick-Smith D et al. JACC 2000
21 Heart Valve Disease and CFR Pre-AVR 6 months post-avr REST PEAK CFR = 67 / 34 = 1.9 CFR = 94 / 33 = 2.9
22 Eligible ADONHERS CANDIDATE DONORS Normal baseline echo PARAMETERS: HR (ECG) BP (cuff sphygmo) WMSI SP/ESV ratio Donor excluded CAD positivity (new wall motion abnormality of 1 segment) Abnormal contractile reserve (Peak SP / ESV < than baseline) Donor excluded WMSI stress = 1 SP / ESV stress > than baseline Eligible for donor
23 Nega8ve stress: Wolf in Sheep clothes? RISK Not- so- low Very low Dose/Load Submaximal Maximal Diabetes + - Therapy + - Mitral Insufficiency + - Ultrasound Lung Comets + - Coro Flow Reserve <2 >2 Force- Frequency Rela0onship Flat- Biphasic Steep Cor=giani, JACC 2006 Sicari, Circula=on 2004 Pierard, NEJM 2005 Agricola, JASE 2006 Rigo, AHJ 2006 Bombardini, EHJ 2005 Death/year >3% <1%
24 Nega8ve stress echo and normal CFR: A whiter shade of pale Time from test An0anginal Therapy Baseline Func0on CFR >1 year + abnormal abnormal Nega8ve stress echo (low risk) Clinical presenta8on <6 months - normal normal Picano E and Sicari R. Eur J Echocard; 2004
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