False Positive Dobutamine Stress Echocardiography Induced by Esmolol

BackgroundAtrioventricular nodal ablation (AVNA) is indicated in drug-refractory atrial fibrillation (AF)[1], and has been shown to improve cardiac resynchronization therapy (CRT) efficacy in this cohort[2]. There is concern over the...

Liver transplantation: Do you have the heart for it?

This study was performed to evaluate whether left ventricular hypertrophy (LVH) can influence the diagnostic accuracy of coronary artery disease (CAD) using the dobutamine stress echocardiography (DSE) in hypertensive patients. In addition to the detection of CAD, the relationship between systolic dysfunction and the quantitation wall motion scoring system of DSE was studied also. DSE was performed in 101 patients. There were 45 (45%) patients with a history of acute myocardial infarction. Twenty-eight patients (28%) had electrocardiographic LVH and 59 patients (58%) had echocardiographic LVH. A total of 74 patients (73%) had angiographically documented CAD defined as > or = 50% diameter stenosis. For the 56 patients without history of myocardial infarction, the diagnostic sensitivity, specificity, and accuracy in detecting CAD were not influenced by LVH defined by either electrocardiography or echocardiography. For the total patients, the diagnostic sensitivity, specificity, and accuracy in detecting multivessel disease were also not influenced by LVH defined by either method. The resting global wall motion score was correlated well with the left ventricular ejection fraction in patients with and without LVH (r = -0.70, p < 0.001 vs. r = -0.70, p < 0.001). When using the resting wall motion score of 24 as a cutoff value, the diagnostic sensitivity, specificity, and accuracy of systolic dysfunction (defined by left ventricular ejection fraction <40%) were 79, 86 and 85%, respectively. In conclusion, the diagnostic accuracy of CAD using the DSE was not affected by LVH in hypertensive patients. In addition to detection of coronary artery disease, the resting wall motion score of DSE was able to detect systolic dysfunction in patients with and without LVH.

The prognostic value of stress echocardiography (SE) in patients with complete bundle branch blocks (BBB) with normal left ventricular ejection fraction (LVEF) has not been well described. We sought to determine the prognostic value of SE in patients with BBB and normal LVEF. We analyzed 7214 patients (58 ± 14 years; 57% female) with a mean follow-up time of 9 ± 4 years. Dobutamine SE was performed in 51% of patients and exercise SE was performed in 49%. All-cause mortality data were obtained from the Social Security Death Index. There were 222 (3%) patients with right bundle branch block (RBBB) and 50 (0.7%) patients with left bundle branch block (LBBB). Patients with LBBB were 3 times more likely to have an abnormal stress test after adjusting for age, gender, mode of stress test, and coronary artery disease risk factors (OR = 3.3; 95% CI: 1.86-5.92; P < 0.001). The mortality rates were 4.5%/year for patients with LBBB, 2.5%/year for patients with RBBB, and 1.9%/year for patients without BBB (P < 0.001). Among patients with a normal SE, those with LBBB had similar mortality to those without LBBB (HR = 0.9; 95% CI: 0.4-2.2; P = 0.8). Patients with LBBB and abnormal SE had more than 2 times greater risk of all-cause mortality (HR = 2.4; 95% CI: 1.4-4.2; P = 0.002). A normal stress echocardiogram in LBBB is associated with benign prognosis while those with LBBB and abnormal SE have the worst outcomes.

61-Year-Old Man With Nausea and Vomiting

Risk Factors for Midterm Cardiac Function Deterioration After Valve Replacement Surgery in Patients With Rheumatic Mitral Stenosis

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain

Background Left ventricular ejection fraction (LVEF), the single most important metric in cardiology, is the cornerstone on which prognosis is estimated and costly decisions such as whether to implant an ICD are based. LVEF is most often assessed by 2D echocardiography (2DE), although 3D echocardiography (3DE) has been shown repeatedly to be more accurate. Aim of the study. We set out to assess whether using 3DE would reclassify the severity of LV impairment in patients with LVEF &lt; 35% by 2DE. Setting. Tertiary cardiac centre serving a population of one million, and performing approximately 100 ICD implants/year. Methods. Successive patients in sinus rhythm, with good endocardial border definition and LVEF&lt;35% by 2D Simpson’s method, had scans according to the BSE protocol. 3D loops were acquired from the apical 4-chamber view and were analysed off-line using for regional wall motion abnormalities (RWMAs) and LVEF. The patients were classified in subgroups according to EF value: less than 20%, 20-25%, 25-30%, 35% and more than 35%. Moderate LV systolic was defined as LVEF between 35% and 45% and severe as LVEF ≤35%. Results. We studied 100 patients (78 M, mean age (SD) 69.94 (13.54) years). 2DE had been requested for decision-making regarding ICD implantation in 86 patients (86%) and for LVEF measurement after acute coronary syndromes in 14 patients (14%). Regional wall motion abnormalities (RWMAs) were present in half of patients (55%, 51 pts – 56% in LAD territory, 31% in RCA/CX territory and 12% multiple territories). 3D LVEF regrouped 67% of patients: 10% to a lower EF and 57% to a higher EF subgroup. Twenty nine patients (29%) were reclassified from severe LV systolic dysfunction by to 2DE to moderate LV systolic dysfunction by 3DE. Patients with RWMAs were more often reclassified than patients without RWMAs (p=0.006). The LV dimensions were lower for the reclassified patients. The image quality had no effect on reclassification. Conclusion Measuring LVEF by 3DE reclassifies the severity of LV systolic impairment in a substantial proportion of patients with 2D LVEF&lt;35% and RWMAs, which may have important clinical and financial implications by resetting thresholds for costly interventions such as ICD implants. Keywords: biological attack, biological warfare, biological agents, international legislation, medical protection.

Inverted stress cardiomyopathy during monitored anesthesia care for endoscopic sinus surgery

Preoperative comparison of different noninvasive strategies for predicting improvement in left ventricular function after coronary artery bypass grafting

Background Participation in comprehensive cardiac rehabilitation (CR) in general, and exercise-based CR (EBCR) in particular, is strongly advocated for patients with myocardial infarction (MI) and for those with heart failure (HF). Despite well-documented benefits, attendance remains low due to barriers at multiple levels. Purpose We aimed to describe determinants of attendance in comprehensive CR and EBCR for patients with MI and i) no history of HF and normal (≥50%) left ventricular ejection fraction (LVEF) post-MI, ii) no history of HF and new LVEF reduction (&amp;lt;50%) post-MI and iii) history of HF (irrespective of LVEF pre/post-MI). Methods In this retrospective observational study, patients &amp;lt;80 years of age registered in the Swedish cardiac registry SWEDEHEART with a MI diagnosis 2010-2019 were included. Patient- and system-level determinants of attendance in CR and EBCR were assessed using adjusted Cox proportional hazards and binary logistic regression models, respectively. Results Out of the 72,977 included patients (median age 64 [IQR 57-69] years, 74% men), 59.3% (n=43,289) had no history of HF and normal LVEF at discharge, 34.3% (n=25,032) had no history HF but developed reduced LVEF post-MI, and 6.4% (n=4676) had a history of HF. Proportion of patients attending CR was highest in patients with no HF history and normal LVEF (82.7%) and lowest in patients with a history of HF (61.8%, Figure 1). Of all MI patients with a history of HF, 19.6% attended EBCR. Compared to patients with no history of HF and normal LVEF, those with new LVEF reduction and those with a history of HF were less likely to attend CR (hazards ratio [95% confidence interval]: 0.97 [0.95-0.99] and 0.82 [0.78-0.85]) and EBCR (0.90 [0.87-0.94] and 0.75 [0.67-0.83]). Patients with lower income, younger patients, women, those born outside of Sweden, prior and current smokers, patients with comorbidities and those living far from the CR centre were less likely to attend CR (Figure 2, Panel A). Among those attending CR, low income and educational level, having no partner, being an active smoker, having comorbidities and living far from the CR centre were associated with lower EBCR attendance (Figure 2, Panel B). Belonging to a small hospital or university hospital predicted higher attendance in both comprehensive CR and EBCR across all groups. No major differences in determinants of attendance were observed between the three strata based on HF and LVEF (data not shown). Conclusion Compared to patients with no history of HF and normal LVEF, CR and EBCR attendance was lower in those with new-onset impairment of LVEF as well as in patients with a history of HF. Additionally, socioeconomically disadvantaged patients and those with comorbidities had the lowest attendance across all groups. Efforts to increase attendance in CR and EBCR in these vulnerable groups should be a priority.Attendance in CR and EBCR Determinants of attendance in CR, EBCR

Global longitudinal strain (GLS) assessed by speckle-tracking echocardiography has been proposed as a parameter able to reflect early changes in left ventricular systolic function at a stage when left ventricular ejection fraction (LVEF) is still normal. This study aimed at assessing prevalence and prognostic value of left ventricular systolic dysfunction (LVSD) assessed by echocardiographic speckle-tracking GLS in a community-based cohort. Participants from the community-based prospective Northern Manhattan Study underwent two-dimensional transthoracic echocardiography as part of the Cardiovascular Abnormalities and Brain Lesions study. Left ventricular systolic function was assessed by LVEF and speckle-tracking GLS. Subjects were followed annually (mean = 4.8 ± 1.5 years) and incident vascular events (ischaemic stroke, myocardial infarction, and vascular death) were reviewed and adjudicated. Of the 708 study participants, 114 (16.1%) had abnormal GLS but normal LVEF (GLS-LVSD), 30 (4.2%) had abnormal LVEF (LVEF-LVSD), and 564 (79.7%) had normal GLS and LVEF (no-LVSD). In multivariate analysis, risk of events was significantly greater in GLS-LVSD [adjusted hazard ratio (HR) = 2.39, 95% confidence interval (CI) = 1.20-4.77] and in LVEF-LVSD (adjusted HR = 3.51, 95% CI = 1.25-9.88) compared with no-LVSD. Among participants with normal LVEF, lower GLS was significantly associated with events (adjusted HR/unit decrease = 1.15, 95% CI = 1.03-1.28) whereas LVEF was not (adjusted HR/unit decrease = 1.01, 95% CI = 0.94-1.07). The GLS prognostic value was incremental to risk factors and LVEF both in the overall population (chi-square change = 7.406, P = 0.006) and in participants with normal LVEF (chi-square change = 6.357, P = 0.012). In a community-based cohort, GLS-LVSD was four times more frequent than LVEF-LVSD. GLS-LVSD was a powerful and independent predictor of cardiovascular events. Left ventricular function assessment by GLS may improve cardiovascular risk stratification in subjects with normal LVEF.

Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis: The TOPAS-TAVI Registry

Although dobutamine stress echocardiography (DSE) is a well-defined tool for the diagnosis of coronary artery disease (CAD), false-negative and false-positive results still occur. This study investigated the diagnostic role of layer-specific analysis using 2-dimensional speckle-tracking echocardiography (STE) during DSE.A total of 121 patients who underwent DSE and showed normal wall motion and ejection fraction during baseline echocardiography were enrolled. All patients underwent coronary angiography after DSE within 2 weeks. The patients were divided into the following 4 groups according to DSE results and CAD status: negative DSE with no significant CAD (n = 73), positive DSE with significant CAD (n = 16), negative DSE with significant CAD (n = 17), and positive DSE with no significant CAD (n = 15). Layer-specific global longitudinal strain (GLS) was assessed in the endocardium, mid-myocardium, and epicardium by STE techniques.Patients with significant CAD were older, more male and showed higher glucose level compared to patients without CAD. But coronary risk factors and previous medications were not different between patients with and without CAD. There were no significant differences in whole myocardium or layer-specific GLS found in the baseline echocardiography. During recovery echocardiography, endocardial GLS was significantly different between patients with and without CAD, regardless of the DSE results. A receiver-operating characteristic curve analysis showed that endocardial GLS (>-16%) was superior for identifying significant CAD during the DSE recovery stage. Diagnostic accuracy was improved by applying the results of endocardial GLS compared with visual estimation of DSE.The assessment of layer-specific strain by STE during DSE was feasible, and the evaluation of poststress endocardial function is a more sensitive tool for the detection of CAD.

Doppler echocardiography using the ratio of early diastolic transmitral velocity to early diastolic mitral annular tissue velocity (E/E') is routinely used to evaluate left ventricular (LV) filling pressures at rest. We tested the hypothesis that measurement of E/E' in patients undergoing dobutamine stress echocardiography (DSE) will detect changes in LV filling pressures. In this prospective study, 16 patients with normal LV ejection fraction and normal coronary arteries by angiography underwent a standard DSE protocol with simultaneous LV filling pressure monitoring with a fluid filled pigtail catheter. Doppler echocardiographic assessment of LV diastolic function was performed using E/E' at rest and during DSE. The average age of the study participants was 57 ± 8 years. Average heart rate was 61 ± 11 bpm at baseline and 141 ± 12 bpm at peak stress. LV mean diastolic pressure decreased from 12.3 ± 2.6 mmHg at baseline to 9.0 ± 2.3 mmHg at peak stress (P = 0.0001). Baseline E/E' at the septum and lateral annulus were 8.7 ± 2.2 and 7.5 ± 1.9 and during peak stress were 8.3 ± 3.1 and 7.9 ± 3.5, respectively. There was no significant change in E/E' at either the septum or the lateral annulus (P = 0.55, P = 0.66). There was no significant correlation between LV mean diastolic pressure and E/E' with dobutamine stress. In patients with normal LV ejection fraction and no significant coronary artery disease undergoing DSE, the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/E') at peak stress with dobutamine does not predict changes in LV filling pressures.