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(Circulation. 1995;91:663-670.)
© 1995 American Heart Association, Inc.
Articles |
Dobutamine Echocardiography in Myocardial Hibernation
Optimal Dose and Accuracy in Predicting Recovery of Ventricular Function After Coronary Angioplasty
Presented in part at the 66th Annual Scientific Session of the American Heart Association, November 1993, Atlanta, Ga.
From the Section of Cardiology, Department of Medicine, Baylor College of Medicine, The Methodist Hospital, Echocardiography Laboratory, Houston, Tex.
Correspondence to William A. Zoghbi, MD, The Methodist Hospital, Section of Cardiology, 6535 Fannin, F905, Houston, TX 77030.
Background Myocardial hibernation is a condition of chronic left ventricular dysfunction associated with severe coronary artery disease whereby significant recovery of function occurs after revascularization. Identification of hibernating myocardium has important prognostic and therapeutic implications. The presence of contractile reserve as assessed by dobutamine echocardiography may be promising in the detection of hibernation. We designed a prospective study to evaluate the accuracy and optimal dose of dobutamine echocardiography for predicting recovery of ventricular function after angioplasty in patients with stable coronary artery disease and ventricular dysfunction.
Methods and Results Twenty patients with stable coronary artery
disease and segmental ventricular dysfunction scheduled for coronary
angioplasty underwent dobutamine echocardiography before
revascularization using incremental doses of 2.5, 5, 7.5, 10, 20, 30,
and 40 µg/kg per minute every 3 minutes. Digital images of all eight
stages were displayed simultaneously (two quad screens side by side)
and interpreted using a 16-segment ventricular model and a 6-grade
scoring system. Serial resting echocardiograms before, early (<1
week), and late (
6 weeks) after angioplasty were digitized and
randomized in a quad-screen format for the assessment of recovery of
function. Wall motion score index in the revascularized regions
decreased from 2.86±0.76 before angioplasty to 2.12±1.03 late
after
angioplasty (P<.05). Of 320 ventricular segments, 148 had
abnormal wall motion at baseline and 114 were revascularized. Recovery
of function (2 grades) occurred in 25% of revascularized segments
early and in 33% late after angioplasty. Of the 34 abnormal segments
not revascularized, recovery of function occurred in only 1. During
dobutamine echocardiography, abnormal segments exhibited one of four
responses: biphasic (improvement at low dose and worsening at high
dose) in 28% of segments, sustained improvement (persistent
improvement till peak dose) in 18%, worsening in 15%, and no change
in 39%. A biphasic response had the highest predictive value (72%)
for recovery of function followed by worsening only (35%), while the
lowest was seen with a "no change" or sustained improvement
response (13% and 15%). Combining biphasic and worsening responses
resulted in a sensitivity of 74% and specificity of 73% for
assessment of recovery of individual segments and 90% and 60%,
respectively, for functional recovery of individual patients (n=10). In
segments with a biphasic response, the low dose at which improvement in
wall motion was most prevalent (84%) was 7.5 µg/kg per minute and
increased to 94% when the 5 and 7.5 µg/kg per minute doses were
displayed. The reworsening phase of the biphasic response was usually
seen with doses 20 µg/kg per minute but was also observed as early
as the 7.5 µg/kg per minute dose.
Conclusions The wall motion response during dobutamine echocardiography is useful in the prediction of recovery of ventricular function after revascularization in patients with stable coronary artery disease and ventricular dysfunction. The administration of low as well as high doses of dobutamine is needed for optimal evaluation.
Key Words: echocardiography • coronary disease • myocardium • angioplasty
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