Dobutamine stress echocardiography in the evaluation of hibernating myocardium
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Impaired left ventricular (LV) systolic function in patients with coronary heart disease is often a partially reversible process (table 1). As an example, left ventricular function may improve markedly, and even normalize, in subsets of patients following successful revascularization (figure 1) [1-3].
Since many studies have established a relation between LV systolic function and cardiovascular prognosis, it is reasonable to speculate that improved LV systolic function following revascularization would be associated with a favorable effect on outcome. The superiority of revascularization compared to medical management in selected patients with coronary disease and LV dysfunction is compatible with this hypothesis [4,5]. The myocardium that recovers function after revascularization has been called "hibernating." To the extent that improvement in regional or global LV systolic function is a significant goal in such patients, the ability to accurately assess regional myocardial viability in a dysfunctional territory prior to revascularization becomes an important component of the decision making process (table 2 and algorithm 1 and algorithm 2). (See "Diagnosis and management of ischemic cardiomyopathy", section on 'Revascularization' and "Clinical syndromes of stunned or hibernating myocardium".)
Dobutamine stress echocardiography has emerged as an important noninvasive clinical tool for the detection of hibernating myocardium [6,7]. The role of dobutamine stress echocardiography in the evaluation of myocardial viability in the setting of hibernation will be reviewed here. The use of other modalities in conjunction with dobutamine stress, such as Doppler studies, the relative efficacy of other imaging modalities (eg, radionuclide imaging, magnetic resonance imaging) for the detection of hibernating myocardium, and protocols for dobutamine stress echocardiography are discussed separately. (See "Evaluation of hibernating myocardium" and "Overview of stress echocardiography", section on 'Dobutamine stress echocardiography'.)
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Pharmacologic stress echocardiography examines the "inotropic reserve" of dysfunctional but viable myocardium at rest by the administration of an inotropic agent, with dobutamine being the most frequently used agent. Viable myocardium shows improved global or regional contractile function (inotropic reserve), as assessed by simultaneous transthoracic echocardiography, in response to inotrope administration . The prevalence of contractile reserve in patients with CHD and LV dysfunction is independent of the angiographic extent and severity of coronary artery disease, and the improvement in contractility in hypoperfused viable myocardium does not require an increase in regional myocardial perfusion [9,10].
A contractile response to dobutamine appears to require that at least 50 percent of the myocytes in a given segment are viable; the contractile response also correlates inversely with the extent of interstitial fibrosis on myocardial biopsy . In comparison, radionuclide myocardial perfusion imaging identifies segments with fewer viable myocytes. In one series, for example, dobutamine stress echocardiography and thallium imaging showed equivalent sensitivity among segments with more than 75 percent viable myocytes (78 versus 87 percent) but dobutamine stress echocardiography was much less sensitive among segments with 25 to 50 percent viable myocytes (15 versus 82 percent) .
- Rees G, Bristow JD, Kremkau EL, et al. Influence of aortocoronary bypass surgery on left ventricular performance. N Engl J Med 1971; 284:1116.
- Chatterjee K, Swan HJ, Parmley WW, et al. Influence of direct myocardial revascularization on left ventricular asynergy and function in patients with coronary heart disease. With and without previous myocardial infarction. Circulation 1973; 47:276.
- Brundage BH, Massie BM, Botvinick EH. Improved regional ventricular function after successful surgical revascularization. J Am Coll Cardiol 1984; 3:902.
- Alderman EL, Fisher LD, Litwin P, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983; 68:785.
- Pigott JD, Kouchoukos NT, Oberman A, Cutter GR. Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function. J Am Coll Cardiol 1985; 5:1036.
- Beckmann S, Schartl M, Bocksch W, Fleck E. Diagnosis of coronary artery disease and viable myocardium by stress echocardiography. Diagnostic accuracy of different stress modalities. Eur Heart J 1995; 16 Suppl J:10.
- Cheirif J, Murgo JP. Assessment of myocardial viability by dobutamine echocardiography. Coron Artery Dis 1995; 6:600.
- Rocchi G, Poldermans D, Bax JJ, et al. Usefulness of the ejection fraction response to dobutamine infusion in predicting functional recovery after coronary artery bypass grafting in patients with left ventricular dysfunction. Am J Cardiol 2000; 85:1440.
- Main ML, Grayburn PA, Landau C, Afridi I. Relation of contractile reserve during low-dose dobutamine echocardiography and angiographic extent and severity of coronary artery disease in the presence of left ventricular dysfunction. Am J Cardiol 1997; 79:1309.
- Barillà F, De Vincentis G, Mangieri E, et al. Recovery of contractility of viable myocardium during inotropic stimulation is not dependent on an increase of myocardial blood flow in the absence of collateral filling. J Am Coll Cardiol 1999; 33:697.
- Nagueh SF, Mikati I, Weilbaecher D, et al. Relation of the contractile reserve of hibernating myocardium to myocardial structure in humans. Circulation 1999; 100:490.
- Baumgartner H, Porenta G, Lau YK, et al. Assessment of myocardial viability by dobutamine echocardiography, positron emission tomography and thallium-201 SPECT: correlation with histopathology in explanted hearts. J Am Coll Cardiol 1998; 32:1701.
- Cornel JH, Bax JJ, Elhendy A, et al. Biphasic response to dobutamine predicts improvement of global left ventricular function after surgical revascularization in patients with stable coronary artery disease: implications of time course of recovery on diagnostic accuracy. J Am Coll Cardiol 1998; 31:1002.
- Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995; 91:663.
- Sawada SG, Lewis SJ, Foltz J, et al. Usefulness of rest and low-dose dobutamine wall motion scores in predicting survival and benefit from revascularization in patients with ischemic cardiomyopathy. Am J Cardiol 2002; 89:811.
- Poldermans, D, Sozzi, FB, Bax, JJ, et al. Influence of continuation of beta blockers during dobutamine stress echocardiography for the assessment of myocardial viability in patients with severe ischemic left ventricular dysfunction. Am J Cardiol 2001; 88:A7, 68.
- Perrone-Filardi P, Pace L, Prastaro M, et al. Dobutamine echocardiography predicts improvement of hypoperfused dysfunctional myocardium after revascularization in patients with coronary artery disease. Circulation 1995; 91:2556.
- Meluzín J, Cerný J, Frélich M, et al. Prognostic value of the amount of dysfunctional but viable myocardium in revascularized patients with coronary artery disease and left ventricular dysfunction. Investigators of this Multicenter Study. J Am Coll Cardiol 1998; 32:912.
- Sawada S, Bapat A, Vaz D, et al. Incremental value of myocardial viability for prediction of long-term prognosis in surgically revascularized patients with left ventricular dysfunction. J Am Coll Cardiol 2003; 42:2099.
- Baer FM, Voth E, Deutsch HJ, et al. Predictive value of low dose dobutamine transesophageal echocardiography and fluorine-18 fluorodeoxyglucose positron emission tomography for recovery of regional left ventricular function after successful revascularization. J Am Coll Cardiol 1996; 28:60.
- Piscione F, Perrone-Filardi P, De Luca G, et al. Low dose dobutamine echocardiography for predicting functional recovery after coronary revascularisation. Heart 2001; 86:679.
- Ma L, Chen L, Gillam L, et al. Nitroglycerin enhances the ability of dobutamine stress echocardiography to detect hibernating myocardium. Circulation 1997; 96:3992.
- Ling LH, Christian TF, Mulvagh SL, et al. Determining myocardial viability in chronic ischemic left ventricular dysfunction: a prospective comparison of rest-redistribution thallium 201 single-photon emission computed tomography, nitroglycerin-dobutamine echocardiography, and intracoronary myocardial contrast echocardiography. Am Heart J 2006; 151:882.
- Afridi I, Grayburn PA, Panza JA, et al. Myocardial viability during dobutamine echocardiography predicts survival in patients with coronary artery disease and severe left ventricular systolic dysfunction. J Am Coll Cardiol 1998; 32:921.
- Senior R, Kaul S, Lahiri A. Myocardial viability on echocardiography predicts long-term survival after revascularization in patients with ischemic congestive heart failure. J Am Coll Cardiol 1999; 33:1848.
- Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002; 39:1151.
- Underwood SR, Bax JJ, vom Dahl J, et al. Imaging techniques for the assessment of myocardial hibernation. Report of a Study Group of the European Society of Cardiology. Eur Heart J 2004; 25:815.
- Smart SC, Knickelbine T, Stoiber TR, et al. Safety and accuracy of dobutamine-atropine stress echocardiography for the detection of residual stenosis of the infarct-related artery and multivessel disease during the first week after acute myocardial infarction. Circulation 1997; 95:1394.
- Bigi R, Cortigiani L, Desideri A, et al. Clinical and angiographic correlates of dobutamine-induced wall motion patterns after myocardial infarction. Am J Cardiol 2001; 88:944.
- Leclercq F, Messner-Pellenc P, Moragues C, et al. Myocardial viability assessed by dobutamine echocardiography in acute myocardial infarction after successful primary coronary angioplasty. Am J Cardiol 1997; 80:6.
- Afridi I, Qureshi U, Kopelen HA, et al. Serial changes in response of hibernating myocardium to inotropic stimulation after revascularization: a dobutamine echocardiographic study. J Am Coll Cardiol 1997; 30:1233.
- Lombardo A, Loperfido F, Trani C, et al. Contractile reserve of dysfunctional myocardium after revascularization: a dobutamine stress echocardiography study. J Am Coll Cardiol 1997; 30:633.
- Nijland F, Kamp O, Verhorst PM, et al. In-hospital and long-term prognostic value of viable myocardium detected by dobutamine echocardiography early after acute myocardial infarction and its relation to indicators of left ventricular systolic dysfunction. Am J Cardiol 2001; 88:949.
- Picano E, Sicari R, Landi P, et al. Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study. Circulation 1998; 98:1078.
- O'Driscoll JM, Marciniak A, Ray KK, et al. The safety and clinical usefulness of dobutamine stress echocardiography among octogenarians. Heart 2014; 100:1001.
- Pratali L, Picano E, Otasevic P, et al. Prognostic significance of the dobutamine echocardiography test in idiopathic dilated cardiomyopathy. Am J Cardiol 2001; 88:1374.
- Ramahi TM, Longo MD, Cadariu AR, et al. Dobutamine-induced augmentation of left ventricular ejection fraction predicts survival of heart failure patients with severe non-ischaemic cardiomyopathy. Eur Heart J 2001; 22:849.
- Lu C, Carlino M, Fragasso G, et al. Enoximone echocardiography for predicting recovery of left ventricular dysfunction after revascularization : a novel test for detecting myocardial viability. Circulation 2000; 101:1255.
- DOBUTAMINE STRESS ECHOCARDIOGRAPHY
- Improvement in LV function after CABG
- Improvement in LV systolic function after percutaneous revascularization
- Improvement in survival after revascularization
- Use after MI
- Use in LV dysfunction after MI
- Use in the elderly
- Comparison with perfusion imaging
- Comparison with CMR
- Role in idiopathic dilated cardiomyopathy
- ENOXIMONE STRESS ECHOCARDIOGRAPHY
- INFORMATION FOR PATIENTS