Physical and Physiologic Effects of Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis

2021 ◽  
Author(s):  
Kimi Sato ◽  
Tom Kai Ming Wang ◽  
Milind Y. Desai ◽  
Samir R. Kapadia ◽  
Amar Krishnaswamy ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stress Echocardiography ◽  
Dobutamine Stress Echocardiography ◽  
Calcium Score ◽  
Dobutamine Stress ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
High Calcium ◽  
Valve Area

Background: Dobutamine stress echocardiography (DSE) is a useful tool for assessing low-gradient significant aortic stenosis (AS) and contractile reserve (CR), but its prognostic utility has become controversial in recent studies. We evaluated the impact of DSE on aortic valve physiological, structural and left ventricular parameters in low gradient AS. Methods: Consecutive patients undergoing DSE for low-gradient AS evaluation from September 2010 to July 2016 were retrospectively studied, and DSE findings divided into four groups with and without severe AS and CR. Relationships between left ventricular chamber quantification, CR, aortic valve Doppler during DSE and calcium score (by CT) were analysed. Results: There were 258 DSE studies performed on 243 patients, mean age 77.6±10.8 years and 183 (70.1%) were male. With increasing dobutamine dose, apart from systolic blood pressure, left ventricular ejection fraction, flow, cardiac power output and longitudinal strain magnitude, along with aortic valve area and mean aortic gradient all significantly increased (P<0.05). Flow and mean gradient increased in both the presence and absence of CR, whereas stroke volume and aortic valve area increased mainly in those with CR only. The aortic valve area increased in both patients with low and high calcium score, however the baseline area was lower in those with a higher calcium score. Conclusion: During DSE, aortic valve area increases with increase aortic valve gradient. Higher calcium score is associated with lower baseline aortic valve area, but the area valve area still increases with dobutamine even in presence of high calcium score.

Take home messages with cases from focused update on echocardiographic assessment of aortic stenosis

Heart ◽  
2018 ◽  
Vol 104 (16) ◽  
pp. 1317-1322 ◽  
Author(s):  
Judy Hung ◽  
Sheila Liu Klassen ◽  
Javier Bermejo ◽  
John Boyd Chambers
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Classification Scheme ◽  
Severe Aortic Stenosis ◽  
Integrated Approach ◽  
Dobutamine Stress ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
American Society ◽  
Valve Area

Echocardiography plays an important role in the assessment of valvular aortic stenosis. Updated recommendations focusing on a stepwise approach to evaluating aortic stenosis have recently been published by the European Association of Cardiovascular Imaging and the American Society of Echocardiography. This review uses illustrative cases to demonstrate technical aspects of aortic stenosis assessment and use of the new proposed classification scheme for aortic stenosis. Key points from the updated recommendations reviewed in this paper are: (1) technical considerations and sources of error in measurement of peak velocity, mean aortic valve gradient and aortic valve area by continuity equation. (2) Application of flow status using indexed left ventricular stroke volume to distinguish patients with low gradients and a low calculated aortic valve area. (3) Use of low-dose dobutamine stress echocardiography in patients with low ejection fraction. (4) Application of the new classification scheme and review of algorithm use for echocardiographic evaluation of severe aortic stenosis. Improved understanding of how to handle unmatched variables and adopting an integrated approach to determine severity is central to guiding the clinician’s management of aortic stenosis.

scholarly journals Aortic valve area, stroke volume,left ventricular hypertrophy, remodeling and fibrosis in aortic stenosis assessed by cardiac MRI

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. P277-P277
Author(s):  
G. Barone-Rochette ◽  
S. Pierard ◽  
S. Seldrum ◽  
C. De Meester De Ravensteen ◽  
J. Melchior ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Left Ventricular Hypertrophy ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Cardiac Mri ◽  
Ventricular Hypertrophy ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
Valve Area

scholarly journals Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis

2019 ◽  
Vol 6 (4) ◽  
pp. 97-103 ◽  
Author(s):  
Andaleeb A Ahmed ◽  
Robina Matyal ◽  
Feroze Mahmood ◽  
Ruby Feng ◽  
Graham B Berry ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Continuity Equation ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Area Measurement ◽  
Aortic Valve Area ◽  
Flow Acceleration ◽  
The Impact ◽  
Valve Area

Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.

scholarly journals Use of passive leg rise as an add-on to dobutamine in patients with paradoxical low-flow, low-gradient aortic stenosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
E Buffle ◽  
A Papadis ◽  
C Seiler ◽  
S F De Marchi
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Stroke Volume Index ◽  
Left Ventricular ◽  
Low Flow ◽  
Volume Index ◽  
Aortic Valve Area ◽  
Low Ejection Fraction ◽  
Valve Area

Abstract Background Dobutamine has been proposed for the assessment of low-flow, low-gradient aortic stenosis (LFLGAS). However, in 1/3 of patients, no increase in stroke volume index can be achieved by Dobutamine, thus hampering its diagnostic value. This study evaluated the manoeuvre of cardiac preload augmentation by passive leg rise (PLR) alone or on top of Dobutamine to increase stroke volume index (SVI) in patients with LFLGAS, particularly in paradoxical LFLGAS. Methods We examined 50 patients with LFLGAS. Patients were assigned to the paradoxical LFLGAS (Paradox) group if left ventricular ejection fraction (LVEF) was ≥50% (n=29) and to the LFLGAS with low ejection fraction (LEF) group if LVEF was &lt;50% (n=21). A modified Dobutamine stress echocardiography was performed in all patients with the following 4 steps: Rest, PLR alone, maximal Dobutamine infusion rate alone (Dmax) and Dobutamine plus PLR (Dmax + PLR). Three SVI measurement methods were used: first the left ventricular outflow tract velocity time integral (LVOT VTI) method, second the 2D Simpson's method, and third the 3D method. The corresponding aortic valve area (AVA) was obtained by the continuity equation. The increase of those values compared to measurements at rest was calculated and compared between the 3 stress steps. Results In the paradoxical LFLGAS group, delta SVI with Dmax assessed by both Simpson's (depicted in the figures) and 3D method was lowest compared to PLR and Dmax + PLR. PLR alone yielded an equally high delta SVI as Dmax + PLR in Simpson's and 3D, and was at least as high as Dmax across all methods. Dobutamine alone yielded the lowest delta transaortic aortic valve VTI. The highest delta aortic valve area resulted for Dmax + PLR. In the LEF group, the three stress steps yielded an equally high delta SVI with Simpson's method. Dmax never yielded a higher delta SVI than PLR alone. The yielded delta SVI was the highest for Dmax + PLR for both LVOT VTI and 3d method, although the difference was overall not as strong as in the Paradox group. Conclusions In patients with paradoxical LFLGAS, Dobutamine alone is inadequate for testing the potential of aortic valve opening augmentation. Instead, PLR alone or the addition of PLR plus Dobutamine should be used for that purpose. In low LVEF, adding PLR to Dobutamine also seems useful although its diagnostic added value is less evident than in the Paradox group. FUNDunding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Gottfried und Julia Bangerter-Rhyner-Foundation Paradox group Low ejection fraction group

scholarly journals Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study

2021 ◽  
Author(s):  
Anastasia Vamvakidou ◽  
Mohamed-Salah Annabi ◽  
Phillipe Pibarot ◽  
Edyta Plonska-Gosciniak ◽  
Ana G. Almeida ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Ventricular Ejection ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Ventricular Ejection Fraction ◽  
Valve Area

Background: Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. Methods: This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm 2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. Results: Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94–0.99]; P =0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm 2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm 2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05–2.82]; P =0.03). Furthermore aortic valve area <1cm 2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention ( P <0.001). Guideline-defined stroke volume flow reserve did not predict mortality. Conclusions: Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.

Abstract 18192: Aortic Stenosis: The Effect of Spectral Broadening in the Left Ventricular Outflow Tract on Stroke Volume and Calculated Aortic Valve Area

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Jeremy J Thaden ◽  
Michael Y Tsang ◽  
Saki Ito ◽  
Sorin V Pislaru ◽  
Vuyisile T Nkomo ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Uniform Flow ◽  
Aortic Valve Area ◽  
Spectral Broadening ◽  
Volumetric Assessment ◽  
Left Ventricular Outflow ◽  
Valve Area

Introduction: Accurate stroke volume (SV) calculation is critical for calculating aortic valve area by echocardiography. 2D-Doppler estimation of SV (SV 2D ) assumes uniform blood flow velocities through the left ventricular outflow tract (LVOT). Non-uniform flow through the LVOT, appreciated as spectral broadening of the LVOT Doppler signal, could result in inaccurate SV calculation. Hypothesis: Increased spectral broadening in the LVOT will result in overestimation of SV by the SV 2D method compared to 3D volumetric assessment of SV (SV 3D ). Methods: Fifty-one consecutive patients with aortic stenosis underwent comprehensive 2D-TTE and assessment of SV 3D . Patients with ≥ moderate mitral or aortic regurgitation were excluded. An LVOT pulse-wave Doppler signal with > 0.4 m/s difference between outer and inner edge of velocity spectral display (at time of peak velocity) was considered non-uniform flow (i.e., spectral broadening). Results: Spectral broadening was present in 33% of the cohort. These patients were commonly female with smaller ventricles and higher ejection fraction. Spectral broadening was associated with a significant overestimation of SV on Doppler-based measurements (101±20 ml vs 78±15 mL, SV 2D vs SV 3D , respectively; r=0.83, p<0.0001); such differences were not seen in patients with uniform flow velocities (82±15 vs 79±14 mL, r=0.83, p=0.03). Patient characteristics by spectral broadening are shown in table 1. Conclusion: In aortic stenosis patients with non-uniform flow, Doppler-based methods overestimated SV by 29.5% on average (maximum 64%) when compared to 3D methods. This results in a proportional increase in calculated valve area despite a similar mean gradient between groups. Substituting SV 3D resulted in similar SV, valve area, and mean gradient between uniform and non-uniform groups. When spectral broadening >0.40 cm/s is present, 3D volumetric assessment of SV should be considered for accurate estimation of aortic valve area.

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