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Non-contrast second harmonic imaging improves interobserver agreement and accuracy of dobutamine stress echocardiography in patients with impaired image quality
  1. A Franke,
  2. R Hoffmann,
  3. H P Kühl,
  4. W Lepper,
  5. O A Breithardt,
  6. M Schormann,
  7. P Hanrath
  1. Medical Clinic I, University Hospital, Pauwelsstrasser 30, D 52057 Aachen, Germany
  1. Dr Franke. email: afra{at}


OBJECTIVE To examine the influence of second harmonic imaging during dobutamine echocardiography on regional endocardial visibility, interobserver agreement in the interpretation of wall motion abnormalities, and diagnostic accuracy in patients with reduced image quality.

DESIGN Blinded comparison.

SETTING Tertiary care centre.

PATIENTS 103 consecutive patients with suspected coronary artery disease and impaired transthoracic image quality (⩾ 2 segments with poor endocardial delineation).

METHODS Fundamental and second harmonic imaging were performed at each stage of a dobutamine stress echocardiography. Coronary angiography was undertaken within three weeks of dobutamine echocardiography in 75 patients.

MAIN OUTCOME MEASURES Evaluation of regional endocardial visibility (scoring from 0 = poor to 2 = good) and of segmental wall motion abnormalities for both modalities separately. A second blinded examiner analysed 70 studies to determine interobserver agreement.

RESULTS Mean (SD) visibility score for all segments was 1.2 (0.4) using fundamental imaging and 1.7 (0.2) using second harmonic imaging at rest (p < 0.001), and 1.1 (0.4)v 1.6 (0.3), respectively, at peak dobutamine dose (p < 0.001). The average number of segments with poor endocardial visibility was lower for second harmonic than for fundamental imaging (0.6 (1.1) v 3.8 (2.6) at rest, p < 0.001; 0.9 (1.3) v 4.3 (2.9) at peak dose, p < 0.001). Improvement was most pronounced in all lateral and anterior segments. The κ value for identical study interpretation increased from 0.40 to 0.69 (p < 0.05). Sensitivity for the diagnosis of coronary artery disease was 64% using fundamental imaging versus 92% using harmonic imaging (p < 0.001), while specificity remained unchanged at 75% for both imaging modalities.

CONCLUSIONS Second harmonic imaging enhances endocardial visibility during dobutamine echocardiography. Consequently, interobserver agreement on stress echocardiography interpretation and diagnostic accuracy are significantly improved compared to fundamental imaging. Thus, in difficult to image patients, dobutamine echocardiography should be performed using second harmonic imaging.

  • coronary artery disease
  • dobutamine stress echocardiography
  • second harmonic imaging
  • interobserver agreement

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