Low-Dose Dobutamine Stress Echocardiography in Children and Young Adults

doi:10.1016/S0002-9149(98)00008-3

The American Journal of Cardiology

Volume 81, Issue 7, 1 April 1998, Pages 895-901

https://doi.org/10.1016/S0002-9149(98)00008-3 Get rights and content

Abstract

Dobutamine stress echocardiography has become widely accepted in the evaluation of adult patients with coronary heart disease. We wanted to assess the feasibility and the physiologic responses of stress echocardiography at low doses of dobutamine in a population of normal children and adults. Once achieved, we submitted a group of post-anthracycline patients to the test to assess the sensitivity of low-dose dobutamine stress echocardiography in the detection of cardiac dysfunction. Thirty-two healthy children and young adults (19 male and 13 female subjects, median age 15 years [range 6 to 26]) were studied. After the initial study of normal subjects, we submitted a cohort of 39 patients (18 female and 21 male, aged 6 to 25 years), who completed anthracycline chemotherapy, to the same protocol. Dobutamine was infused at rates of 0.5 to 2.5 and 5 μg/kg/min and echocardiographic measurements were obtained at rest and at the end of each stage. The test could be completed in 100% of the subjects without major complications. Statistically significant differences between resting echocardiographic values of systolic and diastolic function and values at 2.5 and 5 μg/kg/min of dobutamine were found. Moreover, dobutamine revealed or enhanced differences between normal subjects and the post-anthracycline patients. Thus, low-dose dobutamine stress echocardiography is feasible and safe in older children. The test is very sensitive for the detection of subclinical cardiac dysfunction in post-anthracycline patients and could possibly assess functional myocardial reserve.

Section snippets

Population

Thirty-two healthy children and young adults were studied. They were selected among volunteers and siblings of patients who completed anthracycline chemotherapy. We received the approval of the hospital’s ethical committee. All subjects and their parents gave informed consent. The medium age of the subjects was 15 years ( range 6 to 26), and their medium weight 46.2 kg (range 18 to 68). The age of 6 years reflects the minimum age at which children consented to participate in the study after

Methods

To obtain echocardiographic images of high quality, the subjects were examined in the left decubitus position for the apical and parasternal windows and in the supine position with hyperextension of the neck for the suprasternal window. The echocardiographic equipment consisted of a Toshiba SSH-140A (Tokyo, Japan) with a 5-, 3.75-, and 2.5-MHz transducer with pulsed wave and color Doppler. The measurements were recorded in accordance to standard recommendations.7, 8, 9Dobutamine (Dobutrex, Eli

Results

Because we were not interested in the incidence and the reasons of myocardial dysfunction in post-anthracycline patients for the purpose of this particular study, we did not investigate any risk factors responsible for individual abnormal responses in the anthracycline group. These results are reported elsewhere.[10]We were merely interested in the effect of different dobutamine infusion rates on echocardiographic variables of cardiac function in a normal population and in a population with

Discussion

In this study we evaluated dobutamine stress echocardiography in normal children and young adults. The detection of wall motion disturbances during dobutamine stress echocardiography, using high doses up to 40 μg/kg/min, has been increasingly used in detecting coronary artery disease in the adult population. Low-dose dobutamine stress echocardiography up to 10 μg/kg/min (with maximal yield at 5 and 7.5 μg/kg/min) on the other hand seems important for detecting viable myocardium in patients with

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The Role of Echocardiography: Stress Echocardiography
2016, Anticancer Treatments and Cardiotoxicity: Mechanisms, Diagnostic and Therapeutic Interventions
The most commonly used parameter for monitoring LV function with echocardiography is LV ejection fraction (LVEF). LVEF itself and LVEF drop during and after cancer treatment are currently used to define the onset cardiotoxicity. New, normal cutoff points of LVEF (≥52% in men and ≥54 in women) have been recently established. Changes in LVEF indicative of LV damage can be more appropriately identified when comparisons are made between baseline and follow-up studies. ASE/EACVI recommendations on the use of cardiac imaging in cancer patients fix the drop of LVEF of at least 10 points to an LVEF <50% as indicative of cardiotoxicity. The sensitivity of 2D LVEF appears, however, to be poor for changes during time lower than 10% in cancer patients. Isolated diastolic abnormalities have been identified as early sign of anthracycline-induced LV dysfunction. Pulsed tissue Doppler and E/e′ ratio could be more sensitive than mitral inflow to detect LV diastolic dysfunction as a result of chemotherapy. Nevertheless, diastolic parameters have not shown any power in predicting subsequent cancer therapy-related cardiotoxicity. Right ventricular (RV) abnormalities may occur in oncologic patients for a number of reasons: preexisting RV dysfunction, neoplastic involvement (primary or metastatic), cardiotoxic effects of chemotherapy. However, frequency and prognostic values of RV involvement have not been investigated in the oncologic setting. Valvular heart disease may develop in oncologic patients for several reasons including primary or secondary (metastases) tumors affecting valve function, pancytopenia-related endocarditis, functional mitral and tricuspid regurgitation due to cardiac dysfunction, and pulmonary arterial hypertension, as a consequence of cancer-related cardiotoxicity. Although transthoracic echo is often sufficient to evaluate valve dysfunction and its hemodynamic consequences, transesophageal echocardiography may add incremental information.
Ventricular function and cardiac reserve in contemporary Fontan patients
2015, International Journal of Cardiology
Citation Excerpt :
However, dobutamine-infusion during MRI unmasked an abnormal reaction to stress. This was mainly characterized by a decrease in end-systolic volume and an abnormal decrease in end-diastolic volume, resulting in no significant increase in stroke volume [26]. When comparing the current surgical techniques (ILT vs. ECC) for completion of the TCPC, no differences in ventricular dimensions and global function were found at rest.
Total cavopulmonary connection (TCPC) has been the preferred treatment for patients with univentricular hearts. Current TCPC-techniques are the intra-atrial lateral tunnel (ILT) and the extracardiac conduit (ECC). We aimed to determine ventricular function during rest and stress, and to compare results for both techniques and for left (LV) versus right ventricular (RV) dominance.
99 patients, aged 12.5 ± 4.0 years underwent echocardiography and magnetic resonance imaging (MRI), and 69 patients underwent stress MRI.
Echocardiography showed impaired systolic and diastolic function. MRI parameters were comparable between ILT and ECC at rest. During dobutamine there was a decrease in end-diastolic volume (EDVi) (91 ± 21 vs. 80 ± 20 ml/m² p < 0.001). Ejection fraction (EF) and cardiac index (CI) during dobutamine were lower for ILT patients (59 ± 11 (ILT) vs. 64 ± 7% (ECC), p = 0.027 and 4.2 ± 1.0 (ILT) vs. 4.9 ± 1.0 L/min/m² (ECC), p = 0.006), whereas other parameters were comparable. TEI-index was higher in ILT-patients (0.72 ± 0.27 (ILT) vs. 0.56 ± 0.22 (ECC), p = 0.002). Diastolic function was frequently impaired in patients with a dominant RV (67% (RV) vs. 39% (LV), p = 0.011). Patients with dominant LV's had smaller end-systolic volume (ESVi) (40 ± 13 (LV) vs. 47 ± 16 (RV) ml/m², p = 0.030) and higher EF (55 ± 8 (LV) vs. 49 ± 9 ml/m² (RV), p = 0.001) and contractility (2.3 ± 0.8 (LV) vs. 1.9 ± 0.7 mm Hg/ml/m² (RV), p = 0.050) during rest and higher EF during dobutamine (63 ± 8 (LV) vs. 58 ± 10 ml/m² (RV), p = 0.043).
Ventricular function is relatively well preserved in modern-day Fontan patients. With dobutamine stress there is a decrease in EDVi. ECC patients have higher CI and EF during stress. Patients with a dominant RV have lower systolic, including impaired contractility, and diastolic function.
Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: A report from the American society of echocardiography and the European association of cardiovascular imaging
2014, Journal of the American Society of Echocardiography
Citation Excerpt :
In addition, there are two specific areas in which stress echocardiography may be useful: (1) the evaluation of subclinical LV dysfunction and (2) the evaluation of contractile reserve in patients with CTRCD. Although both exercise27 and dobutamine stress echocardiography27,112,133-140 have been applied to patients with cancer for the identification of anthracycline-induced CTRCD, the results of these studies appear to be inconclusive and contradictory. One of these studies prospectively assessed LV contractile reserve by low-dose dobutamine stress echocardiography in 49 women with breast cancer before each chemotherapy cycle and 1, 4, and 7 months after stopping the treatment.
Advances in noninvasive imaging in pediatric cardiology
2013, Advances in Pediatrics
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In the chronic phase, stress echocardiography can be obtained before return to normal activities. Although there are no specific protocols for stress echocardiography in the pediatric population, studies exist with normative values for healthy children, cancer survivors, and heart transplant recipients [22–25]. In our institution, after resolution of myocarditis with acute change in LV function, we typically recommend a follow-up exercise stress echocardiogram (ESE) 6 months after the acute phase, before lifting sports restrictions.
Impaired cardiac reserve in asymptomatic patients with moderate pulmonary restenosis late after relief of severe pulmonary stenosis: Evidence for diastolic dysfunction
2013, International Journal of Cardiology
Patients with moderate pulmonary valve restenosis late after relief of severe pulmonary stenosis (PS) may show decreased exercise tolerance. To elucidate the mechanism of decreased exercise tolerance, we evaluated cardiac response to physical and pharmacological stress in these patients and compared results with those of patients with native moderate PS.
Twenty asymptomatic patients with moderate PS were divided into 2 groups: Group I (late after relief of severe PS, n = 9), and Group II (no previous intervention, n = 11). All patients underwent an exercise test, dobutamine stress (DS) MRI, and delayed contrast enhanced MRI. The response to physical and pharmacological stress was compared between both groups.
Group I showed impaired exercise capacity compared to Group II (VO₂max = 72.8% ± 3.5% vs. 102.5% ± 16.3%, p < 0.001). During DS-MRI, RV-SV increased in Group II, but not in Group I (+ 13 ± 8 ml, − 5 ± 8 ml, p < 0.001). RV end‐diastolic volume decreased significantly in Group I patients (p = 0.006) while it did not significantly change in Group II patients. The amount of RV-SV increase (∆ RV-SV) correlated negatively with the period of moderate PS existence and the current PG in Group I (r = − 0.82, p = 0.007, and r = − 0.68, p = 0.04, respectively) but not in Group II (r = 0.45, p = 0.1, and r = 0.40, p = 0.2, respectively). Furthermore, ∆ RV-SV correlated negatively with the PG before valvuloplasty (r = − 0.76, p = 0.02).
Impaired exercise capacity in patients with moderate pulmonary restenosis after relief of severe PS is probably caused by inability to increase RV-SV. Disturbed RV filling properties, worsening in time, might play a role.
Diagnosis of cardiotoxicity: Role of conventional and advanced cardiovascular imaging
2011, Journal of Cardiovascular Echography
Early recognition of cardiotoxicity from oncologic treatments is essential to set-up a strategy to prevent irreversible damage and heart failure. The left ventricular ejection fraction, regardless of the technique used for its calculation, is today recognized as inadequate to detect early cardiotoxicity and should not be used anymore as the sole index to assess left ventricular function. In the last years, a number of other parameters derived from cardiovascular imaging techniques have been proposed for cardiotoxicity recognition and many of them have shown a greater diagnostic accuracy in predicting acute and chronic cardiac damage or functional impairment caused by oncology treatments compared to the left ventricular ejection fraction. In addition, data are available that show the opportunity to evaluate also heart valves, pericardium and arterial and venous vasculature. However, because all current information on the role of cardiovascular imaging techniques in cardioncology are derived from monocenter, small, non randomized, observational studies, there is the need for large multicenter trials in this field. This is a challenge for both cardiologists and oncologists, who should work together to achieve this goal.
Riconoscere precocemente la cardiotossicità dei trattamenti oncologici è fondamentale per impostare una strategia mirata a evitare l’instaurarsi di danni irreversibili e di scompenso cardiaco. È oggi evidente che la frazione d’eiezione del ventricolo sinistro è inadeguata, indipendentemente dalla tecnica utilizzata per il calcolo, per rilevare la cardiotossicità in fase precoce e non può più essere utilizzata come unico indice per valutare la funzione ventricolare sinistra. Negli ultimi anni numerosi altri parametri derivati da tecniche di imaging cardiovascolare sono stati proposti per il riconoscimento della cardiotossicità dovuta ai trattamenti oncologici e molti hanno mostrato di possedere una maggiore accuratezza diagnostica nel predire la comparsa di danno cardiaco e di compromissione funzionale, acuta e cronica, rispetto alla frazione di eiezione ventricolare sinistra. Inoltre, vari dati indicano l’opportunità di valutare, oltre alla funzione ventricolare, anche le valvole cardiache, il pericardio e il sistema vascolare arterioso e venoso. Tuttavia, occorre considerare che quasi tutte le informazioni attuali sul ruolo delle tecniche di imaging cardiovascolare in ambito cardioncologico sono derivate da studi monocentrici, di dimensioni in genere contenute, non randomizzati e osservazionali: vi è pertanto la necessità di trial clinici ampi e multicentrici, finalizzati a identificare il miglior approccio allo studio della cardiotossicità. Questa è oggi una grande sfida per i cardiologi e gli oncologi, i quali dovrebbero lavorare insieme per raggiungere tale obiettivo.

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Original ArticlesLow-Dose Dobutamine Stress Echocardiography in Children and Young Adults

Abstract

Section snippets

Population

Methods

Results

Discussion

Am J Med

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty

Circulation

Original Articles
Low-Dose Dobutamine Stress Echocardiography in Children and Young Adults