Real-time three-dimensional dobutamine stress echocardiography for coronary artery disease diagnosis: validation with coronary angiography

Abstract

Objective: To compare real-time three-dimensional echocardiography (RT3DE) with two-dimensional dobutamine stress echocardiography (2DE) for the detection of myocardial ischaemia, with angiographic validation of the results. Methods: 56 patients (mean (SD) age 64.5 (6.2) years, 38 males), referred for coronary angiography, were examined by 2DE and RT3DE during the same dobutamine stress protocol. Results: All 56 patients completed the stress protocol uneventfully. The mean (SD) acquisition time for the necessary views to evaluate all segments was 26.3 (2.5) s for RT3DE and 58.8 (3.7) s for 2DE (p,0.001). At peak stress, RT3DE had a higher wall-motion score index (1.25 (0.24) by 2DE, 1.30 (0.27) by RT3DE; p = 0.014). The regional wall-motion score for the four apical segments at peak stress was compared; it was 1.35 (0.55) by 2DE and 1.52 (0.69) by RT3DE (p = 0.003). The diagnostic parameters of 2DE versus RT3DE were: sensitivity 73% vs 78%, specificity 93% vs 89% and overall accuracy 86% vs 85%, respectively. In the left anterior descending artery territory, in particular, where RT3DE had higher regional wall-motion scores, it showed a tendency towards higher sensitivity (85% vs 78%), although this difference did not achieve statistical significance. Conclusion: RT3DE identifies wall-motion abnormalities more readily in the apical region than 2DE, which may explain the tendency towards higher sensitivity in the left anterior descending artery territory. RT3DE results were validated using angiography as reference and findings indicate diagnostic equivalence to 2DE, with the advantage of considerable shorter acquisition times. D obutamine stress echocardiography has become a well established method of myocardial functional assessment in the diagnosis of coronary artery disease and in evaluation of its prognosis.1-4 The advent of echocardiography machines integrating all necessary systems for performing realtime three-dimensional echocardiography (RT3DE) holds promise as a new useful tool in cardiovascular ultrasonographic imaging. However, the clinical utility of this tool has yet to be adequately investigated. Particularly in the field of diagnosis of coronary artery disease, there is a marked lack of data regarding the usefulness of RT3DE. Our aim was to evaluate RT3DE in detecting myocardial wall-motion abnormalities during a standard dobutamine stress protocol, in comparison to twodimensional echocardiography (2DE), with coronary angiography as the reference method for assessing the diagnostic power of this modality (fig 1). METHODS Study populationThe study population included 56 patients (mean (SD) age 64.5 (6.2) years, 38 males), referred for coronary angiography to the cardiac catheterisation laboratory of a tertiary hospital. All patients were in sinus rhythm. Exclusion criteria included the presence of symptoms of heart failure, a suspected or proven acute coronary event within the previous month, history of sustained ventricular tachycardia, moderate or severe valvular disease, uncontrolled hypertension...

Real-time three-dimensional echocardiography: never before clinical efficacy looked so picturesque

“…The feasibility of real time 3DE and its good concordance with 2D echo on wall motion analysis for detection of inducible ischemia has been reported in several studies (Table 3) [19][20][21][22][23][24][25]. With the exception of few authors [24], reported sensitivity rates are high.…”

“…The strongest point of wall-motion evaluation using 3D echo lies in the evaluation of left anterior descending disease, which is based on the inherent ability of 3D to successfully image the true left ventricular apex. Badano et al [27], using dipyridamole as stressor, proved that 3D echocardiography is feasible for the diagnosis of CAD, based on wallmotion analysis, especially for the left anterior descending vascular bed, while in our recent study, using dobutamine as stressor, the ability of RT3D imaging to overcome left ventricular foreshortening has been reported to improve the detection of apical ischemia [19].…”

“…This could assist in determining the extent of wall motion abnormalities as well as in ruling out artifacts frequently noted in standard imaging planes due to limited endocardial visualization. Moreover, conventional 2D echo requires significant experience in image acquisition, while 3D can provide information even by an inexperienced user [19].…”

Regional Mechanics of Demand Ischemia During Cardiac Stress Testing

“…16 DSE can also be performed using three-dimensional echocardiography (3DE), which captures a pyramidal volume image of the entire LV. 17 DSE using 3DE has been shown to be diagnostically equivalent to 2DE with reduced acquisition time, 18 although lower quality images and lack of single beat acquisition has so far prevented widespread clinical acceptance. 19 One complicating factor in the specificity of stress testing is the prevalence of previous MI or previously unrecognized MI in the patient population.…”

“…However, the data reported in the literature presents a more uncertain view. Data describing global function during dobutamine stress is quite limited, with one study reporting increased EF 131 and a few reporting either no change in stroke volume (SV) at intermediate stress of [15][16][17][18][19][20] μg/kg/min 132 or increased SV at intermediate stress but no change in SV at peak stress. 133,134 Data describing the regional mechanical function of the left ventricle (LV) are more prevalent for established measures of regional mechanics, but can also be conflicting.…”