Dobutamine Echocardiography for Assessment of Viability in the Current Era

Purpose of review Studies from the 1990s and early 2000s documented the utility of dobutamine echocardiography for the prediction of functional recovery and prognosis with revascularization. The results of The Surgical Treatment of Ischemic Heart Failure (STICH) trial called into question the value of viability assessment using dobutamine echocardiography. The purpose of this review is to re-examine the literature on dobutamine echocardiography, put into context the STICH results, and provide insight into the current role of dobutamine echocardiography viability testing. Recent findings In contrast to the results of previous nonrandomized trials, the STICH trial showed that patients with viability defined by nuclear perfusion imaging or dobutamine echocardiography did not have improved survival with CABG compared with optimal medical therapy. Viability by dobutamine echocardiography was defined as the presence of contractile reserve in at least five segments with baseline dysfunction. The results of dobutamine echocardiography studies published before and after initiation of the STICH trial suggest that the definition of viability utilized in that trial may be suboptimal for assessment of improvement in global function and prognosis in patients undergoing revascularization. Assessment of global contractile reserve using wall motion score (WMS) or ejection fraction may be superior to utilization of a binary definition of viability confined to assessment of contractile reserve in a fixed number of segments because these indices provide information on both the magnitude and extent of contractile reserve of the entire left ventricle (LV). Summary Assessment of WMS or ejection fraction with dobutamine echocardiography may be the optimal means of evaluating the impact of viability on prognosis. Video abstract http://links.lww.com/HCO/A5

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19 Infection

Respiratory failure is a major cause of mortality among hospitalized patients with COVID-19. Previous studies have shown that right ventricular (RV) dilation and reduced RV longitudinal strain are markers of poor outcome in this disease. COVID-19 can cause direct myocardial injury resulting in left ventricular (LV) systolic dysfunction and heart failure suggesting that assessment of LV function might also have prognostic value. Reduction of longitudinal systolic function assessed by mitral annular plane systolic excursion (MAPSE) is an early indicator of myocardial disease in various cardiac disorders. In this retrospective study, we investigated the prognostic value of MAPSE in patients admitted with respiratory failure related to COVID-19 infection

Safety and feasibility of dopamine-atropine stress echocardiography

Background Dobutamine-atropine stress echocardiography (DSE) has lower sensitivity in patients with advanced liver disease (ALD) due to vasodilation. Hypothesis Dopamine-atropine stress echocardiography (DopSE) may be an alternative to DSE in ALD patients by improving the blood pressure response to stress. Methods The safety and tolerability of DSE and DopSE were compared in 10 volunteers. The safety, adverse effects, and efficacy of DopSE were then assessed in 105 patients, 98 of whom had ALD. Dopamine was infused in stepwise fashion from 5 µg/kg/min to a peak dose of 40 µg/kg/min. Atropine was given before and in early stages of dopamine infusion up to cumulative dose of 1.5 mg. The hemodynamic responses of 98 ALD patients were compared with 102 patients with ALD who underwent standard DSE. Results In normal volunteers, systolic BP increased more with DopSE compared to DSE (61 ± 19 mm Hg vs 39 ± 15 mm Hg, P = .008). In 105 patients who underwent DopSE, none had adverse effects that required early stress termination. In the groups with ALD, the systolic BP increase (38 ± 28 mm Hg vs 12 ± 27 mm Hg, P < .001) and peak rate pressure product (RPP) (22 861 ± 5289 vs 17 211 ± 3848, P = <.001) were both higher in those undergoing DopSE versus DSE. The sensitivity and specificity of DopSE were 45% and 88%, respectively for coronary disease (≥70% stenosis) in 37 patients who had angiography. Conclusions Dopamine-atropine stress echocardiography appears to be a safe stress modality and provides greater increases in RPP in patients with ALD compared to DSE

Haemodynamic effects of the nitroxyl donor cimlanod (BMS-986231) in chronic heart failure: a randomized trial

Aims Nitroxyl provokes vasodilatation and inotropic and lusitropic effects in animals via post-translational modification of thiols. We aimed to compare effects of the nitroxyl donor cimlanod (BMS-986231) with those of nitroglycerin (NTG) or placebo on cardiac function in patients with chronic heart failure with reduced ejection fraction (HFrEF). Methods and results In a randomized, multicentre, double-blind, crossover trial, 45 patients with stable HFrEF were given a 5 h intravenous infusion of cimlanod, NTG, or placebo on separate days. Echocardiograms were done at the start and end of each infusion period and read in a core laboratory. The primary endpoint was stroke volume index derived from the left ventricular outflow tract at the end of each infusion period. Stroke volume index with placebo was 30 ± 7 mL/m2 and was lower with cimlanod (29 ± 9 mL/m2; P = 0.03) and NTG (28 ± 8 mL/m2; P = 0.02). Transmitral E-wave Doppler velocity on cimlanod or NTG was lower than on placebo and, consequently, E/e′ (P = 0.006) and E/A ratio (P = 0.003) were also lower. NTG had similar effects to cimlanod on these measurements. Blood pressure reduction was similar with cimlanod and NTG and greater than with placebo. Conclusion In patients with chronic HFrEF, the haemodynamic effects of cimlanod and NTG are similar. The effects of cimlanod may be explained by venodilatation and preload reduction without additional inotropic or lusitropic effects. Ongoing trials of cimlanod will further define its potential role in the treatment of heart failure

Using Clinical Data Repositories to Assess the Clinical and Financial Burden of Disease: The Example of Mitral Regurgitation

Although there have been tremendous advances in understanding various disease outcomes, there are significant gaps and the associated costs to investigate disease burden can be exorbitant. Clinical data repositories can be a valuable aid for analysing patient and disease characteristics in a faster and most cost-effective manner. We offer our own example, using mitral regurgitation as the illustration of a disease process that was identified through the use of a clinical data repository in a subset of patients, matched with a control population, and then analysed for clinical and financial factors. Increasing adoption of digital systems to store and analyse large volumes of data paired with incentives by the government and various health systems makes the current environment ripe for an explosion of big data to help guide clinical decision making

Advances in Multimodality Imaging in&nbsp;Cardio-Oncology: JACC State-of-the-Art Review.

The population of patients with cancer is rapidly expanding, and the diagnosis and monitoring of cardiovascular complications greatly rely on imaging. Numerous advances in the field of cardio-oncology and imaging have occurred in recent years. This review presents updated and practical approaches for multimodality cardiovascular imaging in the cardio-oncology patient and provides recommendations for imaging to detect the myriad of adverse cardiovascular effects associated with antineoplastic therapy, such as cardiomyopathy, atherosclerosis, vascular toxicity, myocarditis, valve disease, and cardiac masses. Uniquely, we address the role of cardiovascular imaging in patients with pre-existing cardiomyopathy, pregnant patients, long-term survivors, and populations with limited resources. We also address future avenues of investigation and opportunities for artificial intelligence applications in cardio-oncology imaging. This review provides a uniform practical approach to cardiovascular imaging for patients with cancer