{"title":"低梯度主动脉瓣狭窄的多巴酚丁胺应激超声心动图检查","authors":"","doi":"10.1016/j.echo.2024.06.017","DOIUrl":null,"url":null,"abstract":"<div><h3>Importance</h3><div>Guidelines recommend the use of dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity of DSE data exists when LVEF >35%.</div></div><div><h3>Objective</h3><div>To examine the diagnostic accuracy of DSE in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF.</div></div><div><h3>Design, Setting, and Participants</h3><div>Patients with mean gradient <40 mm Hg, aortic valve area <1.0 cm<sup>2</sup>, and stroke volume index ≤35 mL/m<sup>2</sup> undergoing DSE and cardiac computer tomography (C-CT) were identified from 3 prospectively collected patient cohorts and stratified according to LVEF: LVEF<35%, LVEF 35% to 50%, and LVEF>50%.</div></div><div><h3>Exposure</h3><div>Dobutamine stress echocardiography and C-CT were performed on patients with low-gradient AS.</div></div><div><h3>Main Outcomes and Measures</h3><div>Severe AS was defined as aortic valve calcification score ≥2,000 arbitrary units (AU) among men and ≥1,200 AU for women on C-CT.</div></div><div><h3>Results</h3><div>Of 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35% to 50%, and 76 (34%) with LVEF >50%. Mean-gradient and aortic valve peak velocity during DSE showed significant diagnostic heterogeneity between LVEF groups, being most precise when LVEF <35% (both areas under the curve [AUC] = 0.90), albeit with optimal thresholds of 30 mm Hg and 377 cm/sec and a limited diagnostic yield in patients with LVEF ≥35% (AUC = 0.67 and 0.66 in LVEF 35% to 50% and AUC = 0.65 and 0.60 in LVEF ≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF <50%.</div></div><div><h3>Conclusion and Relevance</h3><div>While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with the highest accuracy in patients with LVEF <35%.</div></div>","PeriodicalId":50011,"journal":{"name":"Journal of the American Society of Echocardiography","volume":null,"pages":null},"PeriodicalIF":5.4000,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis\",\"authors\":\"\",\"doi\":\"10.1016/j.echo.2024.06.017\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Importance</h3><div>Guidelines recommend the use of dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity of DSE data exists when LVEF >35%.</div></div><div><h3>Objective</h3><div>To examine the diagnostic accuracy of DSE in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF.</div></div><div><h3>Design, Setting, and Participants</h3><div>Patients with mean gradient <40 mm Hg, aortic valve area <1.0 cm<sup>2</sup>, and stroke volume index ≤35 mL/m<sup>2</sup> undergoing DSE and cardiac computer tomography (C-CT) were identified from 3 prospectively collected patient cohorts and stratified according to LVEF: LVEF<35%, LVEF 35% to 50%, and LVEF>50%.</div></div><div><h3>Exposure</h3><div>Dobutamine stress echocardiography and C-CT were performed on patients with low-gradient AS.</div></div><div><h3>Main Outcomes and Measures</h3><div>Severe AS was defined as aortic valve calcification score ≥2,000 arbitrary units (AU) among men and ≥1,200 AU for women on C-CT.</div></div><div><h3>Results</h3><div>Of 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35% to 50%, and 76 (34%) with LVEF >50%. Mean-gradient and aortic valve peak velocity during DSE showed significant diagnostic heterogeneity between LVEF groups, being most precise when LVEF <35% (both areas under the curve [AUC] = 0.90), albeit with optimal thresholds of 30 mm Hg and 377 cm/sec and a limited diagnostic yield in patients with LVEF ≥35% (AUC = 0.67 and 0.66 in LVEF 35% to 50% and AUC = 0.65 and 0.60 in LVEF ≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF <50%.</div></div><div><h3>Conclusion and Relevance</h3><div>While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with the highest accuracy in patients with LVEF <35%.</div></div>\",\"PeriodicalId\":50011,\"journal\":{\"name\":\"Journal of the American Society of Echocardiography\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":5.4000,\"publicationDate\":\"2024-11-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Journal of the American Society of Echocardiography\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://www.sciencedirect.com/science/article/pii/S0894731724003456\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"CARDIAC & CARDIOVASCULAR SYSTEMS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of the American Society of Echocardiography","FirstCategoryId":"3","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S0894731724003456","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}
Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis
Importance
Guidelines recommend the use of dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity of DSE data exists when LVEF >35%.
Objective
To examine the diagnostic accuracy of DSE in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF.
Design, Setting, and Participants
Patients with mean gradient <40 mm Hg, aortic valve area <1.0 cm2, and stroke volume index ≤35 mL/m2 undergoing DSE and cardiac computer tomography (C-CT) were identified from 3 prospectively collected patient cohorts and stratified according to LVEF: LVEF<35%, LVEF 35% to 50%, and LVEF>50%.
Exposure
Dobutamine stress echocardiography and C-CT were performed on patients with low-gradient AS.
Main Outcomes and Measures
Severe AS was defined as aortic valve calcification score ≥2,000 arbitrary units (AU) among men and ≥1,200 AU for women on C-CT.
Results
Of 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35% to 50%, and 76 (34%) with LVEF >50%. Mean-gradient and aortic valve peak velocity during DSE showed significant diagnostic heterogeneity between LVEF groups, being most precise when LVEF <35% (both areas under the curve [AUC] = 0.90), albeit with optimal thresholds of 30 mm Hg and 377 cm/sec and a limited diagnostic yield in patients with LVEF ≥35% (AUC = 0.67 and 0.66 in LVEF 35% to 50% and AUC = 0.65 and 0.60 in LVEF ≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF <50%.
Conclusion and Relevance
While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with the highest accuracy in patients with LVEF <35%.
期刊介绍:
The Journal of the American Society of Echocardiography(JASE) brings physicians and sonographers peer-reviewed original investigations and state-of-the-art review articles that cover conventional clinical applications of cardiovascular ultrasound, as well as newer techniques with emerging clinical applications. These include three-dimensional echocardiography, strain and strain rate methods for evaluating cardiac mechanics and interventional applications.