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Dobutamine stress echocardiography: experience in pediatric heart transplant recipients
E Pahl1, S E Crawford, J M Swenson
1Heart Transplantation, The Children's Memorial Hospital, Chicago, Illinois 60614, USA.
Insights
Dobutamine stress echocardiography shows promise for detecting transplant coronary arteriopathy in pediatric patients. Abnormalities during stress tests correlated with coronary artery disease, aiding in risk stratification.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Transplant Medicine
Background:
- Transplant coronary arteriopathy is a significant cause of late mortality in heart transplant recipients.
- Noninvasive detection of transplant coronary arteriopathy remains challenging.
- Dobutamine stress echocardiography is increasingly used for risk stratification in adult heart transplant recipients.
Purpose of the Study:
- To investigate the utility of dobutamine stress echocardiography for detecting transplant coronary arteriopathy in pediatric heart transplant recipients.
- To assess the correlation between stress echocardiographic findings and confirmed coronary arteriopathy.
- To evaluate the potential of dobutamine stress echocardiography for risk stratification in this population.
Main Methods:
- 46 dobutamine stress echocardiography studies were performed in pediatric heart transplant recipients (mean age 11.8 years, mean post-transplant duration 4.3 years).
- A standardized atropine/dobutamine protocol was employed to achieve target heart rates, with serial echocardiographic acquisitions.
- Study findings were correlated with endomyocardial biopsy, coronary angiography, or autopsy data.
Main Results:
- Target heart rate was achieved in 89% of studies, with significant increases in heart rate and blood pressure.
- Coronary arteriopathy was confirmed in 5 patients, with associated abnormalities including reversible wall motion abnormalities, left ventricular dilation, and ischemia.
- Positive stress echocardiography studies significantly predicted death or graft failure (p < .0005).
Conclusions:
- Echocardiographic abnormalities during dobutamine stress testing correlated with the presence of coronary arteriopathy in pediatric heart transplant recipients.
- These findings suggest dobutamine stress echocardiography may be a valuable tool for risk stratification.
- Larger, multi-center studies are needed to confirm the utility of this method for coronary disease risk stratification in pediatric transplant recipients.
Background:
Transplant coronary arteriopathy causes late death and is difficult to detect noninvasively. Dobutamine stress echocardiography is being used for risk stratification in adult recipients at some transplant centers, thus we investigated its role in a pediatric population.
Methods:
We performed 46 stress echo studies (mean age = 11.8 years; mean years post transplantation = 4.3). An atropine/dobutamine protocol (5-40 mcg/kg/min) was used to attain a predicted target heart rate. Serial echocardiographic images were acquired at baseline and at each increment of dobutamine and recovery, and were digitized online. Data were correlated with endomyocardial biopsy (n = 23), coronary angiography (n = 26) or autopsy (n = 6). All studies were well tolerated.
Results:
Target heart rate was achieved in 41/46 (89%) studies. The mean heart rate significantly increased from 95 to 169 beats/min and mean systolic blood pressure from 123 to 153 mm Hg (p<.05). The mean peak pressure-rate product was 23,041 beats-mm Hg/min. Coronary arteriopathy was confirmed in 5 patients by angiography (n = 3) explanted heart (n = 1) or autopsy (n = 4). In this group, abnormalities included a new reversible wall motion abnormality (n = 2), left ventricular cavity dilation with stress (n = 3), ischemia (n = 2), increased mitral insufficiency (n = 1) and marked diastolic dysfunction (n = 1). A positive study predicted death or graft failure (p< .0005).
Conclusions:
Echocardiographic abnormalities during stress correlated with coronary arteriopathy in this small cohort of patients; however, larger multi-center studies are warranted to assess the utility of dobutamine stress echocardiography for risk stratification for coronary disease in pediatric transplant recipients.