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Coronary Flow Velocity Reserve Using Dobutamine Test for Noninvasive Functional Assessment of Myocardial Bridging
Srdjan B Aleksandric1,2, Ana D Djordjevic-Dikic1,2, Vojislav L Giga1,2
1Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia.
Insights
Coronary flow velocity reserve (CFVR) measured by transthoracic Doppler echocardiography during dobutamine infusion effectively identifies myocardial bridging (MB) associated with ischemia. A CFVR cut-off of ≤2.1 during high-dose dobutamine is a reliable indicator for detecting ischemia in MB patients.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Echocardiography
Background:
- Coronary flow velocity reserve (CFVR) using transthoracic Doppler echocardiography (TTDE) during dobutamine (DOB) is superior to adenosine for evaluating myocardial bridging (MB).
- The specific CFVR cut-off value during DOB for identifying MB-related ischemia remains unclear.
Purpose of the Study:
- To establish the TTDE-CFVR cut-off value during DOB for diagnosing isolated MB.
- To compare TTDE-CFVR with exercise stress-echocardiography (SE)-induced wall motion abnormalities (WMA) as a reference standard.
Main Methods:
- Prospective study of 81 symptomatic patients with isolated MB (≥50% systolic compression) in the LAD.
- Patients underwent treadmill exercise-SE, coronary angiography, and TTDE-CFVR measurement during DOB infusion (10-40 μg/kg/min).
- Quantitative coronary angiography assessed minimal luminal diameter (MLD) and diameter stenosis (DS) at end-systole and end-diastole.
Main Results:
- 23 patients (28%) showed stress-induced WMA.
- CFVR was significantly lower in the SE-positive group (1.94 ± 0.16) versus the SE-negative group (2.78 ± 0.53) (p < 0.001).
- An optimal CFVR cut-off of ≤2.1 during high-dose DOB (>20 µg/kg/min) identified WMA with 96% sensitivity and 95% specificity (AUC 0.986).
- MLD and %DS at end-diastole were independent predictors of ischemic CFVR values ≤2.1.
Conclusions:
- Noninvasive CFVR during DOB is a valuable tool for assessing the functional severity of isolated MB.
- A TTDE-CFVR cut-off of ≤2.1 at high-dose DOB effectively detects myocardial ischemia in patients with isolated MB.
Background:
It has been shown that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during dobutamine (DOB) provocation provides a more accurate functional evaluation of myocardial bridging (MB) compared to adenosine. However; the cut-off value of CFVR during DOB for identification of MB associated with myocardial ischemia has not been fully clarified.
Purpose:
This prospective study aimed to determine the cut-off value of TTDE-CFVR during DOB in patients with isolated-MB, as compared with stress-induced wall motion abnormalities (VMA) during exercise stress-echocardiography (SE) as reference.
Methods:
Eighty-one symptomatic patients (55 males [68%], mean age 56 ± 10 years; range: 27-74 years) with the existence of isolated-MB on the left anterior descending artery (LAD) and systolic MB-compression ≥50% diameter stenosis (DS) were eligible to participate in the study. Each patient underwent treadmill exercise-SE, invasive coronary angiography, and TTDE-CFVR measurements in the distal segment of LAD during DOB infusion (DOB: 10-40 μg/kg/min). Using quantitative coronary angiography, both minimal luminal diameter (MLD) and percent DS at MB-site at end-systole and end-diastole were determined.
Results:
Stress-induced myocardial ischemia with the occurrence of WMA was found in 23 patients (28%). CFVR during peak DOB was significantly lower in the SE-positive group compared with the SE-negative group (1.94 ± 0.16 vs. 2.78 ± 0.53; p < 0.001). ROC analyses identified the optimal CFVR cut-off value ≤ 2.1 obtained during high-dose dobutamine (>20 µg/kg/min) for the identification of MB associated with stress-induced WMA, with a sensitivity, specificity, positive and negative predictive value of 96%, 95%, 88%, and 98%, respectively (AUC 0.986; 95% CI: 0.967-1.000; p < 0.001). Multivariate logistic regression analysis revealed that MLD and percent DS, both at end-diastole, were the only independent predictors of ischemic CFVR values ≤2.1 (OR: 0.023; 95% CI: 0.001-0.534; p = 0.019; OR: 1.147; 95% CI: 1.042-1.263; p = 0.005; respectively).
Conclusions:
Noninvasive CFVR during dobutamine provocation appears to be an additional and important noninvasive tool to determine the functional severity of isolated-MB. A transthoracic CFVR cut-off ≤2.1 measured at a high-dobutamine dose may be adequate for detecting myocardial ischemia in patients with isolated-MB.
