Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis

Nils Sofus Borg Mogensen; Mulham Ali; Rasmus Carter-Storch; Mohamed-Salah Annabi; Jasmine Grenier-Delaney; Jacob Eifer Møller; Kristian Altern Øvrehus; Patricia A Pellikka; Philippe Pibarot; Marie-Annick Clavel; Jordi Sanchez Dahl

doi:10.1016/j.echo.2024.06.017

Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis

Nils Sofus Borg Mogensen^*, Mulham Ali, Rasmus Carter-Storch, Mohamed-Salah Annabi, Jasmine Grenier-Delaney, Jacob Eifer Møller, Kristian Altern Øvrehus, Patricia A Pellikka, Philippe Pibarot, Marie-Annick Clavel, Jordi Sanchez Dahl

^*Corresponding author for this work

Department of Cardiology

Abstract

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%.

Original language	English
Journal	Journal of the American Society of Echocardiography
ISSN	0894-7317
DOIs	https://doi.org/10.1016/j.echo.2024.06.017
Publication status	E-pub ahead of print - 5 Jul 2024

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10.1016/j.echo.2024.06.017

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Mogensen, N. S. B., Ali, M., Carter-Storch, R., Annabi, M.-S., Grenier-Delaney, J., Møller, J. E., Øvrehus, K. A., Pellikka, P. A., Pibarot, P., Clavel, M.-A., & Dahl, J. S. (2024). Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis. Journal of the American Society of Echocardiography. Advance online publication. https://doi.org/10.1016/j.echo.2024.06.017

@article{4980e4285a5247fe89d70be639d4c999,

title = "Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis",

abstract = "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%.",

author = "Mogensen, {Nils Sofus Borg} and Mulham Ali and Rasmus Carter-Storch and Mohamed-Salah Annabi and Jasmine Grenier-Delaney and M{\o}ller, {Jacob Eifer} and {\O}vrehus, {Kristian Altern} and Pellikka, {Patricia A} and Philippe Pibarot and Marie-Annick Clavel and Dahl, {Jordi Sanchez}",

note = "Copyright {\textcopyright} 2024. Published by Elsevier Inc.",

year = "2024",

month = jul,

day = "5",

doi = "10.1016/j.echo.2024.06.017",

language = "English",

journal = "Journal of the American Society of Echocardiography",

issn = "0894-7317",

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T1 - Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis

AU - Mogensen, Nils Sofus Borg

AU - Ali, Mulham

AU - Carter-Storch, Rasmus

AU - Annabi, Mohamed-Salah

AU - Grenier-Delaney, Jasmine

AU - Møller, Jacob Eifer

AU - Øvrehus, Kristian Altern

AU - Pellikka, Patricia A

AU - Pibarot, Philippe

AU - Clavel, Marie-Annick

AU - Dahl, Jordi Sanchez

PY - 2024/7/5

Y1 - 2024/7/5

N2 - 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%.

AB - 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%.

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U2 - 10.1016/j.echo.2024.06.017

DO - 10.1016/j.echo.2024.06.017

M3 - Journal article

C2 - 38972614

SN - 0894-7317

JO - Journal of the American Society of Echocardiography

JF - Journal of the American Society of Echocardiography

ER -

Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis

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