Dobutamine stress echocardiography predicts surgical outcome in patients with an aortic aneurysm and peripheral vascular disease

Cardiovascular Division, Washington University School of Medicine, Saint Louis, Missouri 63110.

OBJECTIVES. This study was conducted to assess the utility of dobutamine stress echocardiography for determining the presence of significant coronary artery disease and for predicting surgical outcome and long-term prognosis in patients scheduled to undergo peripheral vascular or aortic aneurysm surgery. BACKGROUND. Assessment of coronary artery disease in patients scheduled to undergo peripheral vascular surgery can avoid perioperative complications. METHODS. Dobutamine stress echocardiography was performed in 98 consecutive patients scheduled to undergo aortic or peripheral vascular surgery. Intravenous dobutamine was infused in a graded fashion, with two-dimensional digital echocardiographic monitoring of ventricular function and segmental wall motion. Group 1 (n = 70) consisted of patients who exhibited a normal response to dobutamine infusion (negative dobutamine study); group 2 (n = 23) comprised those patients with an abnormal response to dobutamine, characterized by the development of new or worsening wall motion abnormalities at rest, indicating the presence of myocardial ischemia (positive dobutamine study). Five patients with an inconclusive dobutamine study (because of inadequate heart rate) were excluded from analysis. RESULTS. No major adverse effects occurred with testing in any patient. Sixty-eight of 70 patients with a negative study had peripheral vascular or aortic surgery performed without perioperative cardiac events (2 patients refused surgery). Nineteen of 23 patients with a positive study underwent coronary angiography and all had > 50% lumen narrowing in one or more major coronary artery distributions; 13 underwent coronary artery bypass grafting or angioplasty before peripheral vascular or aortic surgery and all had an uneventful perioperative period. Four of the 10 patients from group 2 who did not undergo coronary revascularization had a perioperative cardiac event (myocardial infarction in 2, an ischemic episode requiring urgent coronary bypass grafting in 1 and congestive heart failure in 1). CONCLUSIONS. Positive and negative dobutamine study results are significant predictors of the presence or absence of perioperative events (20% vs. 0%, p = 0.003). A positive test warrants coronary angiography and further medical or surgical intervention, or both, but a negative test indicates a low likelihood of perioperative cardiac complications of aortic or peripheral vascular surgery. During the long-term follow-up period in this study (group 1 mean, 24 months; group 2 mean, 15 months), two patients (3%) from group 1 and three (15%) from group 2 developed cardiac complications (p = 0.038). Thus, dobutamine stress echocardiography is safe and can predict surgical outcome in patients undergoing aortic aneurysm repair or surgery for occlusive disease of the peripheral arteries. In addition, a negative test result is a strong predictor of decreased perioperative and long-term cardiac morbidity and mortality.

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