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CLINICAL RESEARCH: VALVULAR HEART DISEASE

Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis

Gilmar Reis, MD, PhD^*,*, Mauro S. Motta, MD, Marcia M. Barbosa, MD, PhD^*, William A. Esteves, MD, Sonia F. Souza, MD and Edimar A. Bocchi, MD, PhD^||

^* Cardiovascular Research Program, Pontificia Universidade Catolica de Minas Gerais, Belo Horizonte, Brazil
Cardiologica, Clinica de Diagnostico Cardiovascular, Belo Horizonte, Brazil
Ecocenter, Vera Cruz and Socor Hospitals, Belo Horizonte, Brazil
Division of Cardiology, Vera Cruz Hospital, Belo Horizonte, Brazil
^|| Heart Institute–University of Sao Paulo Medical School, Sao Paulo, Brazil

Manuscript received October 11, 2002; revised manuscript received September 17, 2003, accepted September 26, 2003.

^* Reprint requests and correspondence: Dr. Gilmar Reis, Pontificia Universidade Catolica de Minas Gerais, R. Grao Para 454, Santa Efigenia, 30150-340 Belo Horizonte–MG, Brazil.
greis{at}pucminas.br

OBJECTIVES: We sought to evaluate the impact of dobutamine stress echocardiography (DSE) in patients with known rheumatic mitral stenosis (MS) in order to assess its safety, feasibility, and prognostic correlation to well-known clinical outcomes.

BACKGROUND: Noninvasive prognostic assessment of MS still represents an unresolved task in patients with clinically challenging disease.

METHODS: Dobutamine stress echocardiography was performed in 53 patients with MS (8 males; age 37.4 ± 11.3 years) with no major complications.

RESULTS: During follow-up (60.5 ± 11.0 months), 29 patients presented with clinical events: 16 hospitalizations, seven cases of acute pulmonary edema, and six symptomatic supraventricular arrhythmias. On multivariate analysis, the diastolic mitral valve mean gradient at peak DSE (DSE-MG) was the best predictor of clinical events (p < 0.008), especially in patients with moderate disease (p < 0.001). The best performance of DSE for the detection of clinical events was obtained at a cut-off value of 18 mm Hg DSE-MG (sensitivity 90%, specificity 87%, and accuracy 90%). The addition of DSE to the conventional cardiology work-up would allow a 17% increment for the detection of high-risk patients in the entire population and a 40% increment in patients with presumed moderate disease.

CONCLUSIONS: In patients with MS, DSE is a safe and highly feasible stress test. A DSE-MG 18 mm Hg identifies a subgroup of high-risk patients in whom a more aggressive approach may be warranted; on the other hand, patients with a DSE-MG <18 mm Hg predicts an uneventful clinical course and may justify a more conservative strategy.

Abbreviations and Acronyms   AF = atrial fibrillation   CAD = coronary artery disease   DSE = dobutamine stress echocardiography   DSE-MG = mean diastolic mitral valve gradient at peak dobutamine stress echocardiography   LV = left ventricular   MR = mitral regurgitation   MS = mitral stenosis   MVA = mitral valve orifice area   NYHA = New York Heart Association   TR = tricuspid regurgitation

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