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Re: [echocardiography] Dobutamine induced LVOT obstruction

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  • Thomas Ketteler
    Dear colleagues, we perform up to 1.200 stressechos per year, nearly about half of them with dobutamine. From time to time, we observe Dobutamine induced LVOT
    Message 1 of 5 , Aug 1, 2002
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      Dear colleagues,

      we perform up to 1.200 stressechos per year, nearly about half of them with
      dobutamine. From time to time, we observe Dobutamine induced LVOT obstruction
      especially in patients with known arterial hypertension, small left
      ventricles and left ventricular hypertrophy. If, in addition to these
      conditions, the patient is in a relatively hypovolemic state, dobutamine
      causes LVOT obstruction because of its peripheral vasodilator
      characteristics, which lead to a reduction of the afterload in addition to
      its postive inotropic properties.
      We do not have criteria to stop dobutamine, unless the patient becomes
      symptomatic.

      Thomas Ketteler
      Wuppertal Heart Center
      Med. Clinic 3
      Germany

      acquatellaharry schrieb:

      > Coleagues
      > We routinely perform CW Doppler of the LVOT during Dob Echo Stress.
      > Mostly in pts with concentric LV hypertrophy it is not unusual in
      > some pts to develop a "dagger shaped" increased velocity of the LVOT
      > close to peak Dob dose. We encountered different responses: few pts
      > develop up to 5 m/sec increase in velocity with no symptoms, while
      > others develop blood pressure drops leading to stop the test. None
      > had developed regional wall motion abnormalities. Questions:
      > 1) Do you have a criteria to stop the test according to the increase
      > in velocity even in asymptomatic pts?
      > 2) In your experience which pts are prone to develop this response?
      > Thanks,
      > Harry Acquatella
      > Cento Medico and Hospital Universitario
      > Caracas, Venezuela
      >
      >
      >
      > Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
    • Weiss, Richard
      Our lab has delt with this same issue with dobutamine I tend to stop the study if the gradient reaches 150 mm Hg or the patient becomes symptomatic. Rcihard
      Message 2 of 5 , Aug 1, 2002
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        RE: [echocardiography] Dobutamine induced LVOT obstruction

        Our lab has delt with this same issue with dobutamine
        I tend to stop the study if the gradient reaches >150 mm Hg
        or the patient becomes symptomatic.

        Rcihard Weiss M.D.
        Presbyterian Med Ctr
        Philadelphia, PA

        -----Original Message-----
        From: Thomas Ketteler [mailto:ketteler@...]
        Sent: Thursday, August 01, 2002 5:35 AM
        To: echocardiography@yahoogroups.com
        Subject: Re: [echocardiography] Dobutamine induced LVOT obstruction


        Dear colleagues,

        we perform up to 1.200 stressechos per year, nearly about half of them with
        dobutamine. From time to time, we observe Dobutamine induced LVOT obstruction
        especially in patients with known arterial hypertension, small left
        ventricles and left ventricular hypertrophy. If, in addition to these
        conditions, the patient is in a relatively hypovolemic state, dobutamine
        causes LVOT obstruction because of its peripheral vasodilator
        characteristics, which lead to a reduction of the afterload in addition to
        its postive inotropic properties.
        We do not have criteria to stop dobutamine, unless the patient becomes
        symptomatic.

        Thomas Ketteler
        Wuppertal Heart Center
        Med. Clinic 3
        Germany

        acquatellaharry schrieb:

        > Coleagues
        > We routinely perform CW Doppler of the LVOT during Dob Echo Stress.
        > Mostly in pts with concentric LV hypertrophy it is not unusual in
        > some pts to develop a "dagger shaped" increased velocity of the LVOT
        > close to peak Dob dose. We encountered different responses: few pts
        > develop up to 5 m/sec increase in velocity with no symptoms, while
        > others develop blood pressure drops leading to stop the test. None
        > had developed regional wall motion abnormalities. Questions:
        > 1) Do you have a criteria to stop the test according to the increase
        > in velocity even in asymptomatic pts?
        > 2) In your experience which pts are prone to develop this response?
        > Thanks,
        > Harry Acquatella
        > Cento Medico and Hospital Universitario
        > Caracas, Venezuela
        >
        >
        >
        > Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/


         

        Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/

      • Lothar Faber
        - we have the same observation from time to time (see also: Aurigemma, Circulation 1992, 86, 926 and Faber, Cardiology 1994, 84, 65). Obviously, high-speed
        Message 3 of 5 , Aug 2, 2002
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          - we have the same observation from time to time (see also: Aurigemma,
          Circulation 1992, 86, 926 and Faber, Cardiology
          1994, 84, 65). Obviously, high-speed flow or "obstruction" - whether these two
          are interchangeable, is another discussion - can be generated in a sizeable
          number of thick-walled ventricles. This also raises the question whether
          dobutamine is the adequate stimulus for provoking gradients in HCM in the
          context of septal ablation or other invasive treatment modalities for this
          disease ( - in our opinion, it is not! ) If these flow signals occur, the
          involved ventricular structures should be identified (papillary muscles? mitral
          valve with a SAM? obliterating cavity?) And sometimes, a "real" HOCM is
          identified that way.
          L. Faber


          PRIV. DOZ. DR. LOTHAR FABER
          INTERNAL MEDICINE - CARDIOLOGY
          Cardiovascular Ultrasound Laboratory
          Dept. of Cardiology, Heart Center NRW
          D - 32545 Bad Oeynhausen, Germany
          Phone: +49 - (0) 5731 97-0 ; Fax: 97-1874
          Echo-Lab: 97-1270 to 1272
          e-mail: faber-lothar@...
          lfaber@...-uni-bochum.de


          Thomas Ketteler schrieb:

          > Dear colleagues,
          >
          > we perform up to 1.200 stressechos per year, nearly about half of them with
          > dobutamine. From time to time, we observe Dobutamine induced LVOT obstruction
          > especially in patients with known arterial hypertension, small left
          > ventricles and left ventricular hypertrophy. If, in addition to these
          > conditions, the patient is in a relatively hypovolemic state, dobutamine
          > causes LVOT obstruction because of its peripheral vasodilator
          > characteristics, which lead to a reduction of the afterload in addition to
          > its postive inotropic properties.
          > We do not have criteria to stop dobutamine, unless the patient becomes
          > symptomatic.
          >
          > Thomas Ketteler
          > Wuppertal Heart Center
          > Med. Clinic 3
          > Germany
          >
          > acquatellaharry schrieb:
          >
          > > Coleagues
          > > We routinely perform CW Doppler of the LVOT during Dob Echo Stress.
          > > Mostly in pts with concentric LV hypertrophy it is not unusual in
          > > some pts to develop a "dagger shaped" increased velocity of the LVOT
          > > close to peak Dob dose. We encountered different responses: few pts
          > > develop up to 5 m/sec increase in velocity with no symptoms, while
          > > others develop blood pressure drops leading to stop the test. None
          > > had developed regional wall motion abnormalities. Questions:
          > > 1) Do you have a criteria to stop the test according to the increase
          > > in velocity even in asymptomatic pts?
          > > 2) In your experience which pts are prone to develop this response?
          > > Thanks,
          > > Harry Acquatella
          > > Cento Medico and Hospital Universitario
          > > Caracas, Venezuela
          > >
          > >
          > >
          > > Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
          >
          >
          >
          > Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
        • Dr. Jamil Mattar Valente, MD, MSc
          We have a female patient, 35 years old, which presented syncope episodes to physical efforts. She was submitted to a treadmill exercise test. On third stage of
          Message 4 of 5 , Aug 3, 2002
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            We have a female patient, 35 years old, which presented syncope episodes to
            physical efforts. She was submitted to a treadmill exercise test. On third
            stage of Bruce's protocol, she had precordial pain, blood pressure drop and
            incapacity to maintain herself stand up and the exam was suspended
            immediately. The echocardiogram was entirely normal. She was submitted to a
            coronary arteriography, which was also normal. We performed a stress
            echocardiogram with dobutamine. On third stage, with 20 mcg/Kg/min, she
            presented precordial pain, drop of the blood pressure, and velocity of the
            flow in the left ventricular outflow tract was 5 m/s. The exam was
            interrupted immediately, and after returning to the basal conditions, there
            was complete resolution of the intraventricular pressure gradient. Because
            she has bronchial asthma, we couldn't use beta blocker. We opted for
            verapamil. She now is well, just with limitation to great efforts. She does
            not tolerate verapamil withdrawal. I think that just as this one patient,
            similar cases should exist, with symptoms to physical efforts, normal
            cardiac evaluation at rest (no cardiomyopathy, no systolic anterior movement
            of anterior mitral leaflet at rest), but with dynamic LV outflow obstruction
            only to physical efforts or with dobutamine. The dobutamine stress
            echocardiography may be able to help us to identify these patients.

            Jamil Mattar Valente, MD
            jamil@...
            Universidade Federal de Santa Catarina
            Instituto de Cardiologia de Santa Catarina
            Florianopolis, Brazil

            ----- Original Message -----
            From: "Lothar Faber" <lfaber@...>
            To: <echocardiography@yahoogroups.com>
            Sent: Friday, August 02, 2002 7:55 AM
            Subject: Re: [echocardiography] Dobutamine induced LVOT obstruction


            > - we have the same observation from time to time (see also: Aurigemma,
            > Circulation 1992, 86, 926 and Faber, Cardiology
            > 1994, 84, 65). Obviously, high-speed flow or "obstruction" - whether
            these two
            > are interchangeable, is another discussion - can be generated in a
            sizeable
            > number of thick-walled ventricles. This also raises the question whether
            > dobutamine is the adequate stimulus for provoking gradients in HCM in the
            > context of septal ablation or other invasive treatment modalities for
            this
            > disease ( - in our opinion, it is not! ) If these flow signals occur, the
            > involved ventricular structures should be identified (papillary muscles?
            mitral
            > valve with a SAM? obliterating cavity?) And sometimes, a "real" HOCM is
            > identified that way.
            > L. Faber
            >
            >
            > PRIV. DOZ. DR. LOTHAR FABER
            > INTERNAL MEDICINE - CARDIOLOGY
            > Cardiovascular Ultrasound Laboratory
            > Dept. of Cardiology, Heart Center NRW
            > D - 32545 Bad Oeynhausen, Germany
            > Phone: +49 - (0) 5731 97-0 ; Fax: 97-1874
            > Echo-Lab: 97-1270 to 1272
            > e-mail: faber-lothar@...
            > lfaber@...-uni-bochum.de
            >
            >
            > Thomas Ketteler schrieb:
            >
            > > Dear colleagues,
            > >
            > > we perform up to 1.200 stressechos per year, nearly about half of them
            with
            > > dobutamine. From time to time, we observe Dobutamine induced LVOT
            obstruction
            > > especially in patients with known arterial hypertension, small left
            > > ventricles and left ventricular hypertrophy. If, in addition to these
            > > conditions, the patient is in a relatively hypovolemic state, dobutamine
            > > causes LVOT obstruction because of its peripheral vasodilator
            > > characteristics, which lead to a reduction of the afterload in addition
            to
            > > its postive inotropic properties.
            > > We do not have criteria to stop dobutamine, unless the patient becomes
            > > symptomatic.
            > >
            > > Thomas Ketteler
            > > Wuppertal Heart Center
            > > Med. Clinic 3
            > > Germany
            > >
            > > acquatellaharry schrieb:
            > >
            > > > Coleagues
            > > > We routinely perform CW Doppler of the LVOT during Dob Echo Stress.
            > > > Mostly in pts with concentric LV hypertrophy it is not unusual in
            > > > some pts to develop a "dagger shaped" increased velocity of the LVOT
            > > > close to peak Dob dose. We encountered different responses: few pts
            > > > develop up to 5 m/sec increase in velocity with no symptoms, while
            > > > others develop blood pressure drops leading to stop the test. None
            > > > had developed regional wall motion abnormalities. Questions:
            > > > 1) Do you have a criteria to stop the test according to the increase
            > > > in velocity even in asymptomatic pts?
            > > > 2) In your experience which pts are prone to develop this response?
            > > > Thanks,
            > > > Harry Acquatella
            > > > Cento Medico and Hospital Universitario
            > > > Caracas, Venezuela
            > > >
            > > >
            > > >
            > > > Your use of Yahoo! Groups is subject to
            http://docs.yahoo.com/info/terms/
            > >
            > >
            > >
            > > Your use of Yahoo! Groups is subject to
            http://docs.yahoo.com/info/terms/
            >
            >
            >
            >
            > Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
            >
            >
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