Authors: P Ciliberti I McLeod F Cairello J P Kaski M Fenton A Giardini J Marek
Publish Date: 2014/11/20
Volume: 36, Issue: 3, Pages: 633-639
Abstract
Although exercise stress echocardiography ESE is a wellvalidated technique in adult population its use in children is quite limited We aimed to assess the feasibility the safety and the reproducibility of ESE using online scanning in semisupine cycloergometer protocol in a large pediatric population Between July 2008 and January 2013 42 patients mean age 14 ± 3 were evaluated with a bicycle ESE performing 50 studies ESE was successfully performed and well tolerated by all patients None of the patients presented with adverse effects of stressinduced ischemia HR was 82 ± 13 at rest and 153 ± 191 during peak exercise Among 544 views analyzed for grading of image quality the visualization was optimal in 473 87 suboptimal in 39 and inadequate in 32 6 37 tests were performed in patients with congenital or acquired coronary abnormality Regional wall motion abnormalities RWMA were revealed in nine cases 24 The agreement between the two different observers showed a K index of 07276 95 CI 06497–08055 for the image quality and a K index of 05125 95 CI 04782–05468 for the RWMA analysis Among ten patients with hypertrophic cardiomyopathy we were able to demonstrate the new comparison of significant left ventricular outflow tract gradient ≥30 mmHg during exercise in three patients 30 Bicycle stress echocardiography performed by online scanning during exercise is a feasible safe and reproducible modality in children Further data to assess its diagnostic accuracy are however needed Stress echocardiography provides a dynamic assessment of the myocardial structure and function under conditions of physiologic or pharmacologic stressStressinduced abnormalities of ventricular wall motion in patients with ischemic heart disease were recognized in 1979 25 Since then stress echocardiography has been extensively applied in patients with coronary artery disease CAD and it has become a wellaccepted modality for diagnosis risk stratification and prognostication in this setting 13 39 Its use has subsequently been extended to other clinical settings such as patients with hypertrophic 32 40 43 or dilated cardiomyopathy valvar heart disease 7 44 45pulmonary hypertension 8 21 22 and recently for selecting potential responders to cardiac resynchronization therapy 33 42 and for the selection of donor hearts for cardiac transplantation 6The stressor agent can be pharmacologic or physiologic Dobutamine is the drug most widely used although adenosine and dipyridamole are also commonly adopted Physical exercise is the ideal stressor being able also to provide information about symptoms exercise capacity and hemodynamic response to exertion 17 39 Exercise stress echocardiography ESE is most commonly performed on the treadmill using similar protocols adopted for exercise ECG or with a bicycle in either upright or supine positionDespite wide experience in adults stress echocardiography in the pediatric age group is rarely used 27 41 and primarily reserved for patients with Kawasaki disease 28 37 and pediatric transplant recipients 12 30 A small number of reports have been published in patients with congenital heart diseases 11 23The major disadvantage of ESE in pediatric age is the precipitous drop in heart rate after peak exercise compared to adults 37 In addition some concerns exist about the image quality due to the higher heart rate in children and the method’s reproducibility in this setting has not previously been assessed Bicycle exercise in the semisupine position compared to treadmill offers the advantage that images can be obtained during all stages of exercise including peak in real time avoiding the rapid heart rate drop Instead of missing the peak heart rate due to its drop from erect position to a bed for imaging recumbent position and continuous scanning should potentially allow better detection of ischemia and time for higher quality of images Our aim hence was to assess the feasibility safety and reproducibility of dynamic ESE using “online” scanning in semisupine cycloergometer protocol in a wide spectrum of children with different types of diseaseAll examinations were performed according to our standardized institutional laboratory protocol A symptomlimited exercise test was conducted on a semisupine bicycle ergometer Lode Medical Technology Groningen The Netherlands using a continuous incremental bicycle protocol with a work rate increment between 5 and 20 W/min according to gender and weight All patients were given the opportunity to familiarize themselves with the cycle ergometer and the procedure was discussed with the patient and parent/guardian prior to the test starting Blood pressure measurement and clinical review preceded all tests To be able to perform the test all the children were at least 120 cm in height and above 7 years of age
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