title: Biphasic response to dobutamine predicts improvement of global left ventricular function after surgical revascularization in patients with stable coronary artery disease: implications of time course of recovery on diagnostic accuracy.
abstract: OBJECTIVE
  This study sought to evaluate the time course of improvement of left ventricular (LV) dysfunction in stable patients and its implications on the accuracy of dobutamine echocardiography for predicting improvement after surgical revascularization.
  
  
  BACKGROUND
  Little is known about the optimal timing for evaluation of postrevascularization recovery of the contractile function of viable myocardium.
  
  
  METHODS
  Sixty-one patients with chronic ischemic LV dysfunction scheduled for elective surgical revascularization were prospectively selected. They underwent dobutamine echocardiography (5 to 40 microg/kg body weight per min) and radionuclide ventriculography both preoperatively and at 3-month follow-up. At 14 months, another evaluation of LV function was obtained. To analyze echocardiograms, a 16-segment model and a five-point scoring system were used. Dyssynergic segments were considered likely to recover in the presence of a biphasic contractile response to dobutamine. Improvement of global function was defined as a > or =5% increase in LV ejection fraction (LVEF).
  
  
  RESULTS
  Of the 61 patients, LVEF improved in 12 at 3 months and in 19 at late follow-up (from 32+/-8% to 42+/-9%, p < 0.0001). The frequency and time course of improvement of LVEF were similar in patients with mild and severe LV dysfunction. A biphasic response, identified in 186 of the 537 dyssynergic segments, was predictive of recovery in 63% at 3 months and in 75% at late follow-up. The positive predictive value was best in the most severe dyssynergic segments (90% vs. 67%). Other responses were highly predictive for nonrecovery (92%). The sensitivity and specificity for improvement of global function on a patient basis (> or =4 biphasic segments) were 89% and 81%, respectively, at late follow-up.
  
  
  CONCLUSIONS
  Serial postoperative follow-up studies demonstrate incomplete recovery of contractile function at 3 months. The diagnostic accuracy of dobutamine echocardiography for predicting recovery is dependent on three factors: the combining of low and high dobutamine dosages, the severity of regional dyssynergy and the timing of evaluation.
authors.affiliation: Department of Cardiology, Medical Center Alkmaar, The Netherlands. jcornel@mca.alkmaar.nl
authors.forename: J H
authors.initials: JH
authors.lastname: Cornel
authors.forename: J J
authors.initials: JJ
authors.lastname: Bax
authors.forename: A
authors.initials: A
authors.lastname: Elhendy
authors.forename: A P
authors.initials: AP
authors.lastname: Maat
authors.forename: G J
authors.initials: GJ
authors.lastname: Kimman
authors.forename: M L
authors.initials: ML
authors.lastname: Geleijnse
authors.forename: R
authors.initials: R
authors.lastname: Rambaldi
authors.forename: E
authors.initials: E
authors.lastname: Boersma
authors.forename: P M
authors.initials: PM
authors.lastname: Fioretti
mesh_terms: D000328:Adult; D000368:Aged; D002316:Cardiotonic Agents; D002908:Chronic Disease; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D004280:Dobutamine; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015635:Radionuclide Ventriculography; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000503:physiopathology*
chemical_list: D002316:Cardiotonic Agents; D004280:Dobutamine