Is there a long-term predictive value of intraoperative low-dose dobutamine echocardiography in patients who have coronary artery bypass graft surgery with cardiopulmonary bypass?
In patients with coronary artery disease, chronic regional left ventricular systolic dysfunction at rest may be caused by hibernating or by infarcted myocardium. Intraoperative low-dose dobutamine (LDD) echocardiography reliably predicts the immediate recovery of regional myocardial function after coronary artery bypass graft (CABG) surgery. We sought to determine whether intraoperative LDD echocardiography would also predict recovery of regional function after 1 yr. Twenty-five patients with coronary artery disease who underwent CABG surgery with intraoperative LDD echocardiography were evaluated 1 yr later with a follow-up transthoracic echocardiogram. The covariates of left ventricular ejection fraction, old myocardial infarction, and diabetes mellitus were considered in an analysis of regional wall motion (RWM). A 16-segment model and a 1-5-point scoring system were used to evaluate 350 myocardial segments. Multiple logistic regression analysis was performed to determine whether response to intraoperative LDD echocardiography (5 microg. kg(-1). min(-1)) predicted changes in regional function at 1 yr. A segment was defined as stunned if the RWM score obtained during LDD infusion deteriorated after cardiopulmonary bypass but recovered in the 1-yr follow-up echocardiogram. A response to intraoperative LDD predicted changes in regional function at 1 yr. The overall odds of improvement in regional function were 2.22 times greater (95% confidence interval = 1.29, 3.82; P = 0.0039) with a positive response to intraoperative LDD. The positive predictive value of intraoperative LDD echocardiography for improvement in myocardial function was 0.81 and the negative predictive value was 0.34. The predictive values did not vary with the examined covariates. Of segments with unexpected deterioration of RWM immediately after cardiopulmonary bypass, 87% recovered at the time of the 1-yr follow-up echocardiogram. Contractile reserve demonstrated by intraoperative LDD echocardiography predicts regional function at 1 yr; however, the test cannot predict which segment will not recover. Most of unexpected regional ventricular systolic dysfunction immediately after CABG surgery can be attributed to myocardial stunning.


CONCLUSIONS
In patients undergoing coronary artery bypass graft surgery, intraoperative low-dose dobutamine echocardiography has only limited value for the prediction of regional myocardial function at 1 yr. Small-dose dobutamine echocardiography predicts regional myocardial function at 1 yr when baseline regional wall motion abnormalities improve with dobutamine; however, the test cannot be used to predict which segment will not recover at 1 yr.
Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Avenue, Box 4028, Chicago, IL 60637, USA.
Frank W
FW
Dupont
Roberto M
RM
Lang
Melinda L
ML
Drum
Solomon
S
Aronson
D000318:Adrenergic beta-Agonists; D000368:Aged; D002315:Cardiopulmonary Bypass / Q000379:methods*; D001026:Coronary Artery Bypass / Q000379:methods*; D004280:Dobutamine; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis; D015428:Myocardial Reperfusion Injury / Q000175:diagnosis*; D011237:Predictive Value of Tests; D011379:Prognosis
D000318:Adrenergic beta-Agonists; D004280:Dobutamine