International Journal of Cardiology 117 (2007) e24 – e26 www.elsevier.com/locate/ijcard Letter to the Editor Mitral stenosis in patient undergoing vascular surgery: Prediction of perioperative hemodynamics by dobutamine stress-echocardiography Petar Otasevic ⁎, Marijana Buljak, Nenad Ilijevski, Srdjan D. Boskovic, Nebojsa Tasic, Djordje Radak, Bosko Djukanovic “Dr. Aleksandar D. Popovic” Cardiovascular Research Center, Dedinje Cardiovascular Institute, Milana Tepica 1, 11040 Belgrade, Serbia Received 4 August 2006; accepted 11 August 2006 Available online 26 January 2006 Abstract Patient was admitted for endarterectomy of the left internal carotid artery. Echocardiography showed mitral stenosis with mitral valve area of 1.4 cm2. Since the patient's functional capacity could not be determined due to left-sided hemiplegia, it was decided to perform high-dose dobutamine stress-echocardiography in order to assess the patient's hemodynamics during stress. Gradients over mitral valve increased from 32/10 mmHg at baseline to 43/16 mmHg at 40 mcg/kg/min dobutamine infusion. Preoperative and 24 hour perioperative hemodynamic variables were monitored by Swan–Ganz catheher, and their values did not change significantly as compared to baseline. Postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Stres-echocardiorgraphy; Mitral stenosis; Carotid endarterectomy 1. Case-report A 66-year-old man was admitted to our hospital for endarterectomy of the left internal carotid artery due to complex 85% stenosis. History revealed that 6 months ago he had a stroke with left-sided hemiplegia, as well as longstanding insulin dependent diabetes. Except diastolic rumble at the apex, physical examination, as well as EKG and chest X-ray, were unremarkable. Transthoracic echocardiography revealed moderate mitral stenosis with mitral valve area of 1.4 cm2 and gradients over mitral valve of 33/11 mmHg, and mild mitral regurgitation. Ejection fraction was visually estimated at 55%. Since patient's functional capacity could not be determined, it was decided to perform high-dose dobutamine stress-echocardiography in order to assess change of gradients over mitral valve and symptoms. Dobutamine stress-echocardiography was performed in incremental stages lasting 3 min each, with an initial dose of 5 mcg/kg/ ⁎ Corresponding author. Tel.: +381 11 360 16 69; fax: +381 11 266 64 45. E-mail address: potasevic@yahoo.com (P. Otasevic). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.092 min, which was increased to 10, 20, and 30 mcg/kg/min, and finally to the maximal dose of 40 mcg/kg/min. During the test gradients over mitral valve increased from 32/10 mmHg at baseline, to 38/12 mmHg at 10 mcg/kg/min, and finally to 43/16 mmHg at 40 mcg/kg/min dobutamine infusion (Fig. 1). Mitral valve area changed from 1.4 cm2, at baseline and 10 mcg/kg/min, to 1.5 cm2 at 40 mcg/kg/min. No new segmental wall motion abnormalities were noted. The patient was entirely asymptomatic during the test. On the next day, standard eversion endarterectomy of the left internal carotid artery was performed. Patient was on bisoprolol, fosinopril, and simvastatin. Preoperative and 24 hour perioperative hemodynamic variables were monitored by Swan–Ganz catheter, and their values did not change significantly throughout the follow-up (Table 1). Postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. 2. Discussion As to our knowledge, there are no studies which used dobutamine stress-echocardiography for preoperative P. Otasevic et al. / International Journal of Cardiology 117 (2007) e24–e26 e25 Fig. 1. Continous wave Doppler tracings of the transmitral flow at baseline (A) and at 40 mcg/kg/min dobutamine infusion (B). See text for details. assessment of patients with mitral stenosis which are scheduled for vascular surgery. On the other hand, a number of papers have demonstrated that dobutamine stressechocardiography can be used for risk stratification in patients with pure mitral stenosis. Recently, it has been suggested that mean gradient over mitral valve during dobutamine infusion of ≥ 18 mm has a sensitivity of 90% and specificity of 87% for detection of dyspnea, pulmonary edema and/or supraventricular arrhythmias during long-term follow-up. Patients with presumed moderate disease were found to have the strongest prognostic benefit from dobutamine stress-echocardiography, as the test allowed the detection of 40% more patients in this particular subgroup, increasing the performance of detecting poten- tially high-risk patients in whom a more aggressive approach is recommended [1]. Additionally, it has been shown that patients with mild-tomoderate mitral stenosis in whom dyspnea is provoked during dobutamine infusion show a greater increase in pulmonary pressures than patients in whom provocation does not occur [2]. Our patient did not have any of these features, so it was concluded that no major hemodynamic disturbances is likely to happen during surgery. Patient's hemodynamics during operation and 24 hours postoperatively were unremarkable, as it was predicted by dobutamine stress-echocardiography. Since carotid endarterectomy is considered to carry intermediate risk (b5%) for cardiac events, prediction of e26 P. Otasevic et al. / International Journal of Cardiology 117 (2007) e24–e26 Table 1 Preoperative and perioperative hemodynamic variables Preoperative Postoperative 6 hours 12 hours 24 hours HR 80 (beats/min) CI 2.3 (L/min) PCWP 13 (mmHg) PA mean 23 (mmHg) RA mean 122 (mmHg) SVR 2115 (dynes/s− 5) PVR 181 (dynes/s− 5) SV 55.3 (ml) 66 71 75 73 2.5 3.6 2.9 3.7 12 16 15 17 15 21 18 21 83 108 81 74 1289 1182 1149 788 49 58 44 44 74.2 97.2 73.3 98.6 Abbreviations: CI, cardiac index; HR, heart rate; PA, pulmonary artery; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RA, radial artery; SV, stroke volume; SVR, systemic vascular resistance. hemodynamic response by dobutamine stress-echocardiography in patients with moderate mitral stenosis should also be tested in patients undergoing high-risk vascular procedures. Although patient did not complain about the chest pain, he had a number of high-risk features for future coronary events, including insulin-dependent diabetes. Therefore, dobutamine challenge helped us to risk-stratify him also in terms of risk for surgery-related acute coronary syndrome. It has been shown that dobutamine stress-echocardiography has a very high negative predictive value, indicating that a negative test is associated with a very low incidence of cardiac events and allows a safe surgical procedure [3]. In conclusion, high-dose dobutamine stress-echocardiography can be used to assess hemodynamic response to lowto-intermediate risk vascular surgery in patients with moderate mitral stenosis. References [1] Reis PD, Motta MS, Barbosa MM, Esteves WA, Souza SF, Bocchi EA. Dobutamine stress-echocardiography for noninvasive assessment and risk-stratification of patients with rheumatic mitral stenosis. J Am Coll Cardiol 2004;43:393–401. [2] Belgi A, Yalcinkaya S, Umuttan D, et al. Echocardiographic predictors of hemodynamic response and significance of dyspnea development in patients with mitral stenosis during dobutamine stress echocardiography. J Heart Valve Dis 2003;12:482–7. [3] Poldermans D, Arnese M, Fioretti PM, et al. Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol 1995;26:648–53.