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Communications to the Editor |

Ventricular Tachycardia During Dobutamine Stress Myocardial Contrast Imaging FREE TO VIEW

Don Poldermans, MD; Folkert J. ten Cate, MD; Abdou Elhendy, MD; Guido Rocchi, MD; Jeroen J. Bax, MD; Wim Vletter; Jos R. T. C. Roelandt, MD
Author and Funding Information

Thoraxcentre Erasmus University Rotterdam, Netherlands



Chest. 1999;115(1):307-308. doi:10.1378/chest.115.1.307
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To the Editor:

Dobutamine-atropine stress echocardiography (DSE) is increasingly used for the diagnostic and prognostic evaluation of coronary artery disease.1,,2,,3,,4 Myocardial ischemia, manifested as transient wall motion abnormalities, can be provoked by dobutamine infusion in patients with significant coronary arterial narrowing. One of the limitations of the test is the insufficient visualization of the left ventricular endocardial borders. To improve left ventricular cavity delineation, echo contrast agents were recently introduced.5 These consist of microbubbles of gas, which are sufficiently small to pass the pulmonary capillary bed and reach the left ventricular cavity after IV injection. Ultrasound induces an oscillation of the bubbles and produces an intense echo signal. It is known that microbubbles can be destroyed by ultrasonic waves.

We present the case of a 73-year-old man who developed ventricular tachycardia during DSE in combination with the contrast agent Levovist (Schering AG; Berlin, Germany). The patient had a previous myocardial infarction and underwent bypass surgery in 1997. After surgery he had atypical chest pain complaints. An angiotensin-converting enzyme inhibitor was prescribed because of hypertension. The patient had normal serum electrolytes and was not receiving diuretics. Left ventricular ejection fraction was 48% by radionuclide angiography. DSE was performed to assess myocardial ischemia. The resting ECG showed an old Q-wave myocardial infarction and no arrhythmias. An imaging system (Sonos 5000; Hewlett-Packard; Andover, MA) with a transducer frequency of 1.8 MHz and a mechanical index of 1.6 was used. Four grams of Levovist (300 mg/mL) was infused continuously through an IV canula in the left antecubital vein over a 3-min period to improve delineation of the left ventricular cavity border. Images were acquired using a trigger mode; every five beats, one image was obtained at end-systole in order to prevent early destruction of the microbubbles. The resting echo showed severe hypokinesia of the inferior wall. Blood pressure was 150/80 mm Hg. Heart rate was 62 beats/min. Dobutamine infusion was started with 5μ g/kg/min up to a maximum 40 μg/kg/min with 3-min intervals. Before peak stress, at 30 μg/kg/min, another 4 g Levovist (300 mg/mL) was continuously infused again over 3 min. At target heart rate, a short ventricular tachycardia occurred (seven complexes) and dobutamine infusion was stopped. Heart rate was 126 beats/min and blood pressure was 125/70 mm Hg. There were no echocardiographic or electrocardiographic signs of myocardial ischemia. The patient had no complaints, and the course was uneventful.

The reported incidence of ventricular tachycardia during DSE varies between 3 – 4% and is not related to the induction of ischemia.2,,3,,4 In theory, the contrast agent may act like a carrier to transport dobutamine to the heart when both agents are infused in the same IV line. Local destruction of the microbubbles by ultrasound may induce high levels of dobutamine at the endocardium. However, considering the chemical composition of Levovist, a galactose solution stabilized by palmitic acid, it is unlikely that a hydrophilic substance like dobutamine will be incorporated in the contrast agent. A possible explanation is that contrast agents enhance the arrhythmogenic effect of dobutamine by local mechanical irritation aggravated by ultrasonic destruction of the microbubbles. We report this case to anticipate a potential proarrhythmic effects of the combination of DSE and contrast agents. Careful monitoring of these patients is required and the safety of this combination should be assessed in a large study.

Correspondence to: Don Poldermans, MD, Thoraxcentre, Room Ba 300, Erasmus University Dr., Molewaterplein 40, 3015 GD Rotterdam, the Netherlands; e-mail: poldermans@hlkd.azr.nl

Williams, MJ, Odabashian, J, Lauer, MS, et al (1996) Prognostic value of dobutamine echocardiography in patients with left ventricular dysfunction.J Am Coll Cardiol27,132-139. [PubMed]
 
Poldermans, D, Arnese, M, Fioretti, PM, et al Improved cardiac risk stratification in major vascular surgery with dobutamine stress echocardiography.J Am Coll Cardiol1995;26,648-653. [PubMed] [CrossRef]
 
Picano, E, Mathias, W, Pingitore, A, et al Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicentre study.Lancet1994;344,1190-1192. [PubMed]
 
Secknus, MA, Marwick, T Evaluation of dobutamine echocardiography protocols and indications: Safety and side effects in 3,011 studies over 5 years.J Am Coll Cardiol1997;29,1234-1240. [PubMed]
 
Kaul, S Myocardial contrast echocardiography: 15 years of research and development.Circulation1997;96,3745-3760. [PubMed]
 

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References

Williams, MJ, Odabashian, J, Lauer, MS, et al (1996) Prognostic value of dobutamine echocardiography in patients with left ventricular dysfunction.J Am Coll Cardiol27,132-139. [PubMed]
 
Poldermans, D, Arnese, M, Fioretti, PM, et al Improved cardiac risk stratification in major vascular surgery with dobutamine stress echocardiography.J Am Coll Cardiol1995;26,648-653. [PubMed] [CrossRef]
 
Picano, E, Mathias, W, Pingitore, A, et al Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicentre study.Lancet1994;344,1190-1192. [PubMed]
 
Secknus, MA, Marwick, T Evaluation of dobutamine echocardiography protocols and indications: Safety and side effects in 3,011 studies over 5 years.J Am Coll Cardiol1997;29,1234-1240. [PubMed]
 
Kaul, S Myocardial contrast echocardiography: 15 years of research and development.Circulation1997;96,3745-3760. [PubMed]
 
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