Thoraxcentre Erasmus University
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: email@example.com
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