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. 2000 Feb;83(2):133–140. doi: 10.1136/heart.83.2.133

Non-contrast second harmonic imaging improves interobserver agreement and accuracy of dobutamine stress echocardiography in patients with impaired image quality

A Franke 1, R Hoffmann 1, H Kuhl 1, W Lepper 1, O Breithardt 1, M Schormann 1, P Hanrath 1
PMCID: PMC1729307  PMID: 10648482

Abstract

OBJECTIVE—To examine the influence of second harmonic imaging during dobutamine echocardiography on regional endocardial visibility, interobserver agreement in the interpretation of wall motion abnormalities, and diagnostic accuracy in patients with reduced image quality.
DESIGN—Blinded comparison.
SETTING—Tertiary care centre.
PATIENTS—103 consecutive patients with suspected coronary artery disease and impaired transthoracic image quality (⩾ 2 segments with poor endocardial delineation).
METHODS—Fundamental and second harmonic imaging were performed at each stage of a dobutamine stress echocardiography. Coronary angiography was undertaken within three weeks of dobutamine echocardiography in 75 patients.
MAIN OUTCOME MEASURES—Evaluation of regional endocardial visibility (scoring from 0 = poor to 2 = good) and of segmental wall motion abnormalities for both modalities separately. A second blinded examiner analysed 70 studies to determine interobserver agreement.
RESULTS—Mean (SD) visibility score for all segments was 1.2 (0.4) using fundamental imaging and 1.7 (0.2) using second harmonic imaging at rest (p < 0.001), and 1.1 (0.4) v 1.6 (0.3), respectively, at peak dobutamine dose (p < 0.001). The average number of segments with poor endocardial visibility was lower for second harmonic than for fundamental imaging (0.6 (1.1) v 3.8 (2.6) at rest, p < 0.001; 0.9 (1.3) v 4.3 (2.9) at peak dose, p < 0.001). Improvement was most pronounced in all lateral and anterior segments. The κ value for identical study interpretation increased from 0.40 to 0.69 (p < 0.05). Sensitivity for the diagnosis of coronary artery disease was 64% using fundamental imaging versus 92% using harmonic imaging (p < 0.001), while specificity remained unchanged at 75% for both imaging modalities.
CONCLUSIONS—Second harmonic imaging enhances endocardial visibility during dobutamine echocardiography. Consequently, interobserver agreement on stress echocardiography interpretation and diagnostic accuracy are significantly improved compared to fundamental imaging. Thus, in difficult to image patients, dobutamine echocardiography should be performed using second harmonic imaging.


Keywords: coronary artery disease; dobutamine stress echocardiography; second harmonic imaging; interobserver agreement

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Figure 1  .

Figure 1  

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Effect of harmonic imaging on the endocardial visibility. Systolic stop frame images of the apical four chamber view at baseline (upper panels) and at peak dobutamine dose (lower panels). Fundamental images on the left, second harmonic images on the right. Note the improved endocardial delineation in the lateral segments at the baseline study and in both the septal and lateral segments during peak stress (arrows).

Figure 2  .

Figure 2  

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Effect of harmonic imaging on the endocardial visibility. Stop frame images of the apical two chamber view. Same orientation as in fig 1. The better endocardial delineation at peak stress is most pronounced in the anterior segments (arrows).

Figure 3  .

Figure 3  

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Average number of segments per patient with a visibility score of 0 at baseline (left) and at peak dobutamine dose (right). The number of segments with poor endocardial delineation with fundamental imaging decreases significantly using second harmonic imaging (SHI). This effect was present both at baseline and at peak dobutamine dose.

Figure 4  .

Figure 4  

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Analysis of the regional distribution of improved visibility at rest. The schematic drawing shows the four different image planes with all 16 segments. Segments where more than a third of the patients had an improvement of at least one score point using second harmonic imaging instead of fundamental imaging are shown in yellow. Segments where more than 50% of the patients had a better image quality are shown in red. Note that the benefit of second harmonic imaging is most pronounced in all lateral and anterior segments, where more than half of the patients improved. LAX, parasternal long axis; SAX, parasternal short axis; 4CV, apical four chamber view; 2CV, apical two chamber view.    

Figure 5  .

Figure 5  

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Regional distribution of improved visibility at peak dobutamine dose. The schematic drawing shows the four different image planes with all 16 segments. Segments where more than a third of the patients had an improvement of at least one score point using second harmonic imaging instead of fundamental imaging are shown in yellow. Segments where more than 50% of the patients had a better image quality are shown in red. Note that the benefit of second harmonic imaging is most pronounced in all lateral and anterior segments, where more than half of the patients improved. LAX, parasternal long axis; SAX, parasternal short axis; 4CV, apical four chamber view; 2CV, apical two chamber view.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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