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�:

Dynamic Left Ventricular Outflow Tract Obstruction: Comparison between Dobutamine and Exercise Stress-Echo


F. Innocenti, C. Burgisser, C. Agresti, R. Pini


Department of Clinical and Experimental Medicine, High Dependency Observation Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy

Corresponding author: Francesca Innocenti, MD, High Dependency Observation Unit, Largo Brambilla 4, 50142 Firenze, Italy; +39 055 7947748; e-mail: innocentif@aou-careggi.toscana.it
Abstract
A 62 years old man with high cardiovascular risk profile underwent dobutamine stress echocardiography for suspected silent myocardial ischemia; the test showed severe dynamic intraventricular obstruction (maximum gradient 210 mmHg) and was prematurely stopper for high intraventricular gradient.
A maximal exercise stress-echo, performed according to Bruce protocol, showed the same response, in absence of any new asynergic area.
Case report
A 62-year old man was referred to our Hypertension Out-patient Clinic for a recent (three month ago) occasional finding of high blood pressure values (180/90 mmHg), treated with irbesartan and manidipine. He reported a long history of dyslipidemia, treated with simvastatin; he was overweight (body mass index  28.4 kg/m2) and, five years before our visit, a diagnosis of type 2 diabetes was established and a treatment with glimepiride was started. 
In total absence of any symptom, the routine EKG showed a 1 mm horizontal  ST-downsloping in inferior and precordial leads; an echocardiogram showed left ventricular (LV) normal dimensions (end-diastolic diameter 46 mm, septal and posterior wall thickness 7 mm), with global  hyperkinesia.
A dobutamine stress echo (DSE) was then performed to rule-out coronary artery disease; during the test the patient developed severe dynamic left ventricular outflow tract obstruction, reaching 210 mmHg as maximum intraventricular gradient (Fig. 1), so that the test was stopped at the end of fourth stage (30 �/kg/min, peak heart rate 116/b/min, arterial pressure 150/40 mmHg) without new asynergic areas or chest pain; EKG showed an ascending ST downsloping 0.5 mm in D2, aVF, V4-V6, evolving in horizontal downsloping fashion during recovery. Coronary flow velocity on left anterior descending artery (LAD) was measured non-invasively, with pulsed-Doppler and color-Doppler guidance, in a modified 2-chamber view, baseline (Fig. 2) and at the end of high dose dobutamine infusion (Fig. 3); coronary flow reserve was calculated as ratio between peak and rest maximal diastolic coronary flow velocity and was normal (2.4, normal value >2).   
The patient underwent thereafter an exercise stress-echo (ESE): we followed a resting and post-exercise protocol and the exercise was performed according to modified Bruce protocol. The test was stopped for hypertensive response (maximal heart rate, HR, 159 b/min, 100% maximal predicted heart rate; systolic arterial pressure, SBP, 240 mmHg; rate pressure product RPP, 39500 b/min*mmHg; work load 6.8 METS) and the post-exercise echocardiographic examination showed a normal global and regional systolic function, with dynamic intraventricular obstruction (peak gradient 165 mmHg) (Fig. 4); the patient remained asymptomatic and there were no significant EKG modifications.
Despite the high risk profile, considering the negative maximal exercise stress-echo and normal CFR during DSE, we decided not to perform a coronary angiography and to begin a treatment with a �-blocking agent. An ergometric test was repeated after one month; the patient reached a higher work load, with lower rate pressure product (work load 8 METS; peak HR 128 b/min, BP 210/110 mmHg, RPP 26800 b/min*mmHg), without symptoms; EKG showed a horizontal  ST-downsloping  0.5-1 mm in V4-V6, with fast recovery.    
Discussion
Dynamic LV outflow tract obstruction (DLVOTO) is a relatively common response to DSE, occurring in about 22% of patients  ADDIN REFMGR.CITE <Refman><Cite><Author>Pellikka</Author><Year>1992</Year><RecNum>2</RecNum><IDText>Dynamic intraventricular obstruction during dobutamine stress echocardiography. A new observation</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>Dynamic intraventricular obstruction during dobutamine stress echocardiography. A new observation</Title_Primary><Authors_Primary>Pellikka,P.A.</Authors_Primary><Authors_Primary>Oh,J.K.</Authors_Primary><Authors_Primary>Bailey,K.R.</Authors_Primary><Authors_Primary>Nichols,B.A.</Authors_Primary><Authors_Primary>Monahan,K.H.</Authors_Primary><Authors_Primary>Tajik,A.J.</Authors_Primary><Date_Primary>1992/11</Date_Primary><Keywords>Aged</Keywords><Keywords>Coronary Disease</Keywords><Keywords>ultrasonography</Keywords><Keywords>Dobutamine</Keywords><Keywords>diagnostic use</Keywords><Keywords>Echocardiography,Doppler</Keywords><Keywords>Exercise Test</Keywords><Keywords>methods</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypotension</Keywords><Keywords>etiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Male</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Ventricular Function,Left</Keywords><Keywords>drug effects</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>1429</Start_Page><End_Page>1432</End_Page><Periodical>Circulation</Periodical><Volume>86</Volume><Issue>5</Issue><Address>Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905</Address><Web_URL>PM:1423956</Web_URL><ZZ_JournalStdAbbrev><f name="System">Circulation</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[1]; the underlying mechanism seems to be an hyperdynamic response of global LV function, that determines a cavity obliteration, perhaps in combination with peripheral vasodilation. It develops more frequently in women and in subjects with little LV and  normal systolic function; also a narrowed left ventricular outflow tract seems to play a significant role  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [2-4]. This response has been advocated, in repeated series, to explain symptoms of chest pain and dyspnea in patients without flow-limiting coronary stenosis  ADDIN REFMGR.CITE <Refman><Cite><Author>Henein</Author><Year>1997</Year><RecNum>4</RecNum><IDText>Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly</Title_Primary><Authors_Primary>Henein,M.Y.</Authors_Primary><Authors_Primary>O&apos;Sullivan,C.</Authors_Primary><Authors_Primary>Sutton,G.C.</Authors_Primary><Authors_Primary>Gibson,D.G.</Authors_Primary><Authors_Primary>Coats,A.J.</Authors_Primary><Date_Primary>1997/11/1</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Dyspnea</Keywords><Keywords>Echocardiography</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Exercise Tolerance</Keywords><Keywords>Female</Keywords><Keywords>Hemodynamic Processes</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>Ventricular Dysfunction,Left</Keywords><Reprint>Not in File</Reprint><Start_Page>1301</Start_Page><End_Page>1307</End_Page><Periodical>J.Am.Coll.Cardiol.</Periodical><Volume>30</Volume><Issue>5</Issue><Address>Cardiac Department, Royal Brompton Hospital, London, England, United Kingdom. m.henein@rbh.nthames.nhs.uk</Address><Web_URL>PM:9350931</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[5], but  it can frequently occur in asymptomatic subjects and its clinical value is a topic of debate  ADDIN REFMGR.CITE <Refman><Cite><Author>Luria</Author><Year>1999</Year><RecNum>5</RecNum><IDText>Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>5</Ref_ID><Title_Primary>Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography</Title_Primary><Authors_Primary>Luria,D.</Authors_Primary><Authors_Primary>Klutstein,M.W.</Authors_Primary><Authors_Primary>Rosenmann,D.</Authors_Primary><Authors_Primary>Shaheen,J.</Authors_Primary><Authors_Primary>Sergey,S.</Authors_Primary><Authors_Primary>Tzivoni,D.</Authors_Primary><Date_Primary>1999/3</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Coronary Disease</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Doppler</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Prevalence</Keywords><Keywords>Prognosis</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Stroke Volume</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Function,Left</Keywords><Reprint>Not in File</Reprint><Start_Page>386</Start_Page><End_Page>392</End_Page><Periodical>Eur.Heart J.</Periodical><Volume>20</Volume><Issue>5</Issue><Address>Department of Cardiology, Jesselson Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel</Address><Web_URL>PM:10206385</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Heart J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[6]. It can reduce DSE sensitivity, especially for single vessels� disease, but we know that it carries a favourable prognostic value, because it may represent a form of increased contractile reserve  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [7,8]. Moreover, in this situation, the RPP underestimates the actual increase in myocardial oxygen demand imposed on the mid-to-apical cavity by the obliteration, so that the real �work load� achieved would be re-evaluated. 
Few reports described this response also during ESE, identifying the same echocardiographic predisposing factors evidenced for DSE  ADDIN REFMGR.CITE <Refman><Cite><Author>Cabrera-Bueno</Author><Year>2007</Year><RecNum>4</RecNum><IDText>Effort angina, normal coronary angiogram, and dynamic left ventricular obstruction</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Effort angina, normal coronary angiogram, and dynamic left ventricular obstruction</Title_Primary><Authors_Primary>Cabrera-Bueno,F.</Authors_Primary><Authors_Primary>Gomez-Doblas,J.J.</Authors_Primary><Authors_Primary>Munoz-Garcia,A.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>Navarro,M.J.</Authors_Primary><Authors_Primary>Teresa-Galvan,E.</Authors_Primary><Date_Primary>2007/4</Date_Primary><Keywords>Blood Flow Velocity</Keywords><Keywords>physiology</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>Diastole</Keywords><Keywords>Echocardiography,Doppler</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>Female</Keywords><Keywords>Heart Ventricles</Keywords><Keywords>physiopathology</Keywords><Keywords>ultrasonography</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Microvascular Angina</Keywords><Keywords>complications</Keywords><Keywords>radiography</Keywords><Keywords>Middle Aged</Keywords><Keywords>Myocardial Contraction</Keywords><Keywords>Prognosis</Keywords><Keywords>Severity of Illness Index</Keywords><Keywords>Stroke Volume</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>415</Start_Page><End_Page>420</End_Page><Periodical>J.Am.Soc.Echocardiogr.</Periodical><Volume>20</Volume><Issue>4</Issue><Address>Servicio de Cardiologia, Hospital Clinico Universitario Virgen de la Victoria, Malaga, Spain. fonendo@hotmail.com &lt;fonendo@hotmail.com&gt;</Address><Web_URL>PM:17400122</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Soc.Echocardiogr.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[9], especially increased LV mass, reduced LV diastolic dimension and outflow tract diameter; abnormal mitral valve anatomy has also been advocated  ADDIN REFMGR.CITE <Refman><Cite><Author>Alhaj</Author><Year>2013</Year><RecNum>128</RecNum><IDText>Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>128</Ref_ID><Title_Primary>Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy</Title_Primary><Authors_Primary>Alhaj,E.K.</Authors_Primary><Authors_Primary>Kim,B.</Authors_Primary><Authors_Primary>Cantales,D.</Authors_Primary><Authors_Primary>Uretsky,S.</Authors_Primary><Authors_Primary>Chaudhry,F.A.</Authors_Primary><Authors_Primary>Sherrid,M.V.</Authors_Primary><Date_Primary>2013/5</Date_Primary><Keywords>Adult</Keywords><Keywords>Cardiomyopathy,Hypertrophic</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>etiology</Keywords><Keywords>Exercise</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy,Left Ventricular</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Mitral Valve</Keywords><Keywords>PATIENT</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Prognosis</Keywords><Keywords>Stress</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>556</Start_Page><End_Page>565</End_Page><Periodical>J Am Soc Echocardiogr</Periodical><Volume>26</Volume><Issue>5</Issue><Misc_3>S0894-7317(13)00112-0 [pii];10.1016/j.echo.2013.02.007 [doi]</Misc_3><Address>Division of Cardiology, Department of Medicine, St. Luke&apos;s-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA</Address><Web_URL>PM:23534983</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Am Soc Echocardiogr</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[10]. When both DSE and ESE were performed in the same patients to compare  DLVOTO prevalence and entity, during DSE this response was more frequent and peak intraventricular gradient was significantly higher  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [11,12]. No study reported detailed data about differences in EKG response to stress test between subjects with and without DLVOTO.
In our patient we observed, during both tests, the same response, comparable also for gradient�s entity (210 mmHg during DSE and 165 mmHg during ESE), that was somewhat lower during ESE, but however severe, always without symptoms or new asynergic areas and with similar EKG modifications. EKG repolarisation changes during stress test have already been described in patients with angiographically normal coronary arteries  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [13] and the meaning of such a response did not find a univocal interpretation.
Previous studies  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [12] investigated reproducibility of DSE induced DLVOTO during ESE to explain angina-like symptoms in patients with angiographically normal coronary arteries. In this patient, we could demonstrate that severe dynamic intraventricular obstruction can be evoked also by physical exercise and could be the pathogenetic mechanism of some cases of unexplained EKG modifications.



 ADDIN REFMGR.REFLIST References 

	1.	Pellikka PA, Oh JK, Bailey KR, Nichols BA, Monahan KH, Tajik AJ (1992) Dynamic intraventricular obstruction during dobutamine stress echocardiography. A new observation. Circulation 86:1429-1432.
	2.	Khanal S, Daggubati R, Gaalla A, Shah PM, Pai RG (1998) Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function. Journal of the American Society of Echocardiography 11:957-960.
	3.	Camara EJ, Oliveira MM, Ribeiro FM (2009) Baseline echocardiographic predictors of dynamic intraventricular obstruction of the left ventricle during dobutamine stress echocardiogram. Echocardiography 26:1195-1203.
	4.	Semba H, Sawada H, Uejima T et al (2012) Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular hypertrophy. Int Heart J 53:230-233.
	5.	Henein MY, O'Sullivan C, Sutton GC, Gibson DG, Coats AJ (1997) Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly. J Am Coll Cardiol 30:1301-1307.
	6.	Luria D, Klutstein MW, Rosenmann D, Shaheen J, Sergey S, Tzivoni D (1999) Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography. Eur Heart J 20:386-392.
	7.	Secknus MA, Niedermaier ON, Lauer MS, Marwick TH (1998) Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography. Am J Cardiol 81:1318-1322.
	8.	Christiaens L, Duplantier C, Allal J et al (2001) Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine. Echocardiography 18:285-290.
	9.	Cabrera-Bueno F, Gomez-Doblas JJ, Munoz-Garcia A, Garcia-Pinilla JM, Navarro MJ, Teresa-Galvan E (2007) Effort angina, normal coronary angiogram, and dynamic left ventricular obstruction. J Am Soc Echocardiogr 20:415-420.
	10.	Alhaj EK, Kim B, Cantales D, Uretsky S, Chaudhry FA, Sherrid MV (2013) Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy. J Am Soc Echocardiogr 26:556-565.
	11.	Cotrim C, Osorio P, Joao I et al (2002) Do patients with intraventricular gradients during dobutamine stress echocardiography have intraventricular gradients with exercise testing? Rev Port Cardiol 21:1461-1465.
	12.	Cabrera-Bueno FJ, Gomez-Doblas JJ, Garcia-Pinilla JM et al (2009) Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise. Echocardiography 26:272-280.
	13.	Panza JA, Laurienzo JM, Curiel RV et al (1997) Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography. J Am Coll Cardiol 29:293-301.


Supplementary Material
Additional Supporting information may be found in the online version of this article. 
Movie clip 1: Baseline LV quad-screen visualization; normal global and segmental kinesis.
Movie clip 2: Quad-screen LV visualization at the end of at low-dose dobutamine infusion; normal global and segmental kinesis .
Movie clip 3: Quad-screen LV visualization at the end of at high-dose dobutamine infusion (up to 40 mcg/kg/min)
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Movie clip 4: Quad-screen LV visualization at peak exercise test: normal hyperkinetic response, no new asynergic area.
.

Images Legend
Figure 1: CW Doppler imaging of left ventricular outflow tract velocity at peak DSE.
Figure 2: PW Doppler imaging of baseline distal left anterior descending coronary artery flow velocity.
Figure 3: PW Doppler imaging of high dose DSE distal left anterior descending coronary artery flow velocity.
Figure 4: CW Doppler imaging of left ventricular outflow tract velocity at peak exercise.

q|q�qCrDr����
�h����^�`��gd�I��d�`�gd�zCrDr�h\uhXmH	sH	,1�h��. ��A!�n"�n#��$�n%��������D<Refman><Cite><Author>Khanal</Author><Year>1998</Year><RecNum>3</RecNum><IDText>Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>3</Ref_ID><Title_Primary>Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function</Title_Primary><Authors_Primary>Khanal,S.</Authors_Primary><Authors_Primary>Daggubati,R.</Authors_Primary><Authors_Primary>Gaalla,A.</Authors_Primary><Authors_Primary>Shah,P.M.</Authors_Primary><Authors_Primary>Pai,R.G.</Authors_Primary><Date_Primary>1998/10</Date_Primary><Keywords>CORONARY-ARTERY DISEASE</Keywords><Keywords>diagnosis</Keywords><Keywords>DYNAMIC INTRAVENTRICULAR OBSTRUCTION</Keywords><Keywords>Female</Keywords><Keywords>HYPOTENSION</Keywords><Reprint>Not in File</Reprint><Start_Page>957</Start_Page><End_Page>960</End_Page><Periodical>Journal of the American Society of Echocardiography</Periodical><Volume>11</Volume><Issue>10</Issue><Address>Jerry L Pettis Mem VA Hosp, Cardiol Sect, Loma Linda, CA 92357 USA&#xA;Loma Linda Univ, Med Ctr, Cardiol Sect, Loma Linda, CA 92350 USA</Address><Web_URL>ISI:000076490500007</Web_URL><ZZ_JournalFull><f name="System">Journal of the American Society of Echocardiography</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Camara</Author><Year>2009</Year><RecNum>41</RecNum><IDText>Baseline echocardiographic predictors of dynamic intraventricular obstruction of the left ventricle during dobutamine stress echocardiogram</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>41</Ref_ID><Title_Primary>Baseline echocardiographic predictors of dynamic intraventricular obstruction of the left ventricle during dobutamine stress echocardiogram</Title_Primary><Authors_Primary>Camara,E.J.</Authors_Primary><Authors_Primary>Oliveira,M.M.</Authors_Primary><Authors_Primary>Ribeiro,F.M.</Authors_Primary><Date_Primary>2009/11</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>DYNAMIC INTRAVENTRICULAR OBSTRUCTION</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Image Enhancement</Keywords><Keywords>Image Interpretation,Computer-Assisted</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>PATIENT</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>Stress</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>1195</Start_Page><End_Page>1203</End_Page><Periodical>Echocardiography.</Periodical><Volume>26</Volume><Issue>10</Issue><Misc_3>ECHO953 [pii];10.1111/j.1540-8175.2009.00953.x [doi]</Misc_3><Address>Universidade Federal da Bahia, Salvador-Bahia, Brazil. ecamara@ufba.br</Address><Web_URL>PM:19725857</Web_URL><ZZ_JournalStdAbbrev><f name="System">Echocardiography.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Semba</Author><Year>2012</Year><RecNum>129</RecNum><IDText>Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular hypertrophy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>129</Ref_ID><Title_Primary>Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular hypertrophy</Title_Primary><Authors_Primary>Semba,H.</Authors_Primary><Authors_Primary>Sawada,H.</Authors_Primary><Authors_Primary>Uejima,T.</Authors_Primary><Authors_Primary>Takeda,N.</Authors_Primary><Authors_Primary>Soma,K.</Authors_Primary><Authors_Primary>Abe,H.</Authors_Primary><Authors_Primary>Yamashita,T.</Authors_Primary><Authors_Primary>Nagai,R.</Authors_Primary><Date_Primary>2012</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Arteries</Keywords><Keywords>ARTERY DISEASE</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>CORONARY-ARTERY-DISEASE</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy,Left Ventricular</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>PATIENT</Keywords><Keywords>Prevalence</Keywords><Keywords>Prognosis</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Risk</Keywords><Keywords>Roc Curve</Keywords><Keywords>Stress</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>230</Start_Page><End_Page>233</End_Page><Periodical>Int.Heart J</Periodical><Volume>53</Volume><Issue>4</Issue><Misc_3>DN/JST.JSTAGE/ihj/53.230 [pii]</Misc_3><Address>Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan</Address><Web_URL>PM:22878800</Web_URL><ZZ_JournalStdAbbrev><f name="System">Int.Heart J</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�D<Refman><Cite><Author>Secknus</Author><Year>1998</Year><RecNum>2</RecNum><IDText>Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography</Title_Primary><Authors_Primary>Secknus,M.A.</Authors_Primary><Authors_Primary>Niedermaier,O.N.</Authors_Primary><Authors_Primary>Lauer,M.S.</Authors_Primary><Authors_Primary>Marwick,T.H.</Authors_Primary><Date_Primary>1998/6/1</Date_Primary><Keywords>Aged</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Cause of Death</Keywords><Keywords>Coronary Disease</Keywords><Keywords>mortality</Keywords><Keywords>physiopathology</Keywords><Keywords>ultrasonography</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>drug effects</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy,Left Ventricular</Keywords><Keywords>diagnosis</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Myocardial Contraction</Keywords><Keywords>physiology</Keywords><Keywords>Risk Factors</Keywords><Keywords>Survival Rate</Keywords><Keywords>Ventricular Dysfunction,Left</Keywords><Keywords>Ventricular Function,Left</Keywords><Reprint>Not in File</Reprint><Start_Page>1318</Start_Page><End_Page>1322</End_Page><Periodical>Am.J.Cardiol.</Periodical><Volume>81</Volume><Issue>11</Issue><Address>Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA</Address><Web_URL>PM:9631970</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Christiaens</Author><Year>2001</Year><RecNum>59</RecNum><IDText>Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>59</Ref_ID><Title_Primary>Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine</Title_Primary><Authors_Primary>Christiaens,L.</Authors_Primary><Authors_Primary>Duplantier,C.</Authors_Primary><Authors_Primary>Allal,J.</Authors_Primary><Authors_Primary>Donal,E.</Authors_Primary><Authors_Primary>Nanadoumgar,H.</Authors_Primary><Authors_Primary>Barraine,R.</Authors_Primary><Authors_Primary>Coisne,D.</Authors_Primary><Date_Primary>2001/5</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>blood</Keywords><Keywords>chemically induced</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>diagnosis</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>285</Start_Page><End_Page>290</End_Page><Periodical>Echocardiography</Periodical><Volume>18</Volume><Issue>4</Issue><Address>Departement de Cardiologie, Centre Hospitalo-Universitaire de Poitiers, 350 Avenue Jacques Coeur, BP 577, 86021 Poitiers Cedex, France. l.christiaens@chu-poitiers.fr</Address><Web_URL>PM:11415497</Web_URL><ZZ_JournalStdAbbrev><f name="System">Echocardiography</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�D<Refman><Cite><Author>Cotrim</Author><Year>2002</Year><RecNum>7</RecNum><IDText>Do patients with intraventricular gradients during dobutamine stress echocardiography have intraventricular gradients with exercise testing?</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>7</Ref_ID><Title_Primary>Do patients with intraventricular gradients during dobutamine stress echocardiography have intraventricular gradients with exercise testing?</Title_Primary><Authors_Primary>Cotrim,C.</Authors_Primary><Authors_Primary>Osorio,P.</Authors_Primary><Authors_Primary>Joao,I.</Authors_Primary><Authors_Primary>Victor,A.R.</Authors_Primary><Authors_Primary>Cordeiro,P.</Authors_Primary><Authors_Primary>Fazendas,P.</Authors_Primary><Authors_Primary>de Oliveira,L.M.</Authors_Primary><Authors_Primary>Carrageta,M.</Authors_Primary><Date_Primary>2002/12</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart Ventricles</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>ultrasonography</Keywords><Reprint>Not in File</Reprint><Start_Page>1461</Start_Page><End_Page>1465</End_Page><Periodical>Rev.Port.Cardiol.</Periodical><Volume>21</Volume><Issue>12</Issue><Address>Servico de Cardiologia do Hospital Garcia de Orta, Almada</Address><Web_URL>PM:12621919</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rev.Port.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Cabrera-Bueno</Author><Year>2009</Year><RecNum>67</RecNum><IDText>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>67</Ref_ID><Title_Primary>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</Title_Primary><Authors_Primary>Cabrera-Bueno,F.J.</Authors_Primary><Authors_Primary>Gomez-Doblas,J.J.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>Montiel-Trujillo,A.</Authors_Primary><Authors_Primary>Jimenez-Navarro,M.</Authors_Primary><Authors_Primary>Martinez-Del-Valle,D.</Authors_Primary><Authors_Primary>Jimenez-Hoyuela,J.M.</Authors_Primary><Authors_Primary>de Teresa-Galvan,E.</Authors_Primary><Date_Primary>2009/3</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>complications</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>HEART-DISEASE</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Prognosis</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>272</Start_Page><End_Page>280</End_Page><Periodical>Echocardiography.</Periodical><Volume>26</Volume><Issue>3</Issue><Misc_3>ECHO808 [pii];10.1111/j.1540-8175.2008.00808.x [doi]</Misc_3><Address>Department of Cardiology, University Hospital Virgen de la Victoria, Malaga, Spain. fjcabrera@secardiologia.es</Address><Web_URL>PM:19175778</Web_URL><ZZ_JournalStdAbbrev><f name="System">Echocardiography.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>	D<Refman><Cite><Author>Panza</Author><Year>1997</Year><RecNum>17</RecNum><IDText>Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>17</Ref_ID><Title_Primary>Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography</Title_Primary><Authors_Primary>Panza,J.A.</Authors_Primary><Authors_Primary>Laurienzo,J.M.</Authors_Primary><Authors_Primary>Curiel,R.V.</Authors_Primary><Authors_Primary>Unger,E.F.</Authors_Primary><Authors_Primary>Quyyumi,A.A.</Authors_Primary><Authors_Primary>Dilsizian,V.</Authors_Primary><Authors_Primary>Cannon,R.O.,III</Authors_Primary><Date_Primary>1997/2</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Arteries</Keywords><Keywords>blood</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Chest Pain</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Transesophageal</Keywords><Keywords>Electrocardiography</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>Humans</Keywords><Keywords>Image Processing,Computer-Assisted</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Myocardial Contraction</Keywords><Keywords>Myocardial Ischemia</Keywords><Keywords>PATIENT</Keywords><Keywords>physiopathology</Keywords><Keywords>Stress</Keywords><Reprint>Not in File</Reprint><Start_Page>293</Start_Page><End_Page>301</End_Page><Periodical>J.Am.Coll.Cardiol.</Periodical><Volume>29</Volume><Issue>2</Issue><Misc_3>S0735109796004810 [pii]</Misc_3><Address>Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892, USA</Address><Web_URL>PM:9014980</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�D<Refman><Cite><Author>Cabrera-Bueno</Author><Year>2009</Year><RecNum>67</RecNum><IDText>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>67</Ref_ID><Title_Primary>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</Title_Primary><Authors_Primary>Cabrera-Bueno,F.J.</Authors_Primary><Authors_Primary>Gomez-Doblas,J.J.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>Montiel-Trujillo,A.</Authors_Primary><Authors_Primary>Jimenez-Navarro,M.</Authors_Primary><Authors_Primary>Martinez-Del-Valle,D.</Authors_Primary><Authors_Primary>Jimenez-Hoyuela,J.M.</Authors_Primary><Authors_Primary>de Teresa-Galvan,E.</Authors_Primary><Date_Primary>2009/3</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>complications</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>HEART-DISEASE</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Prognosis</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>272</Start_Page><End_Page>280</End_Page><Periodical>Echocardiography.</Periodical><Volume>26</Volume><Issue>3</Issue><Misc_3>ECHO808 [pii];10.1111/j.1540-8175.2008.00808.x [doi]</Misc_3><Address>Department of Cardiology, University Hospital Virgen de la Victoria, Malaga, Spain. fjcabrera@secardiologia.es</Address><Web_URL>PM:19175778</Web_URL><ZZ_JournalStdAbbrev><f 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