Stress echocardiography: An overview for use in pediatric and congenital cardiology

Abstract

Currently, the role of stress echocardiography primarily resides in diagnosing acquired coronary artery disease (CAD) in adults. Besides an increasing concern for traditional CAD in young patients due to obesity and other chronic pediatric diseases, there is also a growing population of adolescents and young adults with "at risk" coronary arteries due to: reimplanted coronaries in congenital heart disease, anomalous origin of the native coronary arteries, coronary abnormalities in Kawasaki's disease, and posttransplant coronary vasculopathy. Stress echocardiography is well suited for routine screening and monitoring in these patients. Also, due to the ability of stress echocardiography to provide real-time cardiac imaging, it is useful in areas beyond coronary ischemia. Utilizing Doppler derived velocities and pressure gradients, one is able to further evaluate and risk-stratify patients with valvular heart disease. In addition, stress echocardiography is useful in evaluating other areas including ventricular and coronary reserve. The benefits of stress echocardiography are it is: readily available, portable, and relatively cheap. It can be performed without sedation or radiation exposure which becomes very important in younger patients that require periodic monitoring. Stress echocardiography can also evaluate functional abnormalities instead of relative perfusion defects. Overall, stress echocardiography is currently an underutilized imaging modality that has a wide, and expanding, range of application in the practice of pediatric and congenital cardiology.

Exercise stress echocardiography: Impact on clinical decision‐making in pediatric patients

“…In adults, ESE is a safe, highly specific and highly sensitive well-established diagnostic test with the primary focus of identifying coronary disease and coronary disease-related dysfunction 2,3 In the pediatric population, currently ESE is most commonly utilized to evaluate for ischemia in patients at risk for, or who have known coronary abnormalities. 16 In their paper, Ermis et al 16 ergometer, our study looked at the absolute change in the clinical management based on the specific ESE performed. 11 Finally, this was not an attempt to validate the pretest and post-test probability of ESE, but rather to examine its impact on clinical decision-making in "real-world" clinical care.…”

Complete Transposition of the Great Arteries in the Pediatric Field: A Multimodality Imaging Approach

“…The ASO necessitates coronary artery reimplantation, introducing a potential for complications such as tension, torsion, or the kinking of the vessels. Although coronary issues like stenosis, occlusion, or stretching are rare immediately post-surgery, they might emerge later during follow-up [ 48 , 49 , 50 , 51 ]. The basis of stress echocardiography lies in the observation by Tennant and Wiggers 80 years ago, which noted that coronary stenosis and myocardial ischemia result in myocardial wall motion abnormalities.…”

“…Subsequent research has elaborated on the ischemic cascade, starting from subclinical metabolic changes to myocardial wall motion abnormalities and finally, angina symptoms. Stress echocardiography capitalizes on this knowledge to identify coronary artery disease (CAD) prior to the appearance of symptoms or ECG changes [ 48 , 49 ]. Consequently, as ASO is a substrate for coronary anomalies, stress echocardiography could identify myocardial ischemia before symptoms occur.…”

Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population

“…We consider that ESE has the potential to offer the same benefits to the pediatric population; however, it is an underexplored diagnostic tool, perhaps due to concerns regarding the learning curve of the method and its safety and applicability in terms of pediatric age. Given its diagnostic accuracy, ability to assess cardiac function, and lack of radiation, ESE should be considered a first-line diagnostic method, as it is a helpful tool in the clinical assessment of pediatric patients [2][3][4][5][6][7][8][9][10][11][12][13][14]. Physicians need to be aware that, despite the clinical necessity of imaging studies, the associated ionizing radiation exposure could pose an increased lifetime attributable risk of cancer [15].…”