1) The patient underwent a pre-CRT pharmacologic echocardiogram to assess left ventricular function, dyssynchrony, and viability. Baseline echocardiogram found severe left ventricular dysfunction with an ejection fraction of 13% and evidence of left bundle branch block pattern of dyssynchrony. 2) Low dose dobutamine stress echocardiogram showed improvement in wall motion in several segments, indicating viable myocardium. It also demonstrated increased septal flash and apical rocking, suggestive of stress-induced dyssynchrony. 3) Ejection fraction improved from 13% to 24% with dobutamine, demonstrating contractile reserve. Various techniques confirmed extensive intraventricular dy

1. THE MOHAMMED BIN KHALIFA BIN SULMAN AL-KHALIFA
CARDIAC CENTRE
DEPARTMENT OF DIAGNOSTIC CARDIOLOGY
Tel: +973 17766234
PHARMACOLOGIC ECHOCARDIOGRAPHY REPORT
Name: Anonymised CPR : 560120842
Birth Date: 05-Jan-56 Procedure Date: 03-Aug-17
Referring Consultant: Dr. MARY AL TARIF Reading Physician: Dr. VINAYAK VADGAONKAR
Ordering Practitioner: Dr. MARY AL TARIF Sonographer: Ruby
Nurse: Study Quality: Fair
Indications: CMP+AVR, Pre-CRT study, DSE for assessment of dysynchrony and viability
Stress Information:
Initial Heart Rate: 71 Method of Stress: Pharmacological
Initial Rhythm: NSR
Predicted Maximum HR: 159
Symptoms During Test: Asymptomatic Actual Maximum HR: 85
85% Max. Predicted HR: 135.15
Pharmacological Agent: Dobutamine
Echo Stress Test Exercise
Stage Dose BP HR Symptoms Comments Arrhythmia
Resting 125/59 71 PVCs
I 5
mcg/kg/min
127/59 69 PVCs
II 10
mcg/kg/min
126/58 65
III 15
mcg/Kg/mi
n
145/76 70
IV 20
mcg/kg/min
130/71 74 PVCs
V 25
mcg/kg/min
134/68 74 PVCs
VI 30
mcg/kg/min
126/60 83 PVCs
Baseline LV dysynchrony assessment
Baseline
* There is spherical remodeling of LV with EDD of 6.8cm and ESD of 6.2cm.There is severe MAC with restricted PML
and associated Mild Mitral regurgitation. Status postAVR (SJM regent) with reasonable opening angle of occluders
with no prosthesis related complications.There is mild septal flash with apical rocking at baseline.There is visual
interventricular dysynchrony.
LV systolic function assessment(Baseline)
* LVEDV/LVESD 239ml/207ml Biplane EF 13%; 4D LV assessment-LVEF 13% with EDV/ESV 254/220ml.
Atrio-ventricular dusyncrony
* Ratio of MV Diastolic filling time/RR interval 45%.
Interventricular dysnchrony
* LVPEP - 173ms; LVPEP- RVPEP - 59ms.

2. Patient Name: Anonymised
CPR: 560120842
Date of Procedure: 03-Aug-17
Septal to posterior wall motion delay
* 2D Anatomical M-Mode - 330ms; TDI Anatomical M-Mode - 320ms.
Lateral wall post-systolic displacement
* QRS to lateral wall activation - QRS to MVO = Negative value more than 100ms.
Color TDI strain imaging for assessing horizontal dysynchrony/Qualitative assessment
* There is visual delay between basal septal and basal lateral;Mid septum and mid lateral;Mid and basal anterior and
inferior walls and significant delay betweenmid and basal posteriorand antero -septal walls.
Tissue synchronisation imaging
* SD Ts in 12 basal and mid LV segments - 48ms; Most delayed activationnoted basal lateral and inferolateral ; 4D
Triplane TSI SD of Ts in 12 basal and mid segments - 56ms ; Most delayed activated segments are noted in lateral
and inferolatreal walls.
Speckle tracking strain imaging
* Baseline GLPSS is -6.2% with paradoxical strain in mid to base lateral and inferior walls. There is characteristic
LBBB dysynchrony as noticed on strain time graphs with early septal activation pre -systole and simultaneous lateral
wall pre-stretch followed by septal delayed shortening and active contraction of lateral which is predominantin late
systole. There was no significant improvement after 30mics of DSE protocol. Post DSE GLPSS is -5.6%.But there is
improvement in lateral wall segmental strain. There is increased mechanical dispersioncompared to baseline.
Low dose DSE for viability
* There is improvement in contractility compared to baseline in basal lateral,basal inferior,mid lateral,apical septum
and basal inferolatreal segments. There is no scar noted.
LDDSE for Septal flash and apical rocking
* There is increased septal flash and apical rocking at 30mics of dobutamine suggestive of stress induced
dysynchrony.
Contractile reserve.LVEF/SV
* There is improvement in LVEF from 13% to 24% and Stroke volume reduced significantly from 76ml to 21ml.
LBBB deformation pattern
* There is type 2 LBBB deformation pattern on speckle tracking imaging with with early pre -systolic shortening with
reduced shortening till the end of systole with evidence of post systolic shortening.
Low dose DSE report
REST
ECG: True LBBB
ECHO: There is spherical remodeling of LV wth EDD of 6.8cm and ESD of 6.2cm.There is severe MAC with restricted
PML and associated Mild Mitral regurgitation. Status post AVR (SJM regent) with reasonable opening angle of occluders
with no prosthesis related complications.There is mild septal flash with apical rocking at baseline. There is visual
interventricular dysynchrony.
PEAK :
ECG : Sinus Tachycardia, no significant ST-T changes with multifocal PVCs
ECHO : There is improvement in contrcatility compared to baseline in basal lateral,basal inferior,mid lateral,apical septum
and basal inferolatreal segments.There is no scar noted.There is increased septal flash and apical rocking at 30mics of
dobutamine suggestive of stress induced dysynchrony.There is improvement in LVEF from 13% to 24% and Stroke
volume reduced significantly from 76ml to 21ml.

3. Patient Name: Anonymised
CPR: 560120842
Date of Procedure: 03-Aug-17
Conclusions:
Pre-CRT study with LDDSE for assessment of contractile reserve.
1. LV function assesment
Biplane Simpson,s method
LVEF 13% ; LVEDV/LVESV 239/207ml ; LVEDD/LVESD 6.8/6.2cm
4D LV assessment
LVEF 12%; LVEDV/LVESV 254/220ml
2. Atrio-Ventricular dysynchrony
* Ratio of MV Diastolic filling time/RR interval 45%
3. Interventricular dysynchrony
* LVPEP - 173ms; LVPEP- RVPEP - 59ms.
4. Intraventricular dysynchrony
# Septal to posterior wall motion delay
2D Anatomical M-Mode - 330ms; TDI Anatomical M-Mode - 320ms.
#Lateral wall post-systolic displacement
QRS to lateral wall wall activation - QRS to MVO = Negative value more than 100ms.
#Color TDI strain imaging for assessing horizontal dysynchrony/Qualitative assessment
There is visual delay between basal septal and basal lateral;Mid septum and mid lateral;Mid and basal anterior and
inferior walls and significant delay between mid and basal posterior and antero-septal walls.
#Tissue synchronisation imaging
SD Ts in 12 basal and mid LV segments - 48ms; Most delayed activation noted basal lateral and inferolateral ; 4D
Triplane TSI SD of Ts in 12 basal and mid segments - 56ms ; Most delayed activated segments are noted in latreal
and inferolatreal walls.
#Speckle tracking strain imaging
Baseline GLPSS is -6.2% with paradoxical strain in mid to base lateral and inferior walls.There is charecteristic LBBB
dysynchrony as noticed on strain time graphs with early septal activation pre-systole and simultaneous lateral wall
pre-strech followed by septal delayed shortening and and active contraction of latreal which is predominant in late
systole. There was no significant improvement after 30mics of DSE protocol.Post DSE GLPSS is -5.6%.But there is
improvement in lateral wall segmental strain.There is increased mechanical dispersion compared to baseline.
# LBBB deformation pattern
There is type 2 LBBB deformation pattern on speckle tracking imaging with with early pre-systolic shortening with
reduced shortening till the end of systole with evidence of post systolic shortening.
Low dose dobutamine stress echo for viability and dysynchrony
1. There is improvement in contrcatility compared to baseline in basal lateral,basal inferior,mid lateral,apical septum and
basal inferolatreal segments.There is no scar noted.
2. There is increased septal flash and apical rocking at 30mics of dobutamine suggestive of stress induced dysynchrony.
3. There is improvement in LVEF from 13% to 24% and Stroke volume reduced significantly from 76ml to 21ml.

4. Patient Name: Anonymised
CPR: 560120842
Date of Procedure: 03-Aug-17
Reported By:
Dr. VINAYAK VADGAONKAR,
Mohammed Bin Khalifa Bin Sulman Al Khalifa Cardiac Centre

5. Patient Name: Anonymised
CPR: 560120842
Date of Procedure: 03-Aug-17
Wall Motion
Rest Peak Dose
Key: 1=Normal, 2=Hypokinesis, 3=Akinesis, 4=Dyskinesis, 5=Aneurysmal,
6=Hyperkinetic, X=Not Visualized
(Blank)=Missing

6. Patient Name: Anonymised
CPR: 560120842
Date of Procedure: 03-Aug-17
electronically signed on 04-Aug-17 6:36:25 PM with status of Final by Dr. Vinayak