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

Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population

Background: Exercise stress echocardiography (ESE) is commonly employed in adults, but its applicability in pediatric populations remains to be clarified. Methods: A total of 309 consecutive children (C), with a mean age of 14.1 ± 2.6 years (range 6-17 years), underwent treadmill ESE starting in 2002. They were divided into two groups: Group I comprised 258 children, including 237 with symptoms related to exercise (such as chest pain, fatigue, lipothymia/syncope, or one aborted sudden death), 15 with electrocardiogram (ECG) abnormalities, and 6 with a positive ECG stress test showing ST changes. Group II consisted of 10 asymptomatic children whose parents requested routine screening, 11 with symptoms unrelated to exercise, 12 with a family history of sudden death, and 17 with known pathologies (including 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, and the remainder with various conditions, such as Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, and aortic switch operation). Regional wall motion abnormalities (RWMAs) and transvalvular or intraventricular (IVG) gradients were assessed using 2D and continuous-wave Doppler, respectively, in all cases. Results: The success rate was 100% (309/309). Stress-induced RWMAs were observed in two children. A significant IVG (>30 mmHg) was detected in 101 out of the 258 children (39%) in Group I, who presented with exercise-related symptoms, ECG abnormalities, or positive stress ECG. In Group I, the odds ratio (OR) of ESE reproducing the symptoms in children with IVG compared to those without IVG was 8.22 (95% CI: 4.84-13.99, p < 0.001). Conclusions: Treadmill ESE is both feasible and safe for pediatric populations. RWMAs demonstrated limited utility in our cohort of children, while IVG induced by exercise was frequently observed in symptomatic children.

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

BACKGROUND

The role of exercise stress echocardiography (ESE) in the pediatric population is less well defined as compared to adults. We aimed to determine the utility and impact of ESE on clinical decision-making in pediatric patients.

METHODS

We identified patients who underwent an ESE at our center from 2011 to 2015. Test indications were categorized into symptoms with exercise; sports/activity clearance; hypertrophic cardiomyopathy (HCM) or suspected HCM; coronary anomalies; or abnormal electrocardiogram (EKG). Change in clinical management was assessed by comparing pre- and post-test activity restrictions, which were categorized into unrestricted from exercise or activity; restricted from exercise or activity; and surgical referral.

RESULTS

During the study period, 353 ESEs met inclusion criteria. Of all ESEs performed, 263 (75%) were normal. Clinical management changed as a result of ESE in 144 (40%). Of the abnormal ESEs, 44 were restricted from activity, including 25 (56.8%) restricted from competitive or varsity athletics, 14 (31.8%) restricted from recreational sports, and 5 (11.4%) restricted from all activity. Surgical referrals included valve repair/replacement in 7 (50%), ICD placement in 5 (35.8%), coronary re-implantation in 1 (7.1%), and atrial septal defect repair in 1 (7.1%).

CONCLUSION

Exercise stress echocardiography provides the pediatric cardiologist with useful information that impacts management in a wide variety of cardiac disorders. Clinical management changed in nearly half the patients that were subjected to an ESE at our center. This supports the value of ESE for informing clinical decision-making. Future studies should aim to refine patient selection and examine its impact on patient outcomes.