DSE protocol Interpretation Viability ECG LV pathology guides Stress echo training › Guides › Viability
Myocardial viability on dobutamine stress echo
In a patient with coronary disease and LV dysfunction, a segment that is abnormal at rest can be scar or living myocardium that is not contracting (hibernating or stunned). Low-dose dobutamine tests for contractile reserve : viable myocardium thickens better at low dose; scar does not.
Hibernation, stunning and scar
Hibernating myocardium: chronically underperfused, with reduced function at rest. It can recover after revascularisation.Stunned myocardium: function stays reduced after an ischaemic episode even though blood flow has been restored, and recovers over time.Scar: infarcted tissue, typically thin (end-diastolic thickness below about 6 mm) and bright. It does not recover.
The four responses
Response Low dose Peak Interpretation
Biphasic Improves Worsens again Viable and ischaemic; the best predictor of recovery after revascularisation Sustained improvement Improves Improves further Viable without inducible ischaemia (for example stunning or non-transmural infarction) Worsening No improvement Worsens Ischaemia in a segment without contractile reserve No change No change No change Scar: non-viable
Example: biphasic response
Bullseye Diagrams
Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Hypokinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Normal 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Normal 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 7. Mid anterior — Normal 7 1. Basal anterior — Normal 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 8. Mid anteroseptal — Normal 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Rest · HR 74 · WMSI 1.29 Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Normal 13 14. Apical septal — Hypokinetic 14 15. Apical inferior — Normal 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Normal 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Hypokinetic 14 17. Apex (apical cap) — Normal 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Normal 15 17. Apex (apical cap) — Normal 17 13. Apical anterior — Normal 13 7. Mid anterior — Normal 7 1. Basal anterior — Normal 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Normal 17 13. Apical anterior — Normal 13 8. Mid anteroseptal — Normal 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Low dose · HR 84 · WMSI 1.06 Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Hypokinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Normal 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Normal 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 7. Mid anterior — Normal 7 1. Basal anterior — Normal 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 8. Mid anteroseptal — Normal 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Peak · HR 137 · WMSI 1.29 Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Hypokinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Normal 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Normal 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 7. Mid anterior — Normal 7 1. Basal anterior — Normal 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Hypokinetic 13 8. Mid anteroseptal — Normal 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Normal 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Normal 7 8. Mid anteroseptal — Normal 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Recovery · HR 103 · WMSI 1.29
Simulated hibernating myocardium: abnormal at rest, better at low dose, worse again at peak.
Example: scar
Bullseye Diagrams
Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Akinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Hypokinetic 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Hypokinetic 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 7. Mid anterior — Akinetic 7 1. Basal anterior — Hypokinetic 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 8. Mid anteroseptal — Akinetic 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Rest · HR 68 · WMSI 1.71 Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Akinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Hypokinetic 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Hypokinetic 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 7. Mid anterior — Akinetic 7 1. Basal anterior — Hypokinetic 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 8. Mid anteroseptal — Akinetic 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Low dose · HR 75 · WMSI 1.71 Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Akinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Hypokinetic 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Hypokinetic 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 7. Mid anterior — Akinetic 7 1. Basal anterior — Hypokinetic 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 8. Mid anteroseptal — Akinetic 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Peak · HR 161 · WMSI 1.71 Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 13. Apical anterior — Akinetic 13 14. Apical septal — Akinetic 14 15. Apical inferior — Hypokinetic 15 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 4C 3. Basal inferoseptal — Normal 3 9. Mid inferoseptal — Normal 9 14. Apical septal — Akinetic 14 17. Apex (apical cap) — Akinetic 17 16. Apical lateral — Normal 16 12. Mid anterolateral — Normal 12 6. Basal anterolateral — Normal 6 Right ventricle RV SEP LAT 2C 4. Basal inferior — Normal 4 10. Mid inferior — Normal 10 15. Apical inferior — Hypokinetic 15 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 7. Mid anterior — Akinetic 7 1. Basal anterior — Hypokinetic 1 INF ANT 3C 5. Basal inferolateral — Normal 5 11. Mid inferolateral — Normal 11 16. Apical lateral — Normal 16 17. Apex (apical cap) — Akinetic 17 13. Apical anterior — Akinetic 13 8. Mid anteroseptal — Akinetic 8 2. Basal anteroseptal — Normal 2 Right ventricle RV INF-LAT ANT-SEP SAX base Right ventricle RV 1. Basal anterior — Hypokinetic 1 2. Basal anteroseptal — Normal 2 3. Basal inferoseptal — Normal 3 4. Basal inferior — Normal 4 5. Basal inferolateral — Normal 5 6. Basal anterolateral — Normal 6 SAX mid Right ventricle RV 7. Mid anterior — Akinetic 7 8. Mid anteroseptal — Akinetic 8 9. Mid inferoseptal — Normal 9 10. Mid inferior — Normal 10 11. Mid inferolateral — Normal 11 12. Mid anterolateral — Normal 12 Recovery · HR 113 · WMSI 1.71
Simulated proximal LAD infarct: the same akinetic segments at every stage, with no contractile reserve.
Protocol points
Use small low-dose steps (for example 2.5, 5 and 10 µg/kg/min) and record images at each step, because the improvement can appear at a very low dose. Continue to peak dose if it is safe, to look for the biphasic response. Look at end-diastolic wall thickness and brightness as well as motion: thin, bright segments are unlikely to recover.
Reporting
Report which territories are viable and how many segments show contractile reserve, the type of response (biphasic or sustained), and any inducible ischaemia elsewhere. Viability is one part of the heart-team decision about revascularisation, together with symptoms, anatomy and other imaging.
Practise viability cases → Explore responses 