Opinion statement
Aortic valve disease and especially aortic stenosis (AS) is a growing cardiac pathology. Aortic valve replacement (AVR) is still the only treatment with proven benefit on survival in symptomatic patients and in patients with a left ventricular ejection fraction (LVEF) <50%. The benefit of prophylactic AVR in asymptomatic patients is still unproven. Once symptoms develop, the prognosis worsens. Exercise testing has emerged as a tool to unmask the “pseudo-asymptomatic” patients with AS (those without self-reporting symptoms), to link “exercise induced dyspnea” more confidently and more objectively to aortic valve disease and to allow for a safe “watchful waiting strategy” in “pseudo-symptomatic” patients (those with dyspnea unrelated to aortic valve disease). In cases in which exercise testing is unable to link dyspnea to aortic valve disease, exercise stress echocardiography and cardiopulmonary exercise testing may be helpful. Whatever the results of exercise testing with regard to symptom development, an increase in mean aortic valve pressure gradient >18–20 mmHg was associated with an increased risk of cardiac related events in severe AS patients (class IIb indication for AVR in the ESC guidelines). The decrease in LVEF during exercise as well as the development of exercise induced pulmonary hypertension, as revealed by exercise stress echocardiography, may be also useful in the risk stratification of these asymptomatic patients with severe AS. Data on the role of exercise echocardiography in asymptomatic severe aortic regurgitation patients is still scarce and further studies are needed. It seems that an exercise induced decrease in LVEF by 5% may be a better predictor of LV systolic dysfunction after AVR in asymptomatic patients or in patients with minimal symptoms. Exercise testing and exercise echocardiography are safe in the asymptomatic patients with aortic disease, provide useful clinical information that may help in risk assessment of these complicated patients and their use should be encouraged especially in heart valve clinics.
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References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2438–88.
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.
Amato MC, Moffa PJ, Werner KE, Ramires JA. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart. 2001;86:381–6.
Marechaux S, Hachicha Z, Bellouin A, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J. 2010;31:1390–7.
• Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377–82. First study to look at the increase in mean transaortic gradient during exercise stress echocardiography in patients with severe aortic stenosis.
Marechaux S, Ennezat PV, LeJemtel TH, et al. Left ventricular response to exercise in aortic stenosis: an exercise echocardiographic study. Echocardiography. 2007;24:955–9.
Donal E, Thebault C, O’Connor K, et al. Impact of aortic stenosis on longitudinal myocardial deformation during exercise. Eur J Echocardiogr. 2011;12:235–41.
Lancellotti P, Karsera D, Tumminello G, Lebois F, Pierard LA. Determinants of an abnormal response to exercise in patients with asymptomatic valvular aortic stenosis. Eur J Echocardiogr. 2008;9(3):338-43.
Cooper R, Ghali J, Simmons BE, Castaner A. Elevated pulmonary artery pressure. An independent predictor of mortality. Chest. 1991;99:112–20.
McHenry MM, Rice J, Matlof HJ, Flamm MD Jr. Pulmonary hypertension and sudden death in aortic stenosis. Br Heart J. 1979;41:463–7.
Copeland JG, Griepp RB, Stinson EB, Shumway NE. Long-term follow-up after isolated aortic valve replacement. J Thorac Cardiovasc Surg. 1977;74:875–89.
Carnero-Alcazar M, Reguillo-Lacruz F, Alswies A, et al. Short- and mid-term results for aortic valve replacement in octogenarians. Interact Cardiovasc Thorac Surg. 2010;10:549–54.
Magne J, Lancellotti P, Pierard LA. Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation. 2010;122:33–41.
Brochet E, Detaint D, Fondard O, et al. Early hemodynamic changes versus peak values: what is more useful to predict occurrence of dyspnea during stress echocardiography in patients with asymptomatic mitral stenosis? J Am Soc Echocardiogr. 2011;24:392–8.
Lancellotti P, Magne J, Donal E, et al. Determinants and prognostic significance of exercise pulmonary hypertension in asymptomatic severe aortic stenosis. Circulation. 2012;126:851–9.
Dulgheru R, Magne J, Capoulade R, et al. Impact of global hemodynamic load on exercise capacity in aortic stenosis. Int J Cardiol. 2013;168:2272–7.
•• Perez Del Villar C, Yotti R, Espinosa MA et al. The functional significance of paradoxical low gradient aortic valve stenosis: hemodynamic findings during cardiopulmonary exercise testing. JACC Cardiovasc Imaging. 2017;10(1):29–39. First study to show through a combined Doppler and hemodynamic approach that stenotic low gradient aortic valves may have a significant opening reserve during exercise that may explain, in part, the increase in capillary wedge pressure and exercise inadaptation.
Masri A, Goodman AL, Barr T et al. Predictors of long-term outcomes in asymptomatic patients with severe aortic stenosis and preserved left ventricular systolic function undergoing exercise echocardiography. Circ Cardiovasc Imaging. 2016;9(7). doi:10.1161/CIRCIMAGING.116.004689.
•• Lumley M, Williams R, Asrress KN, et al. Coronary physiology during exercise and vasodilation in the healthy heart and in severe aortic stenosis. J Am Coll Cardiol. 2016;68:688–97. First study to perform an analysis of coronary arteries flow during bicycle exercise in patients with severe aortic stenosis which were symptomatic and to prove that coronary artery coupling is abnormal in these patients, making them possibly at risk for myocardial ischemia during exercise.
Wahi S, Haluska B, Pasquet A, et al. Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation. Heart. 2000;84:606–14.
Lindsay J Jr, Silverman A, Van Voorhees LB, Nolan NG. Prognostic implications of left ventricular function during exercise in asymptomatic patients with aortic regurgitation. Angiology. 1987;38:386–92.
Broch K, Urheim S, Massey R, et al. Exercise capacity and peak oxygen consumption in asymptomatic patients with chronic aortic regurgitation. Int J Cardiol. 2016;223:688–92.
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Luc A. Pierard and Raluca Dulgheru each declare no potential conflicts of interest.
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Movie 1
Comparison of the left ventricular (LV) systolic function and wall motion at rest vs. exercise in a patient with severe AS with preserved left ventricular ejection fraction. At peak exercise there is a decrease of LV systolic function and wall motion at the apex and lateral wall, despite the fact that coronary angiogram does not show any significant stenosis of the epicardial coronary areries. (See Fig. 1, Panel A). (AVI 7718 kb)
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Pierard, L.A., Dulgheru, R. Exercise Testing and Stress Imaging in Aortic Valve Disease. Curr Treat Options Cardio Med 19, 54 (2017). https://doi.org/10.1007/s11936-017-0551-5
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DOI: https://doi.org/10.1007/s11936-017-0551-5