ECHO 2013 / When (and how) to use Stress Testing in Valvular Heart Disease
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When and how to use stress testing in valvular heart diseases
Jae K. Oh, MD
State of the Art Echo in New York City April 3rd, 2013
Disclosure : Echo Core Lab for Core Valve Pivotal Trial
©2013 MFMER | 3259292-1
Valvular heart disease is usually considered static.
Its management relies upon resting evaluation only.
Most valve diseases have a dynamic component
©2013 MFMER | 3259292-2
82 year old man with exertional dyspnea
•Previously healthy other than HTN in the last 2 yrs, treated by ACEI and diuretics
•Progressive shortness of breath on exertion in the last 2 yrs
•Had negative echo, angiogram and LV cath from outside
©2013 MFMER | 3259292-3
82 year old man with dyspnea soon after treated for hypertension
Normal coronary angiogram and stress test
©2013 MFMER | 3259292-4
Before and After exercise
Resting |
Exercise |
What is the mechanism ?
©2013 MFMER | 3259292-5
LVOT gradient before and after exercise
5 m/s
Baseline |
Exercise |
©2013 MFMER | 3259292-6
Repeat Echo 2 months later D/C of ACE i and Lasix Addition of Beta blocker
Rest |
Exercise |
©2013 MFMER | 3259292-7
LVOT gradient before and after exercise After change in Rx
Resting |
Exercise |
|
©2013 MFMER | 3259292-8
Stress Echo in VHD
In Asymptomatic Severe VHD or Symptomatic Non-severe VHD
|
Parameters |
AHA/ACC Guideline |
AS |
Symptoms |
Class II b (1 ESC) |
|
Fall in BP |
Class II b (II a) |
|
↑ ∆ Pmean ≥15-20mmHg |
|
|
↓ LVEF |
|
AR |
Symptoms |
|
|
↓ LVEF |
|
MS |
Symptoms |
Class 1 C |
|
PASP>60mmHg |
Class 1 C |
|
∆ Pmean >15mmHg |
Class 1 C |
MR |
Symptoms |
Class II a |
|
PASP >60mmHg |
|
|
↓LVEF ≥ 4% |
|
©2013 MFMER | 3259292-9
53 year old woman with Dyspnea s/p MV Balloon Valvuloplasty
Mean Gradient |
7 mmHg |
Heart rate |
69 BPM |
TR velocity |
2.8 m/sec |
|
|
©2013 MFMER | 3259292-10