ECHO 2013 / When (and how) to use Stress Testing in Valvular Heart Disease
.pdf
Cardiac Event-Free Survival According to Presence or Absence of Exercise Pulmonary Hypertension
Cardiac event-free survival (%)
100
80
60
40
20
P=0.014
0
No exercise PHT
Exercise PHT
0 6 12 18 24 30 36 42 48
Pt remaining at risk |
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Follow-up (months) |
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47 |
44 |
35 |
22 |
15 |
10 |
5 |
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58 |
47 |
38 |
27 |
24 |
11 |
3 |
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Lancellotti et al: Circ 126:851, 2012
©2013 MFMER | 3259292-21
Asymptomatic Severe AS
All-Cause Death
100 
OP
(%) |
80 |
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Survival |
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60 |
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CONV |
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P<0.001 |
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OP 6-yr survival rate 98±1% |
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CONV 6-yr survival rate 68±6% |
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40 |
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0 |
2 |
4 |
6 |
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No. at risk |
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Years |
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OP |
102 |
96 |
48 |
29 |
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CONV |
95 |
82 |
54 |
32 |
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Cardiac mortality free survival (%)
Cardiac Death
100 
OP
80
CONV
60P<0.001
OP 6-yr survival rate 100% CONV 6-yr survival rate 76±5%
40
0 2 4 6
Years
102 |
96 |
48 |
29 |
95 |
82 |
54 |
32 |
Kang et al: Circulation 121:1502, 2010
©2013 MFMER | 3259292-22
All groups had the same mean gradient (56 mmHg) and AVA (0.792 cm )
JACC CV Imaging Feb 2013
©2013 MFMER | 3259292-23
All groups had the same mean gradient (56 mmHg) and AVA (0.792 cm )
JACC CV Imaging Feb 2013
©2013 MFMER | 3259292-24
Low Gradient Aortic Stenosis
Low Ejection Fraction
LVOT TVI 11 cm/s
AV TVI 58 cm/s
AV MG 23 mmHg
AVA = LVOT area x 11/58 = 0.6 cm2
©2013 MFMER | 3259292-25
Aortic |
Low cardiac output |
Stenosis |
Low pressure gradient |
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Baseline Doppler |
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hemodynamics |
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Dobutamine |
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stress |
Gradient |
Gradient |
AV area |
AV area |
Severe AS |
Not severe AS |
CP979442-15
©2013 MFMER | 3259292-26
Dobutamine Challenge
5 to 20 mic /kg/min
Stroke volume
40 to 60 cc
Mean gradient 25 to 40 mmHg
Baseline 0.65 Dobutamine 0.76 cm2
CP979442-18
©2013 MFMER | 3259292-27
Risk Stratification by DSE
AS with low gradient and low EF
Contractile Reserve |
Yes |
No |
Stroke volume (%Increase) |
34 |
8 |
LVEF change |
12 |
3 |
Peak Mean PG (mmHg) |
41 |
30 |
Aortic valve area |
0.8 |
0.8 |
Peak resistance |
251 |
244 |
Surgical mortaility ( % ) |
8 |
50 |
Monin et al. JACC 2001©20 3 MFMER | 3259292-28
Mitral Regurgitation
•Asymptomatic pts with severe (ERO area >40 mm2) organic MR are a increased risk of cardiac events
•Patient’s symptoms may be related to exercise induced MR
•Some of them might develop significant LV dysfunction after MV repair despite the presence of a normal preoperative resting EF.
©2013 MFMER | 3259292-29
61 asymptomatic moderate to severe degenerative MR (MV prolapse or flail)
Magne, J. et al. JACC 2010;56:300-9
©2013 MFMER | 3259292-30