J Cardiovasc Ultrasound.  2014 Mar;22(1):1-5. 10.4250/jcu.2014.22.1.1.

Exercise Echocardiography in Asymptomatic Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

• Henri C
• Lancellotti P

• KMID: 2177448
• DOI: http://doi.org/10.4250/jcu.2014.22.1.1

Abstract

The management of asymptomatic patients with severe aortic stenosis (AS) remains controversial. Recent series reported that early aortic valve replacement might be associated with improved clinical outcomes. However, the risk-benefit ratio should be carefully evaluated and early surgery only be proposed to a subset of asymptomatic patients considered at higher risk. Exercise echocardiography can help unmask symptomatic patients combined with assessment of the hemodynamic consequences of AS. Recent studies have demonstrated that exercise echocardiography can provide incremental prognostic value to identify patients who may benefit most from early surgery. In "truly" asymptomatic patients, an increase in mean aortic gradient > or = 18-20 mmHg, a limited left ventricular contractile reserve or a pulmonary hypertension during exercise are predictive parameters of adverse cardiac events. Exercise echocardiography is low-cost, safe and available in many referral centers, and does not expose patients to radiation. The purpose of this article is to describe the role of exercise testing and echocardiography in the management of asymptomatic patients with severe AS and preserved left ventricular ejection fraction.

Keyword

Aortic stenosis; Exercise testing; Exercise echocardiography

MeSH Terms

Aortic Valve
Aortic Valve Stenosis*
Echocardiography*
Exercise Test
Hemodynamics
Humans
Hypertension, Pulmonary
Referral and Consultation
Stroke Volume*

Figure

• 

  Fig. 1 Impact on clinical decision-making of exercise testing and exercise echocardiography in asymptomatic patients with severe aortic stenosis and preserved left ventricular function. MG: mean aortic pressure gradient, AVA: aortic valve area, BP: blood pressure, EF: ejection fraction, SPAP: systolic pulmonary artery pressure, ESC: European Society of Cardiology.

• 

  Fig. 2 Exercise echocardiography protocol including the sequence of acquisition. *Should be measured at low-level exercise before E and A wave fusion. CW: continuous-wave Doppler, fps: frame per second, LV: left ventricle, PW: pulsed-wave Doppler, SPAP: systolic pulmonary artery pressure, TDI: tissue Doppler imaging, TR: tricuspid regurgitation.

• 

  Fig. 3 Example of an asymptomatic patient with severe aortic stenosis presenting a significant exercise-induced increase in mean trans-aortic pressure gradient (A) and exercise pulmonary hypertension (B). In addition, a significant exercise-induced increase in estimated left ventricular filling pressure (C) but a normal contractile reserve assessed by 2-D speckle tracking analyzing global longitudinal strain (D) was observed. MTAG: mean aortic pressure gradient, TTG: trans-tricuspid pressure gradient, GLS: global longitudinal strain.

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