The approach to managing asymptomatic or questionably symptomatic patients for aortic stenosis is difficult. We aimed to determine whether cardiopulmonary exercise testing (CPET) is prognostically useful in such patients. Patients judged asymptomatic or questionably symptomatic for aortic stenosis with aortic valve area index <0.6 cm/m and left ventricular ejection fraction ≥0.50 were managed conservatively provided they had either (group 1) normal peak oxygen consumption and peak oxygen pulse (>83% and >95% of the predicted values, respectively) or (group 2) subnormal peak oxygen consumption or peak oxygen pulse but with CPET data pointing to pathologies other than hemodynamic compromise from aortic stenosis. Increase in systolic blood pressure <20 mm Hg, ST depression ≥2 mm, or symptoms during the exercise test were allowed. Unexpected events included cardiac death or hospitalization with heart failure in patients who had not been recommended valve replacement. The median age of the study population (n = 101) was 75 years (interquartile range 65 to 79 years), and 67% were judged questionably symptomatic. During a follow-up at 24 ± 6 months, the rate of unexpected cardiac death and unexpected hospitalization with heart failure was 0% and 6.0%, respectively. All-cause mortality was 4.0% compared with 8.0% in the age- and gender-matched population. For group 1, 26 of 70 (37.1%) succumbed to cardiac death, or were hospitalized because of heart failure, or underwent valve replacement, and for group 2 this was 12 of 31 (38.7%). In conclusion, if CPET does not indicate a significant hemodynamic compromise because of aortic stenosis, an initially conservative strategy results in a good prognosis and an acceptable event rate.

ObjectiveTo assess the change in peak oxygen consumption (pVO2) and determine its outcome predictors after aortic valve replacement (AVR) for aortic stenosis (AS).MethodsPatients with AS and preserved left ventricular ejection fraction who were referred for single AVR had cardiopulmonary exercise testing prior to and 9 months post-AVR. Predictors of outcome for pVO2 were determined by multivariate linear and logistic regression analyses. A significant change in pVO2 was defined as a relative change that was more than twice the coefficient of repeatability by test–retest (>10%).ResultsThe pre-AVR characteristics of the 37 study patients included the following: median age (range) 72 (46–83) years, aortic valve area index (AVAI) 0.41 (SD 0.11) cm2/m2, mean gradient (MG) 49.1 (SD 15.3) mm Hg and New York Heart Association (NYHA)≥II 27 (73%). Pre-AVR and post-AVR mean pVO2 was 18.5 and 18.4 mL/kg/m2 (87% of the predicted), respectively, but the change from pre-AVR was heterogeneous. The relative change in pVO2 was positively associated with the preoperative MG (β=0.50, p=0.001) and negatively associated with brain natriuretic peptide > upper level of normal according to age and gender (β=−0.40, p=0.009). A relative increase in pVO2 exceeding 10% was found in 9 (24%), predicted by lower pre-AVR AVAI (OR 0.18; 95% CI 0.04 to 0.82, p=0.027) and lower peak O2 pulse (OR 0.94; 95% CI 0.88 to 0.99, p=0.045). Decreases in pVO2 exceeding 10% were found in 11 (30%) and predicted by lower MG (OR 0.93; 95% CI 0.86 to 0.99, p=0.033).ConclusionsChange in pVO2 was heterogeneous. Predictors of favourable and unfavourable outcomes for pVO2 were identified.

Objective: To access the prognostic value of cardiopulmonary exercise testing (CPX) in patients with asymptomatic or equivocal symptomatic aortic stenosis (AS/ES-AS). Methods: Patients with AS/ES-AS without left ventricular dysfunction were prospectively grouped according to their CPX outcome: 1) peak oxygen-consumption (pVO 2 ) >83% and peak oxygen-pulse (pO 2 pulse) >95% of that predicted; 2) pVO 2 <83% or pO 2 pulse <95% but CPX pointing to other cause than hemodynamic compromise; 3) pVO 2 <83% and respiratory coefficient >1 or clear exercise-limiting discomfort. At baseline Groups 1 (n=77) and 2 (n=35) were handled conservatively and Group 3 (n=18) referred for aortic valve replacement (AVR). Primary end-point was cardiac death, hospitalization with heart failure or AVR with improvement from just pre-AVR to nine months post-AVR in pVO 2 or Physical Component Score from the SF-36 > the estimated clinical relevant difference (5% and 7.5%, respectively). Results: The mean age, valve area and follow-up was 72.1±6.9 years, 0.45±0.11 cm/m 2 and 24±5 months, respectively; 48% were NYHA class ≥II. The end-point was reached in 25.3%, 26.4% and 62.5% in Group 1, 2 and 3, respectively (Group 3 vs. Group 1+2, p=0.007). One patient (0.7%) suffered cardiac death, eight months after recommendation of AVR, and 7 (6.3%) were hospitalized with heart failure. A pO 2 pulse <100% of that predicted was the single predictor of the end-point, odds-ratio 2.55 (95% CI:1.18;5.54) (Table 1). Conclusions: CPX appears useful to separate those with a high probability of improvement with AVR from those, including patients with decreased pVO 2 , with a low event-rate with a conservative approach.