The Emerging Role of Exercise Testing and Stress Echocardiography in Valvular Heart Disease

Abstract

Exercise testing has an established role in the evaluation of patients with valvular heart disease and can aid clinical decision making. Because symptoms may develop slowly and indolently in chronic valve diseases and are often not recognized by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can help identify patients who would benefit from early valve repair or replacement. In addition, stress echocardiography has emerged as an important component of stress testing in patients with valvular heart disease, with relevant established and potential applications. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. The versatile applications of stress echocardiography can be tailored to the individual patient with aortic or mitral valve disease , both before and after valve replacement or repair. Hence, exercise-induced changes in valve hemodynam-ics, ventricular function, and pulmonary artery pressure, together with exercise capacity and symptomatic responses to exercise, provide the clinician with diagnostic and prognostic information that can contribute to subsequent clinical decisions. Nevertheless, there is a lack of convincing evidence that the results of stress echo-cardiography lead to clinical decisions that result in better outcomes, and therefore large-scale prospective ran-domized studies focusing on patient outcomes are needed in the future. (J Am

2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease

“…The prognostic impact has been shown mainly for aortic stenosis and mitral regurgitation. 9 The search for flow reserve (also called 'contractile reserve') using low-dose dobutamine stress echocardiography is useful for assessing aortic stenosis severity and for operative risk stratification in low-gradient aortic stenosis with impaired LV function as well as to assess the potential of reverse remodelling in patients with heart failure and functional mitral regurgitation after a mitral valve procedure. 10,11…”

Stress Testing in Patients with Asymptomatic Severe Aortic Stenosis

“…On the other hand, dyspnea and chest pain may be non-specific. Exercise testing can identify a limited exercise capacity and unmask symptoms in about one-third of the apparently asymptomatic patients (32)(33). The development of symptoms during exercise seems to be more predictive than the other criteria, but this needs to be confirmed.…”

Primary mitral valve regurgitation: Update and review

“…6 Exercise echocardiography has its role in the evaluation of mitral regurgitation, by providing information on the severity of the regurgitation and the hemodynamic abnormalities (e.g., pulmonary hypertension) during exercise. 38 It is a useful tool to evaluate symptoms in patients that appear to have only mild regurgitation, to determine the functional capacity 39 and the changes in hemodynamics in patients who appear stable or asymptomatic. 40 Cardiac MRI is the most accurate non-invasive technique for measurement of enddiastolic and end-systolic volumes and left ventricular mass.…”