Dynamic Assessment of Stenotic Valvular Heart Disease by Stress Echocardiography
2013; Lippincott Williams & Wilkins; Volume: 6; Issue: 4 Linguagem: Inglês
10.1161/circimaging.113.000201
ISSN1942-0080
AutoresSanjeev Bhattacharyya, Rajdeep Khattar, Nav Chahal, Neil Moat, Roxy Senior,
Tópico(s)Cardiovascular Function and Risk Factors
ResumoHomeCirculation: Cardiovascular ImagingVol. 6, No. 4Dynamic Assessment of Stenotic Valvular Heart Disease by Stress Echocardiography Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBDynamic Assessment of Stenotic Valvular Heart Disease by Stress Echocardiography Sanjeev Bhattacharyya, Rajdeep Khattar, Nav Chahal, Neil Moat and Roxy Senior Sanjeev BhattacharyyaSanjeev Bhattacharyya From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.). , Rajdeep KhattarRajdeep Khattar From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.). , Nav ChahalNav Chahal From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.). , Neil MoatNeil Moat From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.). and Roxy SeniorRoxy Senior From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.). Originally published1 Jul 2013https://doi.org/10.1161/CIRCIMAGING.113.000201Circulation: Cardiovascular Imaging. 2013;6:583–589IntroductionDuring the past 2 decades, the dynamic nature of valvular heart disease has become a recognized phenomenon. Changes in loading conditions, heart rate, and ventricular contractility that occur with exercise can alter the physiological effects of valvular disease.1,2 Disparity between resting evaluation of valve dysfunction and patient symptoms is not uncommon. Stress echocardiography (SE) has emerged as a modality able to provide new diagnostic information by identifying dynamic changes in the severity of valve stenosis on exertion responsible for symptoms and evaluate the severity of valve disease in altered flow states.3 This review seeks to review critically the existing evidence base, identify new emerging prognostic markers, evaluate their role in clinical practice, and identify future directions for research.Aortic StenosisThe clinical scenarios where SE aids diagnosis and has prognostic value include the evaluation of asymptomatic severe aortic stenosis (AS), low-flow (LF), low-gradient (LG) AS, and moderate AS with symptoms (Table).Table. Clinical Use of Stress Echocardiography in Stenotic Valvular Heart DiseaseValve LesionConditionMethodMajor Parameters to be MeasuredPrognostic ParametersDiagnostic ParametersAortic stenosisAsymptomatic severe ASExercise bicycle or treadmillExercise capacity and symptom statusDevelopment of symptoms…Baseline and peak exercise mean aortic valve gradients and LVEF≥18 mm Hg increase in mean aortic valve gradient predicts reduced symptom-free survivalModerate or moderate to severe AS with symptoms of chest pain or dyspnoeaExercise bicycle or treadmillExercise induced new regional wall motion abnormalities…New regional wall motion abnormalities suggest coronary artery diseaseBaseline and peak exercise mean aortic valve gradients and LVEFLow-gradient, low-flow severe ASDobutamineBaseline and low dose>20% increase in stroke volume suggests contractile reserveSevere AS: AVA ↔Mean gradient ↑LVOT VTI, AV VTI, mean AV gradient, AVAPseudosevere AS: AVA ↑Mean gradient ↔Mitral stenosisSymptomatic mild/moderate MSExercise bicycle or treadmillMean transmitral gradient and PASP…>15 mm Hg transmitral gradient or >60 mm Hg PASP explains symptomsDobutamineMean transmitral gradient and PASP>18 mm Hg transmitral valve gradient predicts cardiac events…Asymptomatic severe MSExercise bicycle or treadmillExercise capacity and symptom statusIncrease in gradient and pulmonary artery pressureDevelopment of symptomsAS indicates aortic stenosis; AVA, aortic valve area; LVEF, left ventricular ejection fraction; LVOT, left ventricular outflow tract; MS, mitral stenosis; PASP, pulmonary artery systolic pressure; and VTI, velocity time integral.Asymptomatic Aortic StenosisThe prognosis of patients with symptomatic, severe AS is dismal.4 The prognosis for those who are asymptomatic is more favorable with a 20 mm Hg are associated with a 9-fold increase in event rate (AVR because of symptom development or death) during the next 2 years.9 Importantly, the exercise-induced increase in gradient could not be predicted from resting clinical or echocardiographic data. Recently, exercise-induced pulmonary hypertension (estimated pulmonary artery systolic pressure [PASP], >60 mm Hg) has shown be an independent predictor of cardiac events.10The heterogeneity of the response to exercise may be related to valve compliance, which is a measure of the change in the effective orifice area of a valve in response to alterations in flow.11,12 The increased flow rate during exercise may allow a more compliant valve to open more effectively (thereby reducing the rise in transaortic gradient during exercise) compared with a less compliant valve. Indeed, valve compliance is lower in patients who develop symptoms during exercise than in those who remain asymptomatic.12Exercise SE can be performed using either a treadmill or semisupine bicycle. Treadmill-based protocols require poststress images to be obtained immediately after the patient has transferred from the treadmill to the examination couch. Therefore, the data obtained may not truly represent hemodynamics at peak exercise. However, during bicycle exercise, images can be obtained throughout the test and at peak exercise and this is, therefore, the preferred technique.Implications for Clinical PracticeBoth the American Heart Association/American College of Cardiology and European Society of Cardiology guidelines advocate the use of exercise testing to unmask symptoms in patients who may have sedentary lifestyles.13,14 A positive test (development of symptoms, hypotension, or ventricular arrhythmia during exercise) is graded as an indication to consider AVR. The use of exercise SE is more difficult to establish. This is in part because of the end points used in studies being a composite of death and AVR (especially where AVR was decided on by individual clinicians likely influenced by test results). The new European Society of Cardiology 2012 guidelines recommend consideration of AVR in asymptomatic patients with an exercise increase in mean AV gradient of ≥20 mm Hg (Class IIb).14 It may be reasonable to use exercise SE to risk stratify patients and help identify patients at high risk of developing symptoms and who thereby warrant AVR or closer follow-up (Figures 1 and 2).Download figureDownload PowerPointFigure 1. Exercise stress echocardiogram in a 58-year-old man with severe asymptomatic aortic stenosis. A, At rest mean transaortic gradient=58 mm Hg. Patient exercised on the treadmill for 9 minutes. No adverse hemodynamic changes occurred during exercise and no symptoms were reported. B, Immediately after exercise transaortic gradient. The mean gradient increased to 82 mm Hg. A total of 24 mm Hg increase in mean transaortic gradient during exercise places patient in high-risk group and according to European Society of Cardiology guidelines and this patient could be considered for aortic valve replacement. PG indicates pressure gradient; Vmax, maximum velocity; Vmean, mean velocity; and VTI, velocity time integral.Download figureDownload PowerPointFigure 2. Algorithm for investigation and management of asymptomatic aortic stenosis. Aortic valve (AV), aortic valve replacement (AVR), European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC). *Emerging parameters which require further validation.LF, LG Severe Aortic StenosisThe severity of AS is defined by the degree of reduction in AV area (AVA). An AVA <1 cm2 suggests severe stenosis irrespective of the valve gradient.15 The transvalvular gradient is flow dependent and varies according to the square of the flow rate and inversely to the square of the AVA.16 In situations where AVA is <1 cm2 and the mean gradient is moderate (<40 mm Hg), the discrepancy between the 2 measurements could be because of a reduction in stroke volume in both patients with impaired and normal left ventricular (LV) ejection fraction (EF).17,18 Low stroke volume, in the latter, can occur in patients with severe, concentric LV hypertrophy and small LV volumes, or reduced longitudinal function but preserved radial function.17In both of these groups of patients, the reduction in AVA may be because of true severe AS or the so-called pseudo (nonsevere) AS.3 In severe AS, the valve has limited compliance and a fixed valve area; therefore, an increase in transvalvular flow will increase the transvalvular gradient as the square of flow. In lesser degrees of AS (pseudosevere AS), the valve is more compliant and an increase in transvalvular flow will have a much less significant effect on transvalvular gradient. SE can induce altered flow rates and detect change in hemodynamics, thereby differentiating between truly severely and pseudosevere AS.19LF/LG severe AS with impaired LV function refers to patients with apparently severe AS (AVA≤1 cm2) but low mean AV pressure gradients (<40 mm Hg) and impaired LVEF ( 40 mm Hg), but no change in the AVA ( 1 cm2), but the mean gradient will remain <40 mm Hg (Figure 3). At this point, higher doses of dobutamine may be used to exclude ischemia as the cause of LV dysfunction.Download figureDownload PowerPointFigure 3. Low-dose dobutamine stress echocardiogram in a 75-year-old patient with exertional dyspnoea. Left ventricular outflow tract (LVOT) 2.3 cm. A, LVOT velocity time integral (VTI) 20 cm. B, Mean aortic valve (AV) gradient 30 mm Hg but calculated aortic valve area (AVA) of 20%) suggesting the presence of LV contractile reserve. D, Although there is a mild increase in mean AV gradient to 35 mm Hg, the AVA increases to 1.3 cm2 suggesting pseudosevere (moderate) AS.The main limitation of this test is that it is dependent on flow augmentation, which is highly variable between patients. In patients without contractile reserve, it is not possible to differentiate between true and pseudosevere AS. The concept of projected valve area at normal transvalvular flow rate (250 mL/s) was developed to better differentiate between true and pseudosevere AS.21 To calculate the projected valve area, AVA is plotted against mean transvalvular flow rate (Q) at different stages of the dobutamine SE protocol. Valve compliance is derived from the regression line of this plot. The projected AVA (AVAproj; at a standardized flow rate of 250 mL/s) is then calculated (AVA at rest+valve compliance×[250−flow at rest]). A simplified formula to calculate AVAproj has been validated22Download figureThe use of AVAproj significantly improves the accuracy of discriminating severe (AVAproj≤1 cm2) from pseudosevere AS compared with conventional dobutamine SE indices.21,22 Furthermore, an AVAproj<1.2 cm2 is an independent predictor of prognosis in LF, LG severe AS.23 A suggested algorithm for investigation is displayed in Figure 4. Recent data have validated this concept in patients with LFLG severe AS with preserved EF.24Download figureDownload PowerPointFigure 4. Algorithm for investigation of low-flow, low-gradient severe aortic stenosis. Left ventricular ejection fraction (LVEF), stroke volume (SV), aortic valve area (AVA), projected aortic valve area (AVAproj), *emerging parameters which require further validation.Implications for Clinical PracticeThe prognosis of patients with severe AS and poor LVEF is poor. In a study of 136 patients with LFLG AS, patients were stratified according the results of a dobutamine stress echocardiogram (DSE) into those with or without contractile reserve.17 Within the group of patients who underwent AVR, the perioperative mortality in patients with contractile reserve was 5% compared with 31% in patients without contractile reserve (Figure 5). The long-term outcome of patients without contractile reserve is very poor, although AVR (albeit at a higher perioperative risk) is still associated with a better long-term outcome than medical therapy.25 Therefore, contractile reserve can be used to risk stratify this group of patients, although patients should not be denied AVR on this basis alone and it should be used as a part of the overall management decision.Download figureDownload PowerPointFigure 5. Kaplan–Meier survival curves demonstrating the effect of contractile reserve (CR) and management strategy (medical therapy versus aortic valve replacement [AVR]) on survival. Patients with CR and AVR had improved 3-year survival compared with patients without CR. Reproduced with permission from Monin et al.17A recent multicenter registry of 305 LF/LGAS patients found the survival of patients with pseudosevere AS was significantly better than patients with truly severe LFLG AS and comparable with that of a group of propensity-matched patients with systolic heart failure and no evidence of valve disease.26 This study supports the medical management of these patients.Guidelines advocate DSE in patients with LFLG AS to distinguish between patient with truly severe AS and those with pseudosevere (moderate) AS.13,14 Furthermore in patients with truly severe AS, the findings can be used to risk stratify operative risk and long-term mortality.Evaluation of Concomitant Coronary Artery DiseaseNearly 50% of patients with AS have concomitant coronary artery disease.27 In patients with moderate AS, symptoms of chest pain or exertional dyspnoea may be attributable to underlying coronary artery disease rather than AS per se. In our practice, we routinely perform SE using exercise or dobutamine, not only to determine transaortic parameters, but also to identify stress-induced ischemia, which may clarify the causes of symptoms. In symptomatic patients with LV dysfunction where the severity of AS is in question, if low-dose dobutamine indicates moderate AS, high doses of dobutamine may be used to uncover ischemia as the cause of LV dysfunction (Figure 6). Evaluation of coronary artery disease in patients with significant AS using higher doses of dobutamine to assess for myocardial ischemia has been shown to be safe.28Download figureDownload PowerPointFigure 6. Dobutamine stress echocardiogram in a 72-year-old patient with low-gradient, low-flow aortic stenosis with impaired left ventricular function. Resting heart rate 83 bpm and blood pressure 135/84 mm Hg. At rest, the mean transaortic gradient was 32 mm Hg, aortic valve area=0.9 cm2, left ventricular ejection fraction=29%, flow rate=192 mL/s. After low-dose dobutamine (heart rate 88 bpm; blood pressure 140/90 mm Hg), the flow rate increased to 215 mL/s, the mean gradient increased to 38 mm Hg but remained 60 mm Hg.31 Although physiological exercise would seem to be the most appropriate and clinically relevant form of dynamic assessment, the prognostic value of DSE in MS has also been investigated.32 If a patient develops a mean gradient of 18 mm Hg during DSE, this had a 90% sensitivity and 87% specificity for prediction of a clinical event (death, mitral valve intervention, arrhythmia, or dyspnoea).In patients with resting measurements suggesting severe MS who are asymptomatic, SE is helpful in uncovering symptoms and demonstrating a significant increase in mean gradient and pulmonary artery pressure. In truly asymptomatic patients, high mitral valve compliance improves valve opening with increasing flow rate during exercise with minimal rise in gradient and pulmonary artery pressure.Implications for Clinical PracticeBoth European Society of Cardiology and American Heart Association/American College of Cardiology guidelines recommend that either dobutamine or preferably exercise SE is performed in patients who are symptomatic, despite Doppler measurements which do not indicate significant MS. An increase in mean mitral gradient to ≥15 mm Hg or PASP to ≥60 mm Hg is considered a Class IIb indication for consideration of percutaneous mitral valvotomy in the American College of Cardiology/American Heart Association Guidelines13 (Table). The European Society of Cardiology guidelines do not specify exercise criteria but recommend valve intervention in patients with mitral valve area ≤1.5 cm2 and symptoms.14ConclusionsDynamic evaluation of the severity and hemodynamic effects of valvular stenosis can provide additional diagnostic information and provide prognostic information, which may help refine risk stratification of patients to aid management decisions (Table). The lack of translation of many of the current studies into clinical practice guidelines is because of the lack of multicenter, randomized trials testing the use of stress-induced markers to determine therapy. Second, the use of more refined markers of disease severity (projected valve area) needs further evaluation.DisclosuresNone.FootnotesCorrespondence to Roxy Senior, MD, FRCP, FESC, FACC, Department of Cardiology and Echocardiography Laboratory, Royal Brompton Hospital, London SW3 6NP, United Kingdom. E-mail [email protected]References1. 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July 2013Vol 6, Issue 4 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.113.000201PMID: 23861450 Manuscript receivedJanuary 15, 2013Manuscript acceptedMay 14, 2013Originally publishedJuly 1, 2013 Keywordsechocardiography, stressheart valve diseasesPDF download Advertisement SubjectsEchocardiographyValvular Heart Disease
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