Determinants of an abnormal response to exercise in patients with asymptomatic valvular aortic stenosis.

Adult; Aged; Aged, 80 and over; Aortic Valve Stenosis/physiopathology/ultrasonography; Echocardiography, Doppler; Exercise/physiology; Exercise Test; Hemodynamics; Humans; Middle Aged; Prospective Studies; Rest/physiology; Stroke Volume

Abstract :

[en] AIM: Patients with asymptomatic aortic stenosis (AS) and abnormal haemodynamic responses to exercise testing are at increased risk of cardiac events. This study assesses the Doppler echocardiographic determinants of a positive exercise test in a cohort of asymptomatic patients with AS. METHODS AND RESULTS: One hundred and twenty-eight patients with AS underwent quantitative Doppler echocardiographic measurements at rest and during exercise test. Of these patients, 60 had an abnormal response to exercise. Two independent determinants of an abnormal exercise response were selected in multivariate analysis: a larger increase in mean transaortic pressure gradient (P = 0.00014) and a limited contractile reserve-latent left ventricular dysfunction-as indicated by smaller changes in ejection fraction (P = 0.0002). Limiting symptoms were associated with greater increase in mean transaortic pressure gradient, smaller changes in systolic blood pressure and a lower ejection fraction at peak exercise. The increase in pressure gradient was associated with smaller exercise-induced changes in aortic valve area and in ejection fraction and new or worsening mitral regurgitation during exercise. CONCLUSION: Abnormal responses to exercise in asymptomatic AS patients are mediated by a larger increase in mean transaortic pressure gradient and/or a limited contractile reserve characterized by an inadequate increase in ejection fraction at exercise.

Disciplines :

General & internal medicine

Author, co-author :

Lancellotti, Patrizio ; Centre Hospitalier Universitaire de Liège - CHU > Cardiologie

Karsera, Danai

Tumminello, Gabriele

Lebois, Florence ; Centre Hospitalier Universitaire de Liège - CHU > Cardiologie

Pierard, Luc ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation

Language :

English

Title :

Determinants of an abnormal response to exercise in patients with asymptomatic valvular aortic stenosis.

Publication date :

2008

Journal title :

European Journal of Echocardiography

ISSN :

1525-2167

eISSN :

1532-2114

Publisher :

Harcourt Publishers Limited

Volume :

Issue :

Pages :

338-43

Peer reviewed :

Peer Reviewed verified by ORBi

Additional URL :

http://ejechocard.oxfordjournals.org/cgi/reprint/9/3/338

Available on ORBi :

since 19 February 2010

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Bibliography

Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol 2006;47:2141-51.
Otto CM, Burwash IG, Legget ME, Munt BI, Fujioka M, Healy NL et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997;95:2262-70.
Kelly TA, Rothbart RM, Copper Cm, Kaiser DL, Smucker ML, Gibson RS. Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis. Am J Cardiol 1988;16:123-30.
Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol 1990;15:1012-7.
Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med 2000;343:611-7.
Lund O, Nielsen TT, Emmertsen K, Flo C, Rasmussen B, Jensen FT et al. Mortality and worsening of prognostic profile during waiting time for valve replacement and aortic stenosis. Thorac Cardiovasc Surg 1996;44:289-95.
Amato MCM, Moffa PJ, Werner KE. Ramires. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart 2001;86:381-6.
Alborino D, Hoffmann JL, Fournet PC, Bloch A. Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. J Heart Valve Dis 2002;11:204-9.
Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J 2005;26:1309-13.
Peidro R, Brion G, Angelino A. Exercise testing in asymptomatic aortic stenosis. Cardiology 2006;14:258-64.
Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C, Pierard LA. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation 2005;112:I377- 82.
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 Guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006;48:e1-e148.
Iung B, Gohlke-Bärwolf C, Tornos P. Recommendations on the management of the asymptomatic patient with valvular heart disease. Eur Heart J 2002;23:1253-66.
Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Barwolf C, Levang OW et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on valvular heart disease. Eur Heart J 2003;24:1231-43.
STS national database. STS US cardiac surgery database: 1997 aortic valve replacement patients; preoperative risk variables. Chicago Society of Cardiac Surgeons 2000.
Otto CM. Correspondence: predictors of outcome in asymptomatic aortic stenosis. N Engl J Med 2001;344:228.
Pellikka PA, Sarano ME, Nishimura RA, Malouf JF, Bailey KR, Scott CG et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation 2005;111:3290-5.
Bache RJ, Wang Y, Jorgensen CR. Hemodynamic effects of exercise in isolated valvular aortic stenosis. Circulation 1971;44:1003-13.
Ettinger PO, Frank MJ, Levison ME. Hemodynamics at rest and during exercise in combined aortic stenosis and insufficiency. Circulation 1972;45:267-76.
Martin TW Jr, Moody JMJ, Bird JJ, Slife D, Murgo JP, Moody JM Jr. Effect of exercise on indices of valvular aortic stenosis. Cathet Cardiovasc Diagn 1992;25:265-71.
Otto CM, Pearlman AS, Kraft CD, Miyake-Hull CY, Burwash IG, Gardner CJ. Physiologic changes with maximal exercise in asymptomatic valvular aortic stenosis assessed by Doppler echocardiograhy. J Am Coll Cardiol 1992;20:1160-7.
Burwash IG, Pearlman AS, Kraft CD, Miyake-Hull C, Healy NL, Otto CM. Flow dependence of measures of aortic stenosis severity during exercise. J Am Coll Cardiol 1994;24:1342-50.
Das P, Rimington H, Smeeton N, Chambers J. Determinants of symptoms and exercise capacity in aortic stenosis: a comparison of resting haemodynamics and valve compliance during dobutamine stress. Eur Heart J 2003;24:1254-62.
Ross J. Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol 1985;5:811- 26.
Lund O. Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis. Reasons for earlier operative intervention. Circulation 1990;82:124-39.
Giorgi D, Di Bello V, Talini E, Palagi C, Dele Donne MG, Nardi C et al. Myocardial function in severe aortic stenosis before and after aortic valve replacement: a Doppler tissue imaging study. J Am Soc Echocardiogr 2005;18:8-14.