The Added Value of Exercise Stress Echocardiography in Patients With Heart Failure

Abstract Background Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest and exercise stress echocardiography (ESE). Aim To assess the prevalence of B-lines during ESE in different cardiovascular diseases. Methods We performed ESE plus LUS (4-site simplified scan) in 4419 subjects referred for semi-supine bike ESE in 28 certified centers. B-lines score ranged from 0 (normal) to 40 (severely abnormal). Stress B-lines abnormal result was ≥2 units. Six different populations were evaluated: healthy controls (n=103); chronic coronary syndromes (CCS, n=3701); heart failure with reduced ejection fraction (HFrEF, n=395); heart failure with preserved ejection fraction (HFpEF, n=70); valvular heart disease (VHD) for ischemic mitral regurgitation ≥moderate at rest (n=123); repaired tetralogy of Fallot (ToF, n=27). Results Feasibility of B-lines was 100% at rest and peak ESE in all subjects. Imaging and analysis time were <1 minute. B-lines (median) were not detectable in healthy subjects (rest=0.1 [0–1] vs 0.1 [0–1], p=ns) and TOF (rest=0.2 [0–2] vs 0.3 [0–4], p=ns), but were present in all other groups: see figure. During ESE, B-lines increased in CCS (rest=0.5 [0–24] vs ESE=1.3 [0–28], p<0.001); HFrEF (rest=1.4 [0–35] vs ESE=2.9 [0–40], p<0.001); HFpEF (rest=0.3 [0–2] vs ESE=3.4 [0–12], p<0.001), VHD (rest=1.7 [0–12] vs ESE=4.3 [0–23], p<0.001). Stress B-lines were correlated with stress-rest change in wall motion score index in CCS (r=0.325, p<0.001), contractile reserve in HFrEF (r=−0.266, p<0.001) and in VHD (r=−.0300, p=0.001), left atrial volume stress-rest change in HFpEF (r=0.287, p=0.043). Conclusion B-lines identify the pulmonary congestion phenotype at rest and more frequently during ESE in patients with different coronary, myocardial or valvular heart disease, all sharing the final common pathway of acute backward left heart failure through different disease-specific mechanisms. B-lines are absent in healthy subjects and in conditions inducing a mostly right-sided overload such as repaired ToF. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. B-lines at rest and during stress. Percentage (%) of rest (empty bar) and stress (full bar) B-lines abnormality (≥2 units) in six different study groups.

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Impact of right ventricular contractile reserve on exercise capacity in patients with heart failure: clinical application of low-load exercise stress echocardiography

European Heart Journal ◽

10.1093/ehjci/ehaa946.1014 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Kinoshita ◽

K Inoue ◽

Y Akazawa ◽

H Nakagawa ◽

Y Sasaki ◽

...

Keyword(s):

Heart Failure ◽

Heart Transplantation ◽

Exercise Capacity ◽

Stress Echocardiography ◽

Exercise Stress ◽

Contractile Reserve ◽

Peak Vo2 ◽

Patients With Heart Failure ◽

Low Load ◽

Rv Function

Abstract Background The peak oxygen uptake (VO2) evaluated by the cardiopulmonary exercise test (CPX) is an established marker of exercise capacity in patients with heart failure (HF). In particular, peak VO2 <14 ml/kg/min is used to be one of the criteria for heart transplantation. However, given exercise intolerance in patients with HF, it is difficult for refractory HF patients to reach sufficient exercise load. A recent report has highlighted significant impact of right ventricular (RV) function on mortality and urgent heart transplantation. Taken together, we hypothesized that the assessment of RV function was helpful to predict exercise capacity by using low-load exercise stress echocardiography (low-load ESE) in patients with HF. Purpose We evaluated whether RV dysfunction assessed by the low-load ESE determined a low peak VO2 <14 ml/kg/min in patients with HF. Methods We studied 67 consecutive hospitalized patients with HF (mean age, 65 years; 75% male; mean LV ejection fraction, 36%) who underwent ESE and CPX after stabilized HF condition, and the time interval of CPX and ESE tests was within 48 hours. CPX was performed using an upright cycle ergometer by a ramp protocol, while ESE was performed using ergometer in semi-supine position and the workload was generally increased by 25 watts every 3 minutes. The low-load ESE was defined as the 25 watts exercise. The increments of RV s' velocity at tricuspid annulus and RV strain in the free wall were considered as a preservation of RV contractile reserve. Among the study population, 26 patients were performed right heart catheterization and RV dP/dt/Pmax was estimated as an invasive marker of RV contractility. Results The achieved intensity of exercise was 50.4±21.0 watts, and all patients completed the low-load ESE. The invasive study showed that the change of RV s' velocity during the low-load ESE significantly correlated with RV dP/dt/Pmax (r=0.706, p<0.001). As shown in Figure, the non-invasive parameters of RV contractile reserve during the low-load ESE were significantly correlated with peak VO2 (RV s' velocity: r=0.787, p<0.001; RV strain: r=0.244, p=0.047). ROC analysis showed that the change of RV s' velocity during the low-load ESE correctly identified patients with peak VO2 <14 ml/kg/min (AUC=0.95, sensitivity 92.3%, specificity 85.2%). In terms of inter- and intra-observer variabilities, ICCs of the change of RV s' velocity were 0.86 and 0.96, and ICCs of the changes of RV strain were 0.63 and 0.70, respectively. Conclusion The change of RV s' velocity during the low-load ESE could determine exercise tolerance in patients with HF. The assessment of RV contractile reserve might be clinically useful to discriminate high risk HF patients. Figure 1 Funding Acknowledgement Type of funding source: None

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Prognostic Value of Dynamic Changes in Pulmonary Congestion During Exercise Stress Echocardiography in Heart Failure With Preserved Ejection Fraction

Circulation Heart Failure ◽

10.1161/circheartfailure.119.006769 ◽

2020 ◽

Vol 13 (6) ◽

Cited By ~ 1

Author(s):

Stefano Coiro ◽

Dejan Simonovic ◽

Marina Deljanin-Ilic ◽

Kevin Duarte ◽

Erberto Carluccio ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Prognostic Value ◽

Stress Echocardiography ◽

Exercise Stress ◽

Preserved Ejection Fraction ◽

Pulmonary Congestion ◽

Dynamic Changes ◽

Exercise Stress Echocardiography

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P942 Outcome prediction by exercise stress echocardiography and cardiopulmonary exercise testing assessment in patients with heart failure

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.575 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

K Sakata ◽

H Mitsuda ◽

J Ito ◽

A Isaka ◽

A Gouda ◽

...

Keyword(s):

Heart Failure ◽

Exercise Testing ◽

Cardiac Dysfunction ◽

Stress Echocardiography ◽

Cardiopulmonary Exercise Testing ◽

Exercise Stress ◽

Cardiac Resynchronization ◽

Cardiopulmonary Exercise ◽

Peak Vo2 ◽

Patients With Heart Failure

Abstract Background Cardiopulmonary exercise testing (CPX) is essential to the assessment of functional impairment and prognosis in patients with heart failure (HF). Peak oxygen consumption (peak VO2) continues to be considered the gold standard for assessing prognosis in HF. The minute ventilation-carbon dioxide production (VE-VCO2) slope has recently demonstrated prognostic significance in patients with HF. Ergometer stress echocardiography (Erg-Echo) is useful to evaluate the exercise-induced pulmonary hypertension and the potential cardiac dysfunction that are difficult to evaluate in the resting state. Objective The aim of this study is to evaluate the relationship between CPX and Erg-echo indices, and the usefulness of Erg-echo to determine the severity of cardiac dysfunction and the prognosis in patients with HF. Methods We studied 58 patients with HF (age 65.2 ± 11.9 years) and performed CPX and Erg-Echo. The peak VO2 and the VE-VCO2 slope were measured by CPX. Cardiac output (CO) and estimated mean pulmonary artery pressure (mPAP) were measured by Erg-Echo at rest and peak exercise load, and the change ratio (ΔmPAP / ΔCO) were calculated. We evaluated the clinical outcome during a1 year period. Results The ΔmPAP / ΔCO was significantly correlated with the peak VO2 (R = -0.6767, P <0.0001) and the VE-VCO2 slope (R = 0.6809, P <0.0001). Cardiovascular events (1 patient of cardiovascular death, 8 patients of re-hospitalization due to HF, 4 patients of myocardial ischemia, 2 patients of Cardiac Resynchronization Therapy (CRT) devices implantation, 1 patient of ventricular tachycardia) developed in 16 of the 58 patients (27.5%: Group CE) during the 1 year. The peak VO2 was significantly lower (12.1 ± 2.5 vs. 16.1 ± 3.1ml/min/kg, P <0.0001) and the VE-VCO2 slope was significantly higher (41.1 ±. 12.3 vs. 31.8 ± 6.1ml/ml, P <0.0001) in Group CE compared to the other 42 patients (Group N). The ΔmPAP was significantly higher (19.1 ± 4.4 vs. 14.9 ± 6.4, P = 0.0408) and the ΔCO was significantly lower (2.4 ± 1.2 vs. 4.1 ± 2.0, P = 0.0078), and the ΔmPAP / ΔCO was significantly higher (9.7 ± 4.6 vs. 4.4 ± 2.4, P <0.0001) in Group CE compared to Group N. Conclusions The ΔmPAP/ ΔCO by Erg-Echo is useful to evaluate the severity of cardiac dysfunction and the prognosis of HF patients.

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Exercise stress echocardiography in patients with valvular heart disease

Echo Research and Practice ◽

10.1530/erp-15-0015 ◽

2015 ◽

Vol 2 (3) ◽

pp. 89-98 ◽

Cited By ~ 3

Author(s):

Vishal Sharma ◽

David E Newby ◽

Ralph A H Stewart ◽

Mildred Lee ◽

Ruvin Gabriel ◽

...

Keyword(s):

Heart Failure ◽

Heart Disease ◽

Valvular Heart Disease ◽

Stress Echocardiography ◽

Exercise Stress ◽

Risk Of Death ◽

Exercise Stress Echocardiography ◽

Metabolic Equivalents ◽

Asymptomatic Patients

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved <85% of their predicted metabolic equivalents (METS). There were three deaths and four hospital admissions, and 24 patients underwent surgery during follow-up. An abnormal stress echocardiogram (METS <5, blood pressure rise <20 mmHg, or pulmonary artery pressure post exercise >60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P<0.0001). The assessment of contractile reserve did not offer additional predictive value. In conclusion, an abnormal stress echocardiogram is associated with death and hospitalization with heart failure at 2 years. Stress echocardiography should be considered as part of the routine follow-up of all asymptomatic patients with VHD.

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