Impact of Duration of Mitral Regurgitation on Outcomes in Asymptomatic Patients With Myxomatous Mitral Valve Undergoing Exercise Stress Echocardiography

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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Physiological and prognostic differences between types of exercise stress echocardiography for functional mitral regurgitation

Open Heart ◽

10.1136/openhrt-2021-001583 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001583

Author(s):

Nobuyuki Kagiyama ◽

Misako Toki ◽

Takuya Yuri ◽

Shingo Aritaka ◽

Akihiro Hayashida ◽

...

Keyword(s):

Mitral Regurgitation ◽

Adverse Events ◽

Stress Echocardiography ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Exercise Stress ◽

Functional Mitral Regurgitation ◽

Exercise Stress Echocardiography ◽

Ergometer Exercise ◽

Secondary Mr

ObjectiveSecondary mitral regurgitation (MR) demonstrates dynamic change during exercise. This prospective observational study aimed to compare exercise stress echocardiography (ESE) where handgrip exercise (handgrip-ESE) or semisupine ergometer exercise was performed (ergometer-ESE) for patients with secondary MR.MethodsHandgrip-ESE and symptom-limited ergometer-ESE were performed for 53 patients (median age (IQR): 68 (58–78) years; 70% male) on the same day. Baseline global longitudinal strain (GLS) was 9.2% (6.0%–14.0%) and MR volume was 20 (14–26) mL. All-cause death and cardiac hospitalisation were tracked for median 439 (101–507) days.ResultsHandgrip-ESE induced slightly but significantly greater degrees of MR increase (median one grade increase; p<0.001) than ergometer-ESE, although the changes in other parameters, including GLS (+1.1% vs −0.6%, p<0.001), were significantly smaller. Correlations between the two examinations with respect to the changes in the echocardiographic parameters were weak. Kaplan-Meier analyses revealed poor improvement in GLS during ergometer-ESE, but not the change in MR, was associated with adverse events (p=0.0065). No echocardiographic change observed during handgrip-ESE was prognostic. After adjusting for a clinical risk score, GLS changes during ergometer-ESE remained significant in predicting the adverse events (HR 0.39, p=0.03) A subgroup analysis in patients with moderate or greater MR at baseline (n=27) showed the same results as in the entire cohort.ConclusionsThe physiological and prognostic implications of handgrip-ESE and ergometer-ESE findings significantly differ in patients with left ventricular dysfunction and secondary MR. The type of exercise to be performed in ESE should be carefully selected.

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