The Clinical Significance and advantages of Stress Echocardiography in patients with moderate to severe aortic stenosis

2021 ◽  
pp. 18-24
Author(s):  
S. Yu. Bartosh-Zelenaya ◽  
T. V. Naiden ◽  
A. E. Andreeva ◽  
V. V. Stepanova
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Clinical Significance ◽  
Stress Echocardiography ◽  
Contractile Function ◽  
Stress Test ◽  
Global Longitudinal Strain ◽  
Exercise Stress ◽  
Contractile Reserve ◽  
Exercise Stress Echocardiography

In order to determine the clinical significance of exercise stress echocardiography in patients with severe to moderate aortic stenosis, a stress-induced increase in the mean pressure gradient across the aortic valve was recorded and myocardial contractile reserve was assessed using a number of parameters (ejection fraction, global longitudinal strain, elasticity index). It was found that, with normal values of EF at rest in patients with severe and moderate aortic stenosis, the deficit in contractile function was revealed using the GLS index, which demonstrated a decrease in both groups at the peak of exercise. A decrease in contractile reserve by both parameters (EF and GLS) was found in the group of patients with severe AS, which, combined with a significant stress-induced increase in the gradient on the aortic valve (≥18–20 mm Hg), an increase in pulmonary artery pressure (>  60 mm Hg) and decrease in systemic systolic blood pressure (>20 mm Hg) should be considered as a predictors of a poor prognosis of the natural course of aortic valve disease, and patients with similar stress test results should be possible candidates for surgical aortic valve replacement. A decrease in the in the LV elasticity index augmentation at the peak of exercise, strongly correlated with changes in other considered parameters of contractility and the metabolic power of exercise (MET), significantly complements the functional characteristics of the lesion for choosing the optimal management strategy. Consequently, exercise stress echocardiography is an indispensable diagnostic tool for determining the prognosis and timing of surgery in patients with aortic stenosis.

Prognostic value of peak stress cardiac power in patients with normal ejection fraction undergoing exercise stress echocardiography

2020 ◽  
Author(s):  
Vidhu Anand ◽  
Garvan C Kane ◽  
Christopher G Scott ◽  
Sorin V Pislaru ◽  
Rosalyn O Adigun ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Stress Echocardiography ◽  
Stress Test ◽  
Peak Stress ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Cardiac Power ◽  
Exercise Stress Echocardiography ◽  
Lv Mass

Abstract Aims  Cardiac power is a measure of cardiac performance that incorporates both pressure and flow components. Prior studies have shown that cardiac power predicts outcomes in patients with reduced left ventricular (LV) ejection fraction (EF). We sought to evaluate the prognostic significance of peak exercise cardiac power and power reserve in patients with normal EF. Methods and results  We performed a retrospective analysis in 24 885 patients (age 59 ± 13 years, 45% females) with EF ≥50% and no significant valve disease or right ventricular dysfunction, undergoing exercise stress echocardiography between 2004 and 2018. Cardiac power and power reserve (developed power with stress) were normalized to LV mass and expressed in W/100 g of LV myocardium. Endpoints at follow-up were all-cause mortality and diagnosis of heart failure (HF). Patients in the higher quartiles of power/mass (rest, peak stress, and power reserve) were younger and had higher peak blood pressure and heart rate, lower LV mass, and lower prevalence of comorbidities. During follow-up [median 3.9 (0.6–8.3) years], 929 patients died. After adjusting for age, sex, metabolic equivalents (METs) achieved, ischaemia/infarction on stress test results, medication, and comorbidities, peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.5, 95% confidence interval (CI) 0.4–0.6, P < 0.001] and HF at follow-up [adjusted HR, highest vs. lowest quartile, 0.4, 95% CI (0.3, 0.5), P < 0.001]. Power reserve showed similar results. Conclusion  The assessment of cardiac power during exercise stress echocardiography in patients with normal EF provides valuable prognostic information, in addition to stress test findings on inducible myocardial ischaemia and exercise capacity.

scholarly journals P1303 Pseudo-severe aortic stenosis due to mechanical dyssynchrony in a patient with low contractile reserve

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
U Breskvar ◽  
M Mrak ◽  
A Zupan Meznar ◽  
D Zizek
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Stress Echocardiography ◽  
Mechanical Dyssynchrony ◽  
Left Ventricular ◽  
Low Flow ◽  
Cardiac Resynchronization ◽  
Contractile Reserve ◽  
Severe Stenosis

Abstract Introduction Aortic stenosis characterization in patients with low flow – low gradient stenosis (LF-LG) and reduced left ventricular (LV) ejection fraction (EF) is challenging. In this subgroup, pseudo- severe stenosis should be properly identified, as these patients are treated conservatively with heart failure therapy. Its identification relies mainly on preserved contractile reserve seen during dobutamine echocardiography. We present a patient with low contractile reserve and pseudo-severe stenosis due to mechanical dyssynchrony. Case presentation 83-years old patient with ischemic heart disease and chronic kidney disease was admitted to our department due to progressive exertional dyspnea. In 2014 he underwent dual-chamber pacemaker (PM) implantation due to sick sinus syndrome and was programmed to asynchronous pacing mode (VVI mode) in 2016 as atrial electrode dysfunction was observed. Coronary angiogram was normal. Echocardiography showed enlarged left ventricle (LV EDV 180 ml), reduced EF (33%) and signs of mechanical dyssynchrony. Peak aortic valve velocity was 2.5 m/s, mean pressure gradient (MPG) 13 mmHg and AVA 1.0 cm2. Stroke volume was reduced (SVI 28 ml/m2). LF-LG aortic stenosis was suspected. Stress echocardiography using dobutamine at peak infusion of 15 mcg/kg/min showed low contractile reserve (EF 37%, SVI 33 ml/m2) with no significant changes in aortic valve parameters (MPG 29 mmHg, AVA 0.9 cm2). However, significant masurement disparity was noted and at least partly contributed to atrio-ventricular (A-V) and inter-ventricular dyssynchrony because of asynchronous VVI pacing. To overcome A-V and intraventricular dyssynchrony we decided for atrial lead reposition and upgrade to cardiac resynchronization therapy (CRT-P). After six months of CRT, normalization of EF and improvement of exercise capacity were observed. Furthermore, additional evaluation of aortic valve showed only moderate stenosis (peak velocity 2,8 m/s, MPG 18 mmHg and AVA 1.4 cm2). Stroke volume was normal (SVI 48 ml/m2). Consequently, we postponed potential surgical or interventional treatment of the aortic valve. Conclusion Considerable LV mechanical dyssynchrony could interfere with determining the severity of aortic stenosis. As demonstrated in the present case report, special considerations should be taken in patients with notable LV dyssynchrony and low contractile reserve as it may not be overcome with dobutamine stress echocardiography as recommended by the current guidelines.

scholarly journals Evaluation of right ventricular contractile reserve with exercise stress echocardiography

2019 ◽  
Vol 11 (3) ◽  
pp. e325-e326
Author(s):  
A. Missana ◽  
M. Azzolini-Jacquin ◽  
C. David ◽  
D. Baudouy ◽  
B. Sartre ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Stress Echocardiography ◽  
Exercise Stress ◽  
Contractile Reserve ◽  
Exercise Stress Echocardiography

Exercise testing and exercise stress echocardiography in asymptomatic aortic valve stenosis

Heart ◽  
2008 ◽  
Vol 95 (11) ◽  
pp. 877-884 ◽  
Author(s):  
P V Ennezat ◽  
S Marechaux ◽  
B Iung ◽  
C Chauvel ◽  
T H LeJemtel ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Stenosis ◽  
Exercise Testing ◽  
Stress Echocardiography ◽  
Exercise Stress ◽  
Exercise Stress Echocardiography

scholarly journals Prognostic value of contractile reserve evaluated by global longitudinal strain in patients with asymptomatic severe aortic stenosis

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
RA Rosina Arbucci ◽  
MGR Maria Graciela Rousse ◽  
DML Diego Maximiliano Lowenstein ◽  
AKS Ariel Karim Saad ◽  
CC Cristian Caniggia ◽  
...  
Keyword(s):  
Left Ventricle ◽  
Aortic Stenosis ◽  
Valve Replacement ◽  
Prognostic Value ◽  
Longitudinal Strain ◽  
Severe Aortic Stenosis ◽  
Global Longitudinal Strain ◽  
Exercise Stress ◽  
Contractile Reserve ◽  
Aortic Valve Area

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas. Cardiodiagnóstico. Buenos Aires Introduction. Left ventricle Global Longitudinal Strain(GLS) at rest has shown prognostic value in patients(pts) with severe aortic stenosis(SAS). Contractile reserve(CR) during exercise stress echo(ESE) estimated by GLS(CR-GLS) could better stratify the asymptomatic patients who could benefit from early intervention.  Objective. To establish the long-term prognostic value of CR-GLS in pts with asymptomatic SAS during ESE. Secondly, to compare if the CR evaluated by ejection fraction(CR-EF) presented similar results to those of CR-GLS.  Methodology. In a single center, prospective study carried out between May 2013 to Oct 2019, we enrolled 101 pts(69 ± 12 years,54 men) with asymptomatic SAS(aortic valve area < 0,6cm2/m2) and preserved EF(>55%). GLS value was considered as the average of the 16 segments, obtained from the apical views of 3, 4 and 2 chambers at rest and peak ESE. CR was considered present with stress-rest increase of >5points with EF and >2 absolute points by GLS. The pts were divided into 2 groups(G): G1:Pts with presence of CR-GLS and G2:Pts with absence of CR-GLS. Major cardiovascular event was considered to be: need for valve replacement due to the presence of symptoms, death, acute myocardial infarction and stroke. All patients were followed-up.  Results. Of the 101 pts analyzed, 56pts(55.4%) were included in G1(CR-GLS) and 45pts(44.6%) in G2(no CR-GLS). The G2 patients were older(G2 72.2 ± 8.5 vs G1 66.5 ± 14.1) with lower METS(G1 5.6 ± 2 vs G2 4.2 ± 1.1,p 0.004), a higher percentage of flat blood pressure response(G1 19.6% vs. G2 37.8%,p 0.036), lower peak EF(G1 71.5%±5.8 vs G2 66.8 ± 7.9,p0.001),peak GLS(G1 -22.2%±2.8 vs G2 -18.45%±2.4 p 0.001) and lower ΔGLSstress-rest(G1 GLS 3.07 ± 0.85 vs G2 0.08 ± 1.9 p 0.003). The same behaviour with the EF response(G1 7.32 ± 2.9 vs G2 4.7 ± 5.3,p 0.024). The average follow-up was 46.6 ± 3.4 months, and events occurred in 45 patients: 12 all-cause deaths(9 cardiac), 31 valve replacement, 1 myocardial infarctions, 1 strokes. G2 pts had more events compared to G1 pts (G2 = 26 events 57.8% vs G1 = 19 events 42.2%,p < 0.01)(figure 1). The CR-EF did not separate patients with and without events. At Cox analysis, CR-GLS was the only predictor variable of major events(HR:1.97, 95% CI 1.09-3.58)p < 0.025). Conclusions In patients with asymptomatic SAS, the absence of CR-GLS during ESE identifies a group of patients with a worse prognosis and the need for aotic valve intervention. CR-GLS proved to be superior tan CR-EF. Baselin characteristic between groups Abstract Figure. Left ventricle RC-GLS and survival

scholarly journals Myocardial Work and Left Ventricular Contractile Reserve During Stress Echocardiography: An Angiographic Validation

2021 ◽  
Author(s):  
Natalie Edwards ◽  
Gregory Scalia ◽  
Anthony Putrino ◽  
Vinesh Appadurai ◽  
Surendran Sabapathy ◽  
...  
Keyword(s):  
Stress Echocardiography ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Peak Exercise ◽  
Contractile Reserve ◽  
Surgical Revascularisation ◽  
Constructive Work ◽  
Global Work ◽  
Exercise Induced

Objective This study sought to determine the contractile reserve (CR) response to exercise stress echocardiography (ESE) quantified by the novel parameter, non-invasive myocardial work (MW), in subjects with angiographically proven coronary artery disease (CAD). Methods CR was measured by the relative change in ejection fraction (EF), global longitudinal strain (GLS) and MW indices from rest to peak exercise in 304 patients referred for clinically indicated ESE. Positive ESE patients proceeded to coronary angiography and further risk stratified based on either percutaneous or surgical intervention. Results CR and global work index (CR) significantly decreased with exercise induced ischaemia and angiographically proven significant CAD (CR -1.6±3.5%; CR -8.6±511mmHg% decrement, p<0.001) compared to non-ischaemic patients (CR 1.4±2.2%; CR 398±404mmHg% improvement). Global constructive work (CR) was significantly higher (p<0.0001) in non-ischaemic (818±457mmHg%) and blunted in ischaemic patients (208±550mmHg%). CR (AUC 0.81; 95%CI 0.74-0.88) was superior to CR (AUC 0.75; 95%CI:0.67-0.83), CR (AUC 0.73, 95%CI:0.64-0.82) and CR (AUC 0.71; 95%CI:0.62-0.81, p<0.001) to detect inducible ischaemia. Subgroup analysis showed patients requiring surgical revascularisation demonstrated a significantly lower CR (-11.5±7.6%, p<0.05) as a result of reduced CR (281±573mmHg%, p<0.05) and increased global wasted work (CR, 289±151mmHg%, p=0.09). Conclusion Multivessel disease requiring surgical revascularisation have the greatest reduction in CR. MW may potentially improve detection of ischaemia and further risk stratification during ESE to maximise the benefits of revascularisation.

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