Stress Echocardiography For Valvular Heart Disease
Stress Echocardiography For Valvular Heart Disease
Stress Echocardiography For Valvular Heart Disease
Surgical Risk of
Valve Intervention Timing of Intervention
Risk of Prosthetic Valve Cx
AnticoagulationC Risk Irreversible LV dysfunction
Symptomatic CHF
Sudden Death
Increased mortality
Too Late
Role of Stress Testing Asymptomatic VHD
…….Find the Tipping Point
…….The Decision to Intervene
Stress Protocols
Dobutamine
Bicycle Exercise Test Treadmill Exercise Test
Stress Echo
∆ 18-20 mmHg MPG in AS ∆ < 4-5% LVEF (Lack of CR) ∆ E/e’(LV filling pressure)
MPG ≥ 15-18 mmHg in MS ∆< 2% GLS (lack of CR) PH (SPAP ≥ 60 mmHg)
∆ > 10-13 mm2 EROA in ∆ SV < 20% (lack of FR)
Secondary MR ∆ WMSI (Ischaemia)
RV dysfunction (TAPSE < 19 mm)
Match symptoms with Risk Stratification Guide decision making and help
Cardiac involvement define the optimal timing and surgery
Primary Mitral Regurgitation
Predictors of Outcome-LV systolic Function
LVEF and LVESD
Association Between LVESD and the Risk
Preoperative LVEF
of Overall Mortality Under Conservative Management
Medically managed patients predicts decrease in LVEF and symptoms at follow up.
Surgically treated patients – predicts post-operative LV systolic dysfunction.
Dynamic PH
ACC/AHA and ESC Class lla (SPAP ≥ 60 mmHg)
Limited evidence
Lack of contractile reserve (<5% change in
LVEF) to predict LV systolic dysfunction development
at follow-up or post-operatively.
Bonow RO. Et al.Circulation 1991; 84:1625-35.
Wahi S et al. Heart 2000;84:606-14.
ACC/AHA I
ESC l
ACC/AHA Class lla
ESC lla ? Some Data
Role of Stress Echo in Asymptomatic Aortic Stenosis
Bicycle Exercise Stress Test
Increase in AV MPG > 18-20 mmHg
Rest Exercise
AS
Lower GLS at rest
Smaller Exercise Induced
GLS changes
Associated with
Abnormal Stress Test
SSN
Patient 2
True Pseudo
Severe AS Severe AS
AV velocity ▲ ▼
≥ 4 m/s < 4 m/s
Mean PG ▲ ▼
≥ 40 mmHg < 40 mmHg
AVA ▬ ▲
< 1.0 cm2 > 1.0 cm2
Patient 1 – low dose DSE
↑ Flow
Baseline DSE 10 mcg DSE 20 mcg
↑ SV
30%
↑ Flow
↑ SV
Baseline BSA = 1.75 Baseline AVA = 0.8 cm2 50%
SV index = 32 mL/m2 AVAi = 0.5 cm2/m2
Max MPG 53
Max AVA = 0.9 cm2
mmHg AVAi = 0.51 cm2/m2
Vmax 4.5 m/s
True Severe AS in
impaired LVEF
For AVR
Low Flow, Low gradient Aortic stenosis
LVEF < 50%, AVA ≤ 1.0 cm2, MPG ≤ 40 mmHg
Reduced LVEF
Low Dose Dobutamine Stress Echo
(Incremental Dobutamine Infusion 5 to 20 ug/kg/min)
• Evoke Symptoms