Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines

Abstract

Background-The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation remains a matter of debate because of limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation. Methods and Results-Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15 years; 80% male) with isolated moderately severe to severe aortic regurgitation and preserved left ventricular (LV) function (LV ejection fraction >50%, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm or ≤25 mm/m 2 ) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) during 30±21 months. After adjustment for age and sex in a multivariable Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (TAPSE; hazards ratio [HR], 0.48; P=0.001) was associated with valve surgery-free, independent of resting LV strain (HR, 1.63; P=0.005), exercise LV end-diastolic volume (HR, 1.38; P=0.048), and resting RV strain (HR, 1.69; P=0.002 Kusunose et al Exercise Cardiac Dysfunction in AR 353identify the independent and incremental value of LV and RV function at rest and during exercise in predicting future surgical intervention in patients with asymptomatic AR without the need (ie, without class I or IIa indication) for surgery, but with the need for at least annual echocardiographic follow-up. Methods Study SampleBetween January 2006 and January 2012, consecutive asymptomatic patients with moderately severe to severe AR (vena contracta≥0.3 cm and effective regurgitant orifice [ERO] area≥20 mm, 2 regurgitant fraction≥40%, or regurgitant volume≥45mL) 14 were referred for exercise stress echocardiography at the Cleveland Clinic for the assessment of functional impact of AR. Clinical variables were prospectively gathered from the patients and their medical records at the time of the exercise echocardiogram. We selected patients with preserved LV systolic function (LVEF>50%, LV end-diastolic diameter≤70 mm, LV end-systolic diameter≤50 mm, and LV end-systolic diameter/body surface area≤25 mm/m 2 ). Based on an assumed rate of aortic valve surgery of ≈30% during a follow-up period, we anticipated 160 patients would be needed to develop a stable statistical model with 5 predictor variables. 15 The protocol was approved by the Cleveland Clinic Institutional Review Board. Echocardiographic Assessment at Rest and After ExerciseTransthoracic echocardiography was performed by experienced sonographers before and after symptom-limited exercise using a commercially available ultrasound machine (Vivid 7 or Vivid 9, GE Vingmed, Horten, Norway, Sonos 5500 or iE33, Philips, Andover, MA). All patients underwent...

Prognostic Value of RV Function Before and After Lung Transplantation

“…This suggests that more sensitive markers are required to detect subclinical RV dysfunction. Several investigators have suggested that RV strain can detect cardiac dysfunction earlier than standard imaging parameters and is associated with clinical outcomes(6,7,14).Our findings support the advantage of RV strain in the early detection of RV dysfunction. Therefore, the combination of impaired RV strain and increased SPAP may provide incremental predictive value for the prognosis of LTx patients.…”

“…Therefore, the evaluation of PHT in the absence of knowledge of related cardiac changes, in particular RV function, may be problematic. Recent work has shown that direct measurement of RV function with strain imaging (RV strain) is related to outcome in valve disease and end-stage heart failure (5)(6)(7). In addition, successful LTx may lead to normalization of RV morphology and function, and the prognostic value of RV morphology and function before and after LTx has not been well characterized (8,9).…”

Stress echocardiography in the assessment of native valve disease

“…The PA pressure, presence of dynamic MR and reversible ischaemia may also be assessed as potential contributors to symptoms. Assessment of RV function by TAPSE can be performed with exercise, and if <21 mm has been associated with the need for earlier aortic valve replacement45 GLS and tissue Doppler-derived mitral annular velocities have also been proposed in small studies,46 47 but not included in guidelines.…”

The Role of Stress Echocardiography in Valvular Heart Disease: A Current Appraisal

“…Exercise tricuspid annular plane systolic excursion (TAPSE), a simple parameter used to assess RV function, which can easily be performed with exercise, was found to be independently associated with the need for earlier AVR in patients with asymptomatic severe AR if <21 mm [35]. Other recent research has proposed parameters such as exercise tissue Doppler peak systolic mitral annular velocity and atrioventricular plane displacement, as well as exercise global longitudinal function, which will require further evaluation prior to acceptance in clinical practice [36,37].…”