Background The prognostic value of serial exercise echocardiography (EEC) in asymptomatic severe aortic stenosis is unknown. We sought to evaluate the safety and utility of monitoring patients with asymptomatic severe aortic stenosis by annual EECs to refer them to aortic valve replacement (AVR) or to keep them under follow‐up. Methods and Results The cohort comprised 196 patients, with a normal screening EEC and a minimal follow‐up of 18 months. Follow‐up was planned until there was an indication for AVR, based on a resting transthoracic echocardiography at 6 months and then every year, and an EEC at 1 year and then every year (alternating resting transthoracic echocardiography and EEC every 6 months). During follow‐up, patients were referred to AVR if they reported symptoms, if rest transthoracic echocardiography was positive (left ventricular dysfunction, aortic maximal velocity ≥5 m/s, or severe valve calcification with aortic maximal velocity progression ≥0.3 m/s per year) or if EEC was positive (occurrence during exercise of any aortic stenosis‐related symptoms, significant ventricular arrhythmias, a drop or an insufficient rise (<20 mm Hg) in systolic blood pressure from baseline, or a left ventricular dysfunction). Among the 196 patients (76% men, aged 76.1±11.1 years), a mean 2.85±1.22 EECs were conducted. There were no serious complications during any of the EECs. Each serial transthoracic echocardiography at rest and each EEC yielded 0%–22% and 23.5%–50% of positive results, respectively, leading to AVR. We delayed AVR by a mean of 2.93±1.95 years after the screening EEC. No cardiac‐related death or sudden death was reported during the study. Conclusions Our findings demonstrate the safety and prognostic utility of serial EECs in the management of patients with asymptomatic severe aortic stenosis to guide timely AVR.

Aortic stenosis, the most common valvular heart disease in Western countries, affects predominantly older people. Prompt aortic valve replacement is undoubtedly indicated in symptomatic patients. Management of asymptomatic patients is nowadays shifting from a conservative approach to early aortic valve replacement, as multimodality imaging is increasingly available. However, multimodality imaging has led to multiple prognostic parameters and complex algorithms, as well as a new staging classification that has left patients and physicians somewhat puzzled. We highlight the value of thorough serial clinical examinations, Doppler echocardiography and exercise testing when caring for a growing aortic stenosis population, including that has no or limited access to multimodality imaging. Evidence for early aortic valve replacement versus conservative management in asymptomatic patients with severe aortic stenosis is biased by the lack of serial stress testing evaluation; 30% of so-called asymptomatic patients were in fact symptomatic, and thus were clear candidates for aortic valve replacement in the above-mentioned studies. Randomized trials of aortic valve replacement versus conservative management that include serial stress testing evaluation are needed to ascertain whether early aortic valve replacement actually improves clinical outcome in asymptomatic patients with severe aortic stenosis. Less interventional medicine and healthcare resource utilization can result in better health.

2016 guidelines for the echographic evaluation of left ventricular filling pressure (LVFP) proposed a single algorithm with limited number of criteria (E/A ratio, tricuspid regurgitation velocity, left atrial volume index and average E/e′) mainly related to left atrial pressure. Pulmonary venous flow analysis, evaluating more specifically left ventricular end diastolic pressure (LVEDP) has been withdrawn. We aim to evaluate the proportion of patients diagnosed with normal LVFP according to 2016 recommendations, despite an abnormal pulmonary venous flow profile suggesting high LVEDP. We prospectively studied patients with stable ischemic cardiomyopathy and aortic stenosis, before cardiac surgery. Extensive echocardiography was performed including pulmonary and mitral A wave durations. We included 76 patients (mean age 72 ± 10 years, 78% were men), 37 (49%) with aortic stenosis and 22 (29%) with ischemic cardiomyopathy. Mean left ventricular ejection fraction was 67 ± 11%. Applying recommendations, 58 patients had normal LVFP and 15 patients had high LVFP. Among the 58 patients with normal LVFP, 26 patients had Apd–Amd duration > 30 ms highly suggestive of high LVEDP. These patients had higher LV mass (112 ± 30 g/m2 vs. 86 ± 20 g/m2, p = 0.004) and shorter A wave duration (120 ± 13.6 ms vs. 132 ± 16.5 ms, p = 0.006) as compared to the remaining 15 patients with concordant evaluation (normal LVFP and normal Apd–Amd). In the present study, we found that 26/58 patients with low LVFP according to the 2016 recommendations had Apd–Amd suggestive of high LVEDP. Pulmonary venous flow should be added to the algorithm, particularly in patients with unexplained symptom, high LV mass or truncated mitral A wave.

Prognostic value of right ventricular (RV) systolic function is well established in valvular disease, heart failure but has not been evaluated in patients undergoing cardiac surgery.

HomeCirculationVol. 130, No. 5Letter by Abergel and Chauvel Regarding Article, “Flow-Gradient Patterns in Severe Aortic Stenosis With Preserved Ejection Fraction: Clinical Characteristics and Predictors of Survival” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Abergel and Chauvel Regarding Article, “Flow-Gradient Patterns in Severe Aortic Stenosis With Preserved Ejection Fraction: Clinical Characteristics and Predictors of Survival” Eric Abergel, MD, PhD and Christophe Chauvel, MD Eric AbergelEric Abergel Department of Cardiology, Echocardiography Laboratory, Clinique Saint-Augustin, Bordeaux, France Search for more papers by this author and Christophe ChauvelChristophe Chauvel Department of Cardiology, Echocardiography Laboratory, Clinique Saint-Augustin, Bordeaux, France Search for more papers by this author Originally published29 Jul 2014https://doi.org/10.1161/CIRCULATIONAHA.113.007157Circulation. 2014;130:e38To the Editor:We were very interested in the article by Eleid et al1 reporting a large population of 1704 patients with severe aortic stenosis (<1 cm2) and preserved left ventricular function and showing a low prevalence of patients (3%) with low flow (stroke volume index <35 mL/m2) and low gradient (<40 mm Hg). This prevalence is much lower than previously reported.2 This discrepancy could be explained, at least in part, by the fact that peak aortic valve velocity is carefully measured (multiple imaging windows) to avoid underestimation and false classification as a low gradient.As recommended, severe aortic stenosis is defined using a valve area <1 cm2 or an indexed valve area <0.6 cm2/m2. In patients with obesity, the use of indexed values using body surface area should be avoided (0.6 cm2/m2), and the nonindexed threshold (1 cm2) is applied.3Stroke volume index is the gold standard to define low flow. Interestingly, in the Eleid et al study, among the 53 patients with low flow and low gradient, a large proportion (47%) were obese. It has been demonstrated that in overweight and obese subjects, these indexed values systematically underestimate stroke volume.4 In this population, the derived relationship between resting cardiac output and body surface area was allometric with a scaling exponent of 0.62.These findings suggest that the current use of the stroke volume index in overweight or obese patients may not be appropriate. To classify these 25 patients, and more generally to be able to diagnose a low-flow, low-gradient aortic stenosis in obese patients, it would be necessary to evaluate and validate other index methods such as height or body surface area with a scaling exponent.5Thus, in our opinion, the definition of low flow used in the article by Eleid et al is not appropriate for obese patients. The 3% prevalence of severe aortic stenosis with low flow and low gradient is probably overestimated.Eric Abergel, MD, PhDChristophe Chauvel, MDDepartment of CardiologyEchocardiography LaboratoryClinique Saint-AugustinBordeaux, FranceDisclosuresNone.References1. Eleid MF, Sorajja P, Michelena HI, Malouf JF, Scott CG, Pellikka PA. Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and predictors of survival.Circulation. 2013; 128:1781–1789.LinkGoogle Scholar2. Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival.Circulation. 2007; 115:2856–2864.LinkGoogle Scholar3. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC). Guidelines on the management of valvular heart disease.Eur Heart J. 2012; 33:2451–2496.CrossrefMedlineGoogle Scholar4. de Simone G, Devereux RB, Daniels SR, Mureddu G, Roman MJ, Kimball TR, Greco R, Witt S, Contaldo F. Stroke volume and cardiac output in normotensive children and adults: assessment of relations with body size and impact of overweight.Circulation. 1997; 95:1837–1843.LinkGoogle Scholar5. Dewey FE, Rosenthal D, Murphy DJ, Froelicher VF, Ashley EA. Does size matter? Clinical applications of scaling cardiac size and function for body size.Circulation. 2008; 117:2279–2287.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Rusinaru D, Rietzschel E, Bohbot Y, De Buyzere M, Buiciuc O, Maréchaux S, Gillebert T and Tribouilloy C (2020) Allometric versus ratiometric normalization of left ventricular stroke volume by Doppler-echocardiography for outcome prediction in severe aortic stenosis with preserved ejection fraction, International Journal of Cardiology, 10.1016/j.ijcard.2019.09.056, 301, (235-241), Online publication date: 1-Feb-2020. July 29, 2014Vol 130, Issue 5 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.113.007157PMID: 25070556 Originally publishedJuly 29, 2014 PDF download Advertisement SubjectsEchocardiography

Background and aim: According to recent American guidelines, RV dysfunction can be diagnosed on a single parameter: 1) Peak systolic velocity during ejection period (S') <10 cm/sec 2) RV fractional area change (RVFAC) <35%. The aim of our study was to assess these recent recommendations in a large non-selected cohort of patients awaiting cardiac surgery and to evaluate less validated RV function criteria. Methods: Four hundred and thirteen patients (means values of age and LVEF respectively: 70.3±10.3 years and 62±13%) were enrolled of which 63% were awaiting valve surgery, 49% coronary artery bypass grafting and 3% others. To evaluate RV function, the following parameters were obtained: parameters derived from pulsed tissue Doppler at the tricuspid annulus (S', right myocardial performance index (RMPI), isovolumic acceleration (IVA)), RVFAC, and 2D Strain of the basal lateral wall. Indices of RV preload (IVC collapse index and right atrium RA area) and afterload (systolic pulmonary artery pressure, pulmonary vascular resistance) were also recorded. Results: Out of 413 patients, 320 patients (77.5%) had normal RV function (group 1, defined by S'>10cm/s and RVFAC> 35%,). RV dysfunction was probable in 54 patients (group 2, defined by S'<10cm/s OR RVFAC< 35%). RV dysfunction was highly probable in 39 patients (group 3, defined by S'<10cm/s AND RVFAC< 35%). Using group 1 and 3, other less-validated parameters were evaluated: IVA ≤1.8 m/s2 and basal 2D-Strain ≥-17% had both the best diagnostic value to detect RV dysfunction with a sensitivity of 86% and a specificity > 80%. A cut-off value of RMPI30.60 allowed an acceptable discrimination (AUC 0.79) to predict RV dysfunction with a specificity of 80%. Moreover, IVA was found to be the least load-dependent while basal 2D-Strain and RMPI appeared to be afterload and preload dependent. Conclusions: In patients with a suspicion of RV dysfunction, S' and RVFAC are frequently discordant (58% of the patients). Using a group of highly probable RV dysfunction (S'<10cm/s AND RVFAC< 35%), we found that IVA and basal 2D-Strain have both a good diagnostic value. Moreover, contrary to 2D-strain, IVA was not influenced by loading conditions, adding to its diagnostic value. Our results underline the need of a multiparametric approach to diagnose RV dysfunction, and for this setting both IVA and 2D strain could help.

Background. - The accuracy and reproducibility of stress echocardiography (SE) for the detection of coronary artery lesions requires improvement, particularly in the left circumflex artery (LCx).Aims. - To evaluate the feasibility and diagnostic value of a new sign: Rise of the Apical lateral wall and/or Horizontal displacement of the Apex toward the septum ("RA-HA") in apical echocardiographic views.Methods. - Consecutive patients with normal left ventricular function at rest, positive SE and an indication for coronary angiography were included. SEs were analysed blindly by three independent cardiologists: two seniors (Si and S2) and one junior (J).Results. - Of 81 patients, 58 had an exercise SE and 23 had a dobutamine SE. Significant coronary stenosis was found in 59 of 77 patients who underwent coronary angiography (76.6%). Interobserver reproducibility for the presence of RA-HA was very good between Si and S2 (K = 0.86), and good between 51 and J (0.67) and 52 and J (0.70). The sensitivity, specificity and positive and negative predictive values of RA-HA for the detection of significant coronary artery stenosis were, respectively, 39-41%, 83-89%, 88-92% and 29-31% for S1/S2; and 29%, 83%, 85% and 26% for J. To predict LCx stenosis (single or multivessel): 67-70%, 89%, 80-81% and 80-82% for S1/S2, respectively, and 50%, 89%, 75% and 74% for J.Conclusion. - With a short learning curve, RA-HA is easily diagnosed with a very good inter-observer reproducibility. It has high specificity and PPV for the detection of a coronary artery stenosis, particularly in the LCx artery, during exercise or dobutamine SE. (C) 2012 Elsevier Masson SAS. All rights reserved.

Background. - An accurate assessment of left ventricular (LV) mass is important for the detection of LV hypertrophy.Aims. - To assess the accuracy of four echocardiographic imaging modalities for assessing LV mass compared with cardiac magnetic resonance (CMR).Methods. - We prospectively studied 40 consecutive patients, who underwent an echocardiographic examination using four imaging modalities (M-mode fundamental imaging [FI], M-mode harmonic imaging [HI], two-dimensional [2D] FI and 2D HI) and CMR (our gold standard for LV mass measurement). All echocardiographic measurements were performed by two independent observers.Results. - All echocardiographic modes significantly overestimated LV mass compared with CMR (P <= 0.04), except 20 FI (P=0.25). This overestimation was significantly higher with HI (up to 15.5%) compared with FI (up to 5.7%; P <= 0.04). Significant correlations were observed between the different echocardiographic methods and the two observers. The interobserver agreement over LV mass measurement was lower with FI (intraclass coefficient [ICC] range, 0.66-0.73) than with HI (ICC range, 0.72-0.82), and the best agreement was obtained with 2D HI (ICC, 0.82). Good agreement between CMR and all echocardiographic methods was observed among the smallest LV diameters (ICC range, 0.62-0.85), but not among the largest LV diameters (ICC range, 0-0.22).Conclusions. - HI overestimates LV mass compared with FI and CMR; this leads to overestimation of prevalence of LV hypertrophy in a population of hypertensive patients. HI improves interobserver reproducibility of LV mass measurement compared with FI, leading to a significant decrease in the number of patients required for clinical trials evaluating LV mass regression. Accuracy of LV mass measurement by echocardiography is affected by LV geometry. (C) 2011 Published by Elsevier Masson SAS.