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Stress Echo in

Valvular Heart Disease

Dr. Ding Zee Pin

Senior Consultant,
Advisor Echocardiography,
National Heart Centre Singapore.
Associate Professor
Duke-NUS School of Medicine,
National University of Singapore
No disclosures
What are the indications for stress Test in Valvular Heart Disease?

Asymptomatic Symptomatic Valve disease

Severe Non Severe with
Valve Disease Valve Disease Reduced LVEF

Elicit symptoms Severity, ? Regrade Severe

Hemodynamic consequences Stress induced changes from
of exercise-Hypotension, arrhthymia Dynamic component? pseudosevere
Other etiology for

Identify patients in need of Intervention !

Surgical Risk of Preserved LV function
Valve Intervention No Post op LV dysfunction
Risk of Prosthetic Valve Cx No CHF
Anticoagulation Risk Sudden Death
Just Right
Similar survival

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

✦✦ Clinical Response- can we evoke symptoms ?

✦ Severity of VHD – do the hemodynamics worsen with

Can we unmask subclinical myocardial dysfunction
Is there exercise-induced Pulmonary hypertension
Native Valve Disease
Pg 116-122
Stress Echo in Valvular Heart Disease

Stress Protocols

Bicycle Exercise Test Treadmill Exercise Test
Stress Echo

Start at 25w Bruce Protocol

Increment of 25 W Image immediate Low dose
3 min interval. post exercise 5-20ug/kg/min
Imaging at each Stage Limited indices assessed Increase SV
-structural, functional,
hemodynamic indices.
VHD(MR, MS, AS, AR) Asymptomatic moderate to severe
Severity not matching symptoms VHD (MR, MS, AS, AR)

Symptoms, ∆ Blood Pressure, Exercise tolerance

Valve Ventricle Hemodynamics

∆ 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
Association Between LVESD and the Risk
Preoperative LVEF
of Overall Mortality Under Conservative Management

Postoperative survival depends on

preoperative LVEF Risk increases as LVESD approaches 40mm
Better survival with LVEF > 60%

Enriquez-Sarano et al. Circ 1994 Tribouilloy C. et al. JACC 2009

Frequency of post-operative left ventricular dysfunction
according to preoperative LVEF and LVESD.

Cut-off values were identified by ROC curve analysis.

Tribouiilloy C. et al. Eur J Echocardiogr 2011

Primary MR

Lack of contractile reserve

∆ < 4-5% LVEF (Lack of CR)

∆ < 2% GLS (lack of CR)

Medically managed patients predicts decrease in LVEF and symptoms at follow up.
Surgically treated patients – predicts post-operative LV systolic dysfunction.

Lee R et al.Heart 2005;91: 1407-12.

Haluska BA. et al. Am Heart J 2003;146:183-8.
Magne J. et al. Eur Heart J 2014;35:1608-16.
Donal E et al. Eur Heart J Cardiovasc Imaging 2012;13:922-30.
Lancellotti P. et al. J Am Soc Echocardiogr 2008;21:1331-6.
Paraskevaidis IA et al. Int J Cardiol 2008;124:64-71.
Primary MR Primary Mitral Regurgitation
Poor Prognostic markers

Rest Pulmonary Hypertension Exercise Pulmonary Hypertension

Dynamic PH
ACC/AHA and ESC Class lla (SPAP ≥ 60 mmHg)

Magne J et al . Circ 2010

Heart 2015
Caution: Normal response – Progressive increase with exercise (may exceed PASP 60 mmHg)
Abnormal response – Early and steep response followed by plateau.
Primary MR Primary Mitral Regurgitation
Poor Prognostic markers

Prognostic Significance of Ex-Induced RV dysfunction in Asymptomatic Degenerative MR

Limited RV CR(TAPSE)<18 mm) Kusunose K. et al Circ CVI 2013

Survival worse than Ex PHT

No Recommendation on Role of Stress Echo Recommendation on

in Both ESC and ACC/AHA guidelines ! Rest Echo Parameters
Exercise to unmask symptoms
Secondary MR
Exercise – Induced Changes in MR
Increase in MR grade
Decrease in MR grade
Symptoms disproportion to the degree of Rest MR

Apical four-chamber view Lancellotti JACC 2003;42

Colour Flow Doppler and Proximal Flow Convergence
Secondary MR Long-term outcome of patients with heart failure and
Prognosis dynamic functional mitral regurgitation

Identifies a group of patient at increased risk of morbidity and death

(A) Proportion of patients without admission for heart failure and

(B) without major adverse cardiac events, according to exercise-
induced differences in effective regurgitant orifice area of mitral

Patrizio Lancellotti, Paul L. Gérard, Luc A.Piérard

Eur Heart J (2005) 26 (15): 1528-1532
Severe Aortic Regurgitation without Symptoms

Exercise testing is recommended to reveal


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.

Rest and exercise longitudinal function assessment

(by TDI parameters) may reveal early signs of LV
systolic dysfunction.
Vinereanu D, et al.Heart 2001;85:30-6.
Non Severe Aortic Regurgitation
with Symptoms

Exercise testing (Supine bicycle Exercise Test)

• Confirm equivocal symptoms.

• Reveal another cause for symptoms (e.g. diastolic

dysfunction, PH, or dynamic MR
Severe MS MVA≤1.5cm2
Role of Stress Echo Very Severe MS MVA ≤ 1.0cm
(Asymptomatic ACC/AHA
In Mitral Stenosis Class lla)

Evoke Symptoms Hemodynamic Changes with Exercise

Asymptomatic Severe Mitral Stenosis Symptomatic Non Severe Mitral

(MVA1.1 to ≤ 1.5 cm2) Stenosis (MVA> 1.5cm2)
NOT High risk of Embolism/
Symptoms disproportionate to severity
Hemodynamic decompensation
Mean gradient is >15 mmHg. ACC
Symptomatic Class llb/C
To Intervene SPAP is >60 mmHg
ESC Class I Dobutamine Stress Test
ACC/ AHA Class l Mean gradient is >18 mmHg.
No recommendation for SPAP.
Reis G. JACC 2004
Non Severe Mitral Stenosis with Symptoms

Valve Area Hemodynamics Pulmonary Hypertension


Indication for Intervention !

Severe Aortic Stenosis

Role of Stress Echo

Asymptomatic Severe AS Low Flow Low Gradient

MPG≥40 mmHg, AVA> 1.0 cm2 Aortic Stenosis
Normal LVEF MPG 40 mmHg, AVA ≤ 1.0 cm2
? Limited data

Reduced LVEF Preserved LVEF

(Paradoxical LFLG
Asymptomatic Severe AS
Normal LVEF
Role of Stress Echo (Exercise)

Symptoms Hemodynamic changes Exercise Echo (Bicycle)

Develop symptoms • Decrease in systolic Increase Mean Aortic pressure

within 1 to 2 years BP below baseline ≥ 18-20 mmHg
is high • Failure of BP to increase Lack of contractile reserve
(about 60% to 80%). by at least 20 mm Hg SPAP > 60 mmHg

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

Survival curves and exercise induced

Increase in AV MPG
Incremental Value over Rest AV MPG
Event free survival
Lancellotti P. Circulation 2005
Marechaux S, Pilbarot P. EHJ 2010
Role of Stress Echo in Asymptomatic Aortic Stenosis
Exercise Pulmonary Hypertension (Exercise
PHT > 60 mmHg

Cardiac event Free survival

Lancellotti P. et al. Circulation 2012

Impact of Aortic Stenosis on
Longitudinal myocardial deformation during exercise (bicycle)

Rest Exercise

Lower GLS at rest
Smaller Exercise Induced
GLS changes
Associated with
Abnormal Stress Test

Surrogate for adverse prognosis in AS ! Donal E., Lancellotti P. EJE 2011

Asymptomatic and Severe AS COR LOE
Decreased exercise tolerance or an exercise fall IIa B ACC
Very severe AS (low surgical risk)
Aortic velocity ≥5.0 m/s (ACC) IIa B ACC
Aortic velocity ≥5.5 m/s (ESC) IIa C ESC
Rapid disease progression and low surgical risk IIb C ACC
(Velocity of 0.3 m/s per year) IIa C ESC
Severe valve calcification and low surgical risk IIa C ESC
Severe pulmonary hypertension (systolic IIa C ESC
pulmonary artery pressure at rest >60mmHg
confirmed by invasive measurement)
Markedly elevated BNP levels (>threefold age- IIb C ESC
and sex-corrected normal range)
Concommitent Cardiac surgery (CABG, I B ACC
Ascending aorta, Other Valves) C ESC
Asymptomatic Severe AS
Normal LVEF
Role of Stress Echo (Exercise)

Symptoms Hemodynamic changes Echo

Develop symptoms • Decrease in systolic Increase Mean Aortic pressure

within 1 to 2 years BP below baseline ≥ 18-20 mmHg
is high • Failure of BP to increase Lack of contractile reserve
(about 60% to 80%). by at least 20 mm Hg (?Cut off)
SPAP > 60 mmHg

ACC/AHA I ACC/AHA Class lla Not in Guidelines

ESC l ESC lla Closer FU
Low Flow Low Gradient
Aortic Stenosis
MPG 40 mmHg, AVA ≤ 1.0 cm2

Check for measurement errors

LVOT velocity
AV velocity
LVOT dimension

Reduced LVEF Preserved LVEF

(Paradoxical LFLG
Severity of AS
Mean PG
AVA- Continuity equation RSE V 5.21 m/s RSC 4.5 m/s


Apical 4.6 m/s SSN 3 m/s

Subcostal 4.15 Apical 3.9

Sample Volume location
Laminar flow
SV placed 0.5 to 1.0 cm from the AV
(Avoid flow acceleration
- Septum , close to the valve)
- Align with LVOT flow
SV too far away from the AV, underestimate the AVA
LVOT becomes progressively more
elliptical (rather than circular) in older

Underestimation of LVOT CSA

Underestimation of SV and AVA

In Low flow Severe AS(Svi,35ml/m2)

Confirm LVOT area with MSCT, TEE, CMR –ESC Valve Guideline 2017
Patient 1 Are Both Severe AS ?

AV velocity 3 m/s BSA = 1.65 AVA = 0.8 cm2

Mean PG 23 mmHg SV index = 35 mL/m2 AVAi = 0.5 cm2/m2

Patient 2

AV velocity 3.48 m/s BSA = 1.75 AVA = 0.8 cm2

Mean PG 34 mmHg SV index = 32 mL/m2 AVAi = 0.5 cm2/m2
Effective Aortic Valve Area < 1.0 cm2
LVEF < 40%
Mean Pressure < 30 to 40 mmHg

DSE (low dose – up to 20 ug/kg/m2)

Increase Stroke Volume by 20%

Differentiate True AS from Pseudo AS

True Severe AS vs Pseudo Severe AS

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

Baseline BSA = 1.65 Baseline AVA = 0.8 cm2

SV index = 35 mL/m2 AVAi = 0.5 cm2/m2

Max MPG 33 Max AVA = 1.0 cm2

AVAi = 0.61 cm2/m2
Vmax 3.6 m/s

Moderate AS in impaired LVEF

Not for AVR
Patient 2 – low dose DSE
Baseline DSE 10 mcg DSE 20 mcg

↑ 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
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)

Flow Reserve No Flow Reserve

∆ SV ≥ 20% ∆ SV < 20%

True Severe AS Pseudo Severe AS Calcium Score

Mean PG≥ 40 mmHg MPG< 40 mmHg MSCT
± AVA ≤ 1 cm2 AVA > 1.0 cm2

Calcium Score by MSCT Men Women

Severe AS likely ≥ 2000 ≥ 1200
Severe AS very likely ≥ 3000 ≥ 1600
Severe AS unlikely < 1600 < 800
Role of Stress Echo in Valvular Heart Disease

• Evoke Symptoms

• Hemodynamic Changes with exercise – MS

• Differentiate Severe from Pseudo severe AS (LFLG AS with rEF)

• Closer FU in adverse prognostic markers

(More data in MR and AS, Define cut off limit)