Early Hemodynamic Changes Versus Peak Values: What Is More Useful to Predict Occurrence of Dyspnea During Stress Echocardiography in Patients with Asymptomatic Mitral Stenosis?

doi:10.1016/j.echo.2011.01.006

Journal of the American Society of Echocardiography

Volume 24, Issue 4, April 2011, Pages 392-398

https://doi.org/10.1016/j.echo.2011.01.006 Get rights and content

Background

In asymptomatic mitral stenosis (MS), the usefulness of peak exercise Doppler echocardiography (DE) values is acknowledged, but the role of values recorded during the first stage of DE remains unclear.

Methods

DE was analyzed in 48 asymptomatic patients with significant MS and revealed dyspnea in 22 patients (46%).

Results

MS severity and rest and peak systolic pulmonary artery pressures (SPAPs) were not different between patients who did and did not develop dyspnea. Progressions of mean gradient and relative SPAP (ratio of SPAP/baseline SPAP) were significantly greater in patients who developed dyspnea compared with those who did not (P < .01), whereas no difference was observed for absolute SPAP progression (P = .28). Onset of dyspnea was associated with a high increase of relative SPAP (>90% at 60W, OR 2.31; CI, 1.2–4.8; P = .02) but not with the 60 mm Hg peak SPAP threshold (OR 1.3; CI, 0.7–43.1; P = .40).

Conclusion

DE reveals symptoms in 46% of patients who are considered asymptomatic. Despite similar peak values, these patients have different hemodynamic parameters during the first level of exercise compared with patients remaining asymptomatic. This may lead to the integration of early hemodynamic changes in the evaluation of exercise tolerance.

Section snippets

Study Population

Patients were prospectively enrolled if they (1) claimed to be asymptomatic; (2) had moderate to severe predominant MS (defined as mitral valve area [MVA] ≤1.5 cm²); and (3) were evaluated using semi-supine DE. Exclusion criteria were associated moderate to severe and severe mitral regurgitation (grade >2/4); concomitant significant aortic valve, congenital, or pericardial disease; previous valve repair or replacement; and inability to execute bicycle stress testing. All patients gave informed

Patient Characteristics

A total of 48 patients (mean age 51 ± 14 years, 33% were male) were enrolled in the study. Atrial fibrillation was recorded in only eight patients (17%). Patient characteristics are listed in Table 2. Overall MVA was 1.22 ± 0.16 cm², and mean MG was 7 ± 2 mm Hg. Resting SPAP ranged from 23 to 45 mm Hg. Thirty-two patients (67%) had undergone previous PMC. Cormier’s score was 2 in 20 patients (42%) and 3 in 28 patients (58%), and Wilkins score was 8.7 ± 2.3 overall. Twenty-seven patients (56%)

Discussion

The results of the present study can be summarized as follows: 1) In a group of asymptomatic patients with moderate to severe MS, occurrence of dyspnea during exercise was frequent, occurring in 46% of patients. 2) Analyses of hemodynamic pattern during exercise showed that increases in MG and relative SPAP were significantly higher and more rapid in patients who developed dyspnea than in patients who remained asymptomatic. 3) This contrasts with the lack of significant difference observed in

Study Limitations

Because the study population was restricted to a selected group of patients with significant isolated MS, our results cannot be applied to other groups of patients, such as those with mild MS or associated valvular lesions.

Occurrence of symptoms is a complex process that implies multiple pathophysiologic pathways. The scope of this study was not to address the contributors to the occurrence of dyspnea during exercise but to analyze and compare the progression of hemodynamic parameters in

Conclusions

In a homogenous group of asymptomatic patients with moderate to severe MS, occurrence of dyspnea during exercise is frequent and associated with a distinct hemodynamic response during the first stages of exercise, with a pattern of rapid and high progression of MG and relative SPAP. The cutoff of 60 mm Hg for SPAP peak value is frequently reached but is not discriminant for the prediction of symptoms during DE.

Thus, the present study confirms that assessment of early hemodynamic changes during

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Stress echocardiography (SE) is a well established and valid technique, widely used for the diagnostic evaluation of patients with ischemic and nonischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of present medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training—which focus on the preparation, the protocols used, the analysis of the SE images, and updated, evidence-based knowledge about SE applications on ischemic and nonischemic heart diseases, such as in cardiomyopathies, heart failure, and valvular heart disease.
Advances in Rheumatic Mitral Stenosis: Echocardiographic, Pathophysiologic, and Hemodynamic Considerations
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Citation Excerpt :
Patients who deny symptoms despite severe mitral stenosis often do so because they limit their physical activity. Poor exercise tolerance can nevertheless be demonstrated in almost half of such patients during stress testing.39 Interestingly, high PA systolic pressure (>60 mm Hg) at peak exercise correlates poorly with exercise intolerance in these patients.39
Echocardiography is the primary imaging modality used in patients with mitral stenosis. Doppler-derived measurements of mitral pressure half-time are commonly used to calculate mitral valve area, but a number of hemodynamic confounders associated with advanced age limit its utility. Planimetry remains the gold standard for determining mitral valve area and may be performed using two- or three-dimensional imaging. Although the Wilkins score has been used for >30 years to predict balloon mitral valvuloplasty outcomes, newer scoring systems have been proposed to improve predictive accuracy. Some patients undergoing technically successful balloon mitral valvuloplasty may not have satisfactory clinical outcomes. These individuals may be identified by the presence of reduced net atrioventricular compliance, which can be measured echocardiographically. Exercise testing may be useful in patients with mitral stenosis whose symptomatic status is incongruous their mitral valve area. Last, reduced left atrial systolic strain, an indicator of poor left atrial compliance, has been shown to reliably predict adverse outcomes in patients with mitral stenosis. The author discusses the hemodynamics and path ophysiology of mitral stenosis and reviews current and emerging roles of echocardiography in its evaluation.
Pulmonary Artery Systolic Pressure Response to Exercise in Patients with Rheumatic Mitral Stenosis: Determinants and Prognostic Value
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
In accordance with previous studies, increase in mean mitral gradient is the major determinant of exercise-induced pulmonary artery pressure increase at peak exercise.5,8,23,24 A flow-dependent increase in transmitral gradient leads to an increase in left atrial pressure with elevation of SPAP during exercise, which is an important factor related to exercise intolerance in patients with MS.8,9 Other studies suggest that the pattern of hemodynamic changes at each level of exercise, rather than just peak values, plays a role in exercise capacity in MS.22,26 However, these studies did not analyze the association between the pattern of progression of hemodynamic values during stress echocardiography and outcome. Cn is also an important predictor of elevation of pulmonary arterial pressure during exercise9,10,18,27 and also plays a major role in determining functional status in patients with MS.28 Brochet et al.,22 in a study of 48 asymptomatic patients with MS, showed that Cn was the only independent predictor of the occurrence of dyspnea during exercise.22
Pulmonary hypertension in response to exercise is a marker of the hemodynamic severity of mitral stenosis (MS). However, the factors related to elevated pulmonary pressure with exercise are not well defined. The aim of this study was to assess the parameters associated with the pulmonary pressure response to exercise in patients with pure rheumatic MS. An additional aim was to determine the impact of exercise-induced pulmonary hypertension on clinical outcome.
One hundred thirty patients with MS (94% women; mean age, 45 ± 11 years) underwent exercise echocardiography. A range of echocardiographic parameters were obtained at rest and at peak exercise. Symptom-limited graded ramp bicycle exercise was performed in the supine position. The primary end point was mitral valve intervention, either percutaneous or surgical.
In the overall population, systolic pulmonary artery pressure (SPAP) increased from 38.3 ± 13.4 mm Hg at rest to 65.8 ± 20.7 mm Hg during exercise. Increases in mean mitral gradient, right ventricular function, left atrial volume, and net atrioventricular compliance were independently associated with SPAP at peak exercise, after adjusting for changes in heart rate. During the follow-up period (median, 17 months; range, 1–45 months), 46 adverse clinical events were observed. By multivariate Cox proportional-hazards analysis adjusted for age and sex, SPAP achieved at peak exercise was an important predictor of adverse outcome (adjusted hazard ratio, 1.025; 95% CI, 1.010–1.040; P = .001). New York Heart Association functional class (adjusted hazard ratio, 2.459; 95% CI, 1.509–4.006; P < .001) and the interaction between valve area and net atrioventricular compliance (P = .001) were also significant predictors of adverse events. Time-dependent areas under the receiver operating characteristic curve for the model with SPAP during exercise were better than for the model with SPAP at rest, with a significant improvement from 3 years onward.
In patients with MS, the pulmonary artery pressure response to exercise is determined by a combination of factors, including transmitral mean gradient at exercise, net atrioventricular compliance, left atrial volume, and right ventricular function. Pulmonary artery pressure at peak exercise is a predictor of clinical outcomes and adds incremental prognostic value beyond that provided by standard resting measurements, including valve area.
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Stress echocardiography is an established tool to assess for both myocardial ischemia and viability. However, the utility of exercise echocardiography extends beyond the evaluation of coronary artery disease. Assessing the cardiovascular response to exercise can also be used to unmask the presence of, and to assess the severity of, valvular heart disease, heart failure (HF), hypertrophic cardiomyopathy (HCM), and pulmonary hypertension (PH). Resting echocardiography may not fully capture the dynamic nature of these diseases, which are influenced by loading conditions and changes in cardiac output. In this chapter, we review the use of exercise and pharmacologic stress echocardiography for evaluation of myocardial ischemia and viability. We also discuss the most relevant exercise echocardiographic assessments for individual valvular lesions, HCM, PH, and HF with preserved ejection fraction, along with the existing data supporting these assessments.
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Citation Excerpt :
Subjects will be supervised at least 30 minutes after finishing the test and written informed consent will be obtained for each subject. As recently reviewed,8 exercise-induced PH defined by an abnormally high mPAP alone or in combination with elevated PAWP and CO, measured invasively or noninvasively, has been reported in subjects susceptible to high altitude pulmonary edema, healthy family members of patients with idiopathic PAH, systemic sclerosis, chronic obstructive pulmonary disease or interstitial lung diseases, heart failure with decreased or preserved ejection fraction, mitral valve disease, aortic stenosis, late closure of atrial septal defects, and chronic thromboembolism (see Tables 1–3).19–64 Exercise-induced PH has been typically diagnosed in patients referred for shortness of breath and exercise intolerance without obvious pulmonary or cardiac cause.82

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Clinical InvestigationValvular Heart DiseaseEarly Hemodynamic Changes Versus Peak Values: What Is More Useful to Predict Occurrence of Dyspnea During Stress Echocardiography in Patients with Asymptomatic Mitral Stenosis?

Background

Methods

Results

Conclusion

Section snippets

Study Population

Patient Characteristics

Discussion

Study Limitations

Conclusions

J Am Soc Echocardiogr

J Am Coll Cardiol

Cardiol Clin

J Am Coll Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Int J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Clinical Investigation
Valvular Heart Disease
Early Hemodynamic Changes Versus Peak Values: What Is More Useful to Predict Occurrence of Dyspnea During Stress Echocardiography in Patients with Asymptomatic Mitral Stenosis?