Kusunose - Stress Echo · Contractile reserve: 5% increase in EF J Am SocEchocardiogr. 2017...

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Role of Stress Echoin Valvular Heart Disease

Kenya Kusunose, MD, PhD, FASETokushima University Hospital

Japan

ECHOHAWAII

January 15‐19, 2018

Not only ischemia!

Valvular Heart Disease

Cardiomyopathy

Pulmonary hypertension

Prosthetic Valve

Diastolic Dysfunction

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Not only ischemia!

Aortic regurgitation

Valvular Heart Disease

Aortic stenosis

Mitral regurgitation

Mitral stenosis

Case 1

• 68 y.o. male

• With a history of hypertension and mitral

regurgitation.

• He presented for a second opinion regarding

surgical management of mitral regurgitation.

• He had no symptom during any activities.

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Case 1

Case 1Moderate to severe MR TEE

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Case 1

Question 1

Your recommendation is…

1. Surgical MV repair2. Percutaneous MV replacement3. Anticoagulation therapy4. Stress echocardiography

• 68 y.o. asymptomatic male with moderate to severe MR

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Question 1


1. Surgical MV repair2. Percutaneous MV replacement3. Anticoagulation therapy4. Stress echocardiography

• 68 y.o. asymptomatic male with moderate to severe MR

Baseline

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25W

50W (peak)

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Doppler

Pre Peak

SPAP: 37 mmHg SPAP: 60 mmHg

MR severity

Pre Peak

PISA radius: 6 mm PISA radius: 10 mm

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• Exercise induced pulmonary hypertension:

SPAP: 60 mmHg

• Significant increase in simple PISA radius

from 6 mm to 10 mm (Severe MR)

• Good contractile reserve: EF 62→74%

• Symptom was occurred during exercise.

Recommendation is…

Summary

Decision

Surgery (repair if low risk)

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2017 updated ACC/AHA Guideline

Nishimura RA et al. J Am Coll Cardiol. 2017 Jul 11;70(2):252‐289.

Stress Echocardiography and Mitral RegurgitationExercise ESVI and Post operative EF

Leung DY et al. J Am Coll Cardiol. 1996 Nov 1;28(5):1198‐205.

74 patients with severe MR who underwent exercise echocardiography and mitral valve surgery.

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Prognostic Importance of Exercise-Induced Changes in Mitral regurgitation

Lancellotti P et al. Circulation. 2003 Oct 7;108(14):1713‐7.

98 consecutive patients with MR who underwent exercise echocardiography.

No significant change in MR

Increase in MR

Increase in MR

0 24 480

20

40

60

80

100

Event-free survival (%)

Follow-up, months

Log-rank testP <0.001

12 36

PH (-) and RV dysfunction (-)

PH (+) andRV dysfunction (+)

Predictors of outcomes in Patients with MR undergoing exercise echocardiography

Kusunose K et al. Circ Cardiovasc Imaging. 2013 Mar 1;6(2):167‐76.

196 consecutive patients with moderate to severe MR who underwent exercise echocardiography.

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Mitral regurgitation

Cut offMR grade: an increase by ≥1 gradeSystolic pulmonary artery pressure: 60 mmHgContractile reserve: 5% increase in EF

J Am Soc Echocardiogr. 2017 Feb;30(2):101‐138. doi: 10.1016/j.echo.2016.10.016.

Case 2

• 72 y.o. female

• With a history of hypertension and mitral

stenosis.

• She presented for a second opinion

regarding management of mitral stenosis.

• She noted a slight fatigue.

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Case 2

Wall motion: normal

Mitral stenosis

MVA: 1.7 cm2

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Mitral stenosis

Mean PG: 5.7 mmHg SPAP: 33 mmHg

Question 2


1. Cardiac CT2. Coronary angiography3. Cardiac MRI4. Stress Echocardiography

• 72 y.o. mild symptomatic female with moderate MS

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Question 2


1. Cardiac CT2. Coronary angiography3. Cardiac MRI4. Stress Echocardiography

• 72 y.o. mild symptomatic female with moderate MS

Case 2

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Case 2Mean PG: 5.7 mmHg Mean PG: 14 mmHg

SPAP: 33 mmHg SPSP: 56 mmHg

Summary

• Exercise induced pulmonary

hypertension: SPAP: 56 mmHg

• Significant increase in MV gradient

from baseline of 6 to 14 mmHg

• No wall motion abnormality

• Symptom was not increased


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Decision

• Carefully periodic monitoring

2017 updated ACC/AHA Guideline

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Mitral stenosis

Cut offMean pressure gradient: 15 mmHgSystolic pulmonary artery pressure: 60 mmHg


Case 3

• 82 y.o. male

• With a history of aortic stenosis and

coronary artery disease (post PCI to LAD).

• He noted a fatigue.

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Case 3

LVEF: 25%

Case 3

RCC

NCC

LCC

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Case 3

Ao‐V: 3.0 m/sec

Mean PG: 24 mmHgAVA: 0.8 cm2

Stroke volume index: 34 ml/m2

Question 3


1. AVR2. TAVI3. Exercise echocardiography4. Dobutamine echocardiography

• 82 y.o. mild symptomatic male with low gradient and low flow AS

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Question 3


1. AVR2. TAVI3. Exercise echocardiography4. Dobutamine echocardiography

• 82 y.o. mild symptomatic male with low gradient and low flow AS

Chart


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Dobutamine 20γ

EF: 30%Mean PG: 41 mmHgAVA: 0.82 cm2

Stroke volume index: 44 ml/m2

ΔSV: 23%

Case 3Pre Peak

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Chart

• Preserved contractile reserve:

SVi 34→42 ml/m2 (ΔSV>20%)

• True severe AS


Summary

• 82 y.o. mild symptomatic male with low flow low gradient AS

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Decision

Intervention

(surgical AVR or TAVI)

Aortic stenosis (low gradient)

LV flow reserveTrue AS or pseud‐severe AS


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Problem of AVA in low gradient AS


Projected AVA

Clavel MA et al. JACC Cardiovasc Imaging. 2013 Feb;6(2):175‐83.

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Projected AVA

Yamada H. JACC Cardiovasc Imaging. 2014 Jul;7(7):641‐9.

Projected AVA

DOB‐AVAproj: 1.11 cm2

0.7

0.8

0.9

1

1.1

1.2

1.3

150 200 250

AVA (cm2)

Flow rate (ml/sec)

Rest

Baseline

Peakvelocity

LVOTflow

LVOTdiameter

DOB 20γ

DOB‐AVAproj

DOB

Kusunose K, et al. Circ Cardiovasc Imaging. 2017 Oct;10(10). pii: e006690.

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Projected AVA

LPP‐AVAproj: 1.08 cm2

Baseline

Peakvelocity

LVOTflow

LVOTdiameter

LPP

0.7

0.8

0.9

1

1.1

1.2

1.3

150 200 250

AVA (cm2)

Flow rate (ml/sec)

Rest

LPP LPP‐AVAproj

DOB

DOB‐AVAproj


Projected AVA

Event free survival (%)

0

20

40

60

80

100

5 10 15 20 25

MonthsNumber at riskNF-LG

LF-LG

Low flow - low gradient

Normal flow - low gradient

p =0.18

47 43 33 21 7

32 28 20 14 9

0

20

40

60

80

100

5 10 15 20 25

MonthsNumber at riskAVAiproj ≥0.72

AVAiproj <0.72

Event free survival (%)

p <0.001 LPP-AVAiproj <0.72

LPP-AVAiproj ≥0.72

35 35 28 20 11

44 36 25 15 5


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Management of Low gradient AS

Pibarot P, Clavel MA. Circ Cardiovasc Imaging. 2017 Oct;10(10). pii: e007035.

Management of Low gradient AS

Pibarot P, Clavel MA. Circ Cardiovasc Imaging. 2017 Oct;10(10). pii: e007035.

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Aortic regurgitation

Very few data in this field.

Contractile reserve (>5% change in LVEF)


Take Home MessageStress echocardiography is…

• Documenting functional capacity

• Determining severity of valve disease

• Timing of intervention

• Determining Prognosis

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Kusunose - Stress Echo · Contractile reserve: 5% increase in EF J Am SocEchocardiogr. 2017...

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