1. Asymptomatic Aortic Stenosis and Exercise Test

2. Euro Heart Survey on Valvular Heart Disease1
« The use of stress testing was low
Essentially aimed at identifying coronary artery
disease which it does poorly in the setting of
valve disease
Too seldom used in asymptomatic
patients with valve disease
This is particularly true for Aortic Stenosis
despite the fact that the performance of the test
is strongly advocated »
Iung et al.ESC Survey on Valvular Heart Disease. Eur Heart J 2003; 24 :

3. Exercise tests performed
AS AR MS MR
ET % % % %
AS : % of asymptomatic patients : under-utilisation
3.2% of NYHA3 et 4 patients : ?????
(1) Iung et al.ESC survey on valvular heart disease. Eur Heart J 2003; 24 :

4. Comparison surgical indication/ guidelines2
20,7 % « overused »
of intervention
(2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease.
Eur Heart J 2002; 23 :

5. How to Avoid Sudden Death in Asymptomatic Aortic Stenosis ?
Post operative valve Sudden death surgical mortality relatedcomplication
<1% per year
(0,4%) 1%
(5% after 75 years)
1-2 % per year

6. Mortality after Aortic Valve Replacement
Rahimtoola. Circulation 2000; IV.24-33

7. But dont operate too late …
Valve replacement
No surgery
(Symptomatic Aortic Stenosis)
Scwartz E. Circulation 1982; 66 :

8. Exercise test indications in AS
Symptomatic patients : none
Reduced Ejection Fraction : none
Reduced EF in asymptomatic patients : ~ does not exist
Reduced EF in symptomatic patients
Surgical indication if mild EF reduction
Surgical indication if contractile reserve in low output patients1 (Mean gdt < 30 mm Hg)
(1)Monin . Circulation 2003; 108 :

9. Exercise test indications in AS(2)
Identifying coronary heart disease : none
Asymptomatic patients :
Strongly recommended1,2
Gibbons ACC/AHA guideline update for exercise testing.
Circulation 2002; 106 :
(2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease.
Eur Heart J 2002; 23 :

10. First study : Feasibility : OTTO 1997
123 asymptomatic patients
Followed years
End points : death or AVR
Circulation 1997; 95 :

11. Initial Values End point – (n = 67) End point + (n = 56) P 3.3 + 0.5
Peak Ao jet velocity
<0.001
Mean Ao gdt
25 ± 8
36 ± 12
Valve Area
1.53 ± 0.53
1.11 ± 0.34
Impossibility to perform ET
40 %
70 %
=0.007
Exercise SBP change
29 ± 20
15 ± 17
Exercise Valve Area change
0.27 ± 0.36
0.05 ± 0.26

12. Multivariate Analysis
Aortic jet velocity at baseline (p < )
Rate of change over time in jet velocity (p < )
Baseline functional status score (p = 0.002)
Standardized questionnaire
Validity in asymptomatic patients ?

13. Confirmation : Amato1
Selection : out of 853 diagnosed as having aortic valve stenosis :
Inclusion if
AS < 1 cm2
Asymptomatic
Absence of coronary artery disease
Exercise test interpretable
Absence of LBB
(1) Amato MC; Heart 2001; 86 :

14. Methods Exercise Test positivity criteria :
ST > 2 mm (1mm in men, 2 mm in women, 3 mm for upsloping ST)
AS symptoms
Complex Ventricular Arrythmia
SBP rise < 20 mm Hg
End point : death + symptoms

15. Results Patients Positive exercise test : n = 44 (66%)
years; men 66%
Aortic Valve Area : cm2
Positive exercise test : n = 44 (66%)
Follow up : months

16. Valvular area
Positive ET

17. Events : death or symptoms
ET positive
Symptom free survival : 19 %
4 sudden death (6%)
ET negative
Symptom free survival : 85 % (RR = 7.43 by multivariate analysis).
Zero death
Conclusion :
Aortic valve replacement can be postponed
in asymptomatic patients with negative ET
Heart 2001; 86 : 381-6

18. Other studies Alborino1 Lancellotti2 N = 30 N = 63
Exercise echocardiography
Alborino. J Heart Valve Dis 2002; 11 :
Lancellotti . AHA 2004; abstr n° 3279

19. Positivity criteria of exercise in ECG in patients with aortic stenosis1
Symptoms :
Angina, dyspnea, near syncope
Rise in SBP < 20 mmhg (or fall)
Exercise tolerance < 80% of the normal target
Down-sloping ST > 2mm
Complex Ventricular arrythmia
VT, more than 4 PVC in a row
(1) Iung B et al. Recommendations on the management of the asymptomatic patients
With valvular heart disease. Eur Heart J 2002; 23 :

20. Recommendations for Aortic Valve Replacement in Asymptomatic Aortic Stenosis (<1cm2 ou 0.6 cm2/m2)
Abnormal ET (IIa)
LVEF < 50 % (IIa)
LV Hypertrophy > 15 mm (IIb)
Valve Area < 0.6 cm2 (IIb)
VT (IIb)
Prevention of sudden death in asymptomatic patients
with none of the five findings above (III)
Bonow R et al.ACC/AHA Guidelines for the management
of patients with valvular heart disease. JACC 1998; 32(5) :

21. Aortic Stenosis < 1 cm2
Symptoms
And normal
or subnormal LVEF
Low output
Asymptomatic
Dobutamine Echo
Exercise Test
AVR

22. Severe Aortic stenosis (<1 cm2 or 0.6 cm2/ m2) without symptoms
Echocardiography
Exercise test
BNP ?
Exercise Echocardiography ?
Positive
Negative : close monitoring
Aortic Valve Replacement
-Peak jet velocity > 4m/s and
Progression of PV > 0.3m/s/year
and rather severe calcifications
-Ventricular arrythmia
-> 15 mm Wall thickness