Exercise Stress Echocardiography In Patients Research Articles

Aortic valve area index values of Trifecta implants correlate with energy loss and increased valve stress.

Biological valves are becoming more frequently used in aortic valve replacement. While several reports have evaluated the performance of biological valves, echocardiography studies during exercise stress remain scarce. Furthermore, no current reports compare rate changes in the aortic valve area of biological valves under increased exercise load. Here, we performed exercise stress echocardiography in patients after AVR with Trifecta or Inspiris valves and compared the rates of change in aortic valve areas (AVA). In addition, hydrodynamic analysis at rest was conducted with four-dimensional flow magnetic resonance imaging (4D-flow MRI). Exercise stress echocardiography was performed in seven Trifecta and seven Inspiris patients who underwent AVR at our hospital while 4D flow MRI was performed in all but two Trifecta cases. Comparing the percentage change in AVA when loaded to 25W versus at rest, Trifecta was greater than Inspiris (28.7 ± 36.0 vs - 0.8 ± 12.4%). The smaller AVA at rest was considered causative for this. Meanwhile, Trifecta systolic energy loss in the prosthetic valve segment on 4D-flow MRI (97.5 ± 35.9 vs 52.7 ± 25.3mW) was higher than Inspiris. The opening of the Trifecta valve was considered to be restricted at rest and this may reflect the current reports of early valve degradation requiring reoperation. Taken together, we observed that the Trifecta design may promote faster wear due to higher valve stress.

Prognostic utility of cardiopulmonary exercise testing with simultaneous exercise echocardiography in heart failure with preserved ejection fraction.

Cardiopulmonary exercise testing (CPET) combined with exercise echocardiography (CPETecho) allows simultaneous assessments of cardiac, pulmonary, and ventilation in heart failure (HF) with preserved ejection fraction (HFpEF). This study sought to determine whether simultaneous assessment of CPET variables could provide additive predictive value over exercise stress echocardiography in patients with dyspnoea. CPETecho was performed in 443 patients with suspected HFpEF (240 HFpEF and 203 controls without HF). Patients with HFpEF were divided based on peak oxygen consumption (VO2, ≥10 or <10 ml/min/kg) or the slope of minute ventilation to carbon dioxide production (VE vs. VCO2 slope ≥45.0 or <45.0). The primary endpoint was defined as a composite of all-cause mortality, HF hospitalization, unplanned hospital visits requiring intravenous diuretics, or intensification of oral diuretics. During a median follow-up of 399 days, the composite outcome occurred in 57 patients. E/e' ratio during peak exercise was associated with adverse outcomes. Patients with HFpEF and lower peak VO2 had increased risks of the composite event (hazard ratio [HR] 5.05, 95% confidence interval [CI] 2.65-9.62, p < 0.0001 vs. controls; HR 3.14, 95% CI 1.69-5.84, p = 0.0003 vs. HFpEF with higher peak VO2). Elevated VE versus VCO2 slope was also associated with adverse events in HFpEF. The addition of either the presence of abnormal peak VO2 or VE versus VCO2 slope increased the predictive ability over the model based on age, sex, atrial fibrillation, left atrial volume index, and exercise E/e' (p < 0.05). These data provide new insights into the role of CPETecho in patients with HFpEF.

The effect of cardiac rehabilitation on left ventricular diastolic functions assessed by exercise stress echocardiography in patients with acute coronary syndrome

Objective: The aim of our study is to investigate the impact of cardiac rehabilitation on left ventricular (LV) diastolic function in acute&#x0D; coronary syndrome (ACS) patients.&#x0D; Patients and Methods: Patients were selected consecutively among ACS patients who underwent primary percutaneous intervention&#x0D; and were found eligible for cardiac rehabilitation program from May 2014 to May 2015. Forty-four patients were included in cardiac&#x0D; rehabilitation group and recruited to 30 sessions of Phase-3 cardiac rehabilitation program six weeks after discharge. Twenty&#x0D; consecutive patients were included as control group. LV diastolic functions were assessed by resting and stress echocardiography.&#x0D; Results: There were not any significant differences in characteristics between the groups. Resting and stress E velocities and resting&#x0D; lateral e’ velocity significantly increased after rehabilitation program. Left atrial volume index, resting and stress A velocities and&#x0D; average E/e’ ratios were significantly lower while stress lateral e’ velocity was significantly higher in rehabilitation group after program&#x0D; compared to controls. The number of patients with diastolic dysfunction decreased after rehabilitation program. Final resting and&#x0D; stress echocardiography revealed significantly lower frequency of diastolic dysfunction in rehabilitation group.&#x0D; Conclusion: Cardiac rehabilitation improves diastolic functions in ACS patients, which may be detected by stress echocardiography.

Role of Exercise Stress Echocardiography in Pulmonary Hypertension.

Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.

Usefulness and feasibility of exercise stress echocardiography in patients with congenital heart diseases

Usefulness and feasibility of exercise stress echocardiography in patients with congenital heart diseases

Exercise Stress Echocardiography in Kawasaki Disease Patients with Coronary Aneurysms

The most significant sequelae of Kawasaki disease (KD) are coronary artery aneurysms, which can lead to risk of future myocardial ischemia. Exercise stress echocardiography allows for non-invasive assessment of myocardial dysfunction. We reviewed our single center experience with exercise stress echocardiography in patients with previous history of KD with coronary aneurysms. We reviewed the records of 53 KD patients who underwent exercise stress echocardiography from 2000 to 2020. Abnormal stress echocardiograms were defined as those showing no increase in biventricular systolic function post-exercise or regional wall motion abnormalities. Computed tomography angiography and cardiac magnetic resonance imaging were reviewed for patients with abnormal stress echocardiograms. Clinical data were reviewed and correlated with stress echocardiogram results. Of the 53 patients, three (5.7%) had an abnormal exercise stress echocardiogram. All three patients were classified as AHA Risk Level 4 or 5 by coronary Z-score (internal dimension normalized for body surface area) and were confirmed to have coronary aneurysms, stenosis, or myocardial tissue perfusion defects on advanced cardiac imaging that could account for the results seen on stress echocardiogram. Exercise stress echocardiography detected signs of myocardial ischemia in a subset of high-risk patients with Kawasaki disease and coronary aneurysms and may be considered as a useful screening tool for this complex patient cohort.

Prognostic value of exercise stress echocardiography in patients with known coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Exercise stress echocardiography (EE) is useful for diagnosis and risk stratification in patients (pts) with suspected coronary artery disease (CAD). Pts with known CAD carry a high risk of events. Our aim was to assess the utility of EE in predicting outcomes in this population. Methods Single center retrospective study of consecutive pts with known CAD who performed an EE between 2018 and 2019. The primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up. Results A total of 76 pts were included (mean age 59±9 years; 87% male). Fifty-nine (78%) pts had history of ACS, 51 (67%) of percutaneous coronary intervention (PCI) and 14 (18%) of coronary artery bypass graft. The majority of pts had 2 or more vessel disease (42 pts; 55%). The main reason for performing EE was new onset of chest pain (38 pts; 50%) followed by functional assessment of coronary stenoses after incomplete revascularization (29 pts; 38%). The majority of pts had a preserved left ventricular ejection fraction (67; 88%). The exam was performed under beta-blocker effect in 35 (46%) pts. The results of EE were positive for myocardial ischemia in 7 (9%) pts, negative in 37 (49%) pts and inconclusive in 32 (42%) pts. Mean exercise time was 8±3 minutes and mean METs achieved was 9.4±2.6. ST-segment depression fulfilling electrocardiographic criteria for ischemia occurred in 17 (22%) pts. Eleven (14%) pts complained of chest pain during the exam. During a median follow up of 22 months (IQR 15-26), the primary endpoint occurred in 9 pts (admission for ACS in 5 pts; revascularization for chronic coronary syndrome in 4 pts). No cardiovascular death occurred. The positive predictive value of EE for the primary endpoint was 57.1% and the negative predictive value (NPV) 97.3%. In a survival analysis, the predictors of the primary endpoint were lower exercise time, lower METs achieved, untreated significant coronary lesions and a positive EE (figure). After adjustment in a multivariate analysis, a positive EE was an independent predictor of the primary endpoint (HR 4.6, 95%CI: 1.1-16.7, p=.044). Conclusion In pts with known CAD, EE had a high NPV and a positive result was an independent predictor of future cardiovascular events.

Pulmonary congestion during exercise stress echocardiography in ischaemic, heart failure and valvular patients

Abstract Background Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest and exercise stress echocardiography (ESE). Aim To assess the prevalence of B-lines during ESE in different cardiovascular diseases. Methods We performed ESE plus LUS (4-site simplified scan) in 4419 subjects referred for semi-supine bike ESE in 28 certified centers. B-lines score ranged from 0 (normal) to 40 (severely abnormal). Stress B-lines abnormal result was ≥2 units. Six different populations were evaluated: healthy controls (n=103); chronic coronary syndromes (CCS, n=3701); heart failure with reduced ejection fraction (HFrEF, n=395); heart failure with preserved ejection fraction (HFpEF, n=70); valvular heart disease (VHD) for ischemic mitral regurgitation ≥moderate at rest (n=123); repaired tetralogy of Fallot (ToF, n=27). Results Feasibility of B-lines was 100% at rest and peak ESE in all subjects. Imaging and analysis time were &amp;lt;1 minute. B-lines (median) were not detectable in healthy subjects (rest=0.1 [0–1] vs 0.1 [0–1], p=ns) and TOF (rest=0.2 [0–2] vs 0.3 [0–4], p=ns), but were present in all other groups: see figure. During ESE, B-lines increased in CCS (rest=0.5 [0–24] vs ESE=1.3 [0–28], p&amp;lt;0.001); HFrEF (rest=1.4 [0–35] vs ESE=2.9 [0–40], p&amp;lt;0.001); HFpEF (rest=0.3 [0–2] vs ESE=3.4 [0–12], p&amp;lt;0.001), VHD (rest=1.7 [0–12] vs ESE=4.3 [0–23], p&amp;lt;0.001). Stress B-lines were correlated with stress-rest change in wall motion score index in CCS (r=0.325, p&amp;lt;0.001), contractile reserve in HFrEF (r=−0.266, p&amp;lt;0.001) and in VHD (r=−.0300, p=0.001), left atrial volume stress-rest change in HFpEF (r=0.287, p=0.043). Conclusion B-lines identify the pulmonary congestion phenotype at rest and more frequently during ESE in patients with different coronary, myocardial or valvular heart disease, all sharing the final common pathway of acute backward left heart failure through different disease-specific mechanisms. B-lines are absent in healthy subjects and in conditions inducing a mostly right-sided overload such as repaired ToF. Funding Acknowledgement Type of funding sources: None. Figure 1. B-lines at rest and during stress. Percentage (%) of rest (empty bar) and stress (full bar) B-lines abnormality (≥2 units) in six different study groups.

The Clinical Significance and advantages of Stress Echocardiography in patients with moderate to severe aortic stenosis

In order to determine the clinical significance of exercise stress echocardiography in patients with severe to moderate aortic stenosis, a stress-induced increase in the mean pressure gradient across the aortic valve was recorded and myocardial contractile reserve was assessed using a number of parameters (ejection fraction, global longitudinal strain, elasticity index). It was found that, with normal values of EF at rest in patients with severe and moderate aortic stenosis, the deficit in contractile function was revealed using the GLS index, which demonstrated a decrease in both groups at the peak of exercise. A decrease in contractile reserve by both parameters (EF and GLS) was found in the group of patients with severe AS, which, combined with a significant stress-induced increase in the gradient on the aortic valve (≥18–20 mm Hg), an increase in pulmonary artery pressure (&gt; 60 mm Hg) and decrease in systemic systolic blood pressure (&gt;20 mm Hg) should be considered as a predictors of a poor prognosis of the natural course of aortic valve disease, and patients with similar stress test results should be possible candidates for surgical aortic valve replacement. A decrease in the in the LV elasticity index augmentation at the peak of exercise, strongly correlated with changes in other considered parameters of contractility and the metabolic power of exercise (MET), significantly complements the functional characteristics of the lesion for choosing the optimal management strategy. Consequently, exercise stress echocardiography is an indispensable diagnostic tool for determining the prognosis and timing of surgery in patients with aortic stenosis.

Prognostic value of peak stress cardiac power in patients with normal ejection fraction undergoing exercise stress echocardiography.

Cardiac power is a measure of cardiac performance that incorporates both pressure and flow components. Prior studies have shown that cardiac power predicts outcomes in patients with reduced left ventricular (LV) ejection fraction (EF). We sought to evaluate the prognostic significance of peak exercise cardiac power and power reserve in patients with normal EF. We performed a retrospective analysis in 24885 patients (age 59 ± 13 years, 45% females) with EF ≥50% and no significant valve disease or right ventricular dysfunction, undergoing exercise stress echocardiography between 2004 and 2018. Cardiac power and power reserve (developed power with stress) were normalized to LV mass and expressed in W/100 g of LV myocardium. Endpoints at follow-up were all-cause mortality and diagnosis of heart failure (HF). Patients in the higher quartiles of power/mass (rest, peak stress, and power reserve) were younger and had higher peak blood pressure and heart rate, lower LV mass, and lower prevalence of comorbidities. During follow-up [median 3.9 (0.6-8.3) years], 929 patients died. After adjusting for age, sex, metabolic equivalents (METs) achieved, ischaemia/infarction on stress test results, medication, and comorbidities, peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.5, 95% confidence interval (CI) 0.4-0.6, P < 0.001] and HF at follow-up [adjusted HR, highest vs. lowest quartile, 0.4, 95% CI (0.3, 0.5), P < 0.001]. Power reserve showed similar results. The assessment of cardiac power during exercise stress echocardiography in patients with normal EF provides valuable prognostic information, in addition to stress test findings on inducible myocardial ischaemia and exercise capacity.

Value of Transvalvular Flow Rate during Exercise in Asymptomatic Patients with Aortic Stenosis

The optimal management of asymptomatic aortic stenosis (AS) remains controversial. Although exercise stress echocardiography (ESE) has been applied to nonischemic heart disease, the evidence of the prognostic value for asymptomatic AS has been limited. This study aimed to investigate the value of ESE in patients with asymptomatic AS. This retrospective observational study included consecutive asymptomatic patients with at least moderate AS (mean pressure gradient≥20mm Hg or aortic valve area < 1.5cm2) and preserved left ventricular ejection fraction (≥50%) who underwent ESE. Of these, 10 patients who were referred for aortic valve replacement without symptoms were excluded. A final 99 conservatively managed patients (73±13years; 54% male) were enrolled in this study. All patients were followed for AS-related events. During the mean follow-up period of 14±11months, 23 patients underwent from AS-related events. Although no differences were found between the patients with and without adverse events in terms of mean pressure gradient during exercise, the transvalvular flow rate during exercise (Ex-FR) was lower in the patients who experienced adverse events (236±55 vs 274±64mL/sec, P=.01). Multivariate Cox regression analysis showed a decrease in Ex-FR (<270mL/sec) independently associated with adverse events in patients with asymptomatic AS (hazard ratio=3.53, P<.01). The result of the present study suggests that Ex-FR measured by ESE could play a crucial role in the risk stratification of patients with asymptomatic AS.

P944 From systolic pulmonary arterial pressure to pulmonary vascular resistance and reserve: a simplified method for exercise stress echocardiography

Abstract OnBehalf On behalf of Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI). Background The potential of exercise stress echocardiography (ESE) seems to be still underused especialy in the assessment of pulmonary hemodynamics. Aim To assess the feasibility and compare pulmonary vascular resistance (PVResistance) and reserve (PVReserve) during ESE in patients at risk of pulmonary hypertension (PH) and controls. Methods We performed semi-supine ESE, in 97 subjects (age 49 ± 16 yrs, 63 females): 58 patients (Group 1) at risk for PH (systemic sclerosis and other connective tissue diseases) and 39 healthy controls (Group 2). Rest and stress assessment included: tricuspid regurgitant velocity (TRV), pulmonary acceleration time (ACT), cardiac output (CO), SPAP estimation with Bernouilli equation or from ACT with formula: log10 SPAP= - 0.004 (ACT) + 2.1. We estimated PVResistance from Abbas formula, and PVReserve as ΔCO/ ΔSPAP or (when CO was not available) as minutes of exercise/ΔSPAP. When ΔSPAP was &amp;lt;10 mmHg, it was considered equal to 1. Results With TRV or ACT to estimate pressures, and cardiac output or its proxy to estimate flow, PVResistance or PVReserve could be measured in all patients. At peak exercise, PVResistance was higher and PVReserve lower in Group 1 : see Table. Conclusion Estimation of PVResistance and/or PVReserve can be obtained in all patients during ESE, integrating TRV with ACT, and using exercise-time as a proxy of CO when the latter is not available. These indices may be useful for a better, noninvasive characterization of the heterogeneity of pulmonary hemodynamics. Pulmonary hemodynamics ESE data Parameter Group 1, PH (n = 58) Group 2, normals (n = 39) P value TRV rest (cm/s) 243 ± 63 204 ± 31 =0.0147 TRV peak (cm/s) 344 ± 68 204 ± 53 &amp;lt;0.0001 ACT rest (ms) 113 ± 33 128 ± 20 =0.0205 ACT peak (ms) 86 ± 19 94 ± 22 ns SPAP rest (mm Hg) 26 ± 10 21 ± 4 =0.0039 SPAP peak (mm Hg) 45 ± 19 28 ± 13 &amp;lt;0.0001 CO rest (mL/min) 4.9 ± 1.7 5.1 ± 1.7 ns CO peak (mL/min) 7.8 ± 2.8 7.6 ± 2.9 ns Exercise time (min) 7 ± 2 13 ± 3 &amp;lt;0.0001 PVResistance (WU) rest 1.63 ± 0.52 1.54 ± 0.34 ns PVResistance (WU) peak 2.01 ± 0.89 1.27 ± 0.42 =0.0219 PVReserve (ΔCO/ΔSPAP) 1.38 ± 1.13 3.55 ± 2.45 =0.001 PVReserve (Extime/ΔSPAP) 4.69 ± 2.67 10.96 ± 4.39 &amp;lt;0.0001 Legends: WU -Wood Unit, Ex time - exercise time

1680 Left ventricular filling pressure assessment with exercise stress echocardiography in patients with non-valvular atrial fibrillation

Abstract Background Noninvasive parameters of LV filling pressure (E/e’) and pulmonary pressures (RVSP) by Doppler echocardiography correlate with functional capacity and outcome in sinus rhythm (SR). Their role in AF is less clear. Elevated left ventricular filling pressures (E/e’) and pulmonary artery systolic pressures (PASP) by Doppler stress echocardiography correlate with impaired functional capacity in patients in sinus rhythm (SR). However, there is limited data in atrial fibrillation (AF). Purpose The aim of this study was to delineate the characteristics of patients with AF referred for exercise stress echocardiography and determine the prevalence and significance of E/e’ and PASP elevations in AF. Methods Subjects were patients referred for exercise treadmill stress echocardiography (n= 14,937) and underwent regional wall motion assessment, Doppler assessment of mitral inflow (E) and early tissue relaxation (e’) velocities and PASP at rest and immediately following maximum symptom limited exercise. Exclusion criteria included significant valvular heart disease (moderate or greater stenosis and/or regurgitation of any cardiac valve or previous valve repair or replacement) (1%), congenital heart disease (&amp;lt;1%) or refusal to participate in research (&amp;lt;1%). Results Patients with AF (n = 310, 2%) were older (71 ± 10 vs 59 ± 13 years, p &amp;lt; 0.001). While resting blood pressure was similar, resting heart rates were higher in AF (80 ± 17 bpm vs 73 ± 13 bpm, p &amp;lt; 0.0001). AF patients achieved lower workloads (6.4 ± 2.4 METS vs 9 ± 2.4 METS, p &amp;lt; 0.001) with lower peak double products (22336 ± 6677 vs 25148 ± 5438, p &amp;lt; 0.001). Rates of resting (27% vs 10%, p &amp;lt; 0.0001) and exercise-induced (37% vs 20%, p &amp;lt; 0.0001) regional wall motion abnormalities were higher in AF. Mean E/e’ was higher in AF at rest (12 ± 5 vs 9 ± 3, p &amp;lt; 0.001) and with exercise (12 ± 5 vs 10 ± 4, p &amp;lt; 0.001), with a higher percentage of patients in AF having E/e’ ≥15 at rest (20% vs 6% in SR, p= &amp;lt;0.001) and with exercise in (23% vs 8%, p &amp;lt; 0.001). PASP was higher in AF at rest (33 ± 8 mm Hg vs 28 ± 6 mm Hg, p &amp;lt; 0.001) and with exercise (48 ± 12 vs 42 ± 11, p &amp;lt; 0.001) compared to SR. E/e’ correlated with exercise capacity in AF and in SR, with an E/e’ cutoff of 11.7 that was best predictive of impaired functional capacity (&amp;lt; 5 METS in women and &amp;lt; 7 METS in men). Conclusions Abnormalities of E/e’ and PASP are more prevalent in patients with AF and correlate with impaired functional capacity. In patients with AF, a medial E/e’ ratio of ≥ 12 immediately following exercise is best associated with impaired functional capacity.

P1504Impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block

Abstract Background/Introduction ECG has always provided very useful information that can be used to diagnosis, treatment and prevention of cardiovascular events, but ECG changes is not useful to the detection of myocardial ischemia in patients with left bundle branch block (LBBB). QT dispersion (QTd) is a measure of inhomogeneous repolarization of myocardium. Abnormally high QTd has been correlated with risk of cardiac death in coronary patients. Purpose The aim of this study was to establish the impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block. Methods The study involved 123 patients with LBBB, average age 52.7 years. In all subjects clinical examination, standard ECG and exercise stress echocardiography, were performed. The criterion for myocardial ischemia was the appearance of transient segmental wall motion abnormality. The first ECG was done before the exercise stress echocardiography and the second one was done immediately after exercise, with calculation of corrected QT dispersion (QTdc). Results During exercise stress echocardiography, in 45 (36.6%) subjects wall motion abnormality occurred (group with myocardial ischemia: MI), and 78 (63.4%) subjects were without ischemia (group without myocardial ischemia: NMI). Before starting the exercise stress echocardiography, MI group patients had significantly higher values of QTdc (61.2±17.6 vs 43.6±15.4 ms; p&lt;0.001) in comparison to NMI group patients. During the exercise stress echocardiography, the QTdc significantly increased in MI group from 61.2±17.6 to 87.4±20.3 ms (p&lt;0.001). In the NMI group there were no significant changes in the values QTdc during exercise stress echocardiography (from 43.6±15.4 to 46.5±19.8 ms (p - NS). Conclusions Significant increase of QT dispersion is associated with the occurrence of myocardial ischemia during exercise stress echocardiography in patients with LBBB. This new diagnostic approach, of using QT dispersion, significantly improves the clinical usefulness of exercise stress echocardiography in detecting myocardial ischemia in patients with LBBB.

The Added Value of Exercise Stress Echocardiography in Patients With Heart Failure

Doppler echocardiography can provide reliable and repeatable measures of cardiac index (CI), whereas lung ultrasound (LUS) represents a quantitative approach to assess pulmonary congestion. We tested the hypothesis that simultaneous assessment of CI and LUS during exercise stress echocardiography (ESE) may define heart failure (HF) outpatients with different risk of adverse outcome. Standard transthoracic echocardiography and LUS (B-lines) evaluation were assessed during semisupine ESE. CI and B-lines were measured at baseline and peak exercise. Resting plasma B-type natriuretic peptide levels were also evaluated. We enrolled 105 HF patients (87 males; age 62 ± 11 years; New York Heart Association class I to III) with reduced left ventricular ejection fraction (30 ± 7%). Patients were classified into 4 profiles: (1) peak CI ≥4.0 l/min/m2 and peak B-lines <15 (no evidence of congestion or hypoperfusion, n = 47); (2) peak CI ≥4.0 l/min/m2 and peak B-lines ≥15 (congestion with adequate perfusion, n = 23); (3) peak CI <4.0 l/min/m2 and peak B-lines <15 (hypoperfusion without congestion, n = 13); and (4) peak CI <4.0 l/min/m2 and peak B-lines ≥15 (congestion and hypoperfusion, n = 22). There were 21 cardiovascular deaths and 18 hospitalizations for worsening HF during a median follow-up of 29 months. Multivariate predictors of the combined end point were peak hemodynamic profiles (hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.19 to 2.21; p = 0.002), B-type natriuretic peptide (HR 1.00, 95% CI 1.00 to 1.01; p = 0.001), and rest E/e' (HR 1.09, 95% CI 1.03 to 1.15; p = 0.002). Survival analysis showed a worse survival in patients with ESE-derived D profile, followed by patients with C, B, and A profile (log-rank: chi-square = 40.5; p <0.0001). In conclusion, dual evaluation of CI and LUS during ESE is useful for risk stratification of HF patients with reduced ejection fraction. Evidence of pulmonary congestion and low CI at peak ESE identifies a subgroup with a very high risk of adverse outcome.

Prognostic value of exercise stress echocardiography in patients with secondary mitral regurgitation: a long-term follow-up study.

Secondary mitral regurgitation (MR) remains a challenging problem in the diagnosis and treatment of patients with heart failure. Although it is well known that secondary MR is dynamic, the impact of the severity of MR during exercise on long-term outcome has not been fully evaluated. The aim of the present study was to investigate the prognostic value of exercise stress echocardiography (ESE) in patients with secondary MR. This prospective study included 118 consecutive patients with secondary MR and left ventricular dysfunction (mean ejection fraction at rest: 38 ± 14%) who underwent semi-supine ESE. Their major cardiovascular events (MACE) including cardiac death were followed up for a median of 41.7 (range: 6-128) months. MR significantly increased from rest to exercise (effective regurgitant orifice: 0.18 ± 0.09 vs. 0.25 ± 0.12cm2, P < 0.001). The prevalence of severe MR was higher during exercise than those at rest (37% vs. 56%, P < 0.001). During follow-up, MACE occurred in 49 patients (41.5%) including 12 cardiac deaths. Cox proportional-hazard multivariate analysis revealed that older age and MR severity during exercise were significantly associated with increased risk of MACE (hazard ratio: 1.04 and 8.4, respectively, both P < 0.05). ESE provides prognostic information in patients with secondary MR that is useful for predicting long-term outcome.

Is exercise stress echocardiography useful in patients with suspected obstructive coronary artery disease who have resting left bundle branch block?

Current guidelines support exercise stress echocardiography (ESE) for evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Data regarding the diagnostic utility of ESE in patients with LBBB are limited. We hypothesized that the diagnostic performance of ESE for the assessment of suspected OCAD is reduced in the context of LBBB. We studied 191 consecutive patients with resting LBBB undergoing ESE for the investigation of suspected OCAD between 2008 and 2015 at our center. The studies were categorized as inconclusive, normal, or abnormal. Patients with an abnormal response were subcategorized as regional ischemic response or globally abnormal. Eighty-two patients (43%) demonstrated a normal left ventricular contractile response (LVCR) to exercise; 92 (48%) developed an abnormal LVCR to exercise, including 70 patients with globally abnormal and 22 patients with regional ischemic responses. Of the patients with abnormal responses, 62 patients had anatomic imaging, only 29 of whom had significant OCAD, conferring an overall specificity of ESE for significant OCAD of 21% and accuracy of 52%. Of patients who developed a regionally abnormal response, 89% had significant OCAD. For patients with LBBB who develop a globally abnormal LVCR during ESE, the specificity of ESE for reliably excluding significant OCAD is significantly reduced. ESE appears to be a suboptimal test for the evaluation of OCAD in patients with resting LBBB, as about 50% of patients will have an abnormal response, the majority due to globally abnormal contraction where OCAD cannot be reliably diagnosed. Alternative testing should be considered for the investigation of suspected OCAD in patients with resting LBBB.

Exercise stress echocardiography in hypertrophic cardiomyopathy.

In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.

Exercise stress echocardiography in patients with valvular heart disease.

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved <85% of their predicted metabolic equivalents (METS). There were three deaths and four hospital admissions, and 24 patients underwent surgery during follow-up. An abnormal stress echocardiogram (METS <5, blood pressure rise <20 mmHg, or pulmonary artery pressure post exercise >60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P<0.0001). The assessment of contractile reserve did not offer additional predictive value. In conclusion, an abnormal stress echocardiogram is associated with death and hospitalization with heart failure at 2 years. Stress echocardiography should be considered as part of the routine follow-up of all asymptomatic patients with VHD.

Temporal changes in plasma brain natriuretic peptide levels during exercise stress-echocardiography in patients with dilated cardiomyopathy.

The aim of this study was to evaluate temporal changes in brain natriuretic petide (BNP) levels during exercise stress-echocardiography in patients with dilated cardiomyopathy with respect to the left ventricular contractile reserve. We studied 55 consecutive patients with dilated cardiomyopathy (mean age, 55 ± 10 years, 49 (89.1%) male). All patients underwent exercise stress-echocardiography on a treadmill using the modified Bruce protocol. Contractile reserve was assessed by measuring changes in the wall motion score index (ΔWMSI) at rest and and at peak exercise. Levels of BNP were measured at rest, in the first minute, and after 20 minutes following termination of the stress test. Thirty-six patients had preserved left ventricular contractile reserve and 19 patients did not. Patients with preserved left ventricular contractile reserve showed a continuous rise in BNP levels from baseline to peak exercise and to 20 minutes following exertion (83.95 ± 108.51 versus 105.89 ± 116.00 versus 110.95 ± 119.70 ng/L, P < 0.001, respectively). On the other hand, patients without preserved left ventricular contractile reserve showed a decline in BNP levels at peak exercise as compared to baseline (335.49 ± 693.11 versus 320.08 ± 562.60 P = 0.031). ΔBNP was positively correlated with preserved contractile reserve (r = 0.46, P = 0.03) and lower NYHA class (r = -0.65, P = 0.001) in patients in whom baseline LVEF was lower than 20%. Multivariate analysis identified only WMSI at rest (beta -3.365, P = 0.008, 95 CI 0.03 to 0.411) as an independent predictor of left ventricular contractile reserve.The increase in BNP levels during exercise stress-echocardiography is associated with preserved left ventricular contractile reserve in patients with dilated cardiomyopathy.