Introduction: Exercise Testing in Patients with Valvular Heart Disease
Exercise testing (ET) has been the cornerstone in the diagnosis and prognostic evaluation of coro- nary artery disease (see Chapter 14).1,2 Even in apparently healthy men exercise testing provides important prognostic informations.3Although ET was recently recommended in the management of asymptomatic patients with valvular heart disease (VHD),4,5 this recommendation is based on a small database. In the Euro Heart Survey on Valvular Heart Disease of the European Society of Cardiology, exercise testing was used in less than 8% of 5001 patients, evaluated in hospital or as an outpatient in 27 European countries.6The reasons for performing exercise testing in these patients are listed in Table 16-1.
There are several explanations for the infrequent use of exercise testing in patients with VHD.
Previously exercise testing was used to diagnose coronary artery disease also in adult patients with VHD, particularly in patients with aortic stenosis.
But because of the occurrence of false-positive tests among adult patients with VHD this is considered a class III indication in the ACC/AHA Recommen- dations for exercise testing for the diagnosis of coronary artery disease (CAD) in patients with VHD.1,7 Nonetheless ET is still used for this purpose as shown in Table 16-1. The incidence of false-positive tests in these patients is attributed to left ventricular hypertrophy (LVH) and/or repolar- ization disturbances at rest. Yet many patients with moderate–severe valve lesions may have a normal
ECG and no severe LVH. In these patients the pro- duction of severe ST-segment depression (>2mm) most likely indicates a pathological reaction which requires further diagnosis, even if it may not indi- cate associated CAD.
A further reason for the infrequent use of ET in patients with VHD is the fact that until recently patients with valvular heart disease were operated on only after severe symptoms had occurred, typ- ically NYHA class III or IV; thus in this stage of the disease there is no need for further exercise testing to induce symptoms or hemodynamic alterations. The treatment in these patients is unanimously agreed upon and consists of valve surgery.
In the 2002 update of the AHA guidelines, assessment of functional capacity and symp- tomatic responses was considered a class I recommendation only in patients with aortic insufficiency and a history of equivocal symptoms.1
Yet exercise testing can also be of value in patients with atypical symptoms in other types of valve disease, particularly in the elderly in whom the symptomatic status is difficult to assess because of inactivity.
With the widespread availability of Doppler echocardiography, increasingly asymptomatic or mildly symptomatic patients are being diagnosed for whom exercise testing has become important to assess functional capacity objectively, and to determine if symptoms occur during exercise and if pathological hemodynamic responses (e.g.
inadequate blood pressure increase) appear during exercise. This information is of importance
16
Exercise Testing in Valvular Heart Disease
Christa Gohlke-Bärwolf
110
in the decision on medical or surgical therapy and for advice concerning exercise and leisure time activities (Table 16-2).
The occurrence of hypotension during exercise testing in asymptomatic patients with VHD is also an important indicator of hemodynamic impair- ment. It is not specific for patients with valvular heart disease, since it has been described in patients with CAD8,9and in hypertrophic obstruc- tive cardiomyopathy.10–12
Further Indications for Exercise Testing
Exercise testing has gained an increasing role during follow-up of patients with VHD, particu- larly in patients with aortic stenosis (Table 16-2).
Exercise testing is also of importance concerning recommendations for vocational and recreational activities and sports. During follow-up, detection of newly occurring STT wave changes, blood pres- sure abnormalities, or angina pectoris may be a sign of newly developing coronary artery disease.
After valve interventions or valve surgery, exer- cise testing is helpful to assess the results, to deter- mine the level and type of exercise program during rehabilitation, advise on vocational and leisure time activity, for preoperative assessment before noncardiac surgery, and as a research tool
in long-term follow-up.13That exercise testing can provide valuable information in patients with valvular heart disease, especially in those whose symptoms are difficult to assess was acknowl- edged in the new ACC/AHA guidelines 2006.53
Baseline Information to Be Obtained Prior to Exercise Testing
All patients should undergo a careful clinical eval- uation including history with emphasis on the usual daily activity level, physical examination, and ECG. In patients with evidence of VHD on clinical examination, an echocardiogram should be per- formed prior to exercise testing (Table 16-3).
The level of activity or exercise that is associ- ated with normal hemodynamics without symp- toms is a guide for further medical management, training and leisure time activities, and for the decision about surgery.
The rating of perceived exertion14and the “talk test” (ability to conduct a “small talk” conversation during exercise) are valuable assessments of the intensity of exertion.
Special Test Requirements
The supervising physician should be experienced in exercising high-risk patients, knowing the warning signs of possible problems and following them accordingly.
The test should be started with a low workload, and increased in low workload steps.
The test should be terminated if there is inade- quate blood pressure augmentation, slowing of heart rate, or other significant arrhythmias, if symptoms occur, and if there is more than 2 mm ST depression.1
TABLE16-1. Reasons for performing exercise testing (in 70%
bicycle exercise tests) in 8% of all patients with VHD Reason
Detection of coronary artery disease 61.0%
Assessment of functional capacity in patients with no or 49.1%
equivocal symptoms
Prior to allowing strenuous exercise 13.1%
Prognostic evaluation in the presence of left ventricular 12.1%
dysfunction
Routine basis 22.9%
Source: Lung, 2003.6With permission from Oxford University Press and European Society of Cardiology.
TABLE16-2. Value of exercise testing in patients with VHD To assess objective functional capacity
To assess atypical symptoms
Production of prior unnoticed symptoms To induce pathological hemodynamic responses:
– inadequate blood pressure rise or a fall in blood pressure – inadequate heart rate response (tachycardic or bradycardic) – marked STT wave changes (>2mm)
– severe arrhythmias
TABLE16-3. Baseline information to be obtained during exercise testing
Heart rate and rhythm Blood pressure Symptoms ST-segment changes
Exercise capacity adjusted for age
Rating of perceived exertion such as the Borg scale14or “talk test”
In certain patients Doppler echocardiography to determine:
– valve gradients – pulmonary pressures
Type of Exercise Testing
In Anglo-Saxon countries exercise testing in patients with VHD has been performed predomi- nantly using a treadmill,15–17whereas in European countries it is mostly performed as bicycle ergom- etry,18–22in either supine or upright position. With treadmill exercise only post-exercise imaging is available. Bicycle exercise, particularly in the supine position, has marked advantages concern- ing the quality of ECG monitoring, blood pressure measurement, and safety aspects for the patient, particularly for the elderly.
Stress Doppler echocardiography has recently been employed for the evaluation of patients with VHD. In treadmill exercise testing only post- exercise imaging is available, which may influence the results markedly, for example measuring Doppler gradients after exercise. It may also lead to false-negative results concerning exercise-induced wall motion abnormalities, which may have re- solved rapidly after exercise. In contrast, Doppler gradients and pulmonary artery pressure can be measured continuously during exercise with bicycle ergometry, especially in the supine position.
In patients with unexplained symptoms and apparently only moderate mitral stenosis deter- mination of valve gradients and pulmonary artery pressure assessed from the tricuspid regurgitant jet during exercise is very helpful.23,24 In these patients determination of exercise hemodynamics during supine bicycle ergometry can also eluci- date the causes of symptoms.21,22
Exercise Testing in Patients with Aortic Stenosis (AS)
Since the first description of effort syncope by Gallaverdin in 1933 and the reports of sudden death associated with it, exercise has been consid- ered dangerous in patients with significant AS and thus, exercise testing has been discouraged and considered contraindicated by many experts until recently (see above).
Symptomatic Patients with Significant AS
In these patients the indication for aortic valve replacement is unanimously agreed upon; there-
fore further evaluation with ET is neither neces- sary nor indicated.4
Asymptomatic Patients with AS
Exercise testing has been used for many years to assess severity, progression, and indications for intervention in children with aortic stenosis.25–27
In adult patients with aortic stenosis exercise testing was performed in only 5.7% of asympto- matic patients in the Euro Heart Survey repre- senting the present clinical practice in Europe.6
In adults the first prospective prognostic study in asymptomatic patients with moderate AS16 indicates that ET in asymptomatic or mildly symptomatic patients with AS is not a risky pro- cedure, provided it is performed under expert supervision with appropriate attention to test requirements and criteria for discontinuation of the test.
Three studies in adults with moderate to severe aortic stenosis (valve areas of 0.5 to 1.5 cm2, mean gradients of 18 to 64 mmHg) have shown that with the appropriate precautions, exercise testing can be safely performed in patients with aortic stenosis.16,17,18
Results of Exercise Testing
ET in AS has greatly enhanced our understanding of the pathophysiology and hemodynamic conse- quences of AS.
Even in asymptomatic patients exercise toler- ance is reduced and systemic and LV hemodynam- ics are impaired in a significant number of patients.
Inadequate blood pressure increase during exercise has been demonstrated in 80% of symp- tomatic patients with significant AS28 and about 10% of asymptomatic patients.16
Hypotension or inadequate blood pressure increase has been defined as:
1. blood pressure at maximal exercise less than at rest
2. an increase of less than 20 mmHg
3. a drop to values below the resting value.1,29 The mechanism for hypotension or inadequate blood pressure response in patients with AS is not clear. Studies in patients with hypertrophic cardiomyopathy indicate that hypotension occurs
due to severe hemodynamic left ventricular impairment during exercise.
Due to abnormal baseline ECG, LVH, and impaired coronary reserve, the predictive value for coronary artery disease in AS is limited.1
Pharmacological stress testing has been sug- gested for this purpose.30A definite role for these tests has not yet been established.
Complications of Exercise Testing in AS
A review of case reports on adverse events associ- ated with ET shows that most are from the pre echo-Doppler era and that inadequate pretest diagnosis and test performance with ignorance about premonitory signs have contributed to the complications.19,20
The experience of ET in symptomatic patients with AS from Scandinavia,18,19,31 the studies by Otto et al.,15,16Das et al.,17and our own experience indicated no serious complications in asympto- matic or mildly symptomatic patients with AS.
The total published database for complications during exercise testing in patients with severe AS however is still small.
Since ET uncovers functional and hemody- namic impairment that may be associated with severe AS even in clinically asymptomatic patients, unexpected hypotension, severe rhythm disturbances, and signs of ischemia can occur.
Therefore the physician performing the test should have a high level of suspicion that these events can occur and be prepared to stop the test and deal with these complications. But even if complications at a given exercise level occur in the exercise laboratory, the patient is better served than if they occurred during daily activities.
Exercise Testing for Risk Stratification in Asymptomatic Patients
The excellent early results of aortic valve surgery in symptomatic patients with AS and some late deterioration of LV function in those patients with impaired LV function preoperatively have led to suggestions to operate earlier in patients with AS, and also in those without symptoms.32Yet prog- nostic studies by Pellikka et al.33and Otto et al.16 have shown that as long as symptoms are absent, prognosis is good in the short term.
Exercise Testing to Predict Occurrence of Symptoms in Asymptomatic Patients with Severe AS and Sudden Death
The role of exercise testing for induction of symp- toms was recently evaluated. During treadmill exercise testing 37% of asymptomatic patients deve- loped limiting symptoms (breathlessness, chest tightness, and dizziness). These were independent predictors of symptom onset within 1 year. The positive predictive accuracy for exercise-induced symptoms was 79% for patients aged under 70 without significant limitations in daily life.17
In the study by Pellikka et al.,33sudden death occurred only in those patients who had devel- oped symptoms at least 3 months prior to the occurrence of sudden death or in patients who had been operated upon. In a recent study by Pel- likka et al. in 2005,34only 1% of patients suffered sudden death per year without identified symp- toms prior to death. Medical follow-up was limited in 50% of patients. These patients exhibited a broad range of ages, aortic valve areas, and aortic valve flow velocities. Clinical and echocardio- graphic parameters in this study did not identify these patients.Amato et al.35have shown that exer- cise testing in asymptomatic patients with severe AS identifies those patients at higher risk for sudden death; 6 of 66 patients died during follow- up. All had an abnormal exercise test (develop- ment of angina pectoris or significant ST-segment depression) in the presence of severe AS with a valve area of less than 0.6 cm2.
These exercise parameters (Table 16-4) are of prognostic importance whereby the implications
TABLE16-4. Criteria for an abnormal exercise ECG in patients with severe aortic stenosis
1. Development of symptoms of dyspnea, angina pectoris, syncope, or near syncope
2. Rise in systolic blood pressure during exercise of less than 20 mmHg 3. Inability to reach 80% of the normal level of exercise tolerance
according to age and gender-adjusted levels
4. More than 2 mm horizontal or downsloping ST-segment depression during exercise in comparison to baseline levels, which are not attributable to causes other than severe AS
5. Complex ventricular arrhythmias (ventricular tachycardia, more than four PVCs in a row)
PVC, premature ventricular contraction.
Source: Iung, 2002.5With permission from Oxford University Press and European Society of Cardiology.
of an abnormal exercise test for the indication for surgery are strongest for the occurrence of symp- toms and abnormal blood pressure responses.
In contrast, patients with normal functional aerobic capacity and normal circulatory response to exercise have a good short- and median-term prognosis even in the presence of significant AS.
Thus exercise testing allows risk stratification and identification of those patients in whom the severity of AS is already associated with silent impairment of hemodynamics, LV dysfunction and symptoms which may appear only during exercise testing. These patients can benefit from surgery. The results of exercise testing are also important concerning the recommendations for vocational and recreational activities and sports.36,37
Pharmacological Stress Testing in AS In Patients with Normal Left Ventricular Function Consideration can also be given to stress echocar- diography in these patients, yet there is no con- clusive evidence for its value in asymptomatic patients. In patients with AS and normal left ven- tricular function, valve compliance during dobut- amine stress echocardiography predicted the occurrence of symptoms better than resting measures of AS.38
In Patients with Impaired Left Ventricular Function
In patients with low gradient AS and impaired left ventricular function, stress echocardiography with dobutamine allows evaluation of valve hemodynamics and contractile reserve and is of prognostic value for operative risk stratification and long-term outcome. The hemodynamic response to dobutamine allows the differentiation between patients with true severe AS, with contractile reserve, who have an acceptable operative risk and patients with relative AS with intrinsic impairment of myocardial contractility who have a high operative mortality. When stroke volume and pressure gradient increase with dobutamine, and aortic valve area decreases or remains unchanged, true severe AS is present.
In patients in whom valve area increases with a
rise in stroke volume, relative AS is present. In patients without a change in hemodynamics, severe intrinsic impairment of myocardial con- tractility is present.39
Conclusions
The role of exercise testing in patients with AS has evolved. Exercise testing has become an important method for risk assessment in asymptomatic adult patients with significant AS. It should be included in the decision process for surgery and during clinical follow-up of patients.
Exercise Testing in Patients with Aortic Insufficiency (AI)
Patients with AI are markedly less prevalent than patients with AS, representing only 13.3% of all valve lesions in the Euro Heart Survey on VHD.6 Patients with AI can remain asymptomatic for many years and exercise capacity is usually main- tained until late in the course of the disease. Indi- cations for surgery have been defined on the basis of symptoms, impaired left ventricular ejection fraction at rest, and enlarged left ventricular size.4,5 Since LV dysfunction may occur silently, exercise testing is a reasonable way to identify those patients with severe AI who may develop symptoms and asymptomatic LV dysfunction during exercise. However, studies proving this correlation are lacking. LV ejection fraction response to exercise has been evaluated as a predictor of symptomatic deterioration or LV dysfunction. A positive correlation was identified by Borer et al. in 1998.40Yet this could not be demonstrated in other studies.41,42 The exercise ejection fraction and the change in ejection fraction from rest to exercise are often abnormal in patients with severe AI,43even in asymptomatic patients. However, these have not been proven to have independent prognostic value. In one small study the left ventricular response to exercise was used to monitor the response of asymptomatic patients to medical therapy.44 The indication for exercise testing in patients with AI according to the AHA/ACC is depicted in Table 16-5.
particularly the case in elderly patients. In these patients exercise testing is of clinical value. Induc- tion of dyspnea during exercise, excessive heart rate responses to a relatively low level of exer- cise, and excessive exercise-induced pulmonary hypertension are important parameters, which indicate the need for better medical management or interventional therapy (balloon valvuloplasty or surgery). In patients with only moderate mitral stenosis and unexplained symptoms, determination of valve gradients and pulmonary artery pressure assessed from the tricuspid regurgitant jet during bicycle exercise is very helpful.23
Patients with significant mitral stenosis may have an excessive increase in heart rate during exercise, particularly when atrial fibrillation is present. As stroke volume cannot be increased, the usual increase in cardiac output is less and may eventually fall during exercise, frequently accom- panied by exercise-induced hypotension. The increase in heart rate and right ventricular pres- sure results in an increase in right ventricular myocardial oxygen demand. In patients with mitral stenosis, chest discomfort and ST-segment depression during exercise may occur either due to coronary artery disease or secondary to pul- monary hypertension. The shortening of diastole associated with tachycardia and the increase in pulmonary blood flow associated with exercise increase left atrial pressure and may cause pul- monary congestion and dyspnea.
The value of treadmill stress exercise echocar- diography in patients with mitral stenosis with and without significant mitral insufficiency was shown by Lev et al. in 2004.45 Despite marked differences in mitral valve area between patients with predominantly MS or MR (mitral regurgitation), systolic pulmonary artery pressures were similar both at rest and during peak exercise (Table 16-6).
This demonstrates that patients with combined lesions may become more symptomatic than each lesion by itself would imply. In these patients direct measurement of hemodynamics with right heart catheterization during exercise is of great value in determining the significance of the combined lesion and the indication for surgery.21,22
Although not recommended in the AHA guide- lines for the management of patients with VHD4 (see above) or on exercise testing,1the author feels that during clinical follow-up of asymptomatic patients with severe AI with preserved systolic function, serial exercise testing is helpful to objec- tively assess functional capacity and symptomatic responses. A decrease in exercise tolerance and VO2max, the appearance of marked ST-segment depression, a reduction in heart rate response to each workload, or symptom development on serial exercise testing might be of prognostic value in addition to the resting ejection fraction and end-systolic diameter of the left ventricle. These pathological exercise parameters, particularly new occurrence of symptoms with exercise, should lead to further investigations – such as coronary angiography – and consideration of surgery. But prospective studies to confirm this are lacking.
Exercise Testing in Patients with Mitral Stenosis (MS)
Increasing numbers of asymptomatic patients with severe MS are being diagnosed with echo- Doppler. Due to the long duration of their disease these patients have slowly adjusted to their restrictions and frequently do not report symp- toms or nonspecific symptoms like fatigue. This is TABLE16-5. Recommendations for exercise testing in chronic aortic insufficiency
Indication Class
1. Assessment of functional capacity and symptomatic I responses in patients with a history of equivocal symptoms 2. Evaluation of symptoms and functional capacity before IIa
participation in athletic activities
3. Prognosis assessment before aortic valve replacement IIa in patients with LV dysfunction
4. Exercise hemodynamic measurements to determine the IIb effect of AI on LV function
5. Exercise radionuclide angiography for assessing LV IIb function in symptomatic or asymptomatic patients
6. Exercise echocardiography or dobutamine stress III echocardiography for assessing LV function in
asymptomatic and symptomatic patients
Source: Bonow et al., 1998.4© 1998 American Heart Association Inc.
Reprinted with permission.
Exercise Testing in Patients with Mitral Regurgitation (MR)
Mitral regurgitation has become the second most common valve lesion after aortic stenosis. Mitral regurgitation was present in 31.5% of patients in the Euro Heart Survey on VHD.6 Since these patients are increasingly diagnosed echocardio- graphically, exercise testing has gained an impor- tant role in management of MR.
Exercise testing in patients with severe MR is helpful to identify those clinically asympto- matic patients with impaired exercise tolerance, pathological hemodynamic responses, and the occurrence of symptoms during exercise. To determine the degree of MR and pulmonary artery pressures during exercise, bicycle ergome- try with Doppler echocardiography has been of increasing importance. Because resting ejection fraction is a poor guide to ventricular function in patients with mitral regurgitation, combinations of exercise testing and assessment of left ventric- ular function may be of value in documenting occult dysfunction and influence further medical or surgical management.46In patients with mitral valve prolapse but without regurgitation at rest, exercise-induced MR has been associated
with the subsequent development of progressive MR, congestive heart failure, and syncope.47Con- comitant Doppler imaging during exercise may demonstrate severe MR in patients with symp- toms out of proportion to mild MR observed on the resting echocardiogram. Exercise-induced increases in MR are also of prognostic importance in patients with ischemic heart disease.48–50
Exercise Testing in Patients after Valve Surgery
Valve surgery usually leads to a marked improve- ment in symptoms as evidenced by a decrease in the NYHA class and an increase in exercise toler- ance. The degree of improvement depends on the preoperative symptom status, degree of left ven- tricular impairment, presence of pulmonary hypertension, and the type of valve disease present.
In patients who are asymptomatic prior to surgery a documentation of improvement is fre- quently only possible by comparing the pre- and postoperative exercise tolerance. Thus with exer- cise testing postoperatively improvements in exer- cise parameters can be evaluated. At present, only 7.4% of patients after valve surgery patients undergo exercise testing in representative hospi- tals in Europe.6
Exercise Hemodynamics (see Chapter 20)
After valve intervention or valve surgery in most patients symptomatic and hemodynamic im- provement occurs both at rest and during exer- cise. Particularly in patients with aortic stenosis and impaired left ventricular function preopera- tively, a marked decrease in pulmonary capillary wedge pressure and an increase in ejection frac- tion after surgery can be demonstrated.21,22 Patients after mitral valve replacement have a markedly lower exercise tolerance (Figure 16-1), and only 40–60% of patients have normal hemo- dynamics at rest and only 25% during exercise (Figure 16-2).21,22 Abnormal rest and exercise hemodynamics may persist for 6 to 12 months after surgery21,22,51(Figure 16-3).
The objective assessment of these patients by exercise testing, with determination of TABLE16-6. Echocardiographic parameters at rest and during
peak exercise
Predominantly Predominantly
Parameter MS (n= 24) MR (n= 24) P value
Baseline
Mean mitral gradient 10.2 ± 4.8 7.0 ± 3.1 0.008 (mmHg)
Peak mitral gradient 20 ± 7 15 ± 6 0.02
(mmHg)
Mitral valve area (cm2) 1.1 ± 0.3 2.1 ± 0.6 <0.0001 Tricuspid regurgitation 37 ± 11 37 ± 13 1
systolic gradient (mmHg)
Degree of MR 0.9 ± 0.5 2.1 ± 0.4 <0.0001
Peak exercise
Mean mitral gradient 25 ± 14 17 ± 9 0.04
(mmHg)
Peak mitral gradient 42 ± 18 30 ± 12 0.01
(mmHg)
Tricuspid regurgitation 60 ± 16 55 ± 13 0.8 systolic gradient (mmHg)
Source: Lev et al., 2004.45© 2004 Elsevier. Reprinted with permission.
pulmonary pressures during stress echocardiog- raphy or invasive hemodynamic measurement, can be of help in the postoperative manage- ment of these patients, regarding medical therapy, determination of rehabilitative measures, and advice on vocational and recreational activities.21,22
The results of exercise testing prior to and after mitral valve repair and mitral valve replace- ment are not unanimous. While marked sympto- matic and functional improvement after both aortic and mitral valve replacement was de- monstrated postoperatively by Gohlke-Bärwolf et al.21,22 and Kim et al.52 this could not be shown after mitral valve replacement. Even after mitral valve repair no change in peak VO2was demon- strated in spite of an improvement in NYHA class, exercise duration, and echocardiographic para- meters. We found a constant improvement in exer- cise tolerance between the first and sixth months after surgery, in comparison to preoperatively, in
6 mo
1 mo pre1 mo 6 mo 1 mo6 mo
postop op postop pre postop
op 0
20 40 60 80 100
Exercise tolerance (watt)
AS AI AS+AI
FIGURE16-2. Patients after aortic valve replacement can expect significant improvement in exercise tolerance regardless of preop- erative valve lesion. (AS = aortic stenosis; AI = aortic insufficiency;
Pre = preoperative; postop = postoperative; mo = month; OP = operation.) (From Gohlke-Bärwolf et al.21© 1992 ICR Publishers Ltd. Reprinted with permission.)
Pre 1mo 6mo Pre 1mo 6mo Pre 1mo 6mo
op postop op postop op postop
0 20 40 60 80 100 Exercise tolerance
(watt)
MI MS MI + MS
FIGURE 16-3. Patients with pure mitral insufficiency (usually degenerative lesion) can expect higher exercise tolerance after valve replacement than patients after mitral stenosis or combined usually rheumatic lesions. However, the “relative” improvement is at least as great in patients with rheumatic valvular disease. (MI = mitral insufficiency; MS = mitral stenosis; Pre = preoperative;
postop = postoperative; mo = month; OP = operation.) (From Gohlke-Bärwolf et al.21© 1992 ICR Publishers Ltd. Reprinted with permission.)
AVR = Aortic valve replacement MVR = Mitral valve replacement 0
20 40 60 80 100
N = 211 132
P < 0.01 Exercise tolerance
(watt)
AVR MVR
FIGURE16-1. Patients after aortic valve replacement have better exercise performance than patients after mitral valve replacement.
(From Gohlke-Bärwolf et al.21© 1992 ICR Publishers Ltd. Reprinted with permission.)
all valve lesions, although there was a marked dif- ference between patients with mitral and aortic valve replacement. In patients with AS who were candidates for surgery no preoperative exercise testing was performed (Figure 16-3).
Summary
Exercise testing is of great value in patients with valvular heart disease. It has an important role in eliciting symptoms in asymptomatic patients (which can influence the decision for surgery), in evaluating atypical symptoms and assessing true exercise capacity, and is of prognostic importance in patients with aortic stenosis; this applies also to patients with mitral insufficiency due both to mitral valve prolapse and to coronary artery disease (ischemic mitral insufficiency). After valve interventions or valve surgery, the response to medical and surgical therapy can be evaluated. An exercise test is advised prior to starting an exer- cise training program, to assess its safety but also to evaluate the medical management. The deter- mination of the patient’s exercise capacity affords an objective measurement of the degree of overall cardiac impairment or improvement after valve surgery. At present, exercise testing is underused in clinical practice.
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