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You are here: Contents > 2015 > Volume 24 Number 4 July 2015 > AORTIC VALVE DISEASE > Myocardial and Cardiocirculatory Reserve in Asymptomatic Aortic Stenosis and Preserved Ejection Fraction

Myocardial and Cardiocirculatory Reserve in Asymptomatic Aortic Stenosis and Preserved Ejection Fraction

Olaf Schulz1,2, Debora Brala2,3, Thomas G. Allison4, Ingolf Schimke2

1Praxis für interventionelle und konventionelle Kardiologie Spandau, Kardio-West, Berlin, 2Universitätsmedizin Berlin, Charite, Humboldt Universität Berlin, 3Sana Klinikum Lichtenberg, Berlin, Germany, 4Mayo Clinic and Medical School, Rochester, MN, USA

Background and aim of the study: Managing patients with asymptomatic severe aortic stenosis (AS) remains a major challenge. Myocardial as well as cardiocirculatory reserve have been hypothesized to predict outcome in patients with asymptomatic AS.

Methods: A total of 48 patients (indexed aortic valve area 0.39 ± 0.12 cm2/m2; ejection fraction (EF) 67 ± 7%) underwent spiroergometry and dobutamine stress echocardiography. Death or valve surgery served as a combined endpoint for follow up.

Results: Thirty-seven patients reached the endpoint after a mean of 756 days (range: 100-2146 days). Age- and gender-corrected univariate Cox proportional analysis revealed the presence of mild obstructive lung disease, stroke work loss (SWL), end-systolic diameter index, and E/Flow propagation velocity as the best predictive clinical, valvular, cardiostructural, and left ventricular filling pressure parameters, respectively. After inclusion of these parameters into a baseline multivariable Cox proportional

hazard model, SWL (HR 1.21 per rise of 1 unit, CI 1.08-1.35, p = 0.0005) and female gender (HR 3.37, CI 1.50-7.59, p = 0.0044) were independently predictive. Similarly, the best-performing myocardial parameter, EF after dobutamine, was independently predictive (HR 0.75 per 5 units, CI 0.57-0.99, p = 0.035) after inclusion. The best-performing exercise capacity parameter, Wattmax, was of borderline significance (HR 0.93 per 5 units, CI 0.86-1.00, p = 0.0505). For each parameter, cut-off values were determined by time-dependent receiver-operator characteristics. The Kaplan-Meier curves of the patients above versus below the cut-offs differed significantly for SWL (p = 0.001), Wattmax (p = 0.001), and gender (p = 0.013).

Conclusion: Besides SWL and female gender, the EF after dobutamine as well as highest exercise stress intensity reached are helpful in determining the prognosis of asymptomatic patients with moderate-severe AS.

The Journal of Heart Valve Disease 2015;24:457-464


Myocardial and Cardiocirculatory Reserve in Asymptomatic Aortic Stenosis and Preserved Ejection Fraction

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