Dynamic assessment of %26apos;valvular reserve capacity%26apos; in patients with rheumatic mitral stenosis

作者：Grimaldi Antonio^*; Olivotto Iacopo; Figini Filippo; Pappalardo Federico; Capritti Elvia; Ammirati Enrico; Maisano Francesco; Benussi Stefano; Fumero Andrea; Castiglioni Alessandro; De Bonis Michele; Vermi Anna Chiara; Colombo Antonio; Zangrillo Alberto; Alfieri Ottavio

来源：European Heart Journal-Cardiovascular Imaging, 2012, 13(6): 476-482.

DOI：10.1093/ejechocard/jer269

• Rheumatic valve disease
• Mitral stenosis
• Exercise stress echocardiography

Aims Mitral stenosis (MS) may exhibit a dynamic valvular reserve. When resting gradients and systolic pulmonary pressure (sPAP) do not reflect the real severity of the disease, a dynamic evaluation becomes necessary. The aim of the study was to assess the clinical utility of exercise echocardiography in symptomatic patients with apparently subcritical MS. %26lt;br%26gt;Methods and results One hundred and thirty consecutive patients were referred for symptomatic MS. Patients with unimpressive resting MVA (%26gt;1-1.5 cm(2)) and mean PG (%26gt;= 5-9 mmHg) underwent exercise echocardiography. Cardiac performance and mitral indices (MVA, peak/mean PG, sPAP) were measured. Exhaustion of valvular reserve capacity under exercise was defined as appearance of symptoms and sPAP %26gt; 60 mmHg. Forty-six patients (35%) (age: 53 +/- 10 years; 74%, female) with resting MVA (1.2 +/- 0.36 cm(2)), mean PG (6.8 +/- 2.7 mmHg), and sPAP (38 +/- 7 mmHg) inconsistent with symptoms underwent stress echocardiography. Exercise was stopped for dyspnoea (76%) or fatigue (24%). At peak workloads (57.2 +/- 21.8 Watts), increased mean PG (17.2 +/- 4.8 mmHg, P %26lt; 0.001) and sPAP (67.4 +/- 11.4 mmHg; P %26lt; 0.0001) were observed, without change in MVA (1.25 +/- 0.4 cm(2); P = n.s.). At univariate analysis, predictors of adaptation to exercise were age (-0.345; P = 0.024), mean PG (0.339; P = 0.023), and sPAP (0.354; P = 0.024); at multivariate analysis, best predictor was resting mean PG, although correlation was poor (-0.339; P = 0.015). %26lt;br%26gt;Conclusion In MS with limiting symptoms despite unimpressive findings at rest, valvular capacity exhaustion should be tested on a dynamic background, as no single resting index can predict potential haemodynamic adaptation to exercise. In such context, the contribution of exercise echocardiography remains extremely valuable.

• 出版日期2012-6