Objective: The aim of this study was to determine the feasibility, reproducibility, safety and information obtained on exercise physiology from cardiopulmonary exercise testing (CPX) in patients with aortic stenosis. Methods: Patients with an aortic valve area (AVA) <1.3 cm2 who were judged asymptomatic or equivocal symptomatic underwent CPX and an inert gas rebreathing test. Only those where comprehensive evaluation of CPX results indicated haemodynamic compromise from aortic stenosis were referred for valve replacement. Results: The mean patient age was 72 (±9) years; an AVA index <0.6 cm2/m2 and equivocal symptomatic status were found in 90 and 70%, respectively. CPX was feasible in 130 of the 131 patients. The coefficients of repeatability by test-retest were 5.4% (pVO2) and 4.6% (peak O2 pulse). A pVO2 <83% of the expected was predicted by a lower stroke volume at exercise, lower peak heart rate and FEV1, and higher VE/VCO2, but not by AVA index. Equivocal symptomatic status and a low gradient but high valvulo-arterial impedance were associated with a lower pVO2, but not with an inability to increase stroke volume. In total, 18 patients were referred for valve replacement. At 1 year, no cardiovascular deaths had occurred. Conclusions: CPX was feasible and reproducible and provided comprehensive data on exercise physiology. A CPX-guided treatment strategy was safe up to 1 year.

Journal Section:
Editor's choice
Keywords:
Cardiopulmonary exercise testing, Aortic valve area, Aortic stenosis
1.
Bonow RO, Carabello BA, Chatterjee K, et al: 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol 2008;52:e1-e142.
[PubMed]
https://doi.org/10.1016/j.jacc.2008.05.007
2.
Otto CM, Burwash IG, Legget ME, et al: Prospective study of asymptomatic valvular aortic stenosis. Circulation 1997;95:2262-2270.
[PubMed]
https://doi.org/10.1161/01.CIR.95.9.2262
3.
Das P, Rimington H, Chambers JB: Exercise testing to stratify risk in aortic stenosis. Eur Heart J 2005;26:1309-1313.
[PubMed]
https://doi.org/10.1093/eurheartj/ehi250
4.
Bonow RO: Exercise hemodynamics and risk assessment in asymptomatic aortic stenosis. Circulation 2012;126:803-805.
[PubMed]
https://doi.org/10.1161/CIRCULATIONAHA.112.130591
5.
Rajani R, Rimington H, Chambers JB: Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis; relationship between cardiac index and revealed symptoms. Heart 2010;96:689-695.
[PubMed]
https://doi.org/10.1136/hrt.2009.181644
6.
Wasserman K, Hansen JE, Sue DY, et al: Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications, ed 4. Philadelphia, Lippincott, Williams and Wilkins, 2005, pp 69, 146, 167, 173, 199.
7.
Lang CC, Karlim P, Haythe J, et al: Noninvasive measurement of cardiac output during exercise by inert gas rebreathing technique: a new tool for heart failure evaluation. J Am Coll Cardiol 2005;46:1779-1781.
[PubMed]
https://doi.org/10.1016/j.jacc.2005.08.005
8.
Stringer W, Hansen J, Wassserman K: Cardiac output estimated non-invasively from oxygen uptake (VO2) during exercise. J Appl Physiol 1997;82:908-912.
[PubMed]
9.
Guazzi M, Adams V, Conraads V, et al: Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation 2012;126:2261-2274.
[PubMed]
https://doi.org/10.1161/CIR.0b013e31826fb946
10.
Bruch C, Stypmann J, Grude M, et al: Tissue Doppler imaging in patients with moderate to severe aortic valve stenosis: clinical usefulness and diagnostic accuracy. Am Heart J 2004;148:696-702.
[PubMed]
https://doi.org/10.1016/j.ahj.2004.03.049
11.
Hachicha Z, Dumesnil JG, Bogaty P, et al: Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007;115:2856-2864.
[PubMed]
https://doi.org/10.1161/CIRCULATIONAHA.106.668681
12.
Lancellotti P, Magne J, Donal E, et al: Determinants and prognostic significance of exercise pulmonary hypertension in asymptomatic severe aortic stenosis. Circulation 2012;126:851-859.
[PubMed]
https://doi.org/10.1161/CIRCULATIONAHA.111.088427
13.
Keteyian SJ, Brawner CA, Ehrman JK, Ivanhoe R, Boehmer JP, Abraham WT; PEERLESS-HF Trial Investigators: Reproducibility of peak oxygen uptake and other cardiopulmonary exercise parameters: implications for clinical trials and clinical practice. Chest 2010;138:950-955.
[PubMed]
https://doi.org/10.1378/chest.09-2624
14.
Bensimhon DR, Leifer ES, Ellis SJ, et al; HF-ACTION Trial Investigators: Reproducibility of peak oxygen uptake and other cardiopulmonary exercise testing parameters in patients with heart failure (from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training). Am J Cardiol 2008;102:712-717.
[PubMed]
https://doi.org/10.1016/j.amjcard.2008.04.047
15.
Otto C, Bonow RO: Valvular Heart Disease, ed 3. Philadelphia, Saunders, 2009, p 132.
16.
Dhoble A, Enriquez-Serrano M, Kopecky SL, et al: Cardiopulmonary responses to exercise and its utility in patients with aortic stenosis. Am J Cardiol 2014;113:1711-1716.
[PubMed]
https://doi.org/10.1016/j.amjcard.2014.02.027
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