Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation

Objective-To assess resting and exercise echocardiography for prediction of left ventricular dysfunction in patients with significant asymptomatic aor tic regurgitation. Design-Cohort study of patients with aortic regurgitation. Setting-Tertiary referral centre specialising in valvar surgery. Patients-61 patients (38 men, 23 women; mean (SD) age 53 (14) years) with a symptomatic or minimally symptomatic aortic regurgitation and no known coro nary artery disease; 35 were treated medically and 26 had aortic valve repl acement. Interventions-Exercise echocardiography was used to evaluate ejection fract ion, which was measured on the resting and post-stress images using the mod ified Simpson method. Patients with an increment of ejection fraction after exercise were denoted as having contractile reserve (CR+); those without a n increment were labelled CR-. Main outcome measures-Standard univariate and multivariate methods and rece iver operating characteristic analyses were used to assess the ability of c ontractile reserve to predict follow up ejection fraction. Results-In the 3 5 medically treated patients, 13 of 21 (62%) with CR+ (mean (SD) ejection f raction increment 7 (3)%) had preserved ejection fraction on follow up. In re 14 patients with CR(ejection fraction decrement 8 (4)%), 13 (93%) had a decrement of ejection fraction on follow up from 60 (5)% at baseline to 54 (3)% on follow up (p = 0.005). Age, resting left ventricular dimensions, me dical treatment, aortic regurgitation severity exercise capacity, and rate- pressure product were similar in both CR+ and CR- groups. Among the 26 surg ical patients, 13 showed CR+ (ejection fraction increase 9 (5)%), all of wh om had an increase in ejection fraction on follow up (from 49% to 59%). Of 13 surgical patients with CR- (ejection fraction decrease 7 (5)%), 10 (77%) showed the same or worse ejection fraction on postoperative follow up. Conclusions-Contractile reserve on exercise echocardiography is a better pr edictor of left ventricular decompensation than resting indices in asymptom atic patients with aortic regurgitation. In patients undergoing aortic valv e replacement, contractile reserve had a better correlation with resting ej ection fraction on postoperative follow up. Measurement of contractile rese rve may be useful to monitor the early development of myocardial dysfunctio n in asymptomatic patients with aortic regurgitation, and may help to optim ise the timing of surgery.